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Abi Mosleh K, Belluzzi A, Salame M, Kendrick ML, Abu Dayyeh BK, McKenzie TJ, Ghanem OM. Long-Term Outcomes of Bariatric Surgery in Patients on Chronic Anticoagulation. Obes Surg 2023; 33:4007-4016. [PMID: 37917392 DOI: 10.1007/s11695-023-06910-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Approximately 3% of patients undergoing metabolic and bariatric surgery (MBS) are receiving chronic anticoagulation therapy (CAT) prior to operation. The management of these patients is complex, as it involves balancing the potential risk of thrombosis against that of bleeding. Our primary objective is to assess the long-term bleeding risk in patients undergoing MBS. We also aim to observe the trends in anticoagulant dosing after MBS. METHODS A single-center retrospective review of patients who underwent either primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with preoperative CAT between 2008 and 2022 was performed. Data on baseline demographics, indication for anticoagulation, type of CAT, and dosing were collected. Events of bleeding and the CAT at event were subsequently evaluated. RESULTS A total of 132 patients (82 RYGB and 50 SG) initially on CAT were identified, with atrial fibrillation being the most common indication. Incidence of long-term bleeding was significantly higher in the RYGB group (18.3%) compared to the SG group (4%) (p = 0.017) over a total of 5.2 ± 3.8 years. Bleeding marginal ulcer (MU) was the most common cause of bleeding in the RYGB group (13.4%). 84.2% of all bleeding events occurred in patients on chronic Warfarin therapy. CONCLUSION Long-term CAT is associated with an increased risk of bleeding in RYGB patients, particularly MU bleeds. Patients on CAT seeking MBS should be counseled regarding this risk and potential implications. Direct-acting oral anticoagulants offer promise as an alternative to Warfarin in these patients; further research is necessary to better understand their safety.
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Affiliation(s)
- Kamal Abi Mosleh
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amanda Belluzzi
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Marita Salame
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Balkanay OO, Bulut HI, Albrahimi E, Mirizade M, Yenigün AO, Tomey D, Bistre J, Oviedo RJ, Tel Ustunisik C, Arapi B, Goksedef D, Omeroglu SN, Ipek G. Optimizing aortic valve prosthesis selection in patients with obesity: Institutional experience with multidisciplinary perspective. Asian Cardiovasc Thorac Ann 2023; 31:667-674. [PMID: 37609760 DOI: 10.1177/02184923231197022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND Aortic valve diseases are life-threatening conditions with increasing prevalence worldwide. Risk factors include gender, age, hypertension, dyslipidemia, and type 2 diabetes. Obesity is closely related to these risk factors and has been linked to a higher risk of developing aortic valve diseases. However, there is no specific guideline for managing aortic valve disease in patients with obesity, and the choice of valve type remains uncertain. METHODS A total of 130 patients with obesity who met the inclusion criteria underwent surgical aortic valve replacement. The patients were divided into two groups based on the type of prosthesis used. Among the study cohort, 50 patients received a bioprosthetic valve, while 80 patients received a mechanical valve. We compared these groups in terms of perioperative characteristics and follow-up results. Statistical significance was determined using a p-value threshold of 0.05. RESULTS There were no significant differences in age, gender, body mass index, or cardiac comorbidities between the two groups. Preoperative blood results and echo findings also showed no significant differences. Intraoperative characteristics and postoperative outcomes, including mortality and acute kidney injury, did not differ significantly between the groups. In addition, BHVG patients had shorter ICU stays compared to MHVG patients without significance. CONCLUSION Deliberate consideration is crucial when selecting valves for obese patients, particularly those with class II obesity. This is due to the potential influence of obesity on valve types, as well as the need to account for the possibility of bariatric surgery and its potential effects.
