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Davey MG, Joyce WP. Evaluating the safety profile of anti-platelet therapy in patients undergoing elective inguinal hernia repair: a systematic review and meta-analysis. Ir J Med Sci 2024; 193:897-902. [PMID: 37526871 PMCID: PMC10961273 DOI: 10.1007/s11845-023-03480-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION There remains no consensus surrounding the safety of prescribing anti-platelet therapies (APT) prior to elective inguinal hernia repair (IHR). AIMS To perform a systematic review and meta-analysis evaluating the safety profile of APT use in patients indicated to undergo elective IHR. METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel-Haenszel method using the Review Manager version 5.4 software. RESULTS Five studies including outcomes in 344 patients were included. Of these, 65.4% had APT discontinued (225/344), and 34.6% had APT continued (119/344). The majority of included patients were male (94.1%, 288/344). When continuing or discontinuing APT, there was no significant difference in overall haemorrhage rates (odds ratio (OR): 1.86, 95% confidence interval (CI): 0.29-11.78, P = 0.130) and in sensitivity analysis using only RCT data (OR: 0.63, 95% CI: 0.03-12.41, P = 0.760). Furthermore, there was no significant difference in reoperation rates (OR: 6.27, 95% CI: 0.72-54.60, P = 0.590); however, a significant difference was observed for readmission rates (OR: 5.67, 95% CI: 1.33-24.12, P = 0.020) when APT was continued or stopped pre-operatively. There was no significant difference in the estimated blood loss, intra-operative time, transfusion of blood products, rates of complications, cerebrovascular accidents, myocardial infarctions, or mortality observed. CONCLUSION This study illustrates the safety of continuing APT pre-operatively in patients undergoing elective IHR, with similar rates of haemorrhage, reoperation, and readmission observed. Clinical trials with larger patient recruitment will be required to fully establish the safety profile of prescribing APT in the pre-operative setting prior to elective IHR.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland.
| | - William P Joyce
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
- Department of Surgery, Galway Clinic, Co., Galway, H91 HHT0, Ireland
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Hackner D, Hobbs M, Merkel S, Krautz C, Weber GF, Grützmann R, Brunner M. Impact of Aspirin Intake on Postoperative Survival after Primary Pancreatic Resection of Pancreatic Ductal Adenocarcinoma-A Single-Center Evaluation. Biomedicines 2023; 11:biomedicines11051466. [PMID: 37239137 DOI: 10.3390/biomedicines11051466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The intake of aspirin (ASS) has been demonstrated to have a relevant impact on the pathogenesis, incidence and outcome in different solid gastrointestinal tumors. However, data on the effect of ASS on the short-term outcome and the long-term survival in patients with pancreatic carcinoma are still limited. (2) Methods: A total of 213 patients who underwent primary resection of PDAC at the University Hospital of Erlangen from January 2000 to December 2018 were included in this retrospective single-center study in total. Patients were stratified according to the aspirin intake into three groups: continuous aspirin intake (cASS), perioperatively interrupted aspirin intake (iASS) and no aspirin intake (no ASS) at the timepoint of surgery. The postoperative outcome as well as long-term survival were compared between the groups. (3) Results: There were no differences regarding postoperative morbidity (iASS: 54% vs. cASS: 53% vs. no ASS: 64%, p = 0.448) and in-hospital mortality (iASS: 4% vs. cASS: 10% vs. no ASS: 3%, p = 0.198) between the groups. The overall survival (OS) and disease-free survival (DFS) did not differ in the groups when comparing the ASS-intake status (OS: iASS 17.8 months vs. cASS 19.6 months vs. no ASS 21.6 months, p = 0.489; DFS: iASS 14.0 months vs. cASS 18.3 months vs. no ASS 14.7 months, p = 0.957). Multivariate analysis revealed that age (hazard ratio (HR) 2.2, p < 0.001), lymph node-positive status (HR 2.0, p < 0.001), R status 1 or 2 (HR 2.8, p < 0.001) and differentiation with a grading of 3 (HR 1.7, p = 0.005) were significant independent prognostic factors regarding the OS. Moreover, age (HR 1.5, p = 0.040), lymph node-positive status (HR 1.8, p = 0.002) and high-grade (G3) carcinomas (HR 1.5, p = 0.037) could be identified as independent prognostic parameters for DFS. (4) Conclusions: In patients undergoing primary surgery for curative resection of pancreatic carcinoma, the perioperative intake of ASS had no significant impact on postoperative outcome, overall and disease-free survival.
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Affiliation(s)
- Danilo Hackner
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Mirianna Hobbs
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
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Chen Q, Liu Y, Liu Y, Ji Y, Ye X, Li X, Fu Y, Miao J, Hou S, Hu B. Effect of perioperative aspirin continuation on bleeding after pneumonectomy. Thorac Cancer 2023; 14:1071-1076. [PMID: 36915945 PMCID: PMC10125781 DOI: 10.1111/1759-7714.14846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND To investigate the effect of continuous oral aspirin in perioperative period on bleeding in pneumonectomy. METHODS A total of 170 patients who underwent pneumonectomy in our hospital from March 2021 to March 2022 were selected as the study objects. All patients took oral aspirin before surgery and did not take other antiplatelet agent or anticoagulants at the same time. The continuation group included 85 cases and continued to take aspirin 100 mg/day during the perioperative period, and the interruption group included 85 cases who stopped aspirin for 7 days before surgery and 3 days after surgery, without bridging therapy. The intraoperative blood loss, operation time, conversion to thoracotomy rate, postoperative bleeding rate, blood transfusion rate, thrombotic events, postoperative drainage volume, length of hospital stay, and total hospital cost of the two groups were compared. RESULTS There were no statistically significant differences in intraoperative blood loss, operative time, rate of conversion to open, postoperative drainage, hospital stay, and cost between the two groups (p > 0.05), and there were no reoperations due to bleeding between the two groups. CONCLUSIONS Aspirin should be continued throughout the perioperative period in all high-risk patients requiring pneumonectomy after balancing ischemic-bleeding risks.
