Assessment of the procoagulant potential after laparoscopic sleeve gastrectomy: a potential role for extended thromboprophylaxis

Routine extended (30 days) chemoprophylaxis for patients undergoing laparoscopic sleeve gastrectomy may reduce Portomesenteric vein thrombosis rates

BACKGROUND

Venous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days.

OBJECTIVES

Evaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis.

SETTING

University Hospital.

METHODS

Between 2012-2018, SG patients were discharged on extended chemoprophylaxis for patients deemed "high-risk" for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018-2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed.

RESULTS

A total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m2, respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively.

CONCLUSIONS

Routine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.

Risk factors for hypercoagulability after laparoscopic hepatic haemangioma resection

Background

Laparoscopic hepatectomy with a small incision, light abdominal wall trauma and rapid postoperative recovery has been widely used in the surgical treatment of benign liver diseases. However, the occurrence of complications, such as deep-vein thrombosis, associated with laparoscopic techniques has raised concerns. This study aimed to investigate the factors influencing the development of a hypercoagulable state in patients following laparoscopic hepatic haemangioma resection.

Materials and Methods

Between 2017 and 2019, 78 patients to be treated by laparoscopic hepatic haemangioma resection were selected prospectively for the study. The differences in relevant clinical factors between patients with and without blood hypercoagulability at 24 h after surgery were compared, and the factors influencing the development of blood hypercoagulability after surgery were analysed.

Results

The study included 78 patients, split into the hypercoagulable group (n = 27) and nonhypercoagulable group (n = 51). Compared with patients who did not develop blood hypercoagulability, patients who did had significantly higher preoperative levels of fibrinogen (Fib), D-dimer (D-Di), fibrinogen degradation products (FDP), platelet count (PLT), low-density lipoprotein cholesterol (LDL-C) and history of hyperlipidaemia whereas high-density lipoprotein cholesterol (HDL-C) levels were significantly lower (P < 0.05.) in hypercoagulable group. Univariate and multifactorial logistic regression analyses showed that a history of hyperlipidaemia, Fib ≥3.83 g/L, D-Di ≥9.12 μg/ml, FDP ≥14.64 μg/ml, PLT ≥292 × 109/L, HDL-C ≥1.25 mmol/L and LDL-C ≥2.03 mmol/L was the most common independent risk factors for the development of a hypercoagulable state of blood in patients after laparoscopic hepatic haemangioma resection (P < 0.05).

Conclusion

For patients undergoing laparoscopic hepatic haemangioma resection, attention should be paid to the development of a hypercoagulable state in those with the risk factors described in this study.

The Role of Thromboprophylaxis in Patients with Portal Vein Thrombosis: A Life-Threatening Complication after Laparoscopic Sleeve Gastrectomy Following 8 Years of Experience in a Bariatric Center of Excellence

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Assessment of empiric body mass index-based thromboprophylactic dosing of enoxaparin after bariatric surgery: evidence for dosage adjustment using anti-factor Xa in high-risk patients

BACKGROUND

Despite thromboprophylaxis, postoperative deep vein thrombosis and pulmonary embolism occur after bariatric surgery, perhaps because of failure to achieve optimal prophylactic levels in the obese population.

OBJECTIVES

The aim of this study was to evaluate the adequacy of prophylactic dosing of enoxaparin in patients with severe obesity by performing an antifactor Xa (AFXa) assay.

SETTING

An academic medical center METHODS: In this observational study, all bariatric surgery cases at an academic center between December 2016 and April 2017 who empirically received prophylactic enoxaparin (adjusted by body mass index [BMI] threshold of 50 kg/m²) were studied. The AFXa was measured 3-5 hours after the second dose of enoxaparin.

RESULTS

A total of 105 patients were included; 85% were female with a median age of 47 years. In total, 16 patients (15.2%) had AFXa levels outside the prophylactic range: 4 (3.8%) cases were in the subprophylactic and 12 (11.4%) cases were in the supraprophylactic range. Seventy patients had a BMI <50 kg/m² and empirically received enoxaparin 40 mg every 12 hours; AFXa was subprophylactic in 4 (5.7%) and supraprophylactic in 6 (8.6%) of these patients. Of the 35 patients with a BMI ≥50 who empirically received enoxaparin 60 mg q12h, no AFXa was subprophylactic and 6 (17.1%) were supraprophylactic. Five patients (4.8%) had major bleeding complications. One patient developed pulmonary embolism on postoperative day 35.

