Status of venous thromboembolism prophylaxis among bariatric surgeons: have we changed our practice during the past decade?

BACKGROUND: Venous thromboembolism (VTE) is considered one of the principal causes of morbidity and mortality in patients requiring bariatric surgery. A survey to all members of the American Society for Metabolic and Bariatric Surgery was conducted in 1998 and published in 2000 in the journal "Obesity Surgery." METHODS: A survey was repeated to all physician members of the American Society for Metabolic and Bariatric Surgery to determine the current practices for VTE prophylaxis. The results were compared with those of the previous study. RESULTS: Of the members, 35% completed the survey for a total of 332 responses. The number of cases annually per surgeon almost doubled since 1998 (145 versus 85). Laparoscopic gastric bypass has replaced open gastric bypass as the most common procedure performed, followed by laparoscopic gastric banding as the second most common procedure. Most surgeons (95%) use chemical prophylaxis to prevent VTE, but almost 60% preferred low-molecular-weight heparin compared with 13% in 1998. More than 60% of bariatric surgeons discharged their patients with chemical prophylaxis compared with 12% in 1998. Inferior vena cava filters for prophylaxis are considered by 55% compared with only 7% in 1998. The incidence of reported deep vein thrombosis was significantly lower in 2007 (2.635 versus .93), as was the incidence of pulmonary embolism (.95% versus .75%). Almost 50% of surgeons still reported > or =1 fatality because of VTE complications. CONCLUSION: Chemical prophylaxis for VTE with some type of heparin is the standard of care for patients undergoing bariatric surgery. Low-molecular-weight heparin is now used by two thirds of the respondents to this survey. Most surgeons who responded to the survey discharged their patients home with heparin, and many consider the use of inferior vena cava filters for VTE prophylaxis. Our findings support the American Society for Metabolic Bariatric Surgery position statement regarding VTE prophylaxis in this patient population. Research is necessary to establish the role of inferior vena cava filters, discharging patients with chemoprophylaxis and to determine the adequate dosage and duration of prophylaxis.

Routine cholecystectomy is not mandatory during morbid obesity surgery.

BACKGROUND: Controversy exists concerning the utility of routine cholecystectomy during bariatric surgery. We report our series of bariatric surgical procedures at our institution without concurrent cholecystectomy. METHODS: From October 2003 to August 2005, 621 morbidly obese patients underwent a weight loss operation. Preoperatively, each patient had undergone abdominal ultrasound (AUS) to evaluate for abnormal gallbladder findings. Patients with previous cholecystectomy were excluded. Symptomatic patients with AUS findings consistent with gallbladder disease underwent concomitant cholecystectomy and bariatric surgery. Asymptomatic patients, despite AUS findings, did not undergo cholecystectomy with their bariatric operation. A comparison between the preoperative AUS-positive and AUS-negative, asymptomatic patients after bariatric surgery was performed. RESULTS: Of the 621 patients who underwent bariatric surgery, 170 (27%) had undergone previous cholecystectomy and were excluded. Of the remaining 451 patients, 17 with positive AUS findings and symptoms underwent cholecystectomy during bariatric surgery. The range of follow-up was 4-25 months. Of the 451 patients, 324 were asymptomatic and had negative AUS findings and 102 were asymptomatic and had positive AUS findings for gallbladder abnormalities. Postoperatively, 29 asymptomatic/AUS-negative patients (9%) developed symptoms and had positive AUS findings. Nine asymptomatic patients with AUS positive findings (9%) developed symptoms. Finally, 38 patients (8.4%) went on to undergo elective cholecystectomy. These 2 groups were not signficantly different statistically. CONCLUSIONS: In this study, the development of symptomatic/AUS-positive gallbladder abnormalities was low after obesity surgery, suggesting that mandatory cholecystectomy is not required at bariatric surgery.

Preventing port site inversion in laparoscopic adjustable gastric banding.

OBJECTIVES: Laparoscopic adjustable gastric banding (LAGB) is a safe, controlled method for weight loss in the morbidly obese patient. Inversion or dislodgement of the port leads to difficulty with access for band adjustments and frequently requires reoperation. We report our experience with port fixation to the rectus sheath of the abdominal wall by using port/mesh fixation to prevent port site complications. METHODS: One hundred and ninety-one morbidly obese patients underwent LAGB between April 2002 and August 2005. The first group had ports fixed to the rectus fascia of the abdominal wall with a standard 4-point suture technique. The second group had ports sutured to a mesh, which was then tacked to the rectus sheath of the abdominal wall. Port site complications were analyzed over a 5-month to 40-month period and compared between the 2 groups. Intraoperative port fixation times were recorded for each technique. RESULTS: Thirty-nine patients in the suture fixation group encountered a 20.5% port site complication rate, with 10.3% of the ports becoming dislodged or inverted. The mesh/tack group consisted of 151 patients. The port site complication rate was 5.3%, with only a 1.3% rate of port dislodgement or inversion. The port dislodgement or inversion rates were significantly different between groups (P = .0049). The average operative times for port insertion were 12 minutes for the sutured technique and 5 minutes for the mesh/tack technique. CONCLUSIONS: The mesh/tack method of port fixation reduced the incidence of dislodgement and rotation in our patient population, which resulted in greater ease of access for adjustments. Furthermore, the mesh/tack technique is a quick, safe approach for port fixation through a small incision.