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Affiliation(s)
- Qirui Chen
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yan Liu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yi Liu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ying Ji
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Ye
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Li
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yili Fu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jinbai Miao
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shengcai Hou
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis. Mayo Clin Proc Innov Qual Outcomes 2022; 6:564-573. [PMID: 36304523 PMCID: PMC9594114 DOI: 10.1016/j.mayocpiqo.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures. METHODS This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible. RESULTS In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE). CONCLUSION This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.
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Key Words
- ACCP/CHEST, American College of Chest Physicians
- ASA, acetylsalicylic acid
- ATE, arterial thromboembolism
- CABG, coronary artery bypass graft
- COE, certainty of evidence
- CV, cardiovascular
- DES, drug-eluting stent
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- PE, pulmonary embolism
- PICO, patients–interventions–comparators–outcomes
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT, randomized clinical trial
- RR, relative risk
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Saito K, Saito Y, Muramatsu T, Kitahara H, Fujimoto Y, Isono S, Kobayashi Y. Impact of perioperative antithrombotic strategies on clinical events in non-cardiac surgery. Heart Vessels 2022; 37:1337-1343. [PMID: 35243527 DOI: 10.1007/s00380-022-02044-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/18/2022] [Indexed: 01/01/2023]
Abstract
Antithrombotic therapy including antiplatelet agents and anticoagulants are prescribed for secondary prevention in patients with established cardiovascular disease. Although antithrombotic therapy is often interrupted before non-cardiac surgery with or without perioperative bridging anticoagulation, the impact on thrombotic and bleeding events remains uncertain. A total of 360 patients chronically treated with antithrombotic therapy for secondary prevention underwent elective non-cardiac surgery under general anesthesia, with the complete interruption of antithrombotic agents. The study endpoints included all-cause death, thrombotic events, and major bleeding complications after surgical procedures. Of 360 patients, 190 (52.8%) and 200 (55.6%) received antiplatelet and anticoagulation perioperatively. Atrial fibrillation (32.8%) and coronary artery disease (22.5%) were the major indications for antithrombotic regimens. Antithrombotic therapy was interrupted from 5 [2, 7] days before the surgery to 4 [2, 7] days postoperatively. Perioperative bridging therapy with unfractionated heparin was employed in 113 (31.4%) patients. During the hospitalization, one (0.3%) patient died due to non-cardiovascular causes. Thrombotic events and major bleeding occurred in two (0.6%) and eight (2.2%) patients. Bridging therapy with heparin was significantly associated with an increased risk of bleeding events (5.3% vs. 0.8%, p = 0.02). Pre-operative bridging therapy with heparin and operative duration were significantly associated with bleeding complications. In the present study, complete interruption of antithrombotic therapy resulted in a few thrombotic events in patients undergoing elective non-cardiac surgery. Bridging therapy with heparin and longer operative duration were significantly associated with post-operative bleeding complications.
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Affiliation(s)
- Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan.
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Takahiro Muramatsu
- Department of Anesthesiology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Shiroh Isono
- Department of Anesthesiology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
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Oji K, Otowa Y, Yamazaki Y, Arai K, Mii Y, Kakinoki K, Nakamura T, Kuroda D. Taking antithrombic therapy during emergency laparoscopic cholecystectomy for acute cholecystitis does not affect the postoperative outcomes: a propensity score matched study. BMC Surg 2022; 22:42. [PMID: 35120469 PMCID: PMC8817483 DOI: 10.1186/s12893-022-01501-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/27/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Continuing antithrombic therapy (ATT) during surgery increases the risk of bleeding. However, it is difficult to discontinue the ATT in emergency surgery. Therefore, safety of emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) is still unclear. We aimed to clarify the affect of ATT during emergency LC for AC. METHODS Patients with AC were classified into ATT group (n = 30) and non-ATT group (n = 120). Postoperative outcomes were compared after propensity score matching (n = 22). RESULTS Higher level of c-reactive protein level and shorter activated partial thromboplastin time (APTT) was observed in ATT group than in non-ATT group after matching. No significant difference was found between other patient characteristics and perioperative results. Blood loss over 100 mL was observed in 8 patients. Multivariate analyze showed that APTT was an independent risk factor for bleeding over 100 mL (P = 0.039), while ACT and APT was not. CONCLUSIONS Taking ATT does not affect the blood loss or complications during emergency LC for AC. Controlling intraoperative bleeding is essential for a safe postoperative outcome.
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Affiliation(s)
- Kentaro Oji
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Yasunori Otowa
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan. .,Radiation Biology Branch, National Cancer Institute, 9000 Rockville Pike, Bethesda, Maryland, 20892, USA.
