Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg. 2012;255:811-819. [PMID: 22470078 DOI: 10.1097/sla.0b013e318250504e]

Antithrombotic Effect of a Bivalent DNA Aptamer of Thrombin

Thrombin plays a critical role in both coagulation and platelet activation, and its interaction with thrombin-protease-activated receptor 1 (PAR1) on platelets and vascular smooth muscle cells (VSMCs) leads to a series of pathological processes such as thrombosis, restenosis, and atherosclerosis. This study investigated the antithrombotic properties of a bivalent DNA aptamer (bApt) with phosphorothioate backbone modification designed to inhibit thrombin, with a specific focus on its ability to regulate the thrombin-PAR1 signaling pathway. The results showed that bApt modulated the thrombin-PAR1 pathway, effectively reduced thrombus formation, platelet aggregation, and VSMC proliferation. Key findings from the study highlight that bApt successfully prolonged coagulation reaction time (R value), coagulation time (K value), maximum amplitude (MA) and reduced coagulation angle (α value), and also prolonged thrombin time (TT) and activated partial thromboplastin time (APTT), in a dose-dependent manner. Moreover, in an arterial injury model, bApt reduced thrombus formation significantly, supporting its potential as a therapeutic agent for thrombotic diseases.

Perioperative Management of Patients on Chronic Aspirin Therapy for Elective Brain Surgery: A Delphi Study

BACKGROUND

The perioperative management of chronic aspirin therapy in patients undergoing elective brain surgery is challenging due to the risk of bleeding and thromboembolic events. Although aspirin discontinuation reduces the bleeding risk, it can increase thrombotic complications, particularly in patients at high risk of cardiovascular complications. This Delphi study aimed to develop consensus-based guidelines to address these clinical challenges.

METHODS

A 2-round Delphi survey was conducted among an international panel of 42 experienced anesthesiologists and neurosurgeons. Participants assessed the risks and benefits of perioperative aspirin management, including bleeding risk, thrombotic risk, timing of cessation and resumption, and the utility of platelet function testing. Consensus was defined as ≥80% agreement in round 2.

RESULTS

Round 1 highlighted significant variability in practice patterns. In round 2, consensus was reached on several key areas. Most experts (84%) agreed that continuing aspirin increases perioperative bleeding risk in high-risk procedures, with 87% recommending discontinuing aspirin 5 to 7 days before surgery. Nearly all experts (97%) supported continuing low-dose aspirin in high-thrombotic-risk patients. Conversely, for low-thrombotic-risk patients, only 65% agreed on aspirin continuation, reflecting an ongoing debate. No consensus was reached regarding routine platelet function testing.

CONCLUSIONS

This Delphi study provides experience-based recommendations for managing chronic aspirin therapy in neurosurgical patients. The panel strongly supports aspirin continuation in high-thrombotic-risk patients, with cessation 5 to 7 days before high-bleeding-risk surgeries. Individualized management is advised for low-bleeding-risk procedures and low-thrombotic-risk patients. Future research should further clarify aspirin management in these groups and explore the role of platelet function testing in neurosurgical settings.

Aspirin Continuation or Discontinuation in Surgically Treated Chronic Subdural Hematoma: A Randomized Clinical Trial

Importance

Discontinuation of low-dose acetylsalicylic acid (ASA) during the perioperative phase of treatment for chronic subdural hematoma (cSDH) may reduce recurrence rates but may also increase the risk of cardiovascular or thromboembolic events. However, the efficacy and safety of discontinuing ASA in this patient population remain unclear.

Objective

To assess the risk of recurrence of cSDH and cardiovascular events in patients undergoing surgical treatment of cSDH with continuous vs discontinuous ASA treatment.

Design, Setting, and Participants

The SECA (Surgical Evacuation of Chronic Subdural Hematoma and Aspirin) trial was an investigator-initiated, multicenter, placebo-controlled randomized clinical trial conducted from February 2018 to June 2023 at 6 neurosurgical centers in Switzerland. Adults undergoing burr hole drainage for cSDH and receiving ASA treatment prior to cSDH onset were included. Of 1363 screened patients, 155 were included. Both assessors and participants were blinded to the treatment arms.

Intervention

Participants were randomized 1:1 to receive either continuous ASA or placebo for 12 days during the perioperative phase.

Main Outcome and Measures

The main outcome was the recurrence rate of cSDH necessitating reoperation within 6 months. An intention-to-treat analysis was performed, calculating risk differences. Secondary outcomes were cardiovascular or thromboembolic events, other bleeding events, and mortality.

Results

Of 155 participants, 78 were assigned to continuous ASA and 77 to placebo treatment. The mean (SD) participant age was 77.9 (8.2) years and 77.6 (9.7) years for the ASA and placebo groups, respectively, and 25 participants (16.1%) were female. A primary outcome event occurred in 13.9% of participants for the ASA group and 9.5% for the placebo group (weighted risk difference, 4.4%; 95% CI, -7.2% to 15.9%; P = .56). The incidence of any cardiovascular or thromboembolic event was 0.27 per person half-year in the ASA group and 0.28 in the placebo group. The incidence of a cardiovascular event indicating ASA treatment was 0.02 per person half-year in the ASA group and 0.06 in the placebo group. Other bleeding events showed an incidence of 0.10 per person half-year in the ASA group and 0.08 in the placebo group. All-cause mortality occurred at an incidence of 0.06 per person half-year in the ASA group and 0.03 in the placebo group.

Conclusions and Relevance

The SECA randomized clinical trial suggests that discontinuing ASA treatment did not reduce the recurrence rate of surgically treated cSDH within 6 months. Recurrence risk estimates for continuous ASA treatment in this trial were distinctly lower than previously reported.

Trial Registration

ClinicalTrials.gov Identifier: NCT03120182.

Safety of Continuous Low-Dose Aspirin Therapy for Lumbar Decompression Alone

Introduction

Whether the benefits of continued perioperative aspirin therapy in spinal surgery outweigh the risk of perioperative complications remains unclear. This study evaluates the perioperative effects of continuous low-dose aspirin treatment in patients who underwent lumbar decompression alone.

Methods

This single-institute retrospective study included patients who underwent lumbar decompression for L1/2-L5/S1 lesions. The patient characteristics, perioperative parameters, and complications were compared between 103 patients who continued to take 100 mg/day aspirin during the perioperative period (aspirin group) and 653 patients who did not take antiplatelet or anticoagulant drugs (nonaspirin group).

