Hemorrhagic and Thromboembolic Complications after Hepato-Biliary-Pancreatic Surgery in Patients Receiving Antithrombotic Therapy

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature

BACKGROUND

Postpancreatectomy hemorrhage (PPH) is the most severe type of complication after pancreatic surgery, although the effect of antithrombotic therapy (ATT) on PPH is largely unknown. The safety and efficacy of chemical thromboprophylaxis for venous thromboembolism (VTE) remains controversial.

AIM

To elucidate the effect of ATT on PPH.

METHODS

Published articles between 2013 and 2020 were searched from PubMed and Google Scholar, and after careful reviewing of all studies, studies concerning ATT and pancreatic surgery were included. Data such as study design, type of surgical procedures, type of antithrombotic drugs, and surgical outcome were extracted from the studies.

RESULTS

Nineteen published articles with a total of 37863 patients who underwent pancreatic surgery were included in the systematic review. Fourteen were cohort studies, with only three being prospective in nature. Two studies demonstrated that in patients receiving chronic ATT, which were mostly managed by heparin bridging, the risk of PPH was higher compared with those without ATT, and one study showed that patients with direct-acting oral anticoagulants managed by heparin bridging had significantly higher postoperative bleeding rates than others. The remaining six studies reported that pancreatic surgery can be safely performed in patients receiving chronic ATT, even under preoperative aspirin continuation. Concerning chemical thromboprophylaxis for VTE, most studies have shown a potentially high risk of PPH in patients undergoing chemical thromboprophylaxis; however, its effectiveness against VTE has not been statistically demonstrated, particularly among Asian patients.

CONCLUSION

Pancreatic surgery in chronically ATT-received patients can be safely performed without an increase in the occurrence of PPH, although the safety and efficacy of chemical thromboprophylaxis for VTE during pancreatic surgery is still controversial. Further investigation using reliable studies with good design is required to establish definite protocols or guidelines.

Safety of liver resection in patients receiving antithrombotic therapy: A systematic review of the literature

BACKGROUND

Little is unknown about the effect of chronic antithrombotic therapy (ATT) on bleeding complication during or after hepatectomy. In addition, the safety and effectiveness of chemical prevention for venous thromboembolism (VTE) is still controversial.

AIM

To clarify the effect of ATT on thromboembolism and bleeding after liver resection.

METHODS

Articles published between 2011 and 2020 were searched from Google Scholar and PubMed, and after careful reviewing of all studies, studies concerning ATT and liver resection were included. Data such as study design, type of surgery, type of antithrombotic agents, and surgical outcome were extracted from the studies.

RESULTS

Sixteen published articles, including a total of 8300 patients who underwent hepatectomy, were eligible for inclusion in the current review. All studies regarding patients undergoing chronic ATT showed that hepatectomy can be performed safely, and three studies have also shown the safety and efficacy of preoperative continuation of aspirin. Regarding chemical prevention for VTE, some studies have shown a potentially high risk of bleeding complications in patients undergoing chemical thromboprophylaxis; however, its efficacy against VTE has not been shown statistically, especially among Asian patients.

CONCLUSION

Hepatectomy in patients with chronic ATT can be performed safely without increasing the incidence of bleeding complications, but the safety and effectiveness of chemical thromboprophylaxis against VTE during liver resection is still controversial, especially in the Asian population. Establishing a clear protocol or guideline requires further research using reliable studies with good design.

Impact of antithrombotic therapy on the outcomes with focus on bleeding and thromboembolic events in patients undergoing pancreticoduodenectomy

BACKGROUND

We investigated perioperative outcomes of pancreaticoduodenectomy (PD) in patients receiving antithrombotic therapy (ATT) with a focus on the incidence of perioperative bleeding and thromboembolic complications.

METHODS

A total of 77 patients who underwent PD at our institution between 2013 and 2019 were retrospectively reviewed. Clinical findings and surgical outcomes including bleeding and thromboembolic complications were compared in patients with or without ATT. Interruption of ATT and perioperative heparin bridging were based on our hospital protocol.

RESULTS

Among ATT (30) and non-ATT (47) groups, ATT group had a significantly higher age and history of cardiocerebrovascular diseases. No significant difference was observed in intraoperative and post-pancreatectomy haemorrhage (PPH) between the groups. ATT group was associated with a significantly higher rate of post-operative complications, Clavien-Dindo classification ≥II and thromboembolic events. Operative mortality in ATT and non-ATT groups was 2 (6.7%) and 1 (2.1%), respectively. There was no significant association between ATT and excessive intraoperative blood loss (≥1000 mL), PPH (≥grade B) and thromboembolic complications (Clavien-Dindo classification ≥II).

CONCLUSION

In patients with ATT, PD is a feasible procedure with no major impact on intraoperative bleeding or PPH.