摘要
静脉血栓栓塞（VTE）是减重代谢外科术后常见的并发症之一，极度肥胖患者具有较高的VTE发生风险。笔者就国内外相关指南、文献进行梳理分析，同时结合笔者中心的临床经验，整理并总结极度肥胖患者围手术期VTE预防管理流程，以期为VTE的防治提供参考。
China Journal of General Surgery, 2024, 33(4):539-544.
静脉血栓栓塞（venous thromboembolism，VTE）是一种静脉内血栓形成进而引起静脉阻塞性回流障碍及一系列相关病理生理改变的潜在致死性疾
虽然国内外对减重代谢外科围手术期VTE预防已达成初步共识并制定了相应的VTE防治方案，但有关极度肥胖患者围手术期VTE预防的临床证据依然有
图1 极度肥胖患者VTE防治围手术期管理流程
Figure 1 Perioperative management protocol for the prophylaxis and treatment of VTE in extremely obese patients
在现有的普通外科围手术期VTE风险评估量表中，Caprini静脉血栓栓塞症风险评分（2005版）（简称“Carprini评分”）是较全面的通用型VTE风险评估量表，使用简单方便，涵盖了各种外科手术和外科住院患者可能存在的VTE发生风险因
| 风险因素 | 分值 |
|---|---|
| 手术方式 | |
| 可调节胃绑带术 | 0 |
| 腹腔镜Roux-en-Y胃旁路术 | 3 |
| 腹腔镜胃袖状切除术 | 4 |
| 开腹Roux-en-Y胃旁路术 | 6 |
| 胆胰分流并十二指肠转位术 | 8 |
| 年龄（岁） | |
| <30 | 1 |
| 30~39 | 2 |
| 40~49 | 3 |
| 50~59 | 4 |
| >60 | 5 |
|
BMI（kg/ | |
| <40 | 1 |
| 40~49 | 2 |
| 50~59 | 3 |
| >60 | 4 |
| 男性 | 2 |
| 吸烟史 | 2 |
| 手术时间>3 h | 2 |
| 既往VTE病史 | 5 |
| 总分 |
| 总分 | 风险级别系数 （%） | LMWH使用剂量 | ||
|---|---|---|---|---|
| 围手术期 | 术后 | 出院后 | ||
| 0~14 | 低（<1.0） | 预防量 | 预防量 | — |
| 15~19 | 中（1.0~4.0） | 预防量 | 预防量 | 预防量 |
| 20~28 | 高（>4.0） | 预防量 | 治疗量 | 治疗量 |
MBSC量表是首个基于肥胖患者研究提出的VTE风险评估模型，它依据术式、年龄、BMI、性别、吸烟史、手术时间等维度对接受减重代谢手术的患者进行VTE风险评估，根据总评分将VTE风险程度分为低、中、高三级，并按照不同的风险级别，在围手术期、术后及出院后分别推荐予以不同剂量的低分子量肝素（low molecular weight heparin，LMWH）。
以中位年龄32岁的男性极度肥胖患者接受腹腔镜胃袖状切除术为例，患者常伴有阻塞性睡眠呼吸暂停低通气综合征、下肢肿胀等合并症，术中常规予以中心静脉置管，腹腔镜手术时间>45 min，其Caprini评分至少为6分（基于Caprini评分的外科手术患者VTE评级，当评分≥5分即属于高危人群，需要进行药物预防和机械预防），而采用MBSC量表，其VTE风险总分在13~14分之间，属于低风险级别，推荐围手术期及术后早期的LMWH的预防使用。因此，Caprini评分可能将肥胖患者VTE风险级别升
在Caprini评分与MBSC量表VTE风险联合评估基础上，根据MBSC预防/治疗方案应用预防剂量的LMWH预防极度肥胖患者术前VTE的发生。美国代谢和减重外科学会最新研
对术前服用抗血小板药物的患者，需要根据患者的心脑血管疾病情况、减重代谢手术的类型、血栓形成风险、围手术期出血风险等因素综合评定是否停药及桥
极度肥胖患者手术相对复杂，术中因全麻、长时间被动体位、出血、低体温等因素导致患者容易出现血液高凝、外周血管收缩，下肢静脉回流减慢，进而诱发VTE发
鼓励患者在术后2 h尽早下床活动，穿戴弹力
研
综上所述，随着减重代谢手术在国内的广泛推广，减重代谢患者围手术期VTE预防越来越引起广大减重外科同道的重视。由于绝大多数极度肥胖患者均属于VTE高风险人群，因此重视极度肥胖患者围手术期VTE问题，做好VTE的防治对提高极度肥胖患者手术疗效和医疗安全更具有特别重要的意义。
作者贡献声明
董文培负责文献整理、图表制作、论文撰写和修改；侯栋升、王睿、杨董超负责文献整理、图表制作；宋致成、杨建军负责论文修改；顾岩负责文章构思、论文撰写与修改、经费支持。
利益冲突
所有作者均声明不存在利益冲突。
参考文献
El Ansari W, Sathian B, El-Menyar A. Venous thromboembolic events after bariatric surgery: protocol for a systematic review and meta-analysis[J]. Int J Surg Protoc, 2020, 22:10-14. doi: 10.1016/j.isjp.2020.06.001. [百度学术]
Aminian A, Andalib A, Khorgami Z, et al. Who Should Get Extended Thromboprophylaxis After Bariatric Surgery?: A Risk Assessment Tool to Guide Indications for Post-discharge Pharmacoprophylaxis[J]. Ann Surg, 2017, 265(1):143-150. doi:10.1097/SLA.0000000000001686. [百度学术]