| | - Yuta Yamazaki
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Keisuke Arai
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Yasuhiko Mii
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Keitaro Kakinoki
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Tetsu Nakamura
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Daisuke Kuroda
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
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9
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Ohya H, Watanabe J, Suwa Y, Nakagawa K, Suwa H, Ozawa M, Ishibe A, Kunisaki C, Endo I. Comparison of the continuation and discontinuation of perioperative antiplatelet therapy in laparoscopic surgery for colorectal cancer: A retrospective, multicenter, observational study (YCOG 1603). Ann Gastroenterol Surg 2021; 5:67-74. [PMID: 33532682 PMCID: PMC7832956 DOI: 10.1002/ags3.12387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/08/2020] [Accepted: 07/20/2020] [Indexed: 11/07/2022] Open
Abstract
AIM The present study aimed to examine the effect of continuing antiplatelet therapy in the perioperative period for patients undergoing laparoscopic resection for colorectal cancer who had received preoperative antiplatelet therapy. METHODS This retrospective, multicenter, observational study included patients who underwent laparoscopic surgery for colorectal cancer between January 2011 and May 2020. The study population was limited to patients who used antiplatelet therapy preoperatively. RESULTS A total of 214 colorectal cancer patients who received antiplatelet therapy preoperatively were included in the present study. Eighty-nine patients underwent surgery under the continuation of antiplatelet therapy, and 125 patients underwent surgery under the discontinuation of antiplatelet therapy before surgery. There were no significant differences between the two groups with regard to intraoperative blood loss (P = .889), intraoperative blood transfusion (P = 1.000), and conversion to laparotomy (P = 1.000). There were no significant differences between the two groups in the incidence of postoperative hemorrhagic complications (Clavien-Dindo Grade ≥II, P = .453; Grade ≥III, P = .572) or three-point major adverse cardiovascular events (P = .268). However, there were two cases of postoperative non-fatal stroke in the discontinued antiplatelet therapy group. CONCLUSIONS The present study revealed that there were no significant differences in the surgical outcomes and postoperative complications between colorectal cancer patients who underwent laparoscopic resection with the continuation of antiplatelet therapy in the perioperative period and those in whom antiplatelet therapy was discontinued during the perioperative period. From the viewpoint of cardiovascular and cerebrovascular risk, it may be better for patients undergoing laparoscopic surgery for colorectal cancer to continue antiplatelet therapy. This study was registered with the Japanese Clinical Trials Registry as UMIN000038707 (http://www.umin.ac.jp/ctr/index.htm).
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Affiliation(s)
- Hiroki Ohya
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Jun Watanabe
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Yusuke Suwa
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Kazuya Nakagawa
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Hirokazu Suwa
- Department of SurgeryYokosuka Kyosai HospitalYokosukaJapan
| | - Mayumi Ozawa
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Atsushi Ishibe
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Chikara Kunisaki
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
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Continuation of antithrombotic therapy increases minor bleeding but does not increase the risk other morbidities in open inguinal hernia repair: A propensity score-matched analysis. Hernia 2020; 24:857-865. [PMID: 32162110 DOI: 10.1007/s10029-020-02169-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE An aging population has led to an increased number of patients with cardiovascular comorbidities requiring antithrombotic therapy. Perioperatively, surgeons should consider the increased risk of bleeding and thrombotic events in patients continuing or discontinuing these medications. We aimed to analyze the safety of continued antithrombotic therapy during open inguinal hernia repair. METHODS In this single-center, retrospective study, 4870 adult patients who underwent open inguinal hernia repair surgery by the same surgeon from 2008 January to 2019 March were included. Patients who underwent surgery while continuing antithrombotic therapy were included in the antithrombin group (n = 523) while those who were not under any antithrombotic therapy during the surgery were included in the control group (n = 4333). Using propensity score-matching, we then selected patients from each group with similar backgrounds. Surgery time, anesthesia time, postoperative bleeding, reoperation, and thrombotic event data were compared between the groups. Subgroup analysis based on the type of medications used was performed within the antithrombin group. RESULTS Ten patients in the antithrombin group and seven patients in the control group experienced postoperative bleeding (p < 0.001). The rate of postoperative bleeding was the highest in patients taking multiple medications. However, most were managed conservatively. Three patients from the antithrombin group experienced thrombotic events postoperatively (p = 0.001). CONCLUSIONS Patients receiving continued antithrombotic therapy had an increased risk of minor postoperative bleeding; however, they are a high-risk group for thrombotic events.
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11
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Matsuoka T, Kobayashi K, Lefor AK, Sasaki J, Shinozaki H. Antithrombotic drugs do not increase intraoperative blood loss in emergency gastrointestinal surgery: a single-institution propensity score analysis. World J Emerg Surg 2019; 14:63. [PMID: 31892938 PMCID: PMC6938014 DOI: 10.1186/s13017-019-0284-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/18/2019] [Indexed: 12/26/2022] Open
Abstract
Background The use of antithrombotic drugs is increasing with the aging population. Prior to elective procedures, antithrombotic drugs are often discontinued. For emergency procedures in patients taking antithrombotic drugs, their effect cannot be attenuated which may lead to an increased risk of hemorrhagic events. However, there are few studies showing increased intraoperative blood loss in patients taking antithrombotic drugs who undergo emergency gastrointestinal surgery. The aim of this study is to determine whether the use of antithrombotic agents increases intraoperative blood loss in emergency gastrointestinal surgery. Methods A retrospective review of patients who underwent emergency abdominal surgery between January 2013 and December 2017 was conducted. The primary outcome measure was intraoperative blood loss. Patients were divided into the antithrombotic drug group and a control group, and a propensity score was developed using multivariate logistic regression. We use 1:1 propensity score matching analysis to compare outcomes between the two groups. Results Of 1555 patients included in this study, 1184 patients, including 170 patients taking antithrombotic drugs, were eligible for propensity score matching analysis. A 1:1 matching yielded 117 well-balanced pairs. There was no statistically significant difference in intraoperative blood loss (antithrombotic drug group vs control group, median (interquartile): 60 (225–10) vs 100 (243–10) ml, p = 0.43). Conclusions This study suggests that antithrombotic drugs do not increase intraoperative blood loss in patients undergoing emergency gastrointestinal surgery. Emergency gastrointestinal surgery for patients currently taking antithrombotic drugs can be performed safely, and the use of antithrombotic drugs is not a reason to delay surgical intervention.
