Thrombosis prophylaxis in bariatric surgery

Summary

Patients undergoing bariatric surgery represent a high risk group for venous thromboembolism. We discuss AWMF (Germany), NICE (UK), and ACCP (USA) guidelines, and we give a representative review of the literature. Early ambulation and mechanical prophylaxis are basic procedures that should be offered to all patients. Usually, pharmacologic prophylaxis is also mandatory. Drug of choice is low molecular heparin. For prophylaxis, we recommend a quarter of the weight-adapted therapeutic dose once daily subcutaneously without weight cut-off. Prophylaxis should be started the day before surgery. As an alternative, fondaparinux can be used in a fixed dose of 2,5 mg once daily. To date, there is no indication for new oral anticoagulants in bariatric surgery. Bleeding risk and risk of thromboembolism must be taken into account individually.

English version available at:www.phlebologieonline.de

Keywords

Thrombosis prophylaxis - venous thromboembolism - bariatric surgery - general surgery - low molecular weight heparin

• Literatur

• 1 AWMF-Leitlinie Prophylaxe der venösen Thromboembolie (VTE) http://www.awmf.org/leitlinien/detail/ll/003-001
• 2 N. N. Proceedings of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: evidence-based guidelines. Chest.. 2004; 126 (Suppl. 03) 172S-696S.
• 3 Mismetti P. et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.. The British journal of surgery 2001; 88 (07) 913-930.
• 4 Cohen AT, Wagner MB, Mohamed MS. Risk factors for bleeding in major abdominal surgery using heparin thromboprophylaxis.. American journal of surgery 1997; 174 (01) 1-5.
• 5 Chan MM, Hamza N, Ammori BJ. Duration of surgery independently influences risk of venous thromboembolism after laparoscopic bariatric surgery.. Surg Obes Relat Dis 2011; 9 (01) 88-93.
• 6 Venous thromboembolism: reducing the risk Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital (http://guidance.nice.org.uk/CG92/NICEGuidance/pdf/English)
• 7 Gould MK. et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.. Chest 2012; 141 (Suppl. 02) e227S-277S.
• 8 MacLean S. et al. Patient values and preferences in decision making for antithrombotic therapy: a systematic review: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.. Chest 2012; 141 (Suppl. 02) e1S-23S.
• 9 Raftopoulos I, Martindale C, Cronin A, Steinberg J. The effect of extended post-discharge chemical thromboprophylaxis on venous thromboembolism rates after bariatric surgery: a prospective comparison trial.. Surgical endoscopy 2008; 22 (11) 2384-2391.
• 10 Gonzalez QH. et al. Incidence of clinically evident deep venous thrombosis after laparoscopic Roux-en-Y gastric bypass.. Surgical endoscopy 2004; 18 (07) 1082-1084.
• 11 Kakkos SK. et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients.. Cochrane database of systematic reviews (Online) 2008; (04) CD005258
• 12 Kishimoto TK. et al. Contaminated heparin associated with adverse clinical events and activation of the contact system.. The New England journal of medicine 2008; 358 (23) 2457-2467.
• 13 Carmody BJ, Sugerman HJ, Kellum JM, Jamal MK, Johnson JM, Carbonell AM, Maher JW, Wolfe LG, DeMaria EJ. Pulmonary embolism complicating bariatric surgery: detailed analysis of a single institution’s 24-year experience.. Journal of the American College of Surgeons 2006; 203 (06) 831-837.
• 14 Cotter SA, Cantrell W, Fisher B, Shopnick R. Efficacy of venous thromboembolism prophylaxis in morbidly obese patients undergoing gastric bypass surgery.. Obesity surgery 2005; 15 (09) 1316-1320.
• 15 Miller MT, Rovito PF. An approach to venous thromboembolism prophylaxis in laparoscopic Roux-en-Y gastric bypass surgery.. Obesity surgery 2004; 14 (06) 731-737.
• 16 Prystowsky JB. et al. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients.. Surgery 2005; 138 (04) 759-763. discussion 763-755
• 17 Quebbemann B, Akhondzadeh M, Dallal R. Continuous intravenous heparin infusion prevents peri-operative thromboembolic events in bariatric surgery patients.. Obesity surgery 2005; 15 (09) 1221-1224.
• 18 Shepherd MF, Rosborough TK, Schwartz ML. Heparin thromboprophylaxis in gastric bypass surgery.. Obesity surgery 2003; 13 (02) 249-253.
• 19 Kothari SN, Lambert PJ, Mathiason MA. Best Poster Award. A comparison of thromboembolic and bleeding events following laparoscopic gastric bypass in patients treated with prophylactic regimens of unfractionated heparin or enoxaparin.. AJ Surgery 2007; 194 (06) 709-711.
• 20 Birkmeyer NJ. et al. Comparative effectiveness of unfractionated and low-molecular-weight heparin for prevention of venous thromboembolism following bariatric surgery.. Arch Surg 2012; 147 (11) 994-998.
• 21 Erstad BL. Dosing of medications in morbidly obese patients in the intensive care unit setting.. Intensive Care Medicine 2004; 30 (01) 18-32.