Results

A significantly higher proportion of the patients in the aspirin group were males. The patients in the aspirin group had significantly lower preoperative hemoglobin levels than those in the non-aspirin group (P=0.001 and P=0.044, respectively). No significant differences were detected between the groups in terms of the number of disc decompression levels, duration of surgery, intraoperative blood loss, postoperative drainage volume, number of reoperations required for epidural hematoma formation, or perioperative blood transfusions. No cardiovascular or cerebrovascular ischemic events occurred in either group.

Conclusions

Continuous low-dose aspirin therapy alone during the perioperative period for lumbar decompression did not increase perioperative bleeding or the risk of bleeding-related complications. In conclusion, continuous low-dose aspirin treatment may be acceptable for use in preventing the increased risk of cardiovascular disease caused by aspirin withdrawal in patients undergoing lumbar decompression.

Perioperative Considerations for Hip Arthroplasty in Patients with Rheumatoid Arthritis

Due to its distinct features, rheumatoid arthritis (RA), an inflammatory autoimmune disorder, poses challenges in planning for surgical interventions. This review includes available evidence regarding perioperative considerations in management of RA patients, with a focus on hip surgery. RA can affect multiple joints, with development of extra-articular manifestations; therefore, preoperatively, comprehensive medical assessments, including cardiovascular or pulmonary evaluation must be considered in addition to surgical considerations. Modification of medications capable of controlling RA-related disease activity is critical, and requires collaboration with rheumatologists. Surgical considerations include the choice of surgical approach, implant selection, and problems related to weakened soft tissues, fragile bone density, and bony deformity such as protrusio acetabuli. Careful monitoring and more active rehabilitation are recommended for RA patients due to higher risk of postoperative complications. For achievement of optimal outcomes, use of a multidisciplinary perioperative approach is required for patients with RA.

Medication management in general surgical patients made nil by mouth perioperatively: A quality improvement study

Perioperative medication management in patients who are nil by mouth for surgery or endoscopy is often suboptimal. Inappropriate medication management can prolong postoperative recovery and increase morbidity and mortality. This quality improvement study, carried out in general surgical patients at an 800-bed general hospital, aimed to improve perioperative medication management in accordance with the recommendations of the UK Clinical Pharmacy Association Handbook of Perioperative Medicine. Increasing awareness and educating general surgical team members, including doctors and non-medical prescribers, about perioperative medication management led to a non-significant improvement in medication management. However, a statistically significant improvement was achieved when nursing staff were also included. This study highlights the importance of involving different members of the multidisciplinary team in perioperative medication management.

Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study

BACKGROUND

The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients.

METHODS

In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student's T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure.

RESULTS

The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98-3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups.

CONCLUSION

Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT05151796).

The effect of anti-thrombotics on the postoperative bleeding rate in patients undergoing craniotomy for brain tumor

OBJECTIVE

The peak prevalence of many brain tumors is in elderly patients. These patients are often treated with platelet inhibitors (PIs) or anticoagulants (ACs), creating a challenge for neurosurgeons concerning the perioperative management. The aim of this study is to analyze the effect of PI/AC treatment on the postoperative bleeding rates in patients undergoing craniotomy due to a brain tumor.

METHODS

Retrospective analysis of 415 consecutive patients undergoing craniotomy/craniectomy due to a brain tumor. Ninety-nine patients with PI/AC treatment (PI/AC group consisting of 64 PI, 29 AC, and six multiple) and 316 patients without PI/AC (control group) were primarily compared for hemorrhage rate. Secondary outcome measures were clinical outcome and mortality. The association between short preoperative discontinuation (≤5 days), early postoperative resumption time (≤5 days), as well as short total discontinuation time (≤5 days) of PI/AC and postoperative bleeding rates was analyzed.

RESULTS

Postoperative bleeding rates were comparable between the groups (12.2% and 13.5% in the PI/AC and control group, respectively; p=.74). The majority of bleeds were asymptomatic (85.2%). No significant difference in the postoperative mortality rate was observed (1.0% and 1.6% in the PI/AC and the control group, respectively; p=.67). Shorter discontinuation time of PI/AC was not significantly associated with higher postoperative bleeding rates (preoperative: 12.1% vs. 12.3%; p=.94, postoperative: 11.1% vs. 12.5%, respectively; p=.87, total: 16.7% vs. 12%, respectively; p=.73).

CONCLUSIONS

Patients treated with PI/AC undergoing craniotomy for the resection of brain tumor do not seem to have increased rates of postoperative bleeding or mortality. We did not find a significant correlation between short discontinuation time of PI/AC in the perioperative period and postoperative bleeding.

Haemorrhagic Complications After Microsurgical Treatment for Intracranial Aneurysms Under Acetylsalicylic Acid: An Impact Analysis

BACKGROUND

Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization.

METHODS

From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patients underwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change in hemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS).

RESULTS

At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications.

CONCLUSION

Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.

Aspirin 15cH has Different Effects on Morphology and Function of Lipopolysaccharide-Challenged RAW 264.7 Macrophages In Vitro Compared to a Pharmacological Dose of Aspirin

INTRODUCTION

Aspirin is one of the most commonly used drugs worldwide. It is known to present antipyretic, anti-inflammatory and anti-thrombotic actions, making it extremely useful in a wide range of clinical contexts. Interestingly, homeopathically prepared Aspirin 15cH has been found to have a pro-thrombotic effect in rats, raising the hypothesis that Aspirin 15cH could also modulate the activity of inflammatory cells in different pathological processes.

OBJECTIVE

Our objective was to assess what effect Aspirin 15cH has on RAW 264.7 macrophages in vitro.

METHODS

The effects of Aspirin 15cH on biochemical and morphological activities of lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophages were evaluated. These effects were compared with unchallenged macrophages (negative control), untreated LPS-stimulated macrophages, macrophages treated with succussed water (vehicle control), or aspirin 200 µg/mL (pharmacological inhibitor of LPS activity). Cell morphology (adhered cell area and cytoskeleton arrangements), cell viability, toll-like receptor-4 (TLR-4) expression, and the production of nitric oxide, cytokines and intracellular reactive oxygen species were assessed.

RESULTS

Aspirin 15cH reduced the number of cells expressing TLR-4 on the surface (p = 0.03) and induced a "columnar" morphology of macrophage pseudopods, indicating changes in cytoskeleton arrangement. When cells were treated with both Aspirin 15cH and LPS, cell morphology became heterogeneous, suggesting that sub-populations of cells had differing sensitivities to LPS or Aspirin 15cH. Exposure of the cells to LPS alone, succussed water or aspirin 200 µg/mL produced effects consistent with the literature.