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Affiliation(s)
- Tadashi Matsuoka
- 1Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan.,2Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kenji Kobayashi
- 1Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Junichi Sasaki
- 2Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
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Li J, Wang M, Cheng T. The safe and risk assessment of perioperative antiplatelet and anticoagulation therapy in inguinal hernia repair, a systematic review. Surg Endosc 2019; 33:3165-3176. [DOI: 10.1007/s00464-019-06956-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/01/2019] [Indexed: 01/30/2023]
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13
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Stamenovic D, Schneider T, Messerschmidt A. Aspirin for patients undergoing major lung resections: hazardous or harmless?†. Interact Cardiovasc Thorac Surg 2019; 28:535-541. [PMID: 30346533 DOI: 10.1093/icvts/ivy255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Acetylsalicylic acid (ASA, aspirin) is a medication widely used for primary and secondary prevention of cardiovascular diseases, which are the leading cause of morbidity and mortality worldwide. Whether aspirin should be continued or paused in the perioperative period remains controversial, especially in thoracic surgical settings. METHODS A single-centred retrospective study comprised 486 patients. Of these, 329 patients did not use aspirin (group ASA-0) and 157 did (group ASA-1) during the perioperative period after anatomical lung resection at our hospital from January 2013 to December 2016. Major outcome measures were the amount of blood loss during the operation and during the first 5 days postoperatively (per Mercuriali's formula), as well as the amount and proportion of the blood transfusion (packed red cells) received. The need for reoperation due to a postoperative haemothorax and/or bleeding was recorded. The groups were also compared according to their rates of morbidity and mortality. Inferential statistical methods with bootstrap analysis using 1000 samples and the Mersenne Twister, a random number generator, were used. RESULTS There were no significant differences between the 2 groups in intraoperative bleeding [ASA-0M = 418.69 ml, standard deviation (SD) ± 364.87; ASA-1M = 399.8 ml, SD ± 323.84; P = 0.58] or in total blood loss according to Mercuriali's formula (ASA-0M = 1111.62 ml, SD ± 816.69; ASA-1M = 1115.08 ml, SD ± 682.12; P = 0.95). A total of 104 patients received transfusions up to postoperative day 5: 71 patients in the ASA-0 group received 151 blood transfusions, whereas 33 patients in the ASA-1 group received 65 blood transfusions (P = 0.66). The indication for reoperation due to bleeding (ASA-1 = 3, ASA-0 = 4; P = 0.69) was similar between the groups. There was a trend towards higher rates of postoperative complications in the ASA-1 group (risk ratio (RR) = 1.28; P = 0.055); neither cardiovascular complications nor deaths were more frequent in either of the 2 groups (P = 0.73). CONCLUSIONS Patients taking aspirin therapy and undergoing anatomical lung resection seem not to be at any disadvantage regarding bleeding. However, a trend towards a higher rate of postoperative complications indicates a basically increased risk for operations due to comorbidities in these patients.
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Affiliation(s)
- Davor Stamenovic
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
| | - Thomas Schneider
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
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14
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Goggs R, Blais MC, Brainard BM, Chan DL, deLaforcade AM, Rozanski E, Sharp CR. American College of Veterinary Emergency and Critical Care (ACVECC) Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE) guidelines: Small animal. J Vet Emerg Crit Care (San Antonio) 2019; 29:12-36. [PMID: 30654421 DOI: 10.1111/vec.12801] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/12/2018] [Accepted: 12/07/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To systematically review available evidence and establish guidelines related to the risk of developing thrombosis and the management of small animals with antithrombotics. DESIGN Standardized, systematic evaluation of the literature (identified by searching Medline via PubMed and CAB abstracts) was carried out in 5 domains (Defining populations at risk; Defining rational therapeutic use; Defining evidence-based protocols; Refining and monitoring antithrombotic therapies; and Discontinuing antithrombotic therapies). Evidence evaluation was carried out using Population, Intervention, Comparison, Outcome generated within each domain questions to address specific aims. This was followed by categorization of relevant articles according to level of evidence and quality (Good, Fair, or Poor). Synthesis of these data led to the development of a series of statements. Consensus on the final guidelines was achieved via Delphi-style surveys. Draft recommendations were presented at 2 international veterinary conferences and made available for community assessment, review, and comment prior to final revisions and publication. SETTINGS Academic and referral veterinary medical centers. RESULTS Over 500 studies were reviewed in detail. Worksheets from all 5 domains generated 59 statements with 83 guideline recommendations that were refined during 3 rounds of Delphi surveys. A high degree of consensus was reached across all guideline recommendations. CONCLUSIONS Overall, systematic evidence evaluations yielded more than 80 recommendations for the treatment of small animals with or at risk of developing thrombosis. Numerous significant knowledge gaps were highlighted by the evidence reviews undertaken, indicating the need for substantial additional research in this field.
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Affiliation(s)
- Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY
| | - Marie-Claude Blais
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, Canada
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA
| | - Daniel L Chan
- Department Clinical Science and Services, The Royal Veterinary College, London, United Kingdom
| | - Armelle M deLaforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Elizabeth Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Claire R Sharp
- School of Veterinary and Life Sciences, College of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
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15
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Brainard BM, Buriko Y, Good J, Ralph AG, Rozanski EA. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5-Discontinuation of anticoagulant therapy in small animals. J Vet Emerg Crit Care (San Antonio) 2019; 29:88-97. [PMID: 30654425 DOI: 10.1111/vec.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/10/2018] [Accepted: 12/08/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals DESIGN: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. SETTINGS Academic and referral veterinary medical centers. RESULTS Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed. CONCLUSIONS To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly.
