Laparoscopic Gastric Restrictivee Procedures in the Super Super Obese (BMI > 60 kg/m2) Without the Use of Prophylactic Inferior Vena Cava Filters: Our Experience at a Bariatric Center of Excellence

Salvatore Docimo, Jr., DO, Laura Crankshaw, BS, George Ferzli, MD. Lutheran Medical Center, Brooklyn, NY.

INTRODUCTION

Patients undergoing bariatric surgery are at an increased risk for venous thromboembolism (VTE).The incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients following bariatric surgery ranges from 0%-5.4% 5 and 0%-6.4%. Prophylaxis against VTE is comprised of three options: mechanical (sequential compression devices), chemoprophylaxis (unfractionated heparin and low-molecular weight heparin), and inferior vena cava filters. IVC filters have been recommended for use in high risk bariatric patients – high risk being defined as BMI > 55 kg/m2, immobility, venous stasis, pulmonary hypertension, hypercoaguable state and a history of VTE. Studies by Obeid et al and Trigilio-Black et al suggest a decreased rate of PE and death in patients receiving prophylactic IVC filters. Deployment outside the target area, access ocmplications, recurrent PE, IVC occlusion, filter migraton, and filter fracture have been documented.12 This study seeks to evaluate super super obese patients undergoing laparoscopic bariatric surgery without the prophylactic insertion of IVC filters.

METHODS

Records between 2006-2012 at a community hospital and bariatric center of excellence were reviewed. Fifty-eight patients with a BMI > 60 kg/m2 and no placement of a prophylactic IVC filter who underwent laparoscopic weight loss surgery were included. Parameters such as the type of surgery, demographics, length of stay, change in weight/BMI, reduction of co-morbidities and  complications were determined. Specific attention to the development of DVT or VTE was documented.
 

RESULTS

Thirty-six (62.0%) women and 22 (38.0%) men, 39.75 (20-62) average years of age.  Forty-eight (85.7%) underwent laparoscopic roux-en-y (LRY), 6 (10.7%) underwent a gastric banding (LGB) procedures, and 2 (3.5%) had a sleeve gastrectomy (LSG) procedure.

The average operation time for the LRY was 60-190 minutes and 50-160 minutes for the LGB. The pre-surgical BMI’s were 65 for the LRY, 65 for the LSG, and 61 for the LGB. The post-surgical BMI at the approximately two year period was 44 for the LRY, 57 for the LSG, and 51 for the LGB. No patient underwent prophylactic preoperative insertion of IVC filters. Subcutaneous heparin and sequential compression devices were ordered postoperatively. No significant DVT’s or VTE’s were noted during the patients hospital stay.
 

DISCUSSION

Inferior vena cava filters have been advocated in the high risk bariatric patients. The purpose of this study is to present our experience with super super obese patients (BMI > 60 kg/m2) undergoing laparoscopic gastric restrictive surgery who did not receive prophylactic IVC filters. Our facility is a community based bariatric center of excellence. Patients receive intraoperative and postoperative subcutaneous heparin and also sequential compression devices as DVT prophylaxis. Of the 58 patients undergoing laparoscopic gastric restrictive procedures, each had a BMI > 60 kg/m2 and none received an IVC filter prophylactically. No complications such as DVT, VTE, or PE were noted intraoperatively or postoperatively. These findings are significant as they demonstrate BMI may not be a good indication of a high risk bariatric patient. Thus, patients with BMI > 60 kg/m2 can safely undergo laparoscopic gastric restrictive procedures without the insertion of prophylactic IVC filters.
 

 

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