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Affiliation(s)
- Ozan Onur Balkanay
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Halil Ibrahim Bulut
- Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ergida Albrahimi
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Miri Mirizade
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Abdulgani Orhun Yenigün
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Daniel Tomey
- Department of General Surgery, Houston Methodist Hospital, Houston, TX, USA
- Houston Methodist, Institute for Technology, Innovation & Education, Houston, TX, USA
| | | | - Rodolfo J Oviedo
- Dorrington Medical Associates, Houston, TX, USA
- Weill Cornell Medical College, General Surgery, New York, NY, USA
- Texas A&M University College of Medicine, General Surgery, Bryan, TX, USA
| | - Cigdem Tel Ustunisik
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Berk Arapi
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Deniz Goksedef
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Suat Nail Omeroglu
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gokhan Ipek
- Department of Cardiovascular Surgery Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Sebastian R, Ghanem OM, Cornejo J, Ruttger T, Perales-Villarroel JP, Adrales G, Li C. Is staple line oversewing in patients on chronic anticoagulation during laparoscopic sleeve gastrectomy necessary? Propensity score matching analysis using the 2015-2018 MBSAQIP. Surg Endosc 2022; 36:8481-8489. [PMID: 35226162 DOI: 10.1007/s00464-022-09146-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/15/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND There is an increased incidence of post-operative bleeding in patients on chronic anticoagulation (CAC). This incited some surgeons to oversew the sleeve staple line as a potentially preventive measure for post-operative bleeding. However, there is no clear evidence to assess the effectiveness of staple line oversewing during laparoscopic sleeve gastrectomy (LSG) in patients with CAC. METHODS Using the 2015-2018 metabolic and bariatric surgery accreditation and quality improvement program database, patients between ages 18 and 65 who underwent LSG were included. To investigate the role of CAC, we performed 1:1 propensity score matching (PSM) between the CAC and non-CAC patients. Then, to explore the impact of oversewing, we focused on the CAC patients and divided them into 2 subgroups: oversewing versus non-oversewing. PSM was also performed to compare both subgroups. To avoid confounders, both PSM analyses were performed using 22 preoperative characteristics. 30-day postoperative outcomes including bleeding and blood transfusion requirement were assessed. RESULTS 402,826 patients underwent LSG. 9148 patients (2.3%) were on CAC. In the CAC cohort (8843 matched cases), the anticoagulated patients showed significant increase in postoperative bleeding (1.2% vs. 0.5%; P < 0.001), blood transfusion requirements (1.7% vs. 0.7%; P < 0.001), unplanned ICU admissions (2.0% vs. 1.3%; P = 0.001), interventions (2.0% vs. 1.5%; P = 0.015), and readmissions (6.2% vs. 4.7%; P < 0.001). 1939 (21.2%) patients on CAC underwent oversewing during the LSG. The operative time was significantly longer in these patients (87.11 ± 40 vs. 76.19 ± 37; P < 0.001). Patients who underwent oversewing showed similar results in 30-day outcomes as those who did not, with no statistical difference, including postoperative bleeding (1.0% vs. 0.9%; P = 0.8) and blood transfusion requirements (1.4% vs. 1.8%; P = 0.9). CONCLUSION Incidences of post-operative bleeding and blood transfusion requirements are higher in patients on CAC during the LSG. Oversewing the sleeve staple line leads to longer operative times without additional benefit in 30-day outcomes.
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Affiliation(s)
- Raul Sebastian
- Department of Surgery, Northwest Hospital, 5401 Old Court Road, Randallstown, MD, 21133, USA.
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jorge Cornejo
- Department of Surgery, Northwest Hospital, 5401 Old Court Road, Randallstown, MD, 21133, USA
| | - Thomas Ruttger
- Department of Surgery, Northwest Hospital, 5401 Old Court Road, Randallstown, MD, 21133, USA
| | | | - Gina Adrales
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Christina Li
- Department of Surgery, Northwest Hospital, 5401 Old Court Road, Randallstown, MD, 21133, USA
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Anti-Xa Levels in Morbidly Obese Patients Using Apixaban or Rivaroxaban, Before and After Bariatric Surgery. Obes Surg 2021; 32:607-614. [PMID: 34822108 DOI: 10.1007/s11695-021-05814-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite limited evidence about the efficacy and safety of anticoagulation in patients post bariatric surgery, both vitamin K antagonists (VKA) and direct-acting oral anticoagulants (DOACs) are commonly prescribed. AIM To evaluate plasma anti-Xa levels of DOACs in morbidly obese (MO) patients before and after a Roux-en-Y gastric bypass (RYGB) procedure. PATIENTS AND METHODS Retrospective, cross-sectional, and longitudinal study of anti-Xa activity of apixaban or rivaroxaban in MO patients (N = 41). RESULTS Preoperative analysis of plasma anti-Xa levels were within the normal range in patients using apixaban (n = 29; body mass index [BMI] 44.5 ± 5.1 kg/m2) as well as those using rivaroxaban (n = 12; BMI 42.6 ± 5.9 kg/m2). Postoperative anti-Xa levels of apixaban were all within the therapeutic range, whereas anti-Xa levels of rivaroxaban were subtherapeutic in nine out of 14 (64%) patients. Perioperative longitudinal follow-up in patients using apixaban (n = 18) showed no significant change in anti-Xa levels after RYGB. CONCLUSION Plasma anti-Xa levels of apixaban in MO patients remained within the therapeutic range up to a body weight of 144 kg. In patients using rivaroxaban, no statistically significant relation between anti-Xa levels and bodyweight was found. After RYGB, plasma anti-Xa levels of apixaban were unaffected, whereas plasma anti-Xa levels of rivaroxaban tended to become subtherapeutic.