• 22 Green B, Duffull SB. Development of a dosing strategy for enoxaparin in obese patients.. British Journal of Clin Pharmacol 2003; 56 (01) 96-103.
• 23 Becker RC. et al. Influence of patient characteristics and renal function on factor Xa inhibition pharmacokinetics and pharmacodynamics after enoxaparin administration in non-ST-segment elevation acute coronary syndromes.. American Heart Journal 2002; 143 (05) 753-759.
• 24 Hainer JW. et al. Dosing in heavy-weight/obese patients with the LMWH, tinzaparin: a pharmacodynamic study.. Thromb Haemo 2002; 87 (05) 817-823.
• 25 Roman MJ. et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. NEJM 2003; 349 (25) 2399-2406.
• 26 Wilson SJ, Wilbur K, Burton E, Anderson DR. Effect of patient weight on the anticoagulant response to adjusted therapeutic dosage of low-molecular-weight heparin for the treatment of venous thromboembolism.. Haemostasis 2001; 31 (01) 42-48.
• 27 Al-Yaseen E, Wells PS, Anderson J, Martin J, Kovacs MJ. The safety of dosing dalteparin based on actual body weight for the treatment of acute venous thromboembolism in obese patients. J Thromb Haemost 2005; 3 (01) 100-102.
• 28 de Denus S. et al. Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis.. Arch Int Med 2005; 165 (03) 258-262.
• 29 Frederiksen SG, Hedenbro JL, Norgren L. Enoxaparin effect depends on body-weight and current doses may be inadequate in obese patients.. The British Journal of Surgery 2003; 90 (05) 547-548.
• 30 Heizmann M. et al. Anti-Xa activity in obese patients after double standard dose of nadroparin for prophylaxis.. Thrombosis Research 2002; 106 4-5 179-181.
• 31 Riess H. et al. Fixed-dose, body weight-independent subcutaneous low molecular weight heparin Certoparin compared with adjusted-dose intravenous unfractionated heparin in patients with proximal deep venous thrombosis.. Thrombosis and Haemostasis 2003; 90 (02) 252-259.
• 32 Riess H. et al. A randomized, double-blind study of certoparin vs. unfractionated heparin to prevent venous thromboembolic events in acutely ill, non-surgical patients: CERTIFY Study.. J Thromb Haemost 2010; 8 (06) 1209-1215.
• 33 Simone EP. et al. Comparison of two low-molecular-weight heparin dosing regimens for patients undergoing laparoscopic bariatric surgery.. Surgical endoscopy 2008; 22 (11) 2392-2395.
• 34 Rowan BO. et al. Anti-Xa levels in bariatric surgery patients receiving prophylactic enoxaparin.. Obesity surgery 2008; 18 (02) 162-166.
• 35 Imberti D. et al. Pharmacodynamics of low molecular weight heparin in patients undergoing bariatric surgery: a prospective, randomised study comparing two doses of parnaparin (BAFLUX study).. Thrombosis Research 2009; 124 (06) 667-671.
• 36 Kalfarentzos F. et al. Prophylaxis of venous thromboembolism using two different doses of low-molecular-weight heparin (nadroparin) in bariatric surgery: a prospective randomized trial.. Obesity surgery 2001; 11 (06) 670-676.
• 37 Scholten DJ, Hoedema RM, Scholten SE. A comparison of two different prophylactic dose regimens of low molecular weight heparin in bariatric surgery.. Obesity surgery 2002; 12 (01) 19-24.
• 38 Chow SL. et al. Correlation of antifactor Xa concentrations with renal function in patients on enoxaparin.. Journal of Clinical Pharmacology 2003; 43 (06) 586-590.
• 39 Sanderink GJ. et al. Pharmacokinetics and pharmacodynamics of the prophylactic dose of enoxaparin once daily over 4 days in patients with renal impairment.. Thrombosis Research 2002; 105 (03) 225-231.
• 40 Siguret V. et al. Elderly patients treated with tinzaparin (Innohep) administered once daily (175 anti-Xa IU/kg): anti-Xa and anti-IIa activities over 10 days.. Thromb Haemo 2000; 84 (05) 800-804.
• 41 Mahe I. et al. Tinzaparin and enoxaparin given at prophylactic dose for eight days in medical elderly patients with impaired renal function: a comparative pharmacokinetic study.. Thromb Haemo 2007; 97 (04) 581-586.
• 42 Sanderink GJ. et al. The pharmacokinetics and pharmacodynamics of enoxaparin in obese volunteers.. Clinical pharmacology and therapeutics 2002; 72 (03) 308-318.
• 43 Rabbat CG. et al. Dalteparin thromboprophylaxis for critically ill medical-surgical patients with renal insufficiency.. J Critical Care 2005; 20 (04) 357-363.
• 44 Davidson BL. et al. Effect of obesity on outcomes after fondaparinux, enoxaparin, or heparin treatment for acute venous thromboembolism in the Matisse trials.. J Thromb Haemost 2007; 5 (06) 1191-1194.
• 45 Schindewolf M. et al. Application, tolerance and safety of fondaparinux therapy in a German hospital: a prospective single-centre experience.. Thromb Research 2011; 129 (01) 17-21.
• 46 Decousus H. et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group.. NEJM 1998; 338 (07) 409-415.