Is laparoscopic colorectal surgery with continuation of antiplatelet therapy safe without increasing bleeding complications?

The Safety Assessment of Continuation of Perioperative Antiplatelet Therapy in Elective Robotic Surgery for Colorectal Cancer: A Retrospective Study

INTRODUCTION

Robotic surgery under condition of maintaining perioperative antiplatelet therapy (APT) is considered to have the risk of perioperative hemorrhagic events. We examined whether perioperative continuation of APT increased intraoperative blood loss and incidence of hemorrhagic complications in robot-assisted colorectal resection.

METHODS

The medical records of patients who underwent robotic surgical resection of colorectal cancer at our hospital between September 2020 and December 2023 were enrolled. Intraoperative blood loss, incidence of blood transfusion, and postoperative hemorrhagic complications were evaluated after dividing the study population into an APT group (patients receiving perioperative APT) and a non-APT group.

RESULTS

Twenty-seven patients were included in the APT group and 65 patients were the non-APT group. All patients in the APT group were continued aspirin monotherapy until the day before the surgery. There were more anticoagulated patients in the non-APT group than in the APT-group (27.7% vs. 7.4%, p = 0.0496). Median intraoperative blood loss in the APT and non-APT group were 14 and 15 mL, respectively (p = 0.802). The incidence of intraoperative blood transfusion and postoperative hemorrhagic complication in the respective group were 0% and 4.6% (p = 0.553) and 0% and 1.5% (p = 1.00).

CONCLUSION

The results of this study suggested that perioperative continuation of APT will be allowed in robot-assisted colorectal resection in terms of safety.

Impact of Antithrombotic Therapy on the Outcome of Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Systematic Literature Review

In recent years, many operations have been performed as laparoscopic surgeries in the field of gastrointestinal surgery, but the effect of antithrombotic therapy (ATT) on hemorrhagic complications in patients who have undergone laparoscopic colorectal cancer surgery remains unknown. In addition, the efficacy and safety of pharmacotherapy for the prevention of venous thromboembolism (VTE) have not yet been concluded. The purpose of this systematic review study is to clarify the effect of ATT on hemorrhagic complications in patients undergoing laparoscopic colorectal cancer surgery. Articles published between 2013 and 2020 were searched on Google Scholar and PubMed, and research regarding ATT and laparoscopic colorectal cancer surgery was included after a thorough examination of each study. Each study yielded information on the study's design, type of surgical procedures, antithrombotic medications used, and surgical outcomes (both thromboembolic and hemorrhagic consequences). This systematic review comprised 20 published papers, including a total of 12,751 patients who received laparoscopic colorectal cancer surgery. Four studies on thrombosis prevention in VTE were randomized clinical trials, and the other 16 were cohort or case-control studies. For the effects of prolonged use of ATT on hemorrhagic complications, most studies demonstrated that laparoscopic colorectal cancer surgery with continued preoperative aspirin could be safely conducted without an increase in the frequency of bleeding complications. On the other hand, most included papers have shown that patients receiving VTE pharmacoprophylaxis may be at an increased risk of bleeding complications, but its effectiveness has not been statistically proven, especially in the Asian patient population. Laparoscopic colorectal cancer surgery in patients on prolonged ATT can be safely conducted with no increase in the incidence of hemorrhagic or thrombotic complications. The efficacy and safety of VTE pharmacoprophylaxis in laparoscopic colorectal surgery is still at issue. It is necessary to establish available protocols or guidelines by validating reliable studies.

Impact of aspirin discontinuation on thrombotic complications in laparoscopic colorectal cancer surgery

BACKGROUND

The number of patients taking antiplatelet therapy is increasing. However, there is no definitive guideline for the perioperative management of antiplatelet therapy. Conventionally, the discontinuation of antiplatelet drugs has been the basic treatment as perioperative management. Therefore, we investigated the risk of discontinuing aspirin concerning thrombotic complications in laparoscopic colorectal cancer surgery.

