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