CONCLUSION

Aspirin 15cH, aspirin 200 µg/mL, LPS and succussed water appear to act as independent stimuli able to induce different patterns of macrophage response. Aspirin 15cH induced changes suggestive of M2 polarization of the macrophages (i.e., toward a wound healing or tissue repair, rather than inflammatory, phenotype). These preliminary findings need to be confirmed in further specific studies.

Is it Safe to Continue Aspirin in Patients Undergoing Percutaneous Nephrolithotomy?

OBJECTIVE

To evaluate peri-operative outcomes in patients on chronic aspirin therapy undergoing percutaneous nephrolithotomy (PCNL), with and without discontinuation of aspirin. Anti-coagulation and anti-platelet therapy are contraindications for PCNL per American Urological Association guidelines due to bleeding risk. However, there is potentially increased cardiovascular risk with peri-procedural aspirin withdrawal.

METHODS

Patients on chronic aspirin undergoing PCNL between January 2014 and May 2019 were retrospectively reviewed and stratified by continued or discontinued aspirin >5 days preoperatively. Hematologic complications, transfusions, and thrombotic complications were assessed with logistic regression model.

RESULTS

Three hundred twenty-five patients on chronic aspirin therapy underwent PCNL-85 continued and 240 discontinued aspirin. There were no significant differences in hemoglobin change, estimated blood loss, transfusions, creatinine change, thrombotic complications, 30-days re-admissions, complications, or 30-day emergency department visits. Patients who continued aspirin had longer length of stay (1.6 vs 1.9 days, P = .03). American Society of Anesthesiologists (ASA) score of 3 (OR 3.2, P = .02, 95% confidence intervals (CI) [1.2-8.4]), ASA score of 4 (OR 4.0, P = .02, 95% CI [1.2-13.1]), Black race, and previous smoking (OR 2.1, P = .02, 95% CI [1.1-3.9]) was associated with continued aspirin. Body mass index ≥30 was associated with aspirin discontinuation (OR 0.9, P = .004, 95% CI [0.9-1.0]). Increased postoperative hematologic complications were associated with additional anticoagulation medication (OR 2.9, P = .04, 95% CI [1.0-4.4]).

CONCLUSION

Continued aspirin use did not increase in postoperative complications in patients undergoing PCNL. Patients who are on additional anticoagulation medication are at risk of hematologic complications.

Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants.

RESULTS

Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61).

CONCLUSION

Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Impact of antithrombotic therapy on postpancreatectomy hemorrhage in 7116 patients: A project study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND

We previously reported an association between antithrombotic therapy and an increased risk of postpancreatectomy hemorrhage (PPH). To validate our findings, we conducted a large-scale multicenter retrospective study from 63 high-volume centers in Japan.

METHODS

Between 2015 and 2018, 7116 patients who underwent pancreatectomy were enrolled. The antithrombotic group consisted of 920 patients (12.9%) who received preoperative antithrombotic agents including aspirin, clopidogrel, ticlopidine, prasugrel, warfarin, and direct oral anticoagulants.

RESULTS

PPH occurred in 235 (3.3%) of the patients. The incidence of PPH and mortality were significantly higher in the antithrombotic group than in the control group (5.7 vs. 3.0% and 2.2 vs. 0.9%, respectively; both p < .001). In multivariate analysis, a history of antithrombotic use was an independent risk factor for grade C PPH (p = .036). In the antithrombotic group, PPH tended to be delayed in the patients with restarting antithrombotic therapy. Notably, the occurrence of delayed PPH after restarting antithrombotic therapy was observed only when antithrombotic therapy was restarted within 10 days after pancreatectomy.

CONCLUSIONS

This multicenter study demonstrated that a history of antithrombotic use was a significant risk factor for PPH and mortality. In particular, the resumption of antithrombotic therapy in the early postoperative period should be done with caution.

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

INTRODUCTION

The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan.

METHODS

In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs.

RESULTS

A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery.

CONCLUSIONS

Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.

Safety and Clinical Results of Continuous Low-Dose Aspirin in Microendoscopic Laminectomy

Introduction

It remains controversial whether it is better to continue oral low-dose aspirin (LDA) during the perioperative period in spinal surgery. This study aims to evaluate the safety of continued LDA administration in the perioperative periods of microendoscopic laminectomy (MEL) by assessing perioperative complications and clinical outcomes.

Methods

We ultimately included 88 patients (35 males, 53 females) who underwent one level of MEL for lumbar spinal canal stenosis from April 2016 to March 2022. Patients who did not undergo anticoagulation therapy were classified into Group A (65 patients), those who stopped anticoagulation therapy at the perioperative periods were classified into Group B (9 patients), and those who continued oral administration of LDA throughout the perioperative periods were classified into Group C (14 patients). Surgery time, intraoperative estimate blood loss (EBL), differences between hemoglobin (Hb) and platelet (Plt) before and after surgery, perioperative complications, and cross-sectional area of hematoma and dural sac on MRI taken within 1 week and at 6 months or more after surgery were assessed between three groups. The EuroQol-5 dimensions (EQ-5D), Oswestry Disability Index (ODI), and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were also evaluated as the clinical outcomes.

Results

There was no statistically significant difference between the three groups in operation time, intraoperative EBL, differences between Hb and Plt before and after surgery, and cross-sectional area of hematoma and dural sac on MRI. A case of hematoma removal was confirmed in Group A. There was also no statistically significant difference between the three groups in EQ-5D, ODI, and each domain of JOABPEQ.

Conclusions

The continuation of LDA throughout the perioperative periods did not affect perioperative complications and clinical outcomes of one-level MEL. In MEL, it might be possible to continue oral administration of LDA throughout the perioperative periods.

Impact of Aspirin Intake on Postoperative Survival after Primary Pancreatic Resection of Pancreatic Ductal Adenocarcinoma-A Single-Center Evaluation

(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.

Safety of Continuing Aspirin Use in Cervical Laminoplasty: A Propensity Score-Matched Analysis

Introduction

Aspirin is commonly used for the primary and secondary prevention of cardiovascular disease and stroke. Controversy exists concerning whether and when is the optimal time to stop aspirin before spinal surgery. Previous studies on this topic mainly focused on patients who received thoracolumbar spine surgeries. There are only a few literatures concerning the safety of aspirin use in cervical spine surgery patients.

