Extended Thromboprophylaxis with Enoxaparin After Bariatric Surgery

Study Objective

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a known cause of increased morbidity and mortality in patients after bariatric surgery. However, the optimal thromboprophylaxis strategy for this procedure is still unknown. The aim of this study was to assess the efficacy and safety of extended thromboprophylaxis in operated individuals.  

Methods and Course

This was a retrospective study in patients who underwent bariatric surgery between November 2014 and October 2018. Adults with a BMI ≥ 30 kg/m² who had undergone sleeve gastrectomy, gastric bypass, or stomach plication were included. Individuals on full-dose anticoagulant therapy were excluded. All patients received extended thromboprophylaxis. The primary endpoint was the incidence of symptomatic VTE, including pulmonary embolism, deep vein thrombosis, and splanchnic vein thrombosis, within 3 months after surgery. VTE was objectively verified using imaging methods.

Evaluated Population and Treatment

A total of 374 patients underwent surgery during the study period, with results from at least 3 months of follow-up available for 312 of them. The average age of the patients was 36 years, most were younger than 50 years, and 73% were women. The median body weight was 110 kg, 67% of the patients had a BMI ≥ 40, and 3% had a BMI ≥ 60 kg/m². Comorbidities included hypertension in 16% of patients, diabetes in 14%, and 1 patient had a history of VTE. The majority (95%) underwent sleeve gastrectomy, 4% had a gastric bypass, and 1% had stomach plication.

Postoperatively, 91% of patients used enoxaparin 40 mg subcutaneously twice daily for 10-14 days, 8% used enoxaparin 40 mg once daily, and 3 patients used unfractionated heparin (UFH) 5000 IU twice daily. All patients were mobilized on the first day after surgery. Mechanical thromboprophylaxis or antiplatelets were not used. 

Results

The cumulative incidence of VTE within 3 months was 0.64% (95% confidence interval [CI] 0.20–1.52). These were 2 cases that occurred after hospital discharge, on the 21st day after surgery in a 35-year-old woman with a BMI of 60 kg/m² without comorbidities treated with enoxaparin twice daily, and on the 70th day after surgery in a 50-year-old woman with diabetes and hypertension treated with enoxaparin twice daily. Both underwent sleeve gastrectomy and had deep thrombosis of the proximal veins of the left lower limb.

No deaths due to VTE occurred in the study. There were also no reported cases of bleeding.

Conclusion

VTE is a preventable postoperative complication. According to this retrospective study, extended thromboprophylaxis with enoxaparin for 10-14 days appears to be an effective and safe prevention of VTE after bariatric surgery. Further prospective studies are needed to determine the optimal regimen.

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Source: Almarshad F. M., Almegren M., Alshuaibi T. et al. Thromboprophylaxis after bariatric surgery. Blood Res 2020 Mar; 55 (1): 44–48, doi: 10.5045/br.2020.55.1.44.