CONCLUSION

BMI-based thromboprophylactic dosing of enoxaparin after bariatric surgery could be suboptimal in 15% of patients with obesity. Overdosing of prophylactic enoxaparin can occur more commonly than underdosing. AFXa testing can be a practical way to measure adequacy of pharmacologic thromboprophylaxis, especially in patients who are at higher risk for venous thromboembolism or bleeding.

Laparoscopic Sleeve Gastrectomy Affects Coagulation System of Obese Patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is nowadays the most popular bariatric procedure for obesity. However, whether LSG increases the risk of thrombosis remains unclear. The aim of this study was to investigate potential effects of LSG on coagulation system.

METHODS

Fifty-five obese patients underwent LSG between 2016 and 2018. The LSG was performed with pneumoperitoneum pressure maintained at 13 mmHg. Venous blood specimens were collected from each patient before surgery, at the end of pneumoperitoneum (i.e., 0 h after surgery), and at 24 h after surgery to determine prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), platelet count (PLT), D-dimer (D-D), red blood cell count (RBC), hematocrit (HCT), plateletcrit (PCT), cholesterol (CHOL), triglyceride (TRIG), and serum calcium (Ca). All patients were examined on the veins of the lower limbs by color Duplex sonography (CDS) before surgery and at 24 h after surgery, respectively.

RESULTS

All patients successfully underwent LSG. No severe surgery-related complications were observed during 1-month follow-up after operation. Preoperative BMI was 43.6 ± 8.3 kg/m². The levels of coagulation factors were within the normal range before surgery, except a relatively higher PLT. The PT and D-D were increased at 0 h and 24 h after surgery (P < 0.05), whereas APTT was decreased (P < 0.05). The postoperative FIB remained similar to the preoperative one (P > 0.05). The CDS identified no thrombus in the veins of the lower limbs, either before surgery or at 24 h after surgery.

CONCLUSIONS

LSG may cause postoperative hypercoagulability of patients with obesity.

Bariatric Surgery Outcomes in Patients on Preoperative Therapeutic Anticoagulation: an Analysis of the 2015 to 2017 MBSAQIP

BACKGROUND

Obesity has been found to be an independent predictor of adverse cardiac and pulmonary embolic events. As the popularity of bariatric surgery grows, surgeons are encountering more patients taking therapeutic anticoagulation medications preoperatively. This study aims to assess the safety of bariatric surgery on these patients.

METHODS

Data was extracted from 2015 to 2017 using the MBSAQIP database. Included patients were those who underwent a primary LSG or LRYGB. A multivariable regression analysis was performed looking at 30-day outcomes for pre-operatively anticoagulated patients. A secondary propensity-matched analysis was performed comparing outcomes among patients undergoing LSG vs LRYGB.

RESULTS

A total of 430,396 patients were analyzed, 11,013 (2.56%) of which were taking anticoagulation medications pre-operatively. Absolute 30-day complication rates (8.73% vs 3.36%, p < 0.001), bleed rates (3.78% vs 0.88%, p < 0.001), leak rates (0.55% vs 0.41%, p = 0.021), cardiac event rates (0.43% vs 0.06%, p < 0.001), and venous thromboembolism rates (0.68% vs 0.25%, p < 0.001) were significantly higher among pre-operatively anticoagulated patients. On multivariable analysis, pre-operative anticoagulation was found to be an independent predictor of postoperative bleeding (OR 2.76, CI 2.43-3.14, p < 0.001) and mortality (OR 2.08, CI 1.49-2.90, p < 0.001). The LRYGB was associated with a significantly higher complication rate compared to the LSG (13.27% vs 7.40%, p < 0.001) in the propensity-matched cohorts.

CONCLUSIONS

Patients undergoing bariatric surgery on anticoagulation medications pre-operatively are at a significantly higher risk of adverse outcomes post-operatively. Patients who require long-term anticoagulation should undergo careful consideration before proceeding with bariatric surgery.

Sleeve Gastrectomy: You Might Lose your Liver!

Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.