Impact of laparoscopic liver resection on bleeding complications in patients receiving antithrombotics

The Impact of Modified Two-Surgeon Technique for Laparoscopic Liver Resection on the Training of Surgeons-in-Training

Introduction Although laparoscopic liver resection (LLR) has gained widespread acceptance over the last decade, it is associated with a much steeper learning curve than other laparoscopic procedures. We currently perform a modified two-surgeon technique for LLR. We assessed the effect of our LLR technique on the surgical outcome and the learning curve of surgeons-in-training when pure non-anatomical LLR was performed. Methods Between 2017 and 2021, 118 LLRs were conducted at our institution, 42 of which were pure non-anatomical LLRs performed by five surgeons-in-training (with a career of 6-13 years). The perioperative outcomes of these cases were compared to those performed by the board-certified attending surgeon. Regarding the learning curve of surgeons-in-training, the duration of operation was used as an index of the proficiency level, and the number of surgical cases in which the surgeons reached the median duration of operation was examined. Results Mortality was zero, and neither postoperative bleeding nor bile leak was experienced in the whole cohort. There were no differences between surgeons-in-training and the board-certified surgeon in the duration of the operation, intraoperative blood loss, rate of postoperative complications, or length of postoperative stay (LOS). Among the operations performed by five surgeons-in-training, the rate of LLR with a difficulty score of 4 or higher was 52% (30%-75%). Concerning the learning curve, all five surgeons-in-training gradually shortened the duration of operation for each additional case and reached the median duration (218 minutes) by experiencing a median of five cases (3-8 cases). Conclusion A modified two-surgeon technique during LLR is feasible, with a relatively low number of cases (five cases) required to shorten the duration of operation in non-anatomical LLR. This technique is safe and beneficial to the education of surgeons-in-training.

Laparoscopic liver resection of segment 8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein

Background

Pure laparoscopic liver resection (LLR) of segment 8 (S8) is still rarely performed due to the lack of an appropriate surgical approach. This article discusses the technical tips and operation methods for LLR of S8 via a hepatic parenchymal transection-first approach.

Methods

Clinical data of 22 patients who underwent LLR of S8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein (MHV) in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from May 2017 to February 2020 were retrospectively analyzed.

Results

The mean age was 51.1 ± 11.6 years; mean operation time, 186.6 ± 18.4 min; median blood loss, 170.0 ml (143.8–205.0 ml); and median length of hospital stay, 8.0 days (7.0–9.0 days). There was no case of open conversion. Pathologic findings revealed all cases of hepatocellular carcinoma (HCC). Pathology showed free surgical margins. Post-operative complications included liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. All patients survived tumor-free.

Conclusions

LLR of S8 is still quite challenging at present, and it is our goal to design a reasonable procedure with accurate efficacy and high safety. We use hepatic parenchymal transection-first approach guided by the MHV for LLR of S8. This technique overcomes the problem of high technical risk, greatly reduces the surgical difficulty and achieves technological breakthroughs, but there are still many problems worth further exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02289-8.

Perioperative Antithrombotic Management During Gastroenterological Surgery in Patients With Thromboembolic Risks: Current Status and Future Prospects

Antiplatelet medicines and anticoagulants are two types of antithrombotic pharmaceuticals, with anticoagulants including warfarin and direct oral anticoagulants (DOACs). During the perioperative phase, patients receiving antithrombotic therapy must balance two risks: bleeding and thromboembolism. To date, there are no defined recommendations for antithrombotic drug management in gastroenterological (GE) surgery, and the management strategy varies greatly between hospitals. The perioperative treatment of antithrombotic medications should be centralized according to the mechanism of each drug, and a suitable management strategy should be established. The proposed perioperative management for patients undergoing antithrombotic therapy is as follows: (1) in the case of antiplatelet medication, aspirin monotherapy is continued; (2) for patients on warfarin, it is substituted by DOAC bridging (preferred) or heparin bridging; and (3) in the case of DOACs, the short-term withdrawal of DOACs (typically 1-2 days) without heparin bridging is indicated. In the current review, the current state and future prospects of perioperative antithrombotic medication treatment during gastroenterological surgery are discussed.

Long-term prognosis of laparoscopic gastrectomy for patients on antithrombotic therapy: a retrospective cohort study

PURPOSE

Few studies have reported on the interactions between gastrectomy and antithrombotic therapy, especially the long-term prognosis. We aimed to clarify the short- and long-term prognosis of gastrectomy for patients on antithrombotic therapy.

METHODS

We reviewed the perioperative data and survival rate of patients who underwent laparoscopic distal gastrectomy (LDG) at our institute between 2010 and 2013.

RESULTS

There were 119 patients enrolled in this retrospective study: 31 who were taking antithrombotic drugs (antithrombotic therapy (ATT) group), and 88 who were not (non-ATT group). The mean age was significantly higher in the ATT group than in the non-ATT group. No significant differences were observed in the amount of intraoperative bleeding or blood hemoglobin level after surgery between the groups. Bleeding complications occurred in only one patient from the ATT group, and the postoperative complication rate was comparable between the groups. During follow-up, cerebrovascular or cardiovascular events developed in 19.4% of the ATT group patients and 4.5% of the non-ATT group patients; however, there were no significant differences in the 5-year overall survival rates between the groups (ATT group, 76.9%; non-ATT group, 82.9%).

CONCLUSIONS

Antithrombotic therapy did not affect the short-term or long-term prognosis of patients after LDG.

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 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.