Altieri MS, Yang J, Hajagos J, et al. Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures[J]. Surg Endosc, 2018, 32(12):4805-4812. doi:10.1007/s00464-018-6231-z. [百度学术]
Aminian A, Vosburg RW, Altieri MS, et al. The American Society for Metabolic and Bariatric Surgery (ASMBS) updated position statement on perioperative venous thromboembolism prophylaxis in bariatric surgery[J]. Surg Obes Relat Dis, 2022, 18(2):165-174. doi:10.1016/j.soard.2021.10.023. [百度学术]
Halawani HM, Ripley-Hager CF, Naglak MC, et al. Venous thromboembolism after laparoscopic or robotic biliopancreatic diversion with duodenal switch. Ninety-days outcome of a 10 years' experience[J]. Surg Obes Relat Dis, 2017, 13(12):1984-1989. doi:10.1016/j.soard.2017.09.002. [百度学术]
中华医学会外科学分会. 中国普通外科围手术期血栓预防与管理指南[J]. 中国实用外科杂志, 2016, 36(5):469-474. doi:10.7504/CJPS.ISSN1005-2208.2016.05.01. [百度学术]
Surgery Society of Chinese Medical Association. Guidelines for prevention and management of perioperative thrombosis in general surgery in China[J]. Chinese Journal of Practical Surgery, 2016, 36(5):469-474. doi:10.7504/CJPS.ISSN1005-2208.2016.05.01. [百度学术]
国家卫生健康委员会能力建设和继续教育外科学专家委员会减重与代谢外科专业委员会, 北京市减重与代谢外科质量控制和改进中心.中国减重与代谢外科围手术期静脉血栓栓塞症预防指南（2021版）[J].中国实用外科杂志, 2022, 42(1):7-16. doi:10.19538/j.cjps.issn1005-2208.2022.01.02. [百度学术]
Chinese College of Metabolic and Bariatric Surgeons, Affiliation of National Health Commission Capacity Building and Continuing Education Center, Beijing Quality Control and Improvement Center for Metabolic and Bariatric Surgery. Chinese clinical practice guidelines for the prevention of perioperative venous thromboembolism in metabolic and bariatric surgery (2021 edition)[J]. Chinese Journal of Practical Surgery, 2022, 42(1):7-16. doi:10.19538/j.cjps.issn1005-2208.2022.01.02. [百度学术]
Stier C, Koschker AC, Stier R, et al. Are we missing treatment standards for thromboprophylaxis of the obese and super-obese patient population? A prospective systematic cohort study[J]. Obes Surg, 2020, 30(5):1704-1711. doi: 10.1007/s11695-020-04383-w. [百度学术]
Lovely JK, Hickman JA, Johnson MG, et al. Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis[J]. Mayo Clin Proc Innov Qual Outcomes, 2020, 4(2):159-169. doi:10.1016/j.mayocpiqo.2019.10.006. [百度学术]
Chindamo MC, Paiva EF, Jrdo Carmo PR, et al. Challenges of extended venous thromboembolism prophylaxis in medical and surgical patients[J]. J Vasc Bras, 2022, 21:e20210195. doi: 10.1590/1677-5449.202101951. [百度学术]
王勇, 张旭. 减重及代谢疾病病人围手术期静脉血栓栓塞症预防[J]. 中国实用外科杂志, 2017, 37(2):129-132. doi: 10.19538/j.cjps.issn1005-2208.2017.02.07. [百度学术]