Methods

This pilot study recruited patients who received cervical laminoplasty from January 2010 to December 2021. The operation time, intraoperative blood loss, and postoperative complications of the patients who had taken aspirin during the perioperative period were compared with age, sex, and comorbidity-matched control patients. Propensity score matching was utilized in the selection of control to minimize bias.

Results

Twenty-one patients who have received cervical laminoplasty while taking aspirin during the perioperative period were included. The control group included 21 age, sex, and comorbidity-matched patients who have not taken aspirin. The operation time and intraoperative and postoperative blood loss were higher in patients taking aspirin but were not statistically significant. There was no statistically significant difference in the wound infection rate. No case of epidural hematoma was found.

Conclusions

In patients undergoing cervical laminoplasty, a continuation of aspirin is safe and does not increase the difficulty of the surgery, wound complication, or hemorrhage.

Nonsteroidal anti-inflammatory drugs (NSAID) do not increase blood loss or the incidence of postoperative epidural hematomas when using minimally invasive fusion techniques in the degenerative lumbar spine

Objective

Nonsteroidal anti-inflammatory drugs (NSAID) are essential in surgeons' armamentarium for pain relief and antiphlogistic effects. However, spine surgeons are concerned about the drugs' impact on coagulation, fearing hemodynamic instability due to blood loss and neurological complications due to postoperative hematoma. Furthermore, there are no clear guidelines for the use of these drugs.

Materials and methods

In this retrospective subgroup analysis of a prospective observational study, we investigated 181 patients who underwent minimally invasive spinal fusions in degenerative lumbar spine pathologies. 83 patients were given NSAID perioperatively, 54 of which were female and 29 male. Of these patients who took NSAID, 39 were on NSAID until at least one day before surgery or perioperatively, whilst the others discontinued their NSAID medication at least three days before surgery. Differences in perioperative blood loss, as well as complication rates between patients with and without NSAID treatment, were investigated.

Results

A significantly higher amount of blood loss during surgery and the monitoring period was encountered in patients whose spine was fused in more than one level, regardless of whether NSAID medication was taken or not and up until what point. Furthermore, it was found that taking NSAID medication had no effect on the incidence of postoperative epidural hematomas.

Conclusion

Perioperatively taking NSAID medication does not increase blood loss or the incidence of postoperative hematoma in patients undergoing minimally invasive lumbar spinal fusion surgery.

Who bleeds during elective anterior lumbar surgery?

Background

Blood loss (BL) during elective anterior lumbar access for interbody fusion or disc replacement is a potentially major complication. This study sought to identify factors other than major vascular injury which contribute to BL and therefore this risk. Factors suggested to effect blood loss include age, increasing body mass index (BMI), sex, prothesis, intraoperative heparinization and continuation of low-dose aspirin (LD-ASA).

Methods

A Cell Saver was used in all cases with BL measured and recorded by an independent autotransfusionist. Heparin was administered intravenously when one or both of 2ndtoe saturation metre signal/s lost pulsatility indicating lower limb arterial flow was interrupted.

Results

The mean age of the 364 patients was 47 ± 13.2 yrs. [95% CI: 45 - 48]; and 191 (52%) were male. Age, BMI and heparinization showed a positive correlation with increased BL. There was no significant association with continuation of low-dose ASA with increased BL. Most patients underwent an ALIF - 265 (72%), 52 (14%) had a TDR, and 47 (13%) had a hybrid operation. There was a significant increase in mean BL between single- and two-level procedures in the non-heparinised group (48 vs 83 mls, p = 0.003). Intraoperative heparinization was administered in 102 patients (28%). The total mean BL for the heparin group (104 ml) which was significantly higher than for the non-heparin group (53 ml) (p = 0.001). Heparinisation did not significantly increase the mean BL in single or double level ALIF patients but did significantly increase the BL in single level TDR (57 vs 151 mls, p = 0.039).

Conclusions

Younger, leaner, non-heparinized, single level ALIF patients represented the lowest bleeding risk in anterior lumbar surgery. Conversely, older, increasing BMI, two operative levels, TDR prosthesis and heparinization represent the highest bleeding risk. Continuation of LD-ASA was not associated with an increase in BL.

Elective percutaneous liver biopsy and use of aspirin

OBJECTIVES

Percutaneous liver biopsy is an essential diagnostic investigation in hepatology. Among complications, which are rare, bleeding is the most feared. Many patients scheduled for a liver biopsy are taking aspirin. Surprisingly no information is available in the literature on this frequent clinical situation. The American Association for the Study of Liver Diseases (AASLD) position paper on percutaneous liver biopsy does not specifically recommend stopping low dose aspirin prior to an elective percutaneous liver biopsy. The European Association for the Study of the Liver also remains unspecific without giving clear recommendation on stopping or not low dose aspirin before the procedure. The aim of this study is to document current practice concerning the management of patients scheduled for an elective percutaneous biopsy and taking low dose aspirin.

DESIGN

An online questionnaire was designed to gather data on current practice on the perioperative management of percutaneous liver biopsy and use of aspirin.

SETTINGS

The questionnaire was emailed to AASLD members in September 2018.

PARTICIPANTS

Four hundred sixty six responses were collected.

RESULTS

Seventy eight percent postpone elective percutaneous liver biopsy if International Normalised Ratio is ≥1.5 or Quick ≤50%. Ninety five percent postpone biopsy if platelet count is ≤50,000 × 10⁶ /L. Seventy five percent stop low dose aspirin, on average, 6 days prior to the percutaneous liver biopsy. This choice of management does not seem to be related to previous complications since 86% report not having experienced any bleeding in patients taking low dose aspirin. Nevertheless, this practice has logistic consequences since 61% of the respondents postponed a liver biopsy due to intake of low dose aspirin.

CONCLUSIONS

Despite the lack of clear statement in guidelines and evidence supporting this practice, three quarters of physicians practicing in hepatology stop low dose aspirin before elective percutaneous liver biopsy.

Safety of Continuous Low-Dose Aspirin Therapy for Cervical Laminoplasty

Introduction

Methods

Results

Conclusions

Antithrombotic Therapy in Spinal Surgery Does Not Impact Patient Safety–A Single Center Cohort Study

Objective

Antithrombotic therapy is common in older patients to avoid thromboembolic events. Careful planning is required, particularly in the perioperative environment. There are no clearly date guidelines on the best timing for interrupting the use of anticoagulation in the case of spinal surgery. This study evaluates early per procedural clinical outcomes in patients whose antithrombotic therapy was interrupted for spinal surgery.