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Srivastava K, Patel N, Tabbara M, Liew A, Zaghloul I, Migliore MM, Mekary RA. Thromboembolism, Bleeding, and Mortality Incidence of Direct Oral Anticoagulants Versus Warfarin Postbariatric Surgery. Am J Med 2021; 134:1403-1412.e2. [PMID: 34273283 DOI: 10.1016/j.amjmed.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no randomized controlled trial comparing direct oral anticoagulants (DOACs) and warfarin following bariatric surgery to date. The mortality, thromboembolism, and bleeding risk of DOACs in comparison with warfarin following bariatric surgery remains unclear. We aimed to provide a clinical comparison between DOACs and warfarin for these 3 prespecified outcomes. METHODS A systematic literature search was performed on November 10, 2019, using PubMed, Embase, clinicaltrial.gov, and Cochrane databases. Studies with adult patients who were on either warfarin or DOACs following bariatric surgery and reported the incidence of thromboembolism, bleeding, or mortality were included. Pooled incidence for these prespecified outcomes and its 95% confidence interval (CI) were calculated for each drug separately using the random-effects model, along with a nonadjusted P value comparing the 2 subgroups. RESULTS A total of 11 studies (805 patients) were included. Comparing DOACs to warfarin, the following pooled incidences were observed for mortality (DOACs: 3.0%; 95% CI 0.4%-18.6% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value comparing the 2 subgroups = .38), thromboembolism (DOACs: 4.9%; 95% CI 1%-21.1% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value = .18), and bleeding (DOACs: 3.9%; 95% CI 0.7%-18.2% versus warfarin: 11.3%; 95% CI 5.7%-21.4%; P value = .23). CONCLUSION The results of our meta-analysis remain hypothesis-generating, providing rationale for future randomized controlled trial design or well-designed comparative observational studies. Currently, it does not support the change in the current recommendation from warfarin to DOACs following bariatric surgery.
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Affiliation(s)
- Krutika Srivastava
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Neil Patel
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Malek Tabbara
- Department of Surgery, Maniwaki Hospital, McGill University, Montreal, Canada
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway, Galway, Ireland
| | - Iman Zaghloul
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Mattia M Migliore
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Rania A Mekary
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Wadsworth D, Sullivan E, Jacky T, Sprague T, Feinman H, Kim J. A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant. J Clin Pharm Ther 2021; 46:560-570. [PMID: 33393699 DOI: 10.1111/jcpt.13343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. METHODS We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. RESULTS AND DISCUSSION Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent. WHAT IS NEW AND CONCLUSION New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.
