BARIATRIC SURGERY OUTCOMES IN PATIENTS REQUIRING ANTICOAGULATION: AN ANALYSIS OF THE MBSAQIP
Aryan Modasi*, Jerry Dang, Noah Switzer, Daniel W. Birch, Shahzeer Karmali
General Surgery, University of Alberta, Edmonton, AB, Canada
Background
Obesity has been found to be an independent predictor of both adverse cardiac events and pulmonary embolic events. Thus many bariatric surgeons are encountering patients presenting for bariatric surgery who are chronically anticoagulated pre-operatively. This study aims to assess the safety of bariatric surgery on pre-operatively anticoagulated patients, and to compare outcomes following laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in this patient population.
Methods
Data was extracted from 2015 to 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. This database contains data from 832 centres in the United States and Canada specific to bariatric surgery. Included patients were those who underwent LSG or LRYGB. Patients with a history of a previous bariatric surgery were excluded. A multivariable regression analysis was performed looking at 30-day outcomes for pre-operatively anticoagulated patients undergoing bariatric surgery. A secondary propensity-matched analysis was performed comparing outcomes amongst patients undergoing LSG vs LRYGB.
Results
A total of 430,396 patients were analyzed, 11,013 of which were anticoagulated pre-operatively. Patients on pre-operative anticoagulation medications were older (54.3 (SD 11.3) vs 44.2 (SD 11.9) years, p < 0.001), more likely to be male (41.1% vs 20.1%, p < 0.001), and more likely to have COPD (6.86% vs 1.55%, p < 0.001), diabetes (44.79% vs 25.93%, p < 0.001), renal insufficiency (3.41% vs 0.57%, p < 0.001), and oxygen dependency (3.85% vs 0.62%, p < 0.001).
The absolute 30-day complication rate amongst pre-operatively anticoagulated patients was significantly higher (8.73% vs 3.36%, p < 0.001), as was the 30-day reoperation rate (2.22% vs 1.18%, p < 0.001), bleed rate (3.78% vs 0.88%, p < 0.001), leak rate (0.55% vs 0.41%, p = 0.021), cardiac event rate (0.43% vs 0.06%, p < 0.001) and venous thromboembolism rate (0.68% vs 0.25%, p < 0.001). Mortality was significantly higher in the anticoagulation cohort (0.55% vs 0.08%, p < 0.001). On multivariable analysis, pre-operative anticoagulation was found to be an independent predictor of adverse outcomes (OR 1.75 [1.62 to 1.90], p < 0.001). Amongst pre-operatively anticoagulated patients, the LRYGB was associated with a significantly higher complication rate compared to the LSG (13.27% vs 7.40%, p < 0.001) in the propensity-matched cohorts.
Conclusion
Patients undergoing bariatric surgery on anticoagulation medications pre-operatively are at a significantly higher risk of adverse outcomes post-operatively. This increased risk remains even after controlling for other confounding variables, and is significantly higher with LRYGB compared to LSG. Patients who require long-term anticoagulation should undergo careful consideration before proceeding with bariatric surgery.
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