Methods

This is a retrospective cohort study. All patients who underwent dorsal instrumentation from January 1, 2019 to December 31, 2020 were included. In group A, vitamin K antagonists (VKA) were suspended for 5 days and direct oral anticoagulants (DOAC) for 3 days. In group B, antiplatelet agents (APA) were paused for at least 7 days before surgery to prevent perioperative bleeding. Patients not taking anticoagulation medication were gathered into control group C. We analyzed demographic data, ASA status, blood loss, comorbidities, duration of surgery, blood transfusion, length of hospital stay, complications, thromboembolism, and 30 day in-hospital mortality. Multivariate analyses from the three groups were further analyzed and conducted.

Results

A total of 217 patients were operated and included. Twenty-eight patients taking VKA/DOAC (group A), 37 patients using APA (group B), and 152 patients without anticoagulation (group C) underwent spinal surgery. Those using anticoagulants were significantly older and often with multimorbidity, but did not differ significantly in procedural bleeding, time of surgery, length of hospital stay, complication rate, thromboembolism, or 30 day in-hospital mortality (p > 0.05).

Conclusion

Our data show that dorsal instrumentation safely took place in patients whose antithrombotic therapy was interrupted.

Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality

Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.

Increased rebleeding and mortality in patients with gastrointestinal bleeding treated with anticoagulant drugs compared to antiplatelet drugs

BACKGROUND/AIM

We determined the effect of antiplatelet and anticoagulant agents on rebleeding and mortality in patients with gastrointestinal bleeding.

METHODS

This was a prospective study of patients admitted with gastrointestinal bleeding between 2013 and 2018. Outcomes were compared among patients on antiplatelet agents only, anticoagulant drugs only, combination therapy, and none. The association between mortality, rebleeding, and type of antithrombotic medication on admission and discharge was determined using multivariate analysis.

RESULTS

A total of 509 patients were followed up for a median of 19 months. End of follow-up rebleeding and mortality rates were 19.4% and 23.0%, respectively. Independent predictors of mortality were age [hazard ratio (HR) = 1.025 per year increase, P = 0.002], higher Charlson Comorbidity Index (HR = 1.4, P < 0.0001), severe bleeding (HR = 2.1, P < 0.0001), and being on anticoagulants (HR = 2.3, P = 0.002). Being on antiplatelets was protective against rebleeding (HR = 0.6, P = 0.047). Those on anticoagulants were more likely to die (HR = 2.5, P < 0.0001) and to rebleed (HR = 2.1, P = 0.01) than those on antiplatelets. Antithrombotic drug discontinuation upon discharge was associated with increased mortality in patients with cardiovascular disease.

CONCLUSION

In gastrointestinal bleeding, rebleeding and mortality were associated with being on anticoagulant drugs, while being on antiplatelet agents was protective against rebleeding. Discontinuation of antithrombotics upon discharge increased the risk of death. The findings inform risk stratification and decisions regarding continuation or discontinuation of antithrombotics.

Neurologic Complications of Surgery and Anesthesia

Surgery and anesthesia carry risks of ischemic, hemorrhagic, hypoxic, and metabolic complications, all of which can result in neurologic symptoms and deficits. Patients with underlying cardiovascular and cerebrovascular risk factors are particularly vulnerable. In this article the authors review the neurologic complications of surgery and anesthesia, with a focus on the role of the neurologic consultant in preoperative evaluation and risk stratification and diagnosis and management of postoperative complications.

Delayed massive cerebral infarction after perioperative period of anterior cervical discectomy and fusion: A case report

BACKGROUND

Cerebral infarction is an extremely rare postoperative complication of anterior cervical discectomy and fusion (ACDF), particularly in the delayed setting. We present a case who had a sudden stroke on day 18 after surgery. By sharing our experience with this case, we hope to provide new information about stroke after anterior cervical surgery.

CASE SUMMARY

We present the case of a 61-year-old man with more than 20 years of hypertension and 14 years of coronary heart disease who had suffered a stroke 11 years ago. The patient was admitted for a multiple ACDF due to symptoms of cervical spondylotic myelopathy and had a sudden stroke on day 18 after surgery. Imaging findings showed a large-area infarct of his left cerebral hemisphere and thrombosis in his left common carotid artery. With the consent of his family, the thrombus was removed and a vascular stent was implanted through an interventional operation. Forty days later, the patient was transferred to a rehabilitation hospital for further treatment. He had normal consciousness but slurred speech at the 1-year follow-up evaluation. The motor and sensory functions of his hemiplegic limbs partially recovered.

CONCLUSION

This case illustrated that a postoperative stroke related to anterior cervical surgery may be attributed to prolonged carotid retraction and might have a long silent period. Preventive measures include careful preoperative and postoperative examination for high-risk patients as well as gentle and intermittent retraction of carotid artery sheath during operation.

Prospective Comparative Evaluation of Post-extraction Bleeding in Cardiovascular-Compromised Patients with and without Antiplatelet Medications

BACKGROUND AND OBJECTIVE

A considerable number of patients consulting a dental surgeon are on antiplatelet therapy, and an interruption of these agents for 3 to 7 days has been practised by majority of them prior to dental surgical intervention fearing excessive bleeding, risking the patient for the occurrence of adverse thrombotic events. The dental and medical literature shows a very low risk of excessive bleeding associated on the continuation of antiplatelet therapy. The objective of this study is to compare the bleeding following single-firm molar tooth extraction in patients who interrupt and those who continue antiplatelet therapy perioperatively.

METHODOLOGY

This is a prospective descriptive study on 170 patients on long-term low-dose antiplatelet therapy with 2 groups, each containing 85 patients-Group 1 with patients who interrupted antiplatelet therapy for 5 days before extraction and Group 2, patients who continued it perioperatively. A single molar tooth extraction was done under local anaesthesia with a vasoconstrictor. Gauze pressure pack was placed for 60 min. Socket was observed every 15 min for 1 h to look for excessive post-extraction bleeding.

RESULTS

No statistically significant differences were found in post-extraction bleeding between the patients who stopped antiplatelet therapy and those who continued it.