Wang Y, Zhang X. Prevention of perioperative venous thromboembolism in patients with weight loss and metabolic diseases[J]. Chinese Journal of Practical Surgery, 2017, 37(2):129-132. doi: 10.19538/j.cjps.issn1005-2208.2017.02.07. [百度学术]
中华医学会外科学分会血管外科学组. 深静脉血栓形成的诊断和治疗指南(第三版)[J]. 中国血管外科杂志:电子版, 2017, 9(4):250-257. doi:10.3969/j.issn.1674-7429.2017.04.003. [百度学术]
Group of Vascular Surgery, Society of Surgery, Chinese Medical Association. Guidelines for diagnosis and treatment of deep venous thromboembolism(the third edition)[J]. Chinese Journal of Vascular Surgery: Electronic Version, 2017, 9(4):250-257. doi:10.3969/j.issn.1674-7429.2017.04.003. [百度学术]
Finks JF, English WJ, Carlin AM, et al. Predicting risk for venous thromboembolism with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative[J]. Ann Surg, 2012, 255(6):1100-1104. doi:10.1097/SLA.0b013e31825659d4. [百度学术]
Dang JT, Switzer N, Delisle M, et al. Predicting venous thromboembolism following laparoscopic bariatric surgery: development of the BariClot tool using the MBSAQIP database[J]. Surg Endosc, 2019, 33(3):821-831. doi: 10.1007/s00464-018-6348-0. [百度学术]
Giannopoulos S, Kalantar Motamedi SM, Athanasiadis DI, et al. Venous thromboembolism (VTE) prophylaxis after bariatric surgery: a national survey of MBSAQIP director practices[J]. Surg Obes Relat Dis, 2023, 19(8):799-807. doi:10.1016/j.soard.2022.12.038. [百度学术]
Venclauskas L, Maleckas A, Arcelus JI, et al. European guidelines on perioperative venous thromboembolism prophylaxis: surgery in the obese patient[J]. Eur J Anaesthesiol, 2018, 35(2):147-153. doi: 10.1097/EJA.0000000000000703. [百度学术]
Frantzides CT, Welle SN, Ruff TM, et al. Routine anticoagulation for venous thromboembolism prevention following laparoscopic gastric bypass[J]. JSLS, 2012, 16(1):33-37. doi: 10.4293/108680812X13291597716906. [百度学术]
Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines[J]. Chest, 2012, 141(2 Suppl):e227S-277S. doi: 10.1378/chest.11-2297. [百度学术]
Abuoglu HH, Tolga Müftüoğlu MA, Odabaşı M. A new protocol for venous thromboembolism prophylaxis in bariatric surgery[J]. Obes Surg, 2019, 29(2):729-734. doi: 10.1007/s11695-018-03643-0. [百度学术]
Borkgren-Okonek MJ, Hart RW, Pantano JE, et al. Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration, dose stratification, and antifactor Xa activity[J]. Surg Obes Relat Dis, 2008, 4(5):625-631. doi: 10.1016/j.soard.2007.11.010. [百度学术]
Steele KE, Canner J, Prokopowicz G, et al. The EFFORT trial: Preoperative enoxaparin versus postoperative fondaparinux for thromboprophylaxis in bariatric surgical patients: a randomized double-blind pilot trial[J]. Surg Obes Relat Dis, 2015, 11(3):672-683. doi: 10.1016/j.soard.2014.10.003. [百度学术]
