Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

A nationwide survey on bariatric surgery in Germany--results 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated.

RESULTS

During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

[Echinococcosis - a rare differential diagnosis of a tumorous hepatic lesion]

We report the case of a 44-year-old woman who was admitted to our hospital because of a newly developed painless jaundice. Though she felt quite well sonographic and radiographic evaluation showed a tumor of the liver. An extensive diagnostic workup was performed but it was not until laparotomy that a malignant tumor could definitely be ruled out and the presumptive diagnosis of an echinococcosis was proven. A partial resection of the liver was performed.

[Blood management in surgery--an analysis]

The surgeon has a tremendous influence on the usage of blood and blood products. He determines the indication and operative strategy. So the co-operation of anesthetist, intensivist, transfusion specialist, and surgeon is essential to achieve improvement in blood saving. Guidelines of blood saving methods can support the aim of an effective blood management. We analyzed the today's situation of blood saving in surgery and discuss the matter by a questionnaire sent to all surgical institutions of Nordrhein-Westfalen. The data observed cover the results of the Sanguis study from 1994 and the resume that the indication of blood transfusion mostly is not driven by clinical and scientific facts alone. Till today no evidence based data exist on indications for transfusion of blood and blood products. This is required for the next years in order to create changes in the current system of blood saving. The key points to stay within the low range of the number of transfusions are to develop a specific peri-, intra-, and postoperative strategy according to patient, disease, and expected procedure. The surgical aspects are discussed.

[CT-controlled percutaneous drainage of intra-abdominal abscesses with basket catheters]

Today, CT-guided percutaneous drainage for intraabdominal abscesses of various origin and location is well accepted. With this method open surgery and its complications can be often avoided. We report results of such treatment in 47 patients with intraabdominal abscess formation. 66 "basket" catheters were placed into abscess formations of differing sizes and locations. 27 patients had developed abscess formation after surgery, in 2 patients abscesses after tumorembolisation were drained. In 18 cases there was no previous surgery. No complications occurred. Mean drainage time was 8.5 days. Surgical intervention was avoided in 34/47 patients. 9 of 47 patients received only percutaneous drainage. 25 of 47 patients required concomitant antibiotics for successful treatment. Antibiotics were selected according to bacterial culture with resistance determination. 13/47 cases required secondary surgery. About 80% of intraabdominal abscesses are curable with CT guided percutaneous drainage and systemic antibiotic medication. If a percutaneous drainage fails and signs of infection still remain, the procedure can be repeated. If secondary surgery after failing of percutaneous drainage should become necessary, the extent of the surgical intervention can be reduced. Surgery is necessary, if CT guided percutaneous drainage could not reach the abscess formation, if drainage failed or if an additional illness exists, which requires an operation.

[Experiences with a vent button system in endoscopic and surgical gastrostomy]

INTRODUCTION

In all variants of surgical or endoscopic gastrostomies, the abdominal wall is penetrated by a catheter. This reduces life-quality and often induces complications in gastrostomies.

METHOD

In a prospective trial, an anti-refluxive replacement button was applied as a catheter-substitute in 45 patients after conventional, laparoscopic and percutaneous-endoscopic gastrostomies.

RESULTS

In 1 of 45 patients the button was falsely inserted, only two patients experienced minor local infections of the stoma. No further major complications were noted. The average usage-time is 6.3 +/- 4.9 [1-17] months, the rate of complications in 100 days is 0.06.

CONCLUSIONS

The gastrostomy replacement button is safely applicable and improves clearly the comfort of gastrostomies with a low complication rate.

[Reconstruction of extensive post-traumatic femoral defects by autogenous rib transplants]

Extended deficiency pseudarthroses of the femur (7-18 cm) in nine patients were treated by autogenous rib transplantation. For early active pain-free mobilization we used the technique of bridging plate osteosynthesis for stable internal fixation. Within an average of 5 (range 4-7) months osseous restitution was obvious radiologically. In all nine patients the full weight-bearing capacity of the extremity was restored. There were no soft tissue problems and no bone transplant losses. All patients appreciated the uncomplicated postoperative phase after internal fixation with bridging plate osteosynthesis.