CONCLUSION

The bleeding risk when continuing long-term low-dose antiplatelet therapy following a single molar tooth extraction is minimal. Bleeding, if excessive, can be easily controlled by gauze pressure pack or other local haemostatic agents. Thus, dental extractions can be performed on these patients without interrupting the antiplatelet drug pre-operatively provided a thorough medical history, physician's consent and coagulation profile have been obtained prior to the procedure.

The safety of continued low dose aspirin therapy during Complete Supine Percutaneous Nephrolithotomy (csPCNL)

OBJECTIVE

Using anticoagulants and antiplatelet drugs in patients with cardiovascular and medical comorbidities is prevalent. Because of hyper vascular nature of kidney, physicians tend to stop using aspirin before percutaneous nephrolithotomy (PCNL). We have shown the effects of remaining on low dose aspirin in complete supine PCNL (csPCNL).

MATERIAL AND METHODS

The records of 643 patients who underwent csPCNL between 2012 and 2018 were analyzed. Surgical outcomes and complications of patients who were on aspirin therapy and continued it daily (group A) were compared with those not taking aspirin (group B).

RESULTS

Of the 643 csPCNLs, 40 (6%) were performed in patients of group A and the rest of 603 (94%) cases were in group B. The differences between the mean age of groups were statistically significant (60.08±9.45, group A and 48.66±12.32, group B) (P<0.001). Thirty-nine (97.5%) of patients in group A and 548 (90.9%) of group B were stone free by the end of the study which was not statistically significant (P=0.118). The mean operative time between groups A and B (43.20±21.37 and 44.83±16.83, respectively) was not considered significant (P=0.561). There was also no significant difference between 2 groups in any types of complications. Multivariate analysis showed that, perioperative aspirin use was not a significant predictor of transfusion, Hb drop, operative time and other complications.

CONCLUSIONS

Remaining on aspirin does not increase the risk of bleeding, transfusionand other complications. Consequently, continuing aspirin prioperatively in csPCNL appears safe. There is no fear for continuing aspirin in csPCNL.

LEVEL OF EVIDENCE

3.

Effect of platelet inhibition with perioperative aspirin on survival in patients undergoing curative resection for pancreatic cancer: a propensity score matched analysis

BACKGROUND

The importance of platelets in the pathogenesis of metastasis formation is increasingly recognized. Although evidence from epidemiologic studies suggests positive effects of aspirin on metastasis formation, there is little clinical data on the perioperative use of this drug in pancreatic cancer patients.

METHODS

From all patients who received curative intent surgery for pancreatic cancer between 2014 and 2016 at our institution, we identified 18 patients that took aspirin at time of admission and continued to throughout the inpatient period. Using propensity score matching, we selected a control group of 64 patients without aspirin intake from our database and assessed the effect of aspirin medication on overall, disease-free, and hematogenous metastasis-free survival intervals as endpoints.

RESULTS

Aspirin intake proved to be independently associated with improved mean overall survival (OS) (46.5 vs. 24.6 months, *p = 0.006), median disease-free survival (DFS) (26 vs. 10.5 months, *p = 0.001) and mean hematogenous metastasis-free survival (HMFS) (41.9 vs. 16.3 months, *p = 0.005). Three-year survival rates were 61.1% in patients with aspirin intake vs. 26.3% in patients without aspirin intake. Multivariate cox regression showed significant independent association of aspirin with all three survival endpoints with hazard ratios of 0.36 (95% CI 0.15-0.86) for OS (*p = 0.021), 0.32 (95% CI 0.16-0.63) for DFS (**p = 0.001), and 0.36 (95% CI 0.16-0.77) for HMFS (*p = 0.009).

CONCLUSIONS

Patients in our retrospective, propensity-score matched study showed significantly better overall survival when taking aspirin while undergoing curative surgery for pancreatic cancer. This was mainly due to a prolonged metastasis-free interval following surgery.

Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it?

There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.

[Expert consensus on the implementation of enhanced recovery after surgery in percutaneous endoscopic interlaminar lumbar decompression/discectomy (2020)]

In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients' functional training and perioperative education.

Evaluating the safety of early surgery for ruptured intracranial aneurysms in patients with long-term aspirin use: a propensity score matching study

Background

Early microsurgical clipping is recommended for ruptured intracranial aneurysms to prevent rebleeding. However, dilemma frequently occurs when managing patients with current acetylsalicylic acid (aspirin) use. This study aimed to examine whether aspirin use was associated with worse outcomes after early surgery for aneurysmal subarachnoid hemorrhage (aSAH).

Methods

We retrieved a consecutive series of 215 patients undergoing early microsurgical clipping within 72 h after aneurysmal rupture from 2012 to 2018 in the neurosurgery department of Beijing Tiantan Hospital. The medical records of each case were reviewed. Twenty-one patients had a history of long-term aspirin use before the onset of aSAH, and 194 patients did not. To reduce confounding bias, propensity score matching (PSM) was performed to balance some characteristics of the two groups. The intraoperative blood loss, postoperative hemorrhagic events, postoperative hospital stay, and functional outcome at discharge were compared between aspirin and non-aspirin group.

Results

We matched all the 21 patients in aspirin group with 42 patients in non-aspirin group (1:2). Potential confounding factors were corrected between the two groups by PSM. No hospital mortality occurred after surgery. No significant differences were found in intraoperative blood loss (P = 0.540), postoperative hemorrhagic events (P > 0.999), postoperative hospital stay (P = 0.715), as well as functional outcome at discharge (P = 0.332) between the two groups.

Conclusions

Our preliminary results showed that long-term low-dose aspirin use was not associated with worse outcomes. Early surgery can be safe for ruptured intracranial aneurysms in patients with long-term aspirin use.

Safety of Deep Brain Stimulation Lead Placement on Patients Requiring Anticlotting Therapies

BACKGROUND

Limited studies exist to support the safety of performing neuromodulation surgeries in patients whose anticlotting medication has been held. Here, we assess the safety of performing deep brain stimulation (DBS) in this patient population.

METHODS

All consecutive DBS patients who underwent lead and battery placement/revision at our institution between 2011 and 2020 were included in this Institutional Review Board-approved prospective outcomes database. We retrospectively recorded adverse events occurring within 90 days of surgery.

RESULTS

The study included 226 patients who underwent 381 lead placements in 267 surgeries. Of the 267 surgeries included in this study, 176 (66%) were performed on patients not on anticoagulants and 89 (33%) cases were on patients on 1 drug. Two (0.7%) cases involved a patient taking 2 drugs. A total of 49 adverse events were seen. Thirteen occurred in patients taking anticoagulants. There was no difference in adverse event rate between patients on anticlotting medication and those not (χ² [1] = 1.523, P = 0.2171). No clot-related sequelae occurred in any patient. Three hemorrhages occurred, all in patients not on anticoagulants.