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Affiliation(s)
- Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - Yekaterina Buriko
- Department of Clinical Studies, Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jennifer Good
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA
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16
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Vadivelu N, Kai AM, Dai F, Mikhael H, Aouad R, Blume P. Elevated International Normalized Ratio Is Not Associated With Increased Perioperative Morbidity in Podiatric Limb Salvage Surgery: A Retrospective Analysis. J Foot Ankle Surg 2018; 57:761-765. [PMID: 29752218 DOI: 10.1053/j.jfas.2018.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Indexed: 02/03/2023]
Abstract
The risk of hemorrhage always exists in anticoagulated patients with an elevated international normalized ratio (INR), a risk that must be measured against the necessity for surgical procedures. The objective of the present retrospective medical record study was to assess the safety with which limb salvage procedures can be conducted in patients with an INR >1.4. The medical records of 231 patients who had undergone limb salvage procedures by 1 surgeon at the Yale New Haven Health System from November 2008 through July 2014 were reviewed. All patients were administered foot blocks with monitored intravenous sedation. The patients' demographic data, comorbidities, preoperative anticoagulant use, coagulation profile, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, intraoperative ankle tourniquet use, and postoperative complications within the initial 72 hours were reviewed. We found no differences in intraoperative bleeding, total intraoperative time, or recovery time between the INR <1.4 group (n = 212) and the INR >1.4 group (n = 19). None of the patients experienced any postoperative complications, defined as any cardiac or pulmonary event, the need for invasive monitoring, or admission to the intensive care unit within the initial 72-hour period. Our findings suggest that patients are suitable for undergoing peripheral procedures with foot blocks and monitored intravenous sedation even in the presence of an elevated INR.
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Affiliation(s)
- Nalini Vadivelu
- Professor, Department of Anesthesiology, Yale University, New Haven, CT
| | - Alice M Kai
- Resident, Department of Internal Medicine, NYU Winthrop Hospital, Mineola, NY.
| | - Feng Dai
- Assistant Professor, Yale University, New Haven, CT
| | - Hosni Mikhael
- Assistant Professor, Department of Anesthesiology, Yale University, New Haven, CT
| | - Rima Aouad
- Assistant Professor, Department of Anesthesiology, Yale University, New Haven, CT
| | - Peter Blume
- Assistant Clinical Professor, Departments of Surgery, Anesthesia, and Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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17
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Lewis SR, Pritchard MW, Schofield‐Robinson OJ, Alderson P, Smith AF. Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2018; 7:CD012584. [PMID: 30019463 PMCID: PMC6513221 DOI: 10.1002/14651858.cd012584.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antiplatelet agents are recommended for people with myocardial infarction and acute coronary syndromes, transient ischaemic attack or stroke, and for those in whom coronary stents have been inserted. People who take antiplatelet agents are at increased risk of adverse events when undergoing non-cardiac surgery because of these indications. However, taking antiplatelet therapy also introduces risk to the person undergoing surgery because the likelihood of bleeding is increased. Discontinuing antiplatelet therapy before surgery might reduce this risk but subsequently it might make thrombotic problems, such as myocardial infarction, more likely. OBJECTIVES To compare the effects of continuation versus discontinuation for at least five days of antiplatelet therapy on the occurrence of bleeding and ischaemic events in adults undergoing non-cardiac surgery under general, spinal or regional anaesthesia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (1946 to January 2018), and Embase (1974 to January 2018). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included randomized controlled trials of adults who were taking single or dual antiplatelet therapy, for at least two weeks, and were scheduled for elective non-cardiac surgery. Included participants had at least one cardiac risk factor. We planned to include quasi-randomized studies.We excluded people scheduled for minor surgeries under local anaesthetic or sedation in which bleeding that required transfusion or additional surgery was unlikely. We included studies which compared perioperative continuation of antiplatelet therapy versus discontinuation of antiplatelet therapy or versus substitution of antiplatelet therapy with a placebo for at least five days before surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings. Our primary outcomes were: all-cause mortality at longest follow-up (up to six months); all-cause mortality (up to 30 days). Secondary outcomes included: blood loss requiring transfusion of blood products; blood loss requiring further surgical intervention; risk of ischaemic events. We used GRADE to assess the quality of evidence for each outcome MAIN RESULTS: We included five RCTs with 666 randomized adults. We identified three ongoing studies.All study participants were scheduled for elective general surgery (including abdominal, urological, orthopaedic and gynaecological surgery) under general, spinal or regional anaesthesia. Studies compared continuation of single or dual antiplatelet therapy (aspirin or clopidogrel) with discontinuation of therapy for at least five days before surgery.Three studies reported adequate methods of randomization, and two reported methods to conceal allocation. Three studies were placebo-controlled trials and were at low risk of performance bias, and three studies reported adequate methods to blind outcome assessors to group allocation. Attrition was limited in four studies and two studies had reported prospective registration with clinical trial registers and were at low risk of selective outcome reporting bias.We reported mortality at two time points: the longest follow-up reported by study authors up to six months, and time point reported by study authors up to 30 days. Five studies reported mortality up to six months (of which four studies had a longest follow-up at 30 days, and one study at 90 days) and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality up to six months (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.34 to 4.27; 659 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from eight fewer to 40 more). Combining the four studies with a longest follow-up at 30 days alone showed the same effect estimate, and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality at 30 days after surgery (RR 1.21, 95% CI 0.34 to 4.27; 616 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from nine fewer to 42 more).We found that either continuation or discontinuation of antiplatelet therapy probably makes little or no difference in incidences of blood loss requiring transfusion (RR 1.37, 95% CI 0.83 to 2.26; 368 participants; absolute effect of 42 more participants per 1000 requiring transfusion in the continuation group, ranging