Is rivaroxaban a safe and effective oral alternative to low-molecular-weight heparin in prophylaxis of portomesenteric and lower-limb deep-vein thrombosis after sleeve gastrectomy?

Background
The incidence of symptomatic deep-vein thrombosis (DVT) and pulmonary embolism ranges from 0 to 5.4% and 0 to 6.4%, respectively, but the true incidence remains uncertain. Although the overall incidence is low, venous thromboembolic events (VTE) represents a significant cause of morbidity and mortality after surgery. Even with aggressive prophylaxis, VTE cannot be fully prevented. The American Society of Metabolic and Bariatric Surgeons and the American College of Chest Physicians recommend prophylaxis against DVT for all bariatric surgery patients. Routine prophylactic perioperative use of low-molecular-weight heparins (LMWHs), intermittent pneumatic compression devices, and early mobilization are currently the major accepted measures to prevent VTE, particularly in high-risk groups (BMI >50 kg/m), advanced age, history of previous VTE, obesity hypoventilation syndrome, and open and revisional surgery.
Patients and methods
This prospective randomized clinical trial conducted on all obese patients underwent sleeve gastrectomy during the period from January 2018 to June 2020 (600 patients) with follow-up till January 2021. The patients were randomized into two groups with sealed-envelope technique, group 1 (300 patients) was given LMWH in prophylaxis of VTE. Group 2 (300 patients) was given direct oral anticoagulants (rivaroxaban) in prophylaxis of VTE.
Results
In our study, we compared between both groups as regards the incidence of complications among both groups, bleeding grade, recorded cases of hemoglobin drop during follow-up complete blood count, and any detected cases of abdominal bleeding or perigastric hematoma, and any detected cases of DVT in lower-limb (LL) venous duplex. There was no significant difference between both study groups as regards age. Minor bleeding was statistically higher among group-2 (13.3%) compared with group-1 (0.3%) cases. Moderate-to-major bleeding was statistically higher among group-1 (4%) compared with group-2 cases (0.3%). However, there were no statistically significant difference between both study groups as regards life-threatening bleeding. Throughout the study, no detectable portomesenteric vein occlusion or thrombosis in routine ultrasound was done 3 days postsleeve gastrectomy even if the patient is not complaining. No clinically suspected LL DVT throughout the study with no need to do LL venous duplex.
Conclusion
Rivaroxaban is a safe and effective alternative to LMWH in prophylaxis of portomesenteric and LL DVT after sleeve gastrectomy with better compliance and more patient satisfaction to the oral alternative.