Although there were no cases among the patients who had laparoscopic surgery, there was no statistical difference between the occurrence of this complication. Among the co-morbidities of morbid obesity is chronic venous insufficiency, which in turn is a risk factor for deep vein thrombosis, notably when the patient undergoes surgery. One of the factors that favors venous stasis in the obese is probably high intra-abdominal pressure due to the obesity itself.
Venous Thromboembolic Disease: DVT and PE
This high abdominal pressure results in increased pressure upon the inferior vena cava, iliac and femoral veins, which in turn diminishes venous flow and therefore result in venous valve insufficiency, leading to chronic venous stasis causing swelling, dermatitis, eczema, and finally venous ulcer. The occurrence of chronic venous insufficiency syndrome was observed in 3. In the population here presented, comparing the CEAP classification among the two groups of obesity obese vs morbid obese no correlation was observed between the degree of obesity and the clinical classification of venous disease.
Also there was no statistically significant difference between the degree of obesity and the changes observed in the ultrasonographic examination. It can be assumed that the older the patient, the greater should be the impact of obesity upon the venous stasis.
On the other hand, analyzing the relationship between abdominal circumference and venous disease, we observed statistically significant difference regarding the CEAP, i. However, no correlation could be observed between abdominal circumference and the ultrassonographic examination.
The ultrasound examination performed 25 to 35 days after surgery, did not show any modification regarding the pre-operative findings. Sugerman showed improvement in venous stasis in his patients followed for 5 years after bariatric intervention 3. Surely these data cannot be compared with those of our patients since our follow up was too short.
Regarding thromboembolic disease, bariatric surgery is considered as being of moderate risk, and pharmacological prophylaxis is recommended Despite the fact that this recommendation is not new, some authors do not see the need for prophylaxis considering the low incidence of thromboembolic disease found in their operated populations. Westling 10 found distal vein thrombosis in only two patients of the operated, without prophylaxis. In , Printen asserted that he did not recommend prophylaxis, because the risks would be greater than the benefits.
He based his affirmation on a retrospective study of patients undergoing bariatric surgery without prophylaxis. There were four deadly pulmonary embolisms and three others without complications. On the other hand, Stern, in , in a systematic review found that the relative risk for pulmonary embolism of patients undergoing bariatric surgery is 2. If there is no consensus among surgeons about the need to perform prophylaxis, there is neither consensus regarding the dosage to be used.
Venous thromboembolic diseases: diagnosis, management and thrombophilia testing - NICE guideline
Schelten compared two groups of patients: 30 mg enoxaparin twice a day in 92 patients and 40 mg enoxaparin twice a day in patients. Patients had also intermittent pneumatic compression or used elastic stockings. In the first group, with the lower dose, five cases of venous thrombosis were detected 5. In the other group, with higher dose, there were two cases of venous thrombosis, corresponding to 0. This difference was statistically significant. There was one case in each group with bleeding complications.
Hamad analysed patients in a retrospective study of five different centers in which 40 mg of enoxaparin was used for 10 days postoperatively. There were six 0. In six 0. They reported an incidence of venous thrombosis of 2. Thus, it seems that most surgeons use prophylactic protection for their patients. As regarding the dose, it usually is higher than used in conventional prophylaxis: 60 to 80 mg of enoxaparin per day.
In the group under study, prophylaxis was done with 80 mg enoxaparin per day, as well as additional measures have been used, such as elastic stockings and early ambulation.
What is Venous Thromboembolism (VTE)? | American Heart Association
Even so, a high index of venous thrombosis occurred 5. It should be noted that the 5. It is possible that this difference is due to the fact that the ultrassonographic examination was done between 25 and 35 days after surgery. The before mentioned data were obtained in still hospitalized patients. In these circumstances venous thrombosis may not be detectable since early thrombus has an acoustic interface very similar to the normal blood.
Obesity is linked to numerous co-morbidities and bariatric surgery is a viable option for treatment. The surgical procedure has a risk for thromboembolic events due to changes of venous flow. Our study suggests that prophylaxis with use of elastic stockings, early post-operative ambulation and administration of 40 mg enoxaparin every 12 hours during hospitalization, goes along with a considerable high incidence of venous thrombosis although pulmonary embolism was not detected. Buchwald H; Consensus Conference Panel. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers.
Surg Obes Relar Dis. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. Enoxaparin for thromboprophylaxis in morbidly obese patients undergoing bariatric surgery: findings of the prophylaxis against VTE outcomes in bariatric surgery patients receiving enoxaparin PROBE study.
Patients requiring cranial and spinal surgery present a unique situation of elevated risk for VTE but also high risk for disastrous outcomes should bleeding complications occur in eloquent areas of the brain or spinal cord. Am J Med. Obstet Gynecol. Clin Genet. Sex hormones and venous thromboembolism - from contraception to hormone replacement therapy. Arterioscler Thromb Vasc Biol. Br J Haematol. September Annals of Oncology.
Lancet Haematol. Human Reproduction Update. Thromb Res. Health Technology Assessment Winchester, England. Annals of Internal Medicine. Therapeutics Initiative. The British Journal of Surgery.
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The Cochrane Database of Systematic Reviews. The Annals of Thoracic Surgery. National Institute for Health and Care Excellence. Retrieved Cochrane Database Syst Rev. Journal of Thrombosis and Thrombolysis. Cochrane Vascular Group ed. Cochrane Database of Systematic Reviews. Cardiovascular disease vessels I70—I99 , — Arteritis Aortitis Buerger's disease.
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We found no new evidence that affects the recommendations of this guideline. How we develop NICE guidelines. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.