from 19 fewer to 119 more; four studies; moderate-certainty evidence); and may make little or no difference in incidences of blood loss requiring additional surgery (RR 1.54, 95% CI 0.31 to 7.58; 368 participants; absolute effect of six more participants per 1000 requiring additional surgery in the continuation group, ranging from seven fewer to 71 more; four studies; low-certainty evidence). We found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to incidences of ischaemic events (to include peripheral ischaemia, cerebral infarction, and myocardial infarction) within 30 days of surgery (RR 0.67, 95% CI 0.25 to 1.77; 616 participants; absolute effect of 17 fewer participants per 1000 with an ischaemic event in the continuation group, ranging from 39 fewer to 40 more; four studies; low-certainty evidence).We used the GRADE approach to downgrade evidence for all outcomes owing to limited evidence from few studies. We noted a wide confidence in effect estimates for mortality at the end of follow-up and at 30 days, and for blood loss requiring transfusion which suggested imprecision. We noted visual differences in study results for ischaemic events which suggested inconsistency. AUTHORS' CONCLUSIONS We found low-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery may make little or no difference to mortality, bleeding requiring surgical intervention, or ischaemic events. We found moderate-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery probably makes little or no difference to bleeding requiring transfusion. Evidence was limited to few studies with few participants, and with few events. The three ongoing studies may alter the conclusions of the review once published and assessed.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Perioperative aspirin therapy in non-cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2018; 258:59-67. [DOI: 10.1016/j.ijcard.2017.12.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 12/09/2017] [Accepted: 12/21/2017] [Indexed: 01/18/2023]
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Perioperative Platelet Inhibition in Elective Inguinal Hernia Surgery—Increased Rate of Postoperative Bleeding and Hematomas? Int Surg 2018. [DOI: 10.9738/intsurg-d-16-00041.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In patients on oral antiplatelet therapy secondary to critical vascular diseases, the risk of interrupting antiplatelet therapy has to be weighed against the risk of postoperative hematoma or bleeding when surgery is planned. The goal of this study was to determine the risk of postoperative hematoma and postoperative bleeding in elective inguinal hernia surgery during continuous platelet inhibition. Patients receiving either elective total extraperitoneal hernioplasty or Lichtenstein repair for inguinal hernia were included. Patients with mere suture repair, emergency hernia repair, combination of different simultaneous operations, and patients under therapeutic anticoagulation with heparin were excluded. Postoperative bleeding/hematoma was determined by physical examination and graded according to the Clavien-Dindo classification. Between January 2006 and December 2013, 561 patients with elective surgical repair of an inguinal hernia were included. A total of 29 patients were under continuous perioperative platelet inhibition (PI) with either aspirin or clopidogrel in addition to perioperative antithrombotic prophylaxis with subcutaneous dalteparin injections (PI group). A total of 532 patients received perioperative antithrombotic prophylaxis only (control group). The number of patients under antiplatelet therapy increased from 1.3% (Jan. 2006–Dec. 2009) to 10.0% (Jan. 2010–Dec. 2013; P < 0.0001). Postoperative hematoma/bleeding occurred in 5 PI patients (17.2%) versus 38 control patients (7.1%, P = 0.062). Rate of postoperative bleeding or hematoma is not higher under mono antiplatelet therapy for elective inguinal hernia repair. Since the majority of hematomas can be treated conservatively, it seems unnecessary to stop mono platelet inhibition perioperatively.
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Akahoshi K, Ochiai T, Takaoka A, Kitamura T, Ban D, Kudo A, Tanaka S, Tanabe M. Emergency Cholecystectomy for Patients on Antiplatelet Therapy. Am Surg 2017. [DOI: 10.1177/000313481708300523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
The use of antiplatelet therapy (APT) and/or anticoagulant therapy (ACT) continues to increase due to the aging population. Because the management of patients with acute cholecystitis receiving APT/ACTis still unclear, surgeons are sometimes faced with the difficult decision to delay surgery. We aimed to analyze characteristics and surgical risks of patients who underwent emergency cholecystectomy for acute cholecystitis without discontinuing APT. We conducted a retrospective review of 113 patients between 2006 and 2014. Treatment outcomes among 13 patients who underwent cholecystectomy without discontinuing APT (the cAPT group), 11 patients who discontinued APT and ACT (the D group), and 89 patients who did not receive preoperative APT and/or ACT (the No APT group) were compared. There were no significant differences in intraoperative blood loss, conversion to open surgery, and bleeding-related complications. However, the incidence of intraoperative blood transfusion was higher in the cAPT group (P = 0.04). They presented with severe local inflammation; thus, it was difficult to stop bleeding from the gallbladder bed. Hemostatic tools for liver surgery were used to control bleeding. Emergency cholecystectomy was tolerable for patients with acute cholecystitis while continuing APT. However, in case of severe local inflammation, there is a greater risk for massive hemorrhage.
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Affiliation(s)
| | | | - Ayumi Takaoka
- Departments of Hepatobiliary and Pancreatic Surgery and
| | | | - Daisuke Ban
- Departments of Hepatobiliary and Pancreatic Surgery and
| | - Atsushi Kudo
- Departments of Hepatobiliary and Pancreatic Surgery and
| | - Shinji Tanaka
- Molecular Oncology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Departments of Hepatobiliary and Pancreatic Surgery and
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21
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Kelm C, Engels K. [Perioperative management of patients on NOACs]. Med Klin Intensivmed Notfmed 2017; 112:125-128. [PMID: 28083624 DOI: 10.1007/s00063-016-0244-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/16/2016] [Indexed: 11/24/2022]
Abstract
Regarding thromboembolic events, non-vitamin K antagonists, so-called new oral anticoagulative agents (NOACs), have widely enlarged prophylaxis and therapy. In contrast to vitamin K antagonists they can be administered in a definite dose and do not need any regular control of coagulation parameters. Thus being simple in handling, these drugs have become enormously attractive for both patient and physician.In spite of all their advantages NOACs have to be considered carefully. They have a significant disadvantage: the plasma concentration is not detectable by a simple blood test, nor is there any antidote available. As a consequence the bleeding risk remains unknown.In this review we focus on two different settings in routine surgical work: the preoperative management of patients undergoing elective surgery differs significantly from that needed in urgent surgery.
