Discussion
Candidates for bariatric surgery naturally amass multiple risks of
thrombotic events. They suffer from obesity, chronically venous
insufficiency, a recent surgery, and usually are less physically active
[6]. On the other hand, although these thromboembolic events are not
common, they are highly detrimental and mostly present in the first 30
post-operative days [2, 7, 8]. Nevertheless, unfortunately, there is
not yet an established global consensus on thromboprophylaxis in these
patients. The literature lacks an optimum drug, dosage, and duration for
pharmacologic thromboprophylaxis.
The presentation of PE is unspecific, which makes it difficult to
diagnose. In this condition, the most important differential diagnoses
in patients undergoing bariatric surgery are post-operative bleeding,
anastomotic leakage, and myocardial infarction. Differentiation between
these diagnoses is highly time-sensitive. In our case, we decided to
include spiral abdominopelvic CT scan, spiral CT angiography,
abdominopelvic ultrasonography, and echocardiography. We believed these
evaluations would help narrow the differential diagnosis as quickly as
possible. Then, we followed the therapeutic effects and potential
adverse events by daily follow-ups with abdominopelvic ultrasonography
and echocardiography.
Massive PE is a serious complication and requires rigorous treatment.
Careful clinical assessment must include proper risk stratification
since it will influence both diagnostic and therapeutic decision-making.
Administration of systemic thrombolytics has been shown to resolve
symptoms rapidly [9]. However, systemic thrombolytics are
controversial in bariatric surgery patients due they can adversely cause
life-threatening complications such as anastomotic leakage and
intraabdominal bleeding; therefore, it is considered relatively
contraindicated [6]. Considering the debate mentioned earlier,
massive PE appears to be a significant challenge to manage in bariatric
surgery post-operative settings. However, considering the potentially
fatal outcome of massive PE, we decided to take the risk of systemic
thrombolytic, which was beneficial to the patient