SAGES VTE prophylaxis for laparoscopic surgery guidelines: an update

Portomesenteric Venous Thrombosis after Bariatric Surgery: A Case Series and Systematic Review Comparing LSG and LRYGB

(1) Background: Portomesenteric Venous Thrombosis (PMVT) is a rare but serious complication of Metabolic Bariatric Surgery (MBS). Although more frequently reported after laparoscopic sleeve gastrectomy (LSG), the risk factors for PMVT remain unclear. This study aims to compare the incidence and determinants of PMVT between LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB). (2) Methods: A retrospective analysis of 5235 MBSs conducted at our institution between 2015 and 2023 identified five cases of PMVT. Additionally, a systematic review in March 2023, covering PubMed, Web of Science and Scopus, was performed. Several data were analyzed regarding risk factors. (3) Results: In our case series, the incidence of PMVT was 0.1%. The five cases described involved four females with a BMI between 39.7 and 56.0 kg/m2. Their comorbidities were associated with metabolic syndrome, all women used oral contraceptive and two patients were diagnosed with thrombophilia or pulmonary embolism. Per protocol, thromboprophylaxis was administered to all patients. Diagnosis was made at a median of 16 days post-surgery, with abdominal pain being the main presenting symptom. Acute cases were managed with enoxaparin, unfractionated heparin and fibrinolysis. One patient required surgery. Ten studies were included in the systematic review and 205 patients with PMVT were identified: 193 (94.1%) post-LSG and 12 post-LRYGB. The most common comorbidities were dyslipidemia, hypertension, diabetes, sleep apnea and liver disorders; (4) Conclusions: PMVT is a potentially life-threatening complication after MBS, requiring preventive measures, timely diagnosis and several treatments. Our findings suggest a higher occurrence in women with an elevated BMI and post-LSG. Tailored thromboprophylaxis for MBS patients at risk of PMVT may be warranted.

Outcomes of bariatric surgery in the setting of compensated advanced chronic liver disease associated with clinically significant portal hypertension: a multicenter, retrospective, cohort study on feasibility and safety

BACKGROUND

The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery (MBS) has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of MBS in patients with compensated advanced chronic liver disease (cALCD) and clinically significant portal hypertension (CSPH).

MATERIAL AND METHODS

This is an international, multicentric, retrospective study on 63 individuals affected by obesity with cALCD and CSPH who underwent MBS in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was postoperative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, the authors performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score, and type of surgery.

RESULTS

One patient (1.6%) experienced gastric leakage and mortality. There were three (5%) reported cases of portal vein thrombosis, two (3%) postoperative acute renal failure, and one (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis (OR: 0.73, 95% CI: 0.55-0.97, P =0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication.

CONCLUSION

MBS is safe in patients with cALCD and CSPH performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Intermittent pneumatic compression versus additional prophylaxis with enoxaparin for prevention of venous thromboembolism after laparoscopic surgery for gastric and colorectal malignancies: multicentre randomized clinical trial

Background

The role of antithrombotic chemoprophylaxis in prevention of venous thromboembolism (VTE) in laparoscopic surgery for gastric and colorectal malignancies is unknown. This study compared the addition of enoxaparin following intermittent pneumatic compression (IPC) with IPC alone in patients undergoing laparoscopic surgery for gastrointestinal malignancy.

Methods

In this multicentre RCT, eligible patients were older than 40 years and had a WHO performance status of 0 or 1. Exclusion criteria were prescription of antiplatelet or anticoagulant drugs and history of VTE. Patients were allocated to IPC or to ICP with enoxaparin in a 1 : 1 ratio. Stratification factors included sex, location of cancer, age 61 years and over, and institution. Enoxaparin was administered on days 1–7 after surgery. Primary outcome was VTE, evaluated by multidetector CT on day 7.

Results

Of 448 patients randomized, 208 in the IPC group and 182 in the IPC with enoxaparin group were evaluated. VTE occurred in ten patients (4·8 per cent) in the IPC group and six (3·3 per cent) in the IPC with enoxaparin group (P = 0·453). Proximal deep vein thrombosis and/or pulmonary embolism occurred in seven patients (3·4 per cent) in the IPC group and one patient (0·5 per cent) in the IPC with enoxaparin group (P = 0·050). All VTE events were asymptomatic and non‐fatal. Bleeding occurred in 11 of 202 patients in the IPC with enoxaparin group, and one patient needed a transfusion. All bleeding events were managed by discontinuation of the drug.

Conclusion

IPC with enoxaparin after laparoscopic surgery for gastric and colorectal malignancies did not reduce the rate of VTE. Registration number: UMIN000011667 ( https://www.umin.ac.jp/).