Filipescu DC, Stefan MG, Valeanu L, et al. Perioperative management of antiplatelet therapy in noncardiac surgery[J]. Curr Opin Anaesthesiol, 2020, 33(3):454-462. doi: 10.1097/ACO.0000000000000875. [百度学术]
Banerjee S, Angiolillo DJ, Boden WE, et al. Use of antiplatelet therapy/DAPT for post-PCI patients undergoing noncardiac surgery[J]. J Am Coll Cardiol, 2017, 69(14):1861-1870. doi: 10.1016/j.jacc.2017.02.012. [百度学术]
Buraimoh MA, Nash A, Howard B, et al. Effect of forced-air warming blanket position in elective lumbar spine surgery: Intraoperative body temperature and postoperative complications[J]. Surg Neurol Int, 2019, 10:229. doi: 10.25259/SNI_102_2019. [百度学术]
杨建军, 侯栋升, 董文培, 等.应用胃悬吊技术行单孔腹腔镜胃袖状切除术围手术期疗效对比研究[J].中国实用外科杂志, 2023, 43(5):562-565. doi:10.19538/j.cjps.issn1005-2208.2023.05.16. [百度学术]
Yang JJ, Hou DS, Dong WP, et al. Comparative study of perioperative effect about single port laparoscopic sleeve gastrectomy with gastric suspension technique[J]. Chinese Journal of Practical Surgery, 2023, 43(5):562-565. doi:10.19538/j.cjps.issn1005-2208.2023.05.16. [百度学术]
王存川, 张鹏, 赵玉沛. 腹腔镜袖状胃切除术操作指南(2018版)[J]. 中华肥胖与代谢病电子杂志, 2018, 4(4):196-201. [百度学术]
Wang CC, Zhang P, Zhao YP. The clinical guidline for laparoscopic sleeve gastrectomy procedure(2018 edition)[J]. Chinese Journal of Obesity and Metabolic Diseases: Electronic Edition, 2018, 4(4):196-201. [百度学术]
Stein PD, Matta F, Goldman J. Obesity and pulmonary embolism: the mounting evidence of risk and the mortality paradox[J]. Thromb Res, 2011, 128(6):518-523. doi: 10.1016/j.thromres.2011.10.019. [百度学术]
Winegar DA, Sherif B, Pate V, et al. Venous thromboembolism after bariatric surgery performed by Bariatric Surgery Center of Excellence Participants: analysis of the Bariatric Outcomes Longitudinal Database[J]. Surg Obes Relat Dis, 2011, 7(2):181-188. doi:10.1016/j.soard.2010.12.008. [百度学术]
Imbus JR, Jung AD, JrDavis S, et al. Extended postoperative venous thromboembolism prophylaxis after bariatric surgery: a comparison of existing risk-stratification tools and 5-year MBSAQIP analysis[J]. Surg Obes Relat Dis, 2023, 19(8): 808-816. doi:10.1016/j.soard.2023.04.329. [百度学术]
Farge D, Frere C, Connors JM, et al. 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19[J]. Lancet Oncol, 2022, 23(7):e334-347. doi: 10.1016/S1470-2045(22)00160-7. [百度学术]
Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update[J]. J Clin Oncol, 2013, 31(17):2189-2204. doi: 10.1200/JCO.2013.49.1118. [百度学术]