0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review |

Pharmacologic and Mechanical Strategies for Preventing Venous Thromboembolism After Bariatric Surgery:  A Systematic Review and Meta-analysis

Daniel J. Brotman, MD1; Hasan M. Shihab, MBChB, MPH2; Kalpana R. Prakasa, MBBS, MS1; Sosena Kebede, MD, MPH1; Elliott R. Haut, MD3; Ritu Sharma, BSc2; Kenneth Shermock, PharmD, PhD1,2; Yohalakshmi Chelladurai, MBBS, MPH2; Sonal Singh, MD, MPH1,2; Jodi B. Segal, MD, MPH1,2
[+] Author Affiliations
1Department of Medicine, The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, Maryland
2Health Policy and Management, The Johns Hopkins Bloomberg University School of Public Health, The Johns Hopkins University, Baltimore, Maryland
3Department of Surgery, The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, Maryland
JAMA Surg. 2013;148(7):675-686. doi:10.1001/jamasurg.2013.72.
Text Size: A A A
Published online

We sought to assess the comparative effectiveness and safety of pharmacologic and mechanical strategies to prevent venous thromboembolism (VTE) in patients undergoing bariatric surgery. We searched (through August 2012) for primary studies that had at least 2 different interventions. Of 30 902 citations, we identified 8 studies of pharmacologic strategies and 5 studies of filter placement. No studies randomized patients to receive different interventions. One study suggested that low-molecular-weight heparin is more efficacious than unfractionated heparin in preventing VTE (0.25% vs 0.68%, P < .001), with no significant difference in bleeding. One study suggested that prolonged therapy (after discharge) with enoxaparin sodium may prevent VTE better than inpatient treatment only. There was insufficient evidence supporting the hypothesis that filters reduce the risk of pulmonary embolism, with a point estimate suggesting increased rates with filters (pooled relative risk [RR], 1.21 95% CI, 0.57-2.56). There was low-grade evidence that filters are associated with higher mortality (pooled RR, 4.30 95% CI, 1.60-11.54) and higher deep vein thrombosis rates (2.94 1.35-6.38). There was insufficient evidence to support that augmented subcutaneous enoxaparin doses (>40 mg daily or 30 mg twice daily) are more efficacious than standard dosing, with a trend toward increased bleeding. Of note, for both filters and augmented pharmacologic dosing strategies, patients at highest risk for VTE were more likely to receive more intensive interventions, limiting our ability to attribute outcomes to prophylactic strategies used.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Figures

Place holder to copy figure label and caption
Figure 1.
Flow Diagram of Studies Included in the Systematic Review

HIT indicates heparin-induced thrombocytopenia and VTE, venous thromboembolism. *Total exceeds the number in the exclusion box because reviewers were allowed to mark more than 1 reason for exclusion.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Relative Risk (RR) Meta-analysis of inferior Vena Cava Filters (IVCFs) in Preventing Pulmonary Embolism in Patients Undergoing Bariatric Surgery

The shaded box sizes are proportional to the weight of each study blue diamond shows the CI of the pooled effect size. Black bars denote CIs for individual studies, and dotted line indicates the pooled effect estimate.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Relative Risk (RR) Meta-analysis of Inferior Vena Cava Filters (IVCFs) and Deep Vein Thrombosis in Patients Undergoing Bariatric Surgery
Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Relative Risk (RR) Meta-analysis of Inferior Vena Cava Filters (IVCFs) and Mortality in Patients Undergoing Bariatric Surgery
Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

2,818 Views
8 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
×
brightcove.createExperiences();