What suggestions do you have to reduce the risk of blood clots in bariatric surgery patients?

This is a very important question because persons of size are at greater risk for developing blood clots than persons of standard size no matter what operation they are choosing to have. This is true whether they have a knee replacement, hysterectomy or a bariatric operation.
I think persons of size are at increased risk for several reasons. 1). Increased pressure from the weight that is carried in the abdomen places pressure on the blood vessels returning blood from the lower part of the body back to the heart allowing pressure to develop in the veins of the legs and pelvis. This pressure can injure the valves in the deep veins of the legs and make the veins larger slowing the flow of blood and increasing the risk of clotting. This increased pressure is also the reason many persons of size have developed varicose veins since the pressure is transmitted to the more superficial veins of the legs which have thinner and weaker walls resulting in these veins increasing in diameter. The pressure is transmitted to the vessels of the skin causing leakage of red blood cells causing discoloration and irritation of the skin called venous stasis changes. 2). Many bariatric surgery patients have obstructive sleep apnea which causes the right side of the heart to work less efficiently further retarding the blood flow back to the heart making the pressure situation even worse in the blood vessels returning the blood to the heart. 4). Also, the large amount of fat mass causes the increased production of estrogens in both men and women. This is like being on birth control pills all the time and of course this high level of estrogen may increase the risk of developing blood clots. 4). Finally, a bariatric surgery patient is likely to have an increased level of inflammation which may also increase their risk of forming blood clots.

A person that develops a blood clot in the leg, called a deep vein thrombosis, can have significant symptoms like swelling and pain. However, the more serious risk is if the clot is dislodged from the leg or pelvis and travels up to the heart and out to the lungs. At this stage it is called a pulmonary embolus. This blockage can result in keeping the blood that is pumping out of the heart from getting to the lungs. If enough of the flow to the lungs is interrupted the person will not have enough oxygen and may not survive.
To prevent this problem we do several things for everyone that is having bariatric surgery at Fresh Start Bariatrics at Riverside. Many other bariatric surgeons also do the following: 1). Everyone receives blood thinners that start just before surgery and continues through their hospitalization and is continued for 6 days after they are discharged from the hospital. 2). They have sequential compression devices placed on their legs prior to surgery so the blood will be circulating out of their legs back to their heart even while they are on the operating table and while they are asleep. 3). All of our patients are walking in the halls of the hospital just 6 hours after they leave the operating room. 4). Finally, if a patient is at significantly higher risk than normal I request that they undergo placement of a temporary vena cava filter placed by a cardiologist or other specialist into the main blood vessel, called the vena cava, that returns blood to the heart a few days prior to their bariatric operation.
Although some bariatric surgeons are using vena cava filters for high risk patients the following scoring system is unique to the program I have had the privilege of developing at Fresh Start Bariatrics at Riverside. After reviewing the medical literature I have developed a scoring system that identifies patients that are at significant increased risk for blood clots and will need this temporary filter to protect them from a clot reaching their heart and lungs. The cardiologists I work with most frequently here in the Columbus, Ohio call it the “Myers’ Scoring System”. Take a look at the following:

“Myers’ Scoring System for Venous Thomboembolism Prophylaxis”
In the Bariatric Surgery Population

High Risk Score
History of blood clots (DVT/PE) 4
Venous stasis changes, 4
(cellulitis, ulceration, discoloration)
Genetic clotting disorder 4
Immobility, (wheelchair bound) 4
BMI, (Body Mass Index), over 60 4
Moderate increased risk
Obstructive Sleep Apnea 2
Lower increased risk
Male 1
BMI over 50 1
Recent smoker 1
Hormone replacement therapy 1
Total score ___________
Total Score that is equal to or greater than 4 results in a referral for a vena cava filter.

A vena cava filter is generally placed through the groin much like a heart cath is done. After the risk of developing a blood clot is reduced in 4 to 6 weeks the filter is removed. We have found this scoring system and the placement of a vena cava filter in high risk individuals to be very effective in protection patients form this potentially life threatening problem. I believe we have saved several lives with this intervention. This is just one of many ways we work to decrease the risk of bariatric surgery for patients that select our program for their bariatric surgery. I hope this understanding will be helpful to you regardless of where you chose to have your operation.

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