Carlos A. Barba

Current Practices in the Prophylaxis of Venous Thromboembolism in Bariatric Surgery

Background: Morbidly obese patients undergoing bariatric surgery have commonly been concluded to be at high risk for the development of perioperative venous thromboembolism. Due to its clinically silent nature, primary prevention is the key to reduce morbidity and mortality. There is no clear consensus in the literature regarding the optimum approach to minimize this preventable phenomenon. Methods: Members of the American Society for Bariatric Surgery were surveyed regarding their current practices in the prophylaxis of venous thromboembolism in their bariatric patients. Results: 31% of the members completed the survey. 62% were in private practice, and 38% practiced in an academic hospital. The number of bariatric surgeries done per year ranged from 5 to 325, with a mean of 85 procedures per member. The gastric bypass was the most commonly performed procedure at 61.7%, followed by vertical banded gastroplasty at 23.3%, biliary pancreatic diversion at 9.3%, laparoscopic gastroplasty at 4.0%, laparoscopic gastric bypass at 1.6%, and horizontal banded gastroplasty at 0.1%. 86% felt that their bariatric patients were at high risk for developing deep vein thrombosis (DVT) and pulmonary embolism (PE) with a self-reported incidence of 2.63% and 0.95%, respectively. 48% had at least one death due to PE. Routine prophylaxis is used by over 95% of members. 62% ranked the various methods of prophylaxis from most preferred to least preferred, while 38% used a combination of 2 or more prophylactic methods simultaneously. Low-dose heparin was the most preferred prophylaxis by 50% of members, followed by intermittent pneumatic compression stockings at 33%, low molecular weight heparins at 13%, and other methods at 4%. Over 83% indicated that safety with few complications, ease of administration, and effectiveness were the most important criteria for selecting their most preferred prophylactic method. Only 2% routinely performed testing to rule out venous thromboembolism before discharge, and 11% routinely discharged patients with prophylaxis. Conclusions: The prevailing opinion of members of the American Society for Bariatric Surgery is that morbidly obese patients are at high risk for developing perioperative venous thromboembolism. A vast majority routinely use prophylaxis. Despite these measures, fatal PE is still widespread. A lack of consensus in the method of prophylaxis was seen. A multicentric randomized controlled study comparing the efficacy of the various methods of prophylaxis will be the only manner to determine the best prophylaxis and its usefulness. This study will be costly and probably not warranted due to the low incidence of this condition in the morbidly obese patient.

Screening endoscopy before bariatric surgery: a series of 448 patients

BACKGROUND The role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients before bariatric surgery is controversial. The purpose of this study was to determine the diagnostic yield of routine EGD before bariatric surgery. METHODS A consecutive series of 448 morbidly obese patients, who were otherwise cleared for bariatric surgery, underwent routine EGD. The endoscopic findings were classified by the clinical significance. The findings were tabulated and analyzed. RESULTS A total of 447 patients (389 women and 58 men) underwent EGD successfully. Of the 447 patients, 85% had a body mass index of 40-59.9 kg/m(2), and 93% had significant co-morbidities. Abnormal findings that did not change the surgical approach or postpone surgery were found in 60 patients (13%), including hiatal hernia and benign polyps. Abnormal findings that changed the medical management before surgery were found in 81 patients (18%), including inflammation and/or ulcers. This group included 9 of 61 patients with gastritis who were treated for Helicobacter pylori found within the biopsy specimen. Findings that changed the surgical approach were found in 1 patient, and findings of severe ulcerations that postponed surgery were found in another patient. Of the 447 patients, 389 actually underwent bariatric surgery, including Roux-en-Y gastric bypass in 57% and adjustable gastric banding in 43%. During follow-up, 37 gastric bypass patients (13%) developed ulceration. Both gastritis and duodenitis, but not the presence of H. pylori, was statistically related to ulcer formation (Fishers exact test). CONCLUSION In this consecutive series of 451 successful screening EGDs, positive findings led to a change in medical treatment in a significant number of patients (18%), but a change in the timing of surgery or the surgical technique in relatively few (<1%). In addition, a significant correlation between gastritis and postoperative anastamotic ulceration suggests a causative link, with implications arguing for stronger medical therapy. A randomized trial should be performed to validate the usefulness of preoperative EGD in bariatric patients.