Bariatric venous thromboembolism prophylaxis: an update on the literature

ABSTRACT

Introduction: Rates of obesity have been increasing worldwide and with the current situation obesity now represents an epidemic. Bariatric surgery is one the most effective ways to help reduce weight and sustain weight loss. Venous thromboembolism is a major cause of morbidity and mortality among bariatric surgery patients with no clearly established guidelines on prophylaxis.

Areas covered: In this review the authors summarize clinical studies evaluating unfractionated heparin (UFH) and low molecular weight heparins (LMWH) in bariatric surgery patients. The authors present studies that assessed venous thromboembolic (VTE)-related risk stratification but also various dosing regimens of heparin products in this population of patients. Moreover, the authors will also present the feasibility of using direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) prevention along with providing a summary of few current guidelines for VTE prevention in bariatric surgery patients.

Expert opinion: Based on the data presented in this review, the authors conclude that LMWHs may be better options than UFH for VTE prophylaxis in bariatric surgery patients. We also conclude that risk stratifying bariatric patients may be a better approach when deciding on the best thromboprophylaxis modality, dose and duration.

KEYWORDS:

• Anti-Xa
• bariatric surgery
• direct oral anticoagulants
• low molecular weight heparin
• prophylaxis. venous thromboembolism

Article highlights

• Venous thromboembolism remains to be an important source of morbidity and mortality for bariatric surgery patients.

• Patient-related risk factors for VTE in bariatric surgery patients include but not limited to age, gender, smoking/hormone use, BMI, previous VTE, thrombophilia, immobility, venous stasis, pulmonary hypertension, and obesity hypoventilation syndrome.

• Procedure-related risk factors include open bariatric procedures, and long operative time.

• Though not based on randomized controlled trials, current data suggest that LMWH is more effective than UFH in preventing VTE with no increase in bleeding risk.

• There is no clear data on proper dosing of heparins in bariatric patients though many suggest higher dose LMWH in those with higher BMI.

• DOACs, though convenient, are not currently an appropriate method of prophylaxis due to lack of data and also to their pharmacodynamics/kinetics properties.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded