Role of Tranexamic Acid in Reducing Hemorrhagic Events in Bariatric Surgery

STUDY BACKGROUND:

1. Introduction Obesity, over the past few decades, has become an area of concern as leading to major non-communicable diseases such as cardiovascular diseases, hypertension, type 2 diabetes mellitus, dyslipidemia and cancer. It has been declared a global epidemic by WHO due to the large prevalence of overweight and obese populations. A cross-sectional study conducted in Multan, Pakistan (2019) revealed the prevalence of obesity in women is 30.2% and in men at 24.3%. (1) Bariatric surgery remains an effective method of weight reduction in patients with obesity refractory to diet and drug therapy. Bariatric surgery has been established as a standard of treatment for morbid obesity. Laparoscopic Sleeve Gastrectomy (LSG) and Roux-en-Y Gastric bypass (RYGB) remain the two common surgical techniques. (2) These procedures are generally safe and effective, postoperative complications such as anastomotic leak, hemorrhage, obstruction, and Venous Thromboembolism (VTE) add to associated morbidities with up to 2% risk of serious complications, i.e., bleeding, leak etc. (3)

Though the safety profile of LSG is superior to RYGB, bleeding still remains a significant morbidity peri-operative. (4) Available literature shows evidence of bleeding incidence to be 2-4%. (05) Hemorrhage in RYGB occurs roughly in 3% of the patients, (07) as compared to 2% in LSG. (08) These hemorrhagic events occur as staple line bleed, from mesenteric vessels and iatrogenic injury. () As hemorrhage leads to re-operation, various methods over time have been implied upon to reduce the risk of bleeding intra and post-operatively; these include suturing, buttressing, and human fibrin sealant.

Where these techniques appear to be complicated and expensive, a cost-effective and simpler solution could be the use of Tranexamic acid (TXA). Tranexamic acid is a synthetic lysine analogue that blocks lysine binding sites on plasminogen molecules hence inhibiting the formation of plasmin, thereby inhibiting fibrinolysis. TXA is being successfully used for various gynecological, orthopedic, and cardiothoracic procedures. Its role in bariatric surgery is not very well established. (09) Data on the use of TXA in reducing peri-operative bleeding is not readily available. A prospective cohort on the effectiveness of reducing staple line bleeding in LSG patients suggests the use of TXA to be safe and cost-effective (10). Another retrospective study reported a reduction in staple line bleed by use of TXA (44 patients were given TXA post-operatively, and only 04 out of this required re-operation.) () A retro prospective cohort study conducted on 314 patients undergoing LSG infers that TXA administration at the time on induction reduces hemorrhagic incidents and rate of re-operations. (05) Data on randomized controlled trials investigating the role of TXA in patients undergoing LSG and MGB is not available. 2. OBJECTIVE:

To determine the effectiveness of TXA in reducing hemorrhagic events when given prophylactically and post-operatively in patients undergoing LSG and MGB. 3. STUDY DESIGN: