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Postbariatric Bleeding Linkage to Diabetes and Hypertension
            Table 2: Demographic features, diabetes and hypertension, association   In De Angelis et al.‘s study on 870 patients who underwent
            with RBC transfusion                               sleeve gastrectomy, the postoperative bleeding rate was 1.9%. In
                          With transfusion  Without transfusion  their study, Buttress material was used to prevent bleeding during
                             (n = 20)      (n = 1407)  p value  the operation. They did not do omentopexy and stapler line routine
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                                                               overswing in gastric sleeve surgery.  In the present study, the
             Demographics                                      bleeding rate was 1.3%. We still believe that omentopexy might
               Age (year) a   39 (10.7)    35.8 (9.5)   0.17   reduce intra and postoperative bleeding rates.
             Sex                                                  In a study by Saber et al., omentopexy reduced surgery-
               Male           10 (14.3)     240 (17.7)  0.07   related bleeding. He compared 100 patients with and 100 without
                                                               omentopexy done. They found that omentopexy effectively
               Female         13 (85.7)    1164 (82.7)         reduced postoperative bleeding (0.8 vs 2.3%).  We also performed
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             Weight (kg) a  124.5 (28.1)  121.8 (20.3)  0.7    omentopexy for all SG patients, and the prevalence of bleeding
             Height (cm) a  163.8 (10)    165.3 (28.3)  0.38   after this operation was 1.3% in the current study.
                    2 a
             BMI (kg/m )      44 (5.5)     44.9 (6.3)   0.001     In Lim et al., which examined a database of 633 patients, the
                                                               rate of bleeding after gastric sleeve surgery was 7.4%. Low BMI was
             Comorbidities
                                                               reported as a risk factor for postoperative bleeding in this study.
               DM              7 (35)       222 (15.8)  0.001  They used sealants to strengthen the stapler line, which did not
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               HTN             6 (30)       192 (13.6)  0.007  reduce postoperative bleeding.  In the current study, BMI did not
            BMI, body mass index; DM, diabetes mellitus; HTN, hypertension  affect the bleeding rate after bariatric surgery.
            a Data reported as mean ± standard deviation          In our experience, the best way to reduce bleeding during
            b Data reported as the number and percentage in parentheses  and after surgery is to prevent it. Accordingly, one way to prevent
                                                                 intraoperative bleeding is complete intraoperative homeostasis.
               By Chi-square test (or Fisher exact test) and independent t-test,     Furthermore, we propose omentopexy in SG to prevent intraopera-
            the difference between the two groups (with and without the need   tive and postoperative bleeding.
            for blood transfusion) was statistically significant only in terms of   We still believe that intraoperative drain placement will not be
            diabetes (p <0.03) and hypertension (p <0.048).    necessary to diagnose postoperative bleeding. We also believe that
               Patients who needed blood transfusion were 2.9 times more   controlling the patient’s vital signs and laboratory tests after surgery
            likely to have diabetes OR = 2.9 (95% CI: 1.1–7.3). These patients also   would be the best surveillance method for bleeding.
            suffered from hypertension 2.7 times more often than other patients   In this study, a clear relationship was seen between the history
            who did not need blood transfusions OR = 2.7 (95% CI:1.03–7.3).  of diabetes and hypertension with postoperative bleeding. Previous
                                                               studies have shown an association between intraoperative blood
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            dIscussIon                                         pressure changes and postoperative bleeding,  but no association
            Bariatric surgery is one of the most effective and long-term durable   was found between a history of hypertension and postoperative
            treatments for patients suffering from morbid obesity. In most   bleeding. Therefore, we assume that proper control of the
            bariatric operations, the stomach is manipulated. Excessive gastric   patient’s blood sugar and blood pressure before, during, and after
            perfusion makes these operations prone to bleeding during and   surgery may prevent surgery-related bleeding. However, more
            after surgery. Moreover, bleeding is still one of the most common   postoperative bleeding in diabetic and hypertensive patients may
            early complications after bariatric surgeries. Therefore, knowing   be due to these diseases’ long-term effects on the patient’s vessels.
            more about bleeding risk factors will help take more preventive   So, short-term control of blood sugar and blood pressure factors
            measures in patients.                              might not be useful for omitting these risk factors. We recommend
               In a study by Zafar et al., performed on 168,093 patients from   that in the future, more extensive studies be performed on the exact
            742 centers, the rate of postoperative bleeding was 1.2%. The rate   role of blood sugar, patient’s blood pressure, and their fluctuations
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            of postoperative bleeding in the current study was 1.4.    on bleeding in the perioperative period to develop more accurate
               In a study by Carabajo et al., on 209 patients who underwent   protocols for diabetic and hypertensive patients undergoing
            OAGB surgery, two patients (0.9) needed reoperation to control   bariatric surgery.
            bleeding. The study did not mention patients who needed a   According to the current study, a history of diabetes and
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            blood transfusion following bleeding.  None of the patients who   hypertension might be a risk factor for postbariatric surgery
            underwent OAGB required reoperation to control bleeding in the   hemorrhage. Therefore, it is recommended that bariatric surgeons
            present study, but blood transfusions were given to three patients   pay more attention to hemostasis during surgery and postoperative
            (4.3%) following hemorrhage.                       care for such patients to prevent bleeding after surgery.
               In the study of Spivak et al., bleeding’s relationship after GS   However, multicentric studies are recommended to investigate
            surgery and a history of diabetes was investigated. Examining the   the hemorrhage after bariatric surgery associated with diabetes
            databases of 394 patients, they found a link between a history of   and hypertension.
            diabetes and postoperative bleeding (OR = 2.6). As in the current   One of the limitations of this study was the small number of
            study, the criterion for acute postoperative bleeding in that study   patients who underwent OAGB surgery, so we suggest that these
            was the need for postoperative RBC transfusion. Acute bleeding   variables be examined more in this operation in the future.
            after LSG was reported to be 2.8%, and it was stated that the   Patients with a lower drop in hemoglobin levels who did not
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            operation technique was not related to it.  The rate of bleeding   require blood transfusions were not evaluated in this study. Further
            after LSG was 1.3% in the current study. We also found a link   studies could investigate the risk factors for minor and sub-acute
            between diabetes and postoperative bleeding (OR = 2.9).  bleeding after bariatric surgery.

                                                        World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)  165
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