CONCLUSIONS

We found no increased risk of complications in patients routinely on anticlotting medication undergoing DBS lead placement. We show that our protocol was successful in balancing increased risks of bleeding and of thromboembolic events in this patient group.

A Comprehensive Update on Aspirin Management During Noncardiac Surgery

Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.

An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery

BACKGROUND

Although venous thromboembolism (VTE) is a potentially serious and life-threatening complication, there is no widely accepted protocol to guide VTE prophylaxis in adult degenerative spinal surgery, and pharmacologic overtreatment may result in hemorrhagic complications. Previously, we published the VTE Prophylaxis Risk/Benefit Score, an evidence-based algorithm that balances the risk and consequences of thrombotic versus hemorrhagic complications by taking consideration of patient-related risks, procedure-related risks, and the risk of neurological compromise to guide VTE prophylaxis. To objective of this study was to validate the VTE Prophylaxis Risk/Benefit Score.

METHODS

From January 1, 2016, to December 31, 2017, VTE Prophylaxis Risk/Benefit Scores and corresponding prophylaxes were prospectively assigned. When indicated, chemoprophylaxis was dosed 24 to 36 hours postoperatively to allow for adequate surgical hemostasis. Patients were retrospectively evaluated for immediate and short-term complications. The Fisher exact test compared incidence of complications by VTE prophylaxis. Multinomial logistic regression modeled the probability of complication by prophylaxis type, demographics, and comorbidities. Significance was set at P < .05.

RESULTS

Of the 266 patients who met inclusion criteria, 79.3% were given mechanical prophylaxis alone and 20.7% were given combined mechanical and chemical prophylaxis. Complications including VTE (0.38%), delayed wound healing or infection (2.26%), and hematoma (0.75%) were observed at rates similar to or lower than previously published studies with increased utilization of chemoprophylaxis. Use of chemoprophylaxis and continuation of perioperative aspirin were significantly associated with the development of a hemorrhagic complication. No patient developed persistent neurologic deficit from hematoma or pulmonary embolism.

CONCLUSIONS

The VTE Prophylaxis Risk/Benefit Score comprehensively considers the risk of thrombotic, wound, and bleeding complications and is an effective tool for determining appropriate thromboprophylaxis in adult degenerative spinal surgery.

LEVEL OF EVIDENCE

3.

Impact of Antithrombotic Agents on Postpancreatectomy Hemorrhage: Results from a Retrospective Multicenter Study

BACKGROUND

This retrospective multicenter study aimed to evaluate the risk of postpancreatectomy hemorrhage (PPH) in patients receiving antithrombotic agents (ATAs). PPH is the most severe complication after pancreatectomy. However, there is little known about the strength of the association between ATA use, PPH, and other clinical outcomes.

STUDY DESIGN

Between 2007 and 2016, 1,297 patients underwent pancreatectomy at 2 surgical centers. ATA use included aspirin, clopidogrel, ticlopidine, warfarin, direct oral anticoagulants, and intravenous unfractionated heparin. The ATA group was composed of 144 patients who were taking ATAs before surgery.

RESULTS

A total of 35 patients developed PPH. The patients in the ATA group showed higher frequency (8.3% vs 2.0%, p < 0.001) of PPH compared with the control group (n = 1,153). In multivariate analysis, ATA use was an independent adverse risk factor for PPH (odds ratio [OR] 3.58, 95% CI 1.29-9.91, p = 0.014). Stratification by preoperative ATA therapy revealed a significant risk of PPH Grade C in patients receiving combined AT therapy. The median onset of late hemorrhage (>24 hours post-surgery) in the ATA group was later than in the control group (17.5 vs 8.5 days, p = 0.032), and the incidence tended to be higher in patients who restarted ATAs postoperatively.

CONCLUSIONS

History of ATA use is a significant risk factor for PPH, and postoperative resumption of ATAs appears to be associated with an increased risk of PPH. Patients receiving combined antithrombotic therapy may be at particularly high risk for PPH.

The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario?

STUDY DESIGN

Cohort.

OBJECTIVE

To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs.

SUMMARY OF BACKGROUND DATA

While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression.

METHODS

This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts.

RESULTS

The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups.

CONCLUSION

The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD.

LEVEL OF EVIDENCE

4.

Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study

OBJECTIVE

In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7-10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date.

METHODS

The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications.

RESULTS

A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7-20.5, p = 0.005) and deep-extraaxial-benign ("skull base") tumors (OR 3.6, 95% CI 1.3-9.7, p = 0.011) were found to be independent predictors of thromboembolic complications.

CONCLUSIONS

In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.

Unnecessary Cervical Epidural Injection in An Octogenarian

Background:

Epidural spine injections (ESI) have no documented long-term efficacy. Furthermore, cervical ESI uniquely risk intramedullary injections with resultant neurological deficits (e.g. monoplegia to quadriplegia), and intravascular vertebral injections (e.g. which potentially contribute to stroke, brain stem infarction).

Case Description:

A patient in his mid-eighties presented with 1 year’s duration of neck pain without any accompanying numbness, tingling or weakness in the upper or lower extremities. He had no radiculopathy, myelopathy, or neurological deficit. Two years earlier, the patient sustained a myocardial infarction (MI), requiring over 5 stents and a defibrillator. At the time of presentation, he was still on a baby ASA (81 mg/day), on anti-hypertensives, and cholesterol-lowering medications. His non-contrast cervical CT scan (patient had a pacemaker/defibrillator and could not have an MR) from the summer of 2018 showed no significant spinal cord or nerve root compression at any level. Nevertheless, he was subjected to two cervical epidural injections in the early fall; his baby ASA was stopped 5 days prior to each of these injections. Notably, this placed him at increased risk of MI and/or stroke. When he was seen by neurosurgery, without any neurological deficit or significant cervical radiographic findings, he was referred back to neurology for continued conservative management.

Conclusions:

Patients are increasingly subjected to epidural cervical spinal injections that have no documented long-term efficacy, and expose them to significant risks/complications. This 80+ year-old patient, without a neurological deficit or significant cervical CT-documented pathology, underwent 2 cervical ESI that unnecessarily exposed him to potential cardiac-stent related thrombosis (e.g. stopping ASA for 5 days-a bona-fide requirement for ESI to avoid acute epidural hematomas).

