Sapala James A, Wood Michael H, Schuhknecht Michael P, Sapala M Andrew
Department of Surgery, Harper University Hospital, Detroit Medical Center and Wayne State University School of Medicine, Detroit, MI, USA.
Obes Surg. 2003 Dec;13(6):819-25. doi: 10.1381/096089203322618588.
Pulmonary embolism (PE) is a leading cause of death following gastric bypass operations for morbid obesity. Although its incidence appears to be stable, the number of bariatric operations performed annually is increasing considerably; hence, the isolated fatal PE is no longer a rare occurrence. The records of patients undergoing bariatric surgical operations since 1979 were reviewed to determine specific factors that increased the risk of developing a fatal PE. Both recommended and optional indications for prophylactic inferior vena cava (IVC) filter placement in patients considered at high risk were also examined.
Between September, 1979 and March, 2003, 5,554 operations were performed for clinically severe obesity. These operations included jejuno-ileal bypass, horizontal gastroplasty, Roux-en-Y gastric bypass with a 30-cc pouch, modified biliopancreatic diversion, the Sapala-Wood Micropouch gastric bypass (Micropouch(SM)), Lap-Band, and revisions. 12 fatal pulmonary emboli (0.21 %) were identified. All but 1 embolus occurred within 30 days following surgery.
In 11 of 12 patients, at least 1 co-morbidity known to increase the risk of postoperative venous thromboembolism (VTE) was identified. 4 co-morbidites were common to 4 patients (33%): venous stasis disease (VSD), BMI >/= 60, truncal obesity, and obesity hypoventilation syndrome/sleep apnea syndrome (OHS/SAS). 6 of 12 patients (50%) had a BMI >/= 60. Another 6 had chronic leg swelling with stasis dermatitis. 2 patients experienced a previous PE, and 1 patient reported a history of deep vein thrombosis (DVT).
4 patients (33%) demonstrated a combination of risk factors (VSD, BMI >/= 60, truncal obesity, OHS/SAS) recognized as significant for the development of postoperative VTE. In such patients, prophylactic IVC filter placement is highly recommended. Filter placement for other factors, such as age, body build, hypercoagulable state, etc., should be considered on an individual basis.
肺栓塞（PE）是病态肥胖患者胃旁路手术后死亡的主要原因。尽管其发病率似乎稳定，但每年进行的减肥手术数量却在大幅增加；因此，孤立性致命性肺栓塞已不再罕见。回顾了自1979年以来接受减肥手术患者的记录，以确定增加发生致命性肺栓塞风险的具体因素。还研究了在高危患者中预防性置入下腔静脉（IVC）滤器的推荐和可选指征。
1979年9月至2003年3月期间，对5554例临床严重肥胖患者进行了手术。这些手术包括空肠-回肠旁路术、水平胃成形术、带30毫升胃囊的Roux-en-Y胃旁路术、改良胆胰转流术、萨帕拉-伍德微型胃旁路术（Micropouch(SM)）、可调节胃束带术及修复手术。共识别出12例致命性肺栓塞（0.21%）。除1例栓子外，其余均发生在术后30天内。
12例患者中有11例至少存在1种已知会增加术后静脉血栓栓塞（VTE）风险的合并症。4种合并症在4例患者中常见（33%）：静脉淤滞疾病（VSD）、BMI≥60、躯干肥胖以及肥胖低通气综合征/睡眠呼吸暂停综合征（OHS/SAS）。12例患者中有6例（50%）BMI≥60。另外6例有慢性腿部肿胀伴淤积性皮炎。2例患者曾发生过肺栓塞，1例患者有深静脉血栓形成（DVT）病史。
4例患者（33%）表现出被认为对术后VTE发生具有重要意义的危险因素组合（VSD、BMI≥60、躯干肥胖、OHS/SAS）。对于此类患者，强烈建议预防性置入IVC滤器。对于其他因素，如年龄、体型、高凝状态等，应根据个体情况考虑是否置入滤器。