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Affiliation(s)
- Daniel Wadsworth
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Emma Sullivan
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas Jacky
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Taylor Sprague
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Hannah Feinman
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jennifer Kim
- Cone Health Department of Internal Medicine, Greensboro, NC, USA
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(S029) Managing therapeutic anticoagulation in bariatric surgery patients. Surg Endosc 2020; 35:4779-4785. [PMID: 32909204 DOI: 10.1007/s00464-020-07958-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Patients that undergo bariatric surgery are at risk of bleeding. Some obesity-related comorbidities including venous thromboembolism and heart disease can often require therapeutic anticoagulation. Previous small institutional studies have demonstrated that bariatric surgery can be performed in this patient population. This study attempts to identify best practices in stopping and restarting therapeutic anticoagulation in patients undergoing bariatric surgery. METHODS A retrospective analysis was completed of our institution's database using anticoagulant medications to identify patients on therapeutic anticoagulation. Patients not on therapeutic anticoagulation were excluded, as well as patients that were started on therapeutic anticoagulation only in the post-operative period or those whose anticoagulation was stopped and not restarted. Indications for anticoagulation were recorded, as well as patient demographics and comorbid conditions. The patient chart was examined for when anticoagulation was stopped before surgery, when it was restarted after surgery, and whether or not the patient was therapeutically bridged. Baseline and post-operative hemoglobin values were recorded, as well as bleeding events, transfusions, reoperation, length of stay, and readmissions. Binary variables were compared across groups using Chi-square and Fisher's exact tests, and continuous variables were analyzed using T test. RESULTS There were 2933 bariatric operations performed between January 1, 2012 and August 31, 2019. Of these patients, 64 were on therapeutic anticoagulation before and after the operation for one or more indications, including history of VTE (39), atrial fibrillation (27), clotting disorder (6), ventricular assist device (5), previous PCI (4), or mechanical valve (2). There were 4 (6.2%) patients that experienced bleeding events. All four patients were on Coumadin pre-operatively. Three patients experienced extraluminal bleeding, and one patient had intraluminal bleeding, and all events occurred within 72 h of the operation. All four patients had their anticoagulation restarted prior to the bleeding event becoming evident, with anticoagulation in these patients restarted an average of 1.25 days after surgery. There were no conditions that predisposed a patient to bleeding. There was no significant difference in amount of time anticoagulation was stopped before surgery in bleeding versus non-bleeding patients, and there appeared to be no increased risk of bleeding in patients that were on therapeutic bridging therapy. There were no thrombotic complications from the interruption in anticoagulation therapy. CONCLUSIONS Bariatric surgery can be safely performed in patients on therapeutic anticoagulation, though this population is at greater risk for bleeding complications in the perioperative period. Meticulous hemostasis in the operating room is the most important aspect of preventing bleeding complications.
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, Sharma K, Watthanasuntorn K, Lertjitbanjong P, Pachariyanon P, Prechawat S, Mao MA, Torres‐Ortiz A, Cheungpasitporn W. Incident atrial fibrillation in patients undergoing bariatric surgery: a systematic review and meta‐analysis. Intern Med J 2020; 50:810-817. [DOI: 10.1111/imj.14436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of MedicineFaculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok Thailand
| | | | - Tarun Bathini
- Department of Internal MedicineUniversity of Arizona Tucson Arizona USA
| | - Konika Sharma
- Department of Internal MedicineBassett Medical Center Cooperstown New York USA
| | | | | | - Pavida Pachariyanon
- Department of Internal MedicineTexas Tech University Health Sciences Center Lubbock Texas USA
| | - Somchai Prechawat
- Division of Cardiology, Department of MedicineFaculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok Thailand
| | - Michael A. Mao
- Department of Internal MedicineMayo Clinic Jacksonville Florida USA
| | - Aldo Torres‐Ortiz
- Division of Nephrology, Department of MedicineUniversity of Mississippi Medical Center Jackson Mississippi USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of MedicineUniversity of Mississippi Medical Center Jackson Mississippi USA
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Modasi A, Dang JT, Afraz S, Hefler J, Switzer N, Birch DW, Karmali S. Bariatric Surgery Outcomes in Patients on Preoperative Therapeutic Anticoagulation: an Analysis of the 2015 to 2017 MBSAQIP. Obes Surg 2020; 29:3432-3442. [PMID: 31278654 DOI: 10.1007/s11695-019-04064-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Obesity has been found to be an independent predictor of adverse cardiac and pulmonary embolic events. As the popularity of bariatric surgery grows, surgeons are encountering more patients taking therapeutic anticoagulation medications preoperatively. This study aims to assess the safety of bariatric surgery on these patients. METHODS Data was extracted from 2015 to 2017 using the MBSAQIP database. Included patients were those who underwent a primary LSG or LRYGB. A multivariable regression analysis was performed looking at 30-day outcomes for pre-operatively anticoagulated patients. A secondary propensity-matched analysis was performed comparing outcomes among patients undergoing LSG vs LRYGB. RESULTS A total of 430,396 patients were analyzed, 11,013 (2.56%) of which were taking anticoagulation medications pre-operatively. Absolute 30-day complication rates (8.73% vs 3.36%, p < 0.001), bleed rates (3.78% vs 0.88%, p < 0.001), leak rates (0.55% vs 0.41%, p = 0.021), cardiac event rates (0.43% vs 0.06%, p < 0.001), and venous thromboembolism rates (0.68% vs 0.25%, p < 0.001) were significantly higher among pre-operatively anticoagulated patients. On multivariable analysis, pre-operative anticoagulation was found to be an independent predictor of postoperative bleeding (OR 2.76, CI 2.43-3.14, p < 0.001) and mortality (OR 2.08, CI 1.49-2.90, p < 0.001). The LRYGB was associated with a significantly higher complication rate compared to the LSG (13.27% vs 7.40%, p < 0.001) in the propensity-matched cohorts. CONCLUSIONS Patients undergoing bariatric surgery on anticoagulation medications pre-operatively are at a significantly higher risk of adverse outcomes post-operatively. Patients who require long-term anticoagulation should undergo careful consideration before proceeding with bariatric surgery.