Impact of preoperative aspirin continuation on bleeding complications during or after liver resection: Propensity score-matched analysis

BACKGROUND

There is insufficient evidence concerning the effect of preoperative continuation of antiplatelet therapy (APT) on intraoperative and postoperative bleeding during liver resection. This study investigated the efficacy and safety of preoperative aspirin continuation on bleeding complications during or after liver resection using propensity score matching (PSM).

METHODS

Between 2005 and 2018, 425 patients who underwent liver resection were enrolled in this study. Patients were divided into two groups; the cAPT group received continued aspirin monotherapy preoperatively (n = 63) and the control group did not (n = 362). Propensity score matching was performed based on the preoperative clinical parameters. Intraoperative and postoperative complications, including bleeding complications, were compared between groups.

RESULTS

After propensity score matching, 126 patients were included in the analysis (cAPT group, n = 63 and control group, n = 63). There were no differences in patients' background characteristics, and intraoperative blood loss was identical between the groups (200 vs 180 mL, P = .54). The frequency of postoperative complications (Clavien-Dindo class 2 or higher, 13/63 [20.6%] vs 13/63 [20.6%], P = 1.00) and postoperative hemorrhagic complication (3/63 [4.8%] vs 3/63 [4.8%], P = 1.00) was also similar between the groups; no difference was observed in the length of postoperative stay (11 days vs 14 days, P = .08).

CONCLUSION

Preoperative continuation of aspirin monotherapy does not affect intraoperative or postoperative bleeding in patients receiving liver resection. Either open or laparoscopic liver resection can be safely performed in patients with continued aspirin therapy.

Risk of postoperative thromboembolic complication after major digestive surgery in patients receiving antiplatelet therapy: Lessons from more than 3,000 operations in a single tertiary referral hospital

BACKGROUND

Although recent studies have suggested that the continuation of preoperative antiplatelet therapy with aspirin does not affect intraoperative or postoperative bleeding in patients undergoing digestive surgery, its preventive effect against thromboembolic complication remains largely unknown.

METHODS

A total of 3,072 patients who underwent major digestive surgery (esophago-gastrointestinal and hepatobiliary-pancreatic resection for malignancy) between 2005 and 2018 at our institution were enrolled in this study. The patients were divided into 3 groups: patients continuing to receive preoperative antiplatelet therapy with aspirin (continued-antiplatelet therapy group, n = 425), those discontinuing preoperative antiplatelet therapy (discontinued-antiplatelet therapy group, n = 549), and those who were not receiving antiplatelet therapy (non-antiplatelet therapy group, n = 2,117). The CHADS₂ and the CHA₂DS₂-VASc scoring system were used to assess potential thromboembolic risk. Surgical outcomes were compared between the groups and the risk factors for thromboembolic complication, bleeding complication, and operative mortality were determined by multivariate analysis.

RESULTS

There was no difference between the discontinued-antiplatelet therapy and continued-antiplatelet therapy groups in the rate of high risk patients categorized by CHADS₂ and CHA₂DS₂-VASc scores; however, the occurrence of thromboembolic complication in the discontinued-antiplatelet therapy group was significantly higher compared with the continued-antiplatelet therapy group (2.8% vs 0.5%; P = .006). In a multivariate analysis using the whole cohort, discontinuation of antiplatelet therapy (odds ratio = 4.39; P < .001), poor performance status (odds ratio = 4.14; P = .001), and hypertension (odds ratio = 3.46; P = .005) were the independent risk factors for thromboembolic complication. In the groups of patients receiving antiplatelet therapy, multivariate analysis showed that preoperative aspirin continuation had a significant negative impact (odds ratio = 0.10, P = .029) on the occurrence of thromboembolic complication, but did not affect either postoperative bleeding complication or operative mortality.

CONCLUSION

Discontinuation of antiplatelet therapy during major digestive surgery is the most significant risk factor for thromboembolic complication, and the continuation of preoperative aspirin therapy significantly reduces the occurrence of thromboembolic complication in patients receiving antiplatelet therapy. It is suggested that the preoperative continuation of aspirin monotherapy is one of the preferred options to prevent severe thromboembolic events during major digestive surgery in patients receiving antiplatelet therapy.

Safety of laparoscopic surgery in digestive diseases with special reference to antithrombotic therapy: A systematic review of the literature

AIM

To elucidate the effect of antithrombotic therapy (ATT) on bleeding and thromboembolic complications during or after laparoscopic digestive surgery.

METHODS

Published articles or internationally accepted abstracts between 2000 and 2017 were searched from PubMed, Cochrane Database, and Google Scholar, and studies involving laparoscopic digestive surgery and antiplatelet therapy (APT) and/or anticoagulation therapy (ACT) were included after careful review of each study. Data such as study design, type of surgical procedures, antithrombotic drugs used, and surgical outcome (both bleeding and thromboembolic complications) were extracted from each study.

RESULTS

Thirteen published articles and two internationally accepted abstracts were eligible for inclusion in the systematic review. Only one study concerning elective laparoscopic cholecystectomy in patients with perioperative heparin bridging for ACT showed that the risk of postoperative bleeding was higher compared with those without ACT. The remaining 14 studies reported no significant differences in the incidence of bleeding complications between the ATT group and the group without ATT. The risk of thromboembolic events (TE) associated with laparoscopic digestive surgery in patients receiving ATT was not significantly higher than those with no ATT or interrupted APT.

CONCLUSION

Laparoscopic digestive surgery in ATT-burdened patients for prevention of bleeding and TE showed satisfactory results. The risk of hemorrhagic complication during or after these procedures in patients with continued APT or heparin bridging was not significantly higher than in patients with no ATT or interrupted APT.