How to better prevent bleeding in bariatric surgery

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Better measures of accurate dosages of blood thinners for obese patients who have bariatric surgery could reduce bleeding, researchers say.

Obesity affects more than 30 percent of adults in the United States. In 2018, surgeons performed 228,000 bariatric surgeries, which causes weight loss by restricting the amount of food the stomach can hold.

Clots that block blood vessels are a risk of bariatric surgery and while blood thinners before surgery and during hospitalization reduce clot risk, experts have yet to determine the best timing and duration of treatment.

“There is no requirement for drug manufacturers to perform research studies in obese individuals, which means there are no standard recommendations,” says lead investigator Luigi Brunetti of the Rutgers University Ernest Mario School of Pharmacy. “We do not know which methods perform best in preventing blood clots without risk of bleeding in cases of extreme body weight.”

For the study in Surgery for Obesity and Related Disorders, patients received one of two types of blood thinners before surgery: subcutaneous enoxaparin, which lowers the activity of clotting proteins in the blood, and unfractionated heparin (UFH), which works with a natural protein in the body to block clot formation.

Researchers looked at two measures for determining effectiveness in preventing blood clots: anti-Xa, the standard measure, which assesses blood clot inhibitors in plasma, and endogenous thrombin potential (ETP), which measures the enzyme in blood plasma that causes blood to clot.

The results showed that while both types of blood thinners prevented clots, 80 percent of patients receiving enoxaparin had minor bleeding during surgery, which correlated with the ETP measurement. The results suggest that ETP, which identified the bleeding risk, provides a more accurate assessment of the best dosage for the various blood thinners.

“Currently, most physicians prescribe 40 milligrams of enoxaparin twice daily, and some are advocating for even higher doses for patients with extreme obesity,” Brunetti says. “That dosage is ill-advised based on our study, which found that patients who received that dose experienced minor bleeding.

“I suspect a higher dosage would result in more minor bleeding and perhaps major bleeding as well. ETP can potentially help physicians better understand the right dosage, so obese patients will see benefits without being harmed.”

Coauthors are from Rutgers and Advanced Surgical and Bariatrics of New Jersey.

Source: Rutgers University