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Affiliation(s)
- Aryan Modasi
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada.
| | - Jerry T Dang
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada
| | - Sadaf Afraz
- Department of Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Joshua Hefler
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada
| | - Noah Switzer
- Department of Surgery, Royal Alexandra Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
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10
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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11
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Abstract
Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.
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Affiliation(s)
- J Danion
- Assistance Publique-Hôpitaux de Paris, Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver Transplantation, Pitié-Salpêtrière University Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - L Genser
- Assistance Publique-Hôpitaux de Paris, Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver Transplantation, Pitié-Salpêtrière University Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - O Scatton
- Assistance Publique-Hôpitaux de Paris, Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver Transplantation, Pitié-Salpêtrière University Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
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12
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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13
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Preoperative anticoagulation in patients undergoing bariatric surgery is associated with worse outcomes. Surg Endosc 2019; 34:4177-4184. [DOI: 10.1007/s00464-019-07191-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/01/2019] [Indexed: 11/25/2022]
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14
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Zafar SN, Miller K, Felton J, Wise ES, Kligman M. Postoperative bleeding after laparoscopic Roux en Y gastric bypass: predictors and consequences. Surg Endosc 2019; 33:272-280. [PMID: 30232617 DOI: 10.1007/s00464-018-6365-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/20/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, safe and effective bariatric procedure. Bleeding is a significant source of postoperative morbidity. We aimed to determine the incidence, outcomes, and predictors of postoperative bleeding after LRYGB. METHODS LRYGB patients included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset were identified. Preoperative and intraoperative factors were tested for associations with bleeding using univariable and multivariable logistic regression analysis. Outcomes of length of stay, in-hospital mortality, 30-day mortality, discharge disposition, and 30-day complications among patients with and without clinically significant postoperative bleeding were compared using multivariable regression. RESULTS In the 43,280 LRYGB patients included in this analysis, postoperative bleeding occurred in 652 (1.51%) patients. Of these, 165 (25.3%) underwent a re-operation and 97 (14.9%) underwent an unplanned endoscopy for 'bleeding'. Postoperative bleeding was associated with a longer median postoperative length of stay (4 vs. 2 days), higher in-hospital mortality (1.23 vs. 0.04%), higher 30-day mortality (1.38 vs. 0.15%), discharge to an extended-care facility (3.88 vs. 0.6%), and higher rates of major complications (all P < 0.05). Independent predictors of postoperative bleeding included; a history of renal insufficiency (OR 2.55, 95% CI 1.43-4.52), preoperative therapeutic anticoagulation (OR 2.44, 95% CI 1.69-3.53), and revisional surgery (OR 1.45, 95% CI 1.06-1.97). Intraoperative associated factors included conversions (OR 3.37, 95% CI 1.42-7.97), and drain placement (OR 1.40, 95% CI 1.18-1.67). Robotic approaches resulted in independently lower postoperative bleeding rates (OR 0.50, 95% CI 0.32-0.77). CONCLUSIONS Postoperative bleeding occurs in 1.5% of patients undergoing a LRYGB and is associated with significantly increased morbidity and mortality. We have identified patient and operative factors that are independently associated with postoperative bleeding.
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Affiliation(s)
- Syed Nabeel Zafar
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kaylie Miller
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jessica Felton
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Eric S Wise
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mark Kligman
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA. .,Center for Weight Management & Wellness, University of Maryland Medical Center, 29 South Greene Street, Suite 105, Baltimore, MD, 21201, USA.
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