Laparoscopic Paraesophageal Hernia Repair and Pulmonary Embolism

OBJECTIVE

Pulmonary embolism (PE) following laparoscopic paraesophageal hernia repair (PEHR) is rare but occurs at a higher frequency than other laparoscopic procedures. We describe a series of patients who developed PEs after PEHR in hopes of capturing potential risk factors for further study.

MATERIALS AND METHODS

Five cases of PE after PEHR were observed between 2017 and 2018. Individual and perioperative risk factors, and postoperative courses were reviewed.

RESULTS

Patients had a mean age of 73 years (range, 59 to 86). All were female. Two patients presented acutely. Three patients underwent revisional surgery. The average procedure duration was 248 minutes (range, 162 to 324). All patients had gastrostomy tubes placed. The diagnosis of PE occurred within 3 to 19 days postoperatively. Four were treated with 3 months of oral anticoagulation; 1 was managed expectantly.

CONCLUSIONS

Highly complex cases, marked by revisional status, need for mesh, large hernia size, and percutaneous endoscopic gastrostomy placement are likely at increased risk for PEs. Preoperative venous thromboembolism chemoprophylaxis should be considered in the majority of laparoscopic PEHR patients.

Who gets a PEG? An analysis of simultaneous PEG placement during elective laparoscopic paraesophageal hernia repair

INTRODUCTION

Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG "may facilitate postoperative care in selected patients." Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes.

METHODS

The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class.

RESULTS

15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45, p = 0.0110), pre-operative weight loss (OR 2.87, p = 0.0001), and lower pre-operative albumin (3.92 vs. 4.01, p = 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38, p < 0.0001) and longer case durations (170 vs. 148 min, p < 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days, p = 0.0001), rates of superficial SSI (OR 5.82, p = 0.0012), peri-operative transfusions (OR 2.68, p = 0.0197), and pulmonary emboli (OR 3.61, p = 0.0359).

CONCLUSION

Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.

Venous thromboembolism in colorectal surgery: Incidence, risk factors, and prophylaxis

Colorectal surgery is associated with a high risk of perioperative venous thromboembolism (VTE), and this risk is especially high following colorectal cancer resection and surgery for inflammatory bowel disease. Previous analyses of large databases have reported the incidence of postoperative VTE in this population to be approximately 1.1%-2.5%. Therefore, to minimize this risk, patients should be offered appropriate prophylaxis, which may involve a combination of mechanical and pharmacologic prophylaxis with low-dose unfractionated heparin or low molecular weight heparin as recommended by several guidelines. Prior to initiation of treatment, appropriate risk stratification should be performed according to the patients' basic and disease-related as well as procedure-related risk factors, and post-operative factors. Furthermore, a risk-benefit calculation that takes into account patients' VTE and bleeding risk should be performed prior to starting pharmacologic prophylaxis and to help determine the duration of treatment.

A New Protocol for Venous Thromboembolism Prophylaxis in Bariatric Surgery

BACKGROUND

Morbidly obese patients are at high risk for developing venous thromboembolism (VTE). The aim of this study was to evaluate the effect of a new VTE prophylaxis protocol (low dosage, low-molecular-weight heparin [LMWH]) with a pneumatic compression device (PCD) in patients undergoing bariatric surgery.

MATERIALS AND METHODS

Between November 2015 and December 2017, 368 patients underwent surgery due to obesity. The patients received 0.2 ml of nadroparin (Fraxiparine, GlaxoSmithKline) 12 h before the operation. A PCD (Kendall SCD Compression System) was applied to the patient during the operation and left on the patient during the subsequent 24 h. Nadroparin 0.4 ml was started subcutaneously after the PCD was removed from the patient and the same dosage of nadroparin was given daily for 15 days following the bariatric operation. Ambulation within 2 h of surgery was encouraged and was performed frequently.

RESULTS

A total of 368 patients underwent laparoscopic bariatric surgery. The median age was 34.1 years (range, 18-61), the median weight was 128 kg (range, 90-182), and the median body mass index (BMI) was 47.2 kg/m² (range, 36-72). No thrombotic events were observed postoperatively or at the 1-, 3-, and 6-month follow-up visits. Four bleedings occurred requiring transfusions. None of these patients required a re-laparotomy for hemorrhage control. The mortality rate was 0% at 30 and 90 days and during the hospitalization.

CONCLUSION

Low dosage LMWH with PCD is very effective for VTE prophylaxis in bariatric surgery.

Acute Biliary Disease

Acute biliary disease is a ubiquitous acute surgical complaint. General surgeons managing emergency surgical patients must be knowledgeable and capable of identifying and caring for common presentations. This article discusses the work-up, diagnosis, and management of the varying pathologies that make up biliary disease including cholelithiasis, cholecystitis, biliary dyskinesia, choledocholithiasis, cholangitis, gallstone pancreatitis, and gallstone ileus. Also addressed are more challenging and rare presentations including pregnancy and bariatric anatomy.