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Affiliation(s)
- C Kelm
- Chirurgie 1, Klinik für Allgemein-, Visceral- und spezielle Visceralchirurgie, Klinikum Lüdenscheid, Paulmannshöherstr.14, 58515, Lüdenscheid, Deutschland.
| | - K Engels
- Chirurgie 1, Klinik für Allgemein-, Visceral- und spezielle Visceralchirurgie, Klinikum Lüdenscheid, Paulmannshöherstr.14, 58515, Lüdenscheid, Deutschland
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22
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Yeung LYY, Sarani B, Weinberg JA, McBeth PB, May AK. Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation. Trauma Surg Acute Care Open 2016; 1:e000022. [PMID: 29767644 PMCID: PMC5891708 DOI: 10.1136/tsaco-2016-000022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 02/01/2023] Open
Abstract
An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two part review, agents commonly encountered by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part one, we review warfarin and the new direct oral anticoagulants. In part two, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulation and antiplatelet therapy.
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Affiliation(s)
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia, USA
| | - Jordan A Weinberg
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Paul B McBeth
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Chu EW, Chernoguz A, Divino CM. The evaluation of clopidogrel use in perioperative general surgery patients: a prospective randomized controlled trial. Am J Surg 2016; 211:1019-25. [DOI: 10.1016/j.amjsurg.2015.05.036] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/26/2015] [Accepted: 05/27/2015] [Indexed: 12/24/2022]
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Fang X, Baillargeon JG, Jupiter DC. Continued Antiplatelet Therapy and Risk of Bleeding in Gastrointestinal Procedures: A Systematic Review. J Am Coll Surg 2016; 222:890-905.e11. [PMID: 27016908 DOI: 10.1016/j.jamcollsurg.2016.01.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated with perioperative use of antiplatelet medication. However, cessation of these drugs may be unsafe for patients who are required to maintain antiplatelet use due to cardiovascular conditions. The objective of this systematic review was to compare the risk of intraoperative or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy) with the risk among those not taking continuous antiplatelet medication. STUDY DESIGN We reviewed articles published between January 2000 and July 2015 from the Medline Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies involving any GI procedures were included if the articles met our inclusion criteria (listed in Methods). The following key words were used for the search: clopidogrel, Plavix, aspirin, antiplatelet, bleeding, hemorrhage, and digestive system surgical procedures. Quality of the studies was assessed, depending on their study design, using the Newcastle-Ottawa score or the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Twenty-two studies were eligible for inclusion in the systematic review. Five showed that the risk of intraoperative bleeding or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy was higher compared that for those not on continuous therapy. The remaining 17 studies reported that there was no statistically significant difference in the risks of bleeding between the continuous antiplatelet therapy group and the group without continuous antiplatelet therapy. CONCLUSIONS The risk of bleeding associated with GI procedures in patients receiving antiplatelet therapy was not significantly higher than in patients with no antiplatelet or interrupted antiplatelet therapy.
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Affiliation(s)
- Xiao Fang
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
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25
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Vela Vásquez R, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality? Br J Anaesth 2015; 115:688-98. [DOI: 10.1093/bja/aev348] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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26
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Has endoscopic (TEP, TAPP) or open inguinal hernia repair a higher risk of bleeding in patients with coagulopathy or antithrombotic therapy? Data from the Herniamed Registry. Surg Endosc 2015; 30:2073-81. [PMID: 26275547 PMCID: PMC4848330 DOI: 10.1007/s00464-015-4456-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/17/2015] [Indexed: 12/22/2022]
Abstract
Introduction
Inguinal hernia operations in the presence of antithrombotic therapy, based on antiplatelet or anticoagulant drugs, or existing coagulopathy are associated with a markedly higher risk for onset of postoperative secondary bleeding. To date, there is a paucity of concrete data on this important clinical aspect of inguinal hernia surgery. Up till now, the endoscopic (TEP, TAPP) techniques have been considered to be more risky because of the extensive dissection involved. Patients and methods Out of the 82,911 patients featured in the Herniamed Hernia Registry who had undergone inguinal hernia repair, 9115 (11 %) were operated on while receiving antithrombotic therapy or with existing coagulopathy. The implications of that risk profile for onset of postoperative bleeding were investigated in multivariable analysis. In addition, other influence variables were identified. Results The rate of postoperative secondary bleeding, at 3.91 %, was significantly higher in the risk group with coagulopathy or receiving antithrombotic therapy than in the group without that risk profile at 1.12 % (p < 0.001). Multivariable analysis revealed other influence variables which, in addition to coagulopathy or antithrombotic therapy, had a relevant influence on the occurrence of postoperative bleeding. These were open operation, a higher age, a higher ASA score, recurrence, male gender and a large hernia defect. Summary Patients receiving antithrombotic therapy or with existing coagulopathy who undergo inguinal hernia operation have a fourfold higher risk for onset of postoperative secondary bleeding. Despite the extensive dissection required for endoscopic (TEP, TAPP) inguinal hernia repair, the risk of bleeding complications and complication-related reoperation appears to be lower.
