Risks and Benefits of Gastric Bypass in Morbidly Obese Patients With Severe Venous Stasis Disease

Abstract

ObjectiveTo determine the risks and benefits of gastric bypass-induced weight loss on severe venous stasis disease in morbid obesity. Summary Background DataSevere obesity is associated with a risk of lower extremity venous stasis disease, pretibial ulceration, cellulitis, and bronze edema. MethodsThe GBP database was queried for venous stasis disease including pretibial venous stasis ulcers, bronze edema, and cellulitis. ResultsOf 1,976 patients undergoing GBP, 64 (45% female) met the criteria. Mean age was 44 Ϯ 10 years. Thirty-seven patients had pretibial venous stasis ulcers, 4 had bronze edema, 23 had both, and 17 had recurrent cellulitis. All had 2 to 4ϩ pitting pretibial edema. Mean preoperative body mass index (BMI) was 61 Ϯ 12 kg/m 2 and weight was 179 Ϯ 39 kg (270 Ϯ 51% ideal body weight), significantly greater than in patients who underwent GBP without venous stasis disease. Two patients had a pulmonary embolus and four had Greenfield filters in the remote past. Additional comorbidities included obesity hypoventilation syndrome, sleep apnea syndrome, hypertension, gastroesophageal reflux, degenerative joint disease symptoms, type 2 diabetes mellitus, pseudotumor cerebri, and urinary incontinence. Comorbidities were significantly more frequent in the patients with venous stasis disease than for those without. At 3.9 Ϯ 4 years after surgery, patients lost 55 Ϯ 21% of excess weight, 62 Ϯ 33 kg, reaching 40 Ϯ 9 kg/m 2 BMI or 176 Ϯ 41% ideal body weight. Venous stasis ulcers resolved in all but three patients. Complications included anastomotic leaks with peritonitis and death, fatal pulmonary embolism, fatal respiratory arrest, wound infections or seromas, staple line disruptions, marginal ulcerations treated with acid suppression, stomal stenoses treated with endoscopic dilatation, late small bowel obstructions, and incisional hernias. There were six other late deaths.

The relationship between increased body mass index and primary venous disease severity and concomitant deep primary venous reflux

“…In our patient population, increasing weight was not only associated with an elevated VCSS but also with other obesity-related problems such as hypertension and diabetes. Sugerman et al 18 found that severe venous stasis disease was associated with significantly greater weight, BMI, male gender, age, comorbidity, and surgical risk. After gastric bypass surgery, the weight loss corrected the venous stasis disease as well as the other obesity-related problems in almost all patients.…”

Surgical treatment of obesity

“…With a protocol consisting of early ambulation, compression stockings, intermittent compression stockings, and enoxaparin, a low rate of postoperative venous thromboembolism was described (74). In patients at especially high risk for venous thromboembolism (e.g., patients: older than 65 years, BMIO50, a previous venous thromboembolism, venous insufficiency, sleep apnea), placement of a vena cava filter as well as a prolonged course of oral anticoagulants should be seriously considered (75)(76)(77)(78).…”

Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

“…Risk factors for DVT/PE include history of a prior thromboembolic event, central fat distribution, and smoking (34); female gender and age (31); venous stasis, venous insufficiency, and OSA (35); hypercoagulable state; and use of oral contraceptives. Data suggest perioperative benefit from placement of inferior vena cava filters in high-risk patients (7,36).…”

“…Approximately two-thirds of early postoperative mortality from WLS is associated with anastomotic leaks and PEs (5)(6)(7)(8)(9)(10). Potential long-term problems include not only those seen after any abdominal procedure, such as ventral hernia, but also those specific to WLS procedures, e.g., gastric outlet obstruction, marginal ulceration, bowel obstruction, protein malnutrition, and vitamin deficiencies (3).…”