METHODS

Between January 2015 and December 2019, a total of 729 patients underwent laparoscopic colorectal cancer surgery in Toyonaka Municipal Hospital. Sixty-four patients taking antithrombotic drugs aside from aspirin were excluded from this study; the remaining 665 patients were considered eligible and divided into three groups. The patients not taking aspirin were classified as the "Control group" (n = 588). Among the patients taking aspirin, those who continued preoperative aspirin were classified as the "Aspirin group" (n = 30), and those who discontinued preoperative aspirin were classified as the "No-aspirin group" (n = 47). The Aspirin, No-aspirin, and Control groups were compared retrospectively.

RESULT

Among the 3 groups, there were no significant difference in operative time (p = 0.14), bleeding volume (p = 0.63), or postoperative hospital stay (p = 0.06). Assessing the postoperative complication, bleeding complications were significantly more frequent in the Aspirin group (p < 0.01), although those complications were all Clavien-Dindo grade II. In contrast, thrombotic complications were significantly more frequent in the No-aspirin group (p < 0.01). Note that those complications were all Clavien-Dindo Grade III/IV. This result suggested that discontinuing aspirin increased the risk of severe thrombotic complication.

CONCLUSION

Discontinuation of aspirin as perioperative management in laparoscopic colorectal cancer surgery increased the risk of severe thrombotic complications.

The incidence of cardiovascular thrombotic complications after laparoscopic resection in colorectal cancer in Japanese hospitals: A large‐scale clinical study

Aim

The aim of this retrospective study was to investigate the incidence of cardiovascular thrombotic complications after laparoscopic resection in colorectal cancer.

Methods

This study involved 2017 patients with stages 0‐III colorectal cancer who underwent laparoscopic surgery at 17 Japanese hospitals between January 2010 and December 2013. We assessed the incidence of postoperative cardiovascular thrombotic and haemorrhagic complications.

Results

Laparoscopic surgeries were performed in 1152 men and 865 women with 1405 colon and 612 rectal cancers, respectively. Overall, 3%, 38%, 17%, 8%, and 9% of patients had comorbidities of heart failure, high blood pressure, diabetes, history of stroke, and vascular disease, respectively. Antithrombotic agents were being consumed by 17% of patients. The types (and perioperative rest periods) of the antithrombotic agents were aspirin in 58% (18.6 days), clopidogrel in 19% (21.1 days), cilostazol in 13% (13.3 days), and warfarin potassium in 21% (14.6 days) of cases with antithrombotic agents. Surgical time and blood loss in the total cohort were 234 minutes and 56 mL. Four cases (0.2%) had cardiovascular thrombotic complications, including one severe cardiac infarction and one stroke with major sequelae (CHADS2 scores were 2 points in both cases). Hemorrhagic complications occurred in 19 cases (0.9%). In particular, the incidence of the major gastroduodenal haemorrhagic ulcer was higher in cases with antithrombotic agents than without them (0.05% vs 0%, P = .02).

Conclusion

The incidence of cardiovascular thrombotic complications was rare, although severe cardiac infarction and stroke could occur even after minimally invasive surgery in colorectal cancer.

Continuing acetylsalicylic acid during Robotic-Assisted Radical Cystectomy with intracorporeal urinary diversion does not increase hemorrhagic complications: results from a large multicentric cohort

OBJECTIVES

To evaluate whether continuing the antiplatelet drug acetylsalicylic acid≤100mg (ASA) during Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) increases the risk of peri-and postoperative hemorrhagic complications and overall morbidity. Indeed, guidelines recommend interrupting antiplatelet therapy before radical cystectomy; however, RARC with ICUD is associated to reduced estimated blood loss and blood transfusions compared to its open counterpart.

METHODS

Data from a multicentric European database were analyzed. All participating centers maintained a prospective database of patients undergoing RARC with ICUD. We identified patients receiving antiplatelet therapy by acetylsalicylic acid ≤100mg. Patients were divided into three groups: those not taking acetylsalicylic acid (no-ASA), those where ASA was continued perioperatively (c-ASA) and those where ASA was interrupted perioperatively (i-ASA). Estimated blood loss and peri-and post-operative transfusions were recorded. Hemorrhagic complications, ischemic, thrombotic and cardiac morbidity was recorded and classified using the Clavien-Dindo score by a senior urologist.

