Alexander W Nielsen1, Melissa C Helm1, Tammy Kindel1, Rana Higgins1, Kathleen Lak1, Zachary M Helmen1, Jon C Gould2. 1. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA. 2. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA. jgould@mcw.edu.
Abstract
BACKGROUND: Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion. RESULTS: The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9-7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05). CONCLUSIONS: Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.
BACKGROUND: Morbidly obesepatients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion. RESULTS: The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9-7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05). CONCLUSIONS: Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.
Authors: Elizabeth R Berger; Kristopher M Huffman; Teresa Fraker; Anthony T Petrick; Stacy A Brethauer; Bruce L Hall; Clifford Y Ko; John M Morton Journal: Ann Surg Date: 2018-01 Impact factor: 12.969
Authors: Christopher C Silliman; Ernest E Moore; Jeffrey L Johnson; Ricardo J Gonzalez; Walter L Biffl Journal: Shock Date: 2004-04 Impact factor: 3.454
Authors: Jonathan F Finks; Wayne J English; Arthur M Carlin; Kevin R Krause; David A Share; Mousumi Banerjee; John D Birkmeyer; Nancy J Birkmeyer Journal: Ann Surg Date: 2012-06 Impact factor: 12.969
Authors: Michal R Janik; Maciej Walędziak; Jakub Brągoszewski; Andrzej Kwiatkowski; Krzysztof Paśnik Journal: Obes Surg Date: 2017-04 Impact factor: 4.129
Authors: Alenka Premuš Marušič Kovačič; Martin Caprnda; Aleš Mrhar; Peter Kubatka; Igor Locatelli; Barbora Zolakova; Ludovit Gaspar; Robert Prosecky; Peter Kruzliak; Robert Staffa; Luis Rodrigo; Jozef Radonak; Danijel Petrovič Journal: Eur J Clin Pharmacol Date: 2019-02-05 Impact factor: 2.953
Authors: Feichen Shen; David W Larson; James M Naessens; Elizabeth B Habermann; Hongfang Liu; Sunghwan Sohn Journal: J Healthc Inform Res Date: 2018-11-06
Authors: Antonio Buondonno; Pasquale Avella; Micaela Cappuccio; Andrea Scacchi; Roberto Vaschetti; Giancarlo Di Marzo; Pietro Maida; Claudio Luciani; Bruno Amato; Maria Chiara Brunese; Daniela Esposito; Lucio Selvaggi; Germano Guerra; Aldo Rocca Journal: Front Surg Date: 2022-03-24
Authors: Rabi R Datta; Sebastian Schönhage; Thomas Dratsch; Justus Toader; Dolores T Müller; Roger Wahba; Robert Kleinert; Michael Thomas; Georg Dieplinger; Dirk L Stippel; Christiane J Bruns; Hans F Fuchs Journal: Surg Endosc Date: 2020-09-23 Impact factor: 4.584