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Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4583 (Published 04 December 2009) Cite this as: BMJ 2009;339:b4583

Rapid Response:

Extended VTE prophylaxis and bariatric surgery

The paper by Sweetland et al. (1) is commendable for raising
awareness of
the significant risk of venous thromboembolism (VTE) after cancer and
major
lower-limb joint surgery, but we were disappointed that VTE risk
associated
with morbid obesity and bariatric surgery merited only a brief mention.
Bariatric surgeons are already very aware of the risk of post-operative
venous
thromboembolism, as VTE is the commonest cause of death following
laparoscopic bariatric surgery (2). This relatively high risk of VTE
reflects not
only the severity of obesity in bariatric surgical patients, but also
factors such
as the over-representation of venous hypertension in the morbidly obese
population (3).
Mechanical prophylaxis with TED stockings in these patients can be
physically impossible even using below-knee stockings. In response to
these
concerns we prospectively introduced an extended thromboprophylaxis
regimen for patients undergoing bariatric surgery several years ago. In
addition to pre-operative low molecular weight heparin (LMWH) at a
standard
dose, patients undergoing laparoscopic gastric bypass or duodenal switch
also self-administer a 3-week course of double standard dose LMWH (a
shorter one week course is given to those who have undergone the simpler
laparoscopic gastric band procedure).
We have performed over 1300 laparoscopic bariatric procedures with up to
12
years of carefully audited follow-up and have only seen three symptomatic
venous thromboembolic events (two deep vein thromboses and one case of
minor peripheral pulmonary embolism) using this extended LMWH regime.
These results have been presented internationally (4) and our formal paper
is
currently undergoing peer review.
In keeping with our own experience, and that of this paper, we would
recommend extended thromboprophylaxis as a standard of care in the post-
operative management of patients undergoing laparoscopic bariatric
surgery.

1. Siân Sweetland, Jane Green, Bette Liu, Amy Berrington de
González,
Marianne Canonico, Gillian Reeves, Valerie Beral on behalf of the Million
Women Study collaborators
Duration and magnitude of the postoperative risk of venous
thromboembolism in middle aged women: prospective cohort study
BMJ 2009; 339: b4583

2. LABS Writing Group for the LABS Consortium, Belle SH, Chapman
W,
Courcoulas AP, Flum DR, Gagner M, Inabnet WB, King WC, Mitchell JE,
Patterson EJ, Thirlby R, Wolfe BM, Yanovski SZ.
Relationship of body mass index with demographic and clinical
characteristics
in the Longitudinal Assessment of Bariatric Surgery (LABS).
Surg Obes Relat Dis. 2008 Jul-Aug;4(4):474-80.

3. Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT.
Complications after laparoscopic gastric bypass: a review of 3464 cases.
Arch Surg 2003;138:957-61.

4. Comparison of Dalteparin and Enoxaparin in preventing venous
thromboembolism following laparoscopic bariatric surgery

CJ Magee, JD Barry, J Ahmed, MS Javed, RC Macadam, DD Kerrigan
Obesity Surgery 2009 19: 1000

Competing interests:
None declared

Competing interests: No competing interests

13 January 2010
Conor J Magee
Gravitas Fellow in Bariatric Surgery
David D. Kerrigan
Gravitas Centre for Bariatric Surgery, Murrayfield Hospital, Wirral, CH61 1AU