International expert Delphi consensus on thromboprophylaxis in metabolic and bariatric surgery

Metabolic and bariatric surgery (MBS) is highly effective for severe obesity but carries rare, serious risks, most notably venous thromboembolism (VTE), the leading cause of postoperative death. Strikingly, most VTE events occur after patients leave the hospital. Yet, despite guidelines, there is no global agreement on prevention strategies. This international expert consensus unites specialists worldwide to provide clarity and practical recommendations for safer outcomes in MBS. This study used a two-round modified Delphi process to unite 102 experts from 42 countries on thromboprophylaxis in MBS. Guided by evidence and ethical approval, participants, surgeons, hematologists, and pharmacologists reviewed 25 statements online. In the second round, the remaining three were revised and re-evaluated. This method ensured balanced input, minimized bias, and produced a robust international consensus to guide safer surgical practice. In round one, 22 of 25 statements met the ≥ 80% consensus threshold. In round two, the experts re-evaluated the remaining three statements, with one more reaching agreement. Overall, consensus was achieved on 23 of 25 statements. This international Delphi consensus achieved agreement on 23 of 25 statements (92%), offering evidence-based guidance for VTE prophylaxis in MBS. Key recommendations include individualized risk assessment, extended prophylaxis for high-risk patients, preference for LMWH, and growing support for direct oral anticoagulants (DOACs), especially apixaban. The consensus promotes personalized strategies over uniform protocols while highlighting research priorities on dosing, duration, and DOAC comparisons. Implementing these recommendations can standardize care, improve safety, and reduce VTE-related morbidity and mortality worldwide.