RESULTS

640 patients were analyzed. Patients on acetylsalicylic acid were significantly older and had more comorbidities. No significant difference was found for estimated blood loss between no-ASA, c-ASA and i-ASA (280 vs. 300 vs. 200ml respectively; P = 0.09). Similarly, no significant difference was found for intraoperative (5% vs. 9% vs. 11%; P = 0.07) and postoperative transfusion rate (11% vs. 13% vs. 18%; P = 0.17). Higher ischemic complications were noted in the i-ASA group compared to no-ASA and c-ASA (4% vs. 0.6% vs. 1.4%; P = 0.03). On uni and multivariate logistic regression, continuing acetylsalicylic acid was not significantly associated to either major complications or post-operative transfusions.

CONCLUSIONS

Peri-operative acetylsalicylic acid continuation in RARC with ICUD does not increase hemorrhagic complications. Interrupting acetylsalicylic acid peri-operatively may expose patients to a higher risk of ischemic events.

Continuation of aspirin perioperatively for lung resection: a propensity matched analysis

PURPOSE

To clarify the safety and effectiveness of continuing aspirin during the perioperative period of lung resection.

METHODS

We analyzed, retrospectively, consecutive patients who underwent lung resection between 2008 and 2017. To investigate the safety of aspirin continuation, patients who continued taking aspirin perioperatively (Group C) were matched to other patients (Group O), using a propensity score, and bleeding outcomes were compared. To assess the effect of aspirin interruption, Group C was matched to a group of patients whose aspirin regimen was interrupted (Group I), and the postoperative complications related to thromboembolism were compared.

RESULTS

Among 3393 patients, 52 continued on aspirin (Group C) perioperatively, whereas 184 had their aspirin discontinued (Group I). Comparing the matched cohorts extracted from Group C and Group O (n = 45), there were no significant differences in bleeding outcomes. Comparing the matched cohorts extracted from Group C and Group I (n = 40), group C had fewer postoperative complications related to thromboembolism (0% vs. 7.5%, p = 0.039).

CONCLUSION

Bleeding complications did not increase by continuing aspirin, but thromboembolic complications increased when the aspirin regimen was interrupted during the perioperative period of lung resection. Thus, in the absence of a prohibitive bleeding risk, the continuation of aspirin during the perioperative period of lung resection appears to be desirable.

Comparison of the continuation and discontinuation of perioperative antiplatelet therapy in laparoscopic surgery for colorectal cancer: A retrospective, multicenter, observational study (YCOG 1603)

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).

Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis

BACKGROUND

In laparoscopic surgery for colorectal cancer (CRC) for patients who receive antiplatelet therapy (APT), it remains unclear whether APT should be continued or temporarily withdrawn. We investigated the safety of perioperative aspirin continuation, specifically focused on bleeding complications.

METHODS

We performed retrospective analysis utilizing propensity score-matching (PSM). In total, 789 patients satisfied the inclusion criteria, and were divided into two groups. Patients in the continued aspirin monotherapy (cAPT) group continued treatment perioperatively with not more than 2 days of withdrawal (n = 140). Patients with more than 3 days withdrawal of aspirin or who did not receive APT at all were assigned to the non-cAPT group (n = 649). After 1:1 PSM, 105 patients were extracted from each group. Perioperative APT management was determined based on our institutional committee-approved guidelines for antithrombotic management.

RESULTS

In PSM cohorts, all patient demographics were comparable between the groups. Regarding intraoperative outcomes, we found no significant difference in operation duration (p = 0.969), blood loss (p = 0.068), and blood transfusion (p = 0.517). Postoperative overall morbidity was 20.0% and 13.3% in the cAPT and non-cAPT groups, respectively (p = 0.195). The incidence of bleeding complications was also comparable between the groups (2.9% vs. 1.0%, p = 0.317). Assessing the 14 cases with bleeding complications overall in the full cohort, all 7 cases in the non-cAPT group had anastomotic bleeding, which was generally observed shortly after surgery [median postoperative day (POD) 1]. All 7 cases in the cAPT group received additional antithrombotics other than aspirin; bleeding occurred at various sites relatively later (median POD 7), mostly after reinstitution of additional antithrombotic agents.

CONCLUSIONS

For patients receiving APT, perioperative continuation of aspirin monotherapy could be safe in laparoscopic CRC surgery; however, careful consideration is required at reinstitution of additional antithrombotics where multiple antithrombotic agents are used.