When to stop anticoagulation, anti-platelet aggregates, and non-steroidal anti-inflammatories (NSAIDs) prior to spine surgery

Background

Based upon a select review of the literature, in my opinion, spine surgeons, not just our medical/cardiological colleagues, need to know when to stop anticoagulant, anti-platelet aggregates, and non-steroidal anti-inflammatory (NSAIDs) medications prior to spine surgery to avoid perioperative bleeding complications.

Methods

Typically, medical/cardiological consultants, who "clear our patients" are not as aware as we are of the increased risks of perioperative bleeding if anticoagulant, anti-platelet, and NSAIDs are not stopped in a timely fashion prior to spine surgery (e.g. excessive intraoperative hemorrhage, and postoperative seromas, hematomas, and wound dehiscence).

Results

Different medications need to be discontinued at varying intervals prior to spinal operations. The anticoagulants include; Warfarin (stop at least 5 preoperative days), and Xa inhibitors (Eliquis (Apixaban: stop for 2 days) and Xarelto (Rivaroxaban: stop for 3 days)); note presently data vary. The anti-platelet aggregates include: Aspirin/Clopidogrel (stop >7-10 days preoperatively). The multiple NSAIDs should be stopped for varying intervals ranging from 1-10 days prior to spine surgery, and increase bleeding risks when combined with any of the anticoagulants or anti-platelet aggregates. NSAIDs (generic name/commercial names should be stopped preoperatively for at least; 1 day- Diclofenac (Voltaran), Ibuprofen (Advil, Motrin), Ketorolac (Toradol); 2 days- Etodolac (Lodine), Indomethacin (Indocin); 4-days-Meloxicam (Mobic) and Naproxen (Aleve, Naprosyn, Anaprox); 4 days- Nabumetone (Relafen); 6 days - Oxaprozin (Daypro); and 10 days- Piroxicam (Feldene).

Conclusions

Spine surgeons need to know when anti-platelet, anticoagulant, and NSAIDs therapies should be stopped prior to spine surgery to avoid perioperative bleeding complications.

A Clinical Review of Common Medications Used in Emergency Dermatological Situations

BACKGROUND

Medical emergencies can occur in any environment, including dermatologic and procedural surgical settings. There are many options available to dermatologic surgeons, which they should consider having easily accessible in the office in case an emergency arises.

OBJECTIVE

To summarize the current understanding about major medications that should be on-hand during dermatological surgeries. To review their mechanism of action, examine their general use, and dermatological use during surgical emergencies.

METHODS AND MATERIALS

A comprehensive review using PubMed was performed, searching for studies using these various medications in relation to cutaneous surgeries.

RESULTS

Distinct items such as hyaluronidase, nitroglycerin paste, aspirin, injectable epinephrine, and defibrillators are potential options to address various emergencies and should be readily accessible to dermatologic surgeons.

CONCLUSION

Dermatologic surgeons' knowledge of key medications and options to have in the office allow for a proper response in the event an emergency arises.

Avoiding inappropriate spine surgery in a patient with major cardiac comorbidities

Background:

We as spine surgeons increasingly need to carefully screen our own patients for major medical/cardiac comorbidities to determine if they are candidates for spine surgery. Our medical/cardiac colleagues rarely understand how long anti-platelet aggregates and non-steroidal anti-inflammatories (NSAIDs) have to be stopped prior to spine operaeitons, and when it is safe for them to be reinstated.

Case Study:

A patient over 65 years of age, presented with 6 months of increased bilateral lower extremity sciatica, and 2-block neurogenic claudication. The MR scan showed moderate to severe lumbar stenosis L2-S1 with grade I L4-L5 spondylolisthesis, and multiple bilateral synovial cysts. Nevertheless, his neurological examination was normal. Further, he had > 5 stents placed within the last five years, and had undergone cardiac surgery two years ago requiring placement of a bovine aortic valve, and resection of a left ventricular wall aneurysm. He was also still on full dose Aspirin (325 mg/day), and Clopidogrel (75 mg po bid). Notably, 3 prior spinal surgeons (neurosurgery/orthopedics) had recommended multilevel lumbar laminectomy with instrumented fusions (e.g. including multilevel transforaminal lumbar interbody fusions (TLIF)).

Conclusions:

Despite multilevel L2-S1 stenosis, Grade I L4-L5 spondylolisthesis, and multilevel bilateral synovial cysts, the patient’s normal neurological examination and multiple cardiac comorbidities (i.e. requiring continued full-dose ASA/Clopidogrel) precluded, in my opinion, offering surgical intervention. Rather, I referred the patient to neurology for conservative management. What would you have done?

The evidence-based preoperative assessment for the otolaryngologist

There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient-centric, personalized, and often multidisciplinary approach. We present an up-to-date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38-44, 2020.

Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study

BACKGROUND

Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA.

METHODS

In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome.

DISCUSSION

To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017.

STUDY PROTOCOL

V2_23.02.2017.

Does continued aspirin mono-therapy lead to a higher bleeding risk after total knee arthroplasty?

BACKGROUND

Evidence about the risk of bleeding and thromboembolism because of aspirin mono-therapy in total knee arthroplasty (TKA) is scant. We wanted to validate the risks of bleeding and thromboembolism with continued aspirin mono-therapy in unilateral and simultaneous bilateral TKA.

METHODS

We enrolled a series of 1655 patients who underwent unilateral or simultaneous bilateral TKA between December 2010 and December 2012. Drainage amount, postoperative hemoglobin level, change in hemoglobin, calculated blood loss, incidence and the amount of blood transfused, and the proportion of thromboembolic events were compared between patients who were and patients who were not on continued aspirin mono-therapy.

RESULTS

Calculated blood loss (969.1 ± 324.9 vs. 904.0 ± 315.5 ml), transfusion amounts (1.3 ± 1.5 vs. 1.0 ± 1.3 IU), and percentage of transfused patients (53.0% vs. 40.2%) were higher in unilateral TKA patients on continued aspirin mono-therapy. Outcome parameters and the proportion of DVT between groups were not significantly different. One patient (0.3%) not on aspirin mono-therapy developed a pulmonary embolism, and two others (0.6%) had cerebrovascular events.

CONCLUSION

Despite the slightly higher risks of bleeding, continuing aspirin mono-therapy during TKA might be safe with low risks of perioperative cerebrovascular, cardiovascular, and venous thromboembolic events.