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27
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An acute care surgery dilemma: emergent laparoscopic cholecystectomy in patients on aspirin therapy. Am J Surg 2014; 209:689-94. [PMID: 25064416 DOI: 10.1016/j.amjsurg.2014.04.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 04/08/2014] [Accepted: 04/17/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on prehospital aspirin (ASP) therapy undergoing emergent cholecystectomy. METHODS We performed a 1-year retrospective analysis of our prospectively maintained acute care surgery database. The 2 groups (ASP group vs No ASP group) were matched in a 1:1 ratio for age, sex, previous abdominal surgeries, and comorbidities. Primary outcome measures were intraoperative hemorrhage, postoperative anemia, need for blood transfusion, and conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of ≥ 100 mL; postoperative anemia was defined by ≥ 2 g/dL drop in hemoglobin. RESULTS A total of 112 (ASP: 56, no ASP: 56) patients were included in the analysis. The mean age was 65.9 ± 10 years, and 50% were male. There was no difference in age (P = .9), sex (P = .9), and comorbidities (P = .7) between the 2 groups. There was no difference in intraoperative blood loss >100 mL (P = .5), postoperative anemia (P = .8), blood transfusion requirement (P = .9), and conversion to open surgery (P = .7) between patients on American Society of Anesthesiologists therapy and patients not on American Society of Anesthesiologists therapy. CONCLUSIONS Emergent laparoscopic cholecystectomy is a safe procedure in patients on long-term ASP. Prehospital use of ASP as an independent factor should not be used to delay emergent cholecystectomy.
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Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
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Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Sahebally SM, Healy D, Coffey JC, Walsh SR. Should patients taking aspirin for secondary prevention continue or discontinue the medication prior to elective, abdominal surgery? Best evidence topic (BET). Int J Surg 2013; 12:16-21. [PMID: 24246172 DOI: 10.1016/j.ijsu.2013.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 10/07/2013] [Accepted: 11/02/2013] [Indexed: 11/20/2022]
Abstract
This best evidence topic was investigated according to a described protocol. The question asked was: should patients on acetylsalicylic acid (ASA) for secondary prevention stop or continue the medication prior to elective, abdominal surgery. Using the reported search 826 papers were found of which five represented the best evidence to answer the clinical question. The strongest evidence was from a randomized controlled trial (RCT) specifically looking at elective abdominal surgery, which showed no statistically significant difference between ASA continuation and discontinuation in terms of haemorrhagic or thrombotic events. Two other RCT's examined elective non-cardiac surgery but only a minor proportion (20.6% and 23.6%) of patients underwent abdominal surgery and data were unavailable regarding adverse events in these patients. However, one of these trials did show a 7.2% absolute risk reduction in postoperative cardiac adverse events when ASA was continued. One prospective cohort study found no difference between ASA maintenance and cessation except for longer duration of surgery in the ASA continuation group. Finally one recent retrospective cohort study revealed similar bleeding rates between ASA-treated and non-ASA-treated patients but increased cardiac complication rates in the ASA group. Only two studies compared continuation versus discontinuation of ASA, while the remaining three looked at patients on ASA versus those not on ASA. This heterogeneity in methodology makes it difficult to draw justifiable conclusions from the data. However, it appears that continuing ASA isn't associated with excessive bleeding. Further adequately powered trials with well-defined end points are needed to answer this important clinical question.
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Affiliation(s)
| | - Donagh Healy
- Department of Surgery, University Hospital Limerick, Ireland
| | - J Calvin Coffey
- Department of Surgery, University Hospital Limerick, Ireland
| | - Stewart R Walsh
- Department of Surgery, University Hospital Limerick, Ireland.
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Bogunovic L, Gelberman RH, Goldfarb CA, Boyer MI, Calfee RP. The impact of antiplatelet medication on hand and wrist surgery. J Hand Surg Am 2013; 38:1063-70. [PMID: 23707007 PMCID: PMC3989887 DOI: 10.1016/j.jhsa.2013.03.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/09/2013] [Accepted: 03/18/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify the impact of maintaining antiplatelet medication during hand and wrist surgery on bleeding and functional outcomes. METHODS This prospective cohort trial compared operative outcomes and complications of hand and wrist surgery in patients without interruption of daily antiplatelet medications (n = 107 procedures) with control patients (n = 107 procedures). We determined rates of complications requiring reoperation for each group. We compared measures of surgical site bleeding (extent of ecchymosis or hematoma formation), patient-rated outcome assessment (Quick Disabilities of the Arm, Shoulder, and Hand score and visual analog scales of pain and swelling), and 2-point discrimination between groups. Data were collected preoperatively and postoperatively at 2 and 4 weeks. We confirmed control and antiplatelet populations to be similar for data analysis according to health status (Short Form-12) and percentage of bony procedures. RESULTS One patient receiving antiplatelet medication required reoperation for surgical site bleeding after wrist arthrodesis (0.9%). There were no complications in the control group. The extent of postoperative ecchymosis was similar in the antiplatelet and control patients at 2 weeks (16 vs 19 mm) and 4 weeks (1 vs 1 mm). Hematoma rates were not increased for patients receiving antiplatelet medication (17% vs 14% at 2 wk). Patient-rated function scores were equivalent at baseline and at follow-up between groups. A total of 22 control patients and 20 patients receiving antiplatelet medication had transiently increased 2-point discrimination (≥ 2-mm change) postoperatively. CONCLUSIONS Bleeding-related perioperative complications were rare when continuing antiplatelet medications without interruption for hand and wrist surgery. Maintenance of antiplatelet medication does not appear to negatively affect patient-rated or objective measures of function, although surgical-site bleeding may be greatest in patients taking higher-dose antiplatelet medication and undergoing bony procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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