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Davey MG, Joyce WP. Evaluating the safety profile of anti-platelet therapy in patients undergoing elective inguinal hernia repair: a systematic review and meta-analysis. Ir J Med Sci 2024; 193:897-902. [PMID: 37526871 PMCID: PMC10961273 DOI: 10.1007/s11845-023-03480-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION There remains no consensus surrounding the safety of prescribing anti-platelet therapies (APT) prior to elective inguinal hernia repair (IHR). AIMS To perform a systematic review and meta-analysis evaluating the safety profile of APT use in patients indicated to undergo elective IHR. METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel-Haenszel method using the Review Manager version 5.4 software. RESULTS Five studies including outcomes in 344 patients were included. Of these, 65.4% had APT discontinued (225/344), and 34.6% had APT continued (119/344). The majority of included patients were male (94.1%, 288/344). When continuing or discontinuing APT, there was no significant difference in overall haemorrhage rates (odds ratio (OR): 1.86, 95% confidence interval (CI): 0.29-11.78, P = 0.130) and in sensitivity analysis using only RCT data (OR: 0.63, 95% CI: 0.03-12.41, P = 0.760). Furthermore, there was no significant difference in reoperation rates (OR: 6.27, 95% CI: 0.72-54.60, P = 0.590); however, a significant difference was observed for readmission rates (OR: 5.67, 95% CI: 1.33-24.12, P = 0.020) when APT was continued or stopped pre-operatively. There was no significant difference in the estimated blood loss, intra-operative time, transfusion of blood products, rates of complications, cerebrovascular accidents, myocardial infarctions, or mortality observed. CONCLUSION This study illustrates the safety of continuing APT pre-operatively in patients undergoing elective IHR, with similar rates of haemorrhage, reoperation, and readmission observed. Clinical trials with larger patient recruitment will be required to fully establish the safety profile of prescribing APT in the pre-operative setting prior to elective IHR.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland.
| | - William P Joyce
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
- Department of Surgery, Galway Clinic, Co., Galway, H91 HHT0, Ireland
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Niebuhr H, Köckerling F, Fortelny R, Hoffmann H, Conze J, Holzheimer RG, Koch A, Köhler G, Krones C, Kukleta J, Kuthe A, Lammers B, Lorenz R, Mayer F, Pöllath M, Reinpold W, Schwab R, Stechemesser B, Weyhe D, Wiese M, Zarras K, Meyer HJ. [Inguinal hernia operations-Always outpatient?]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:230-236. [PMID: 36786812 PMCID: PMC9950173 DOI: 10.1007/s00104-023-01818-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 06/17/2023]
Abstract
Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.
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Affiliation(s)
- H Niebuhr
- Hamburger Hernien Centrum, Eppendorfer Baum 8, 20249, Hamburg, Deutschland.
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Zhu X, Liu Z, Shen J, Liu J, Tang R. Comparison of open and laparoscopic inguinal-hernia repair in octogenarians. Asian J Surg 2023; 46:738-741. [PMID: 35843826 DOI: 10.1016/j.asjsur.2022.06.149] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/17/2021] [Accepted: 06/28/2022] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Although the advantages of laparoscopic inguinal hernia repair in the general population have been reported, its role in octogenarians has yet to be elucidated. This retrospective study was designed to compare the outcomes of open and laparoscopic inguinal hernia repairs in octogenarians. MATERIALS AND METHODS The data of octogenarians who underwent laparoscopic (n = 81) or open (n = 121) inguinal hernia repair were collected from January 2017 to December 2019. Statistical analysis variables included basic epidemiological data of patients, surgical procedures, comorbidities, postoperative pain, complications, recurrence, and other data. RESULTS There were no significant differences between the two groups in terms of sex, body mass index, recurrent hernias, comorbidities, postoperative complications, and recurrence. The American Society of Anesthesiologists (ASA) class and the proportion of scrotal hernias in the open group were higher than those of the laparoscopic group, whereas the proportion of bilateral hernias in the laparoscopic group was higher than that in the open group. The postoperative pain scores of the laparoscopic group were lower than those of the open group. CONCLUSIONS In octogenarians, both laparoscopic and open inguinal hernia repairs are safe and feasible, but an appropriate surgical plan is crucial for obtaining better treatment effect.
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Affiliation(s)
- Xiaoqiang Zhu
- Department of Hernia and Abdominal Wall Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China
| | - Zhengni Liu
- Department of Hernia and Abdominal Wall Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China
| | - Jianfeng Shen
- Department of Hernia and Abdominal Wall Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China
| | - Jiajie Liu
- Department of Hernia and Abdominal Wall Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China
| | - Rui Tang
- Department of Hernia and Abdominal Wall Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China.
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Hajili K, Vega Hernandez A, Otten J, Richards D, Rudroff C. Risk factors for early and late morbidity in patients with cardiovascular disease undergoing inguinal hernia repair with a tailored approach: a single-center cohort study. BMC Surg 2023; 23:11. [PMID: 36641449 PMCID: PMC9840298 DOI: 10.1186/s12893-023-01905-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Inguinal hernia repair is a common procedure in surgery. Patients with cardiovascular disease have an increased operative risk for postoperative morbidity. The study aimed to identify the most beneficial surgical procedure for these patients. METHODS Patients undergoing elective surgery for unilateral or bilateral inguinal hernia between December 2015 and February 2020 were included. The cohort was divided into the group of patients with (CVD group) and without (NO group) cardiovascular disease and analyzed according to the postoperative morbidity distribution and correlated to the surgical technique used. RESULTS Of the 474 patients included 223 (47%) were operated on using the Lichtenstein technique and 251 (53%) using TAPP, respectively. In the CVD group the Lichtenstein procedure was more common (n = 102, 68.9%), in the NO group it was TAPP (n = 205, 62.9%; p < 0.001). 13 (8.8%) patients in the CVD group and 12 (3.7%) patients in the NO group developed a postoperative hematoma (p = 0.023). In the further subgroup analysis within the CVD group revealed cumarine treatment as a risk factor for postoperative hematoma development, whereas the laparoscopic approach did not elevate the morbidity risk. CONCLUSION CVD is a known risk factor for perioperative morbidity in general surgery, however, the TAPP method does not elevate the individual perioperative risk.
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Affiliation(s)
- Kamran Hajili
- grid.419829.f0000 0004 0559 5293Department for Cardiology and Intensive Care Medicine, Klinikum Leverkusen, Leverkusen, Germany ,grid.6190.e0000 0000 8580 3777Promotion in Medical Studies, Medical Faculty of the University of Cologne, Cologne, Germany
| | - Alberto Vega Hernandez
- Department of Visceral Surgery and Functional Surgery of the Lower Gastrointestinal Tract (UGI), Evangelisches Klinikum Koeln Weyertal, Weyertal 76, 50931 Cologne, Germany
| | - Jakob Otten
- Department of Visceral Surgery and Functional Surgery of the Lower Gastrointestinal Tract (UGI), Evangelisches Klinikum Koeln Weyertal, Weyertal 76, 50931 Cologne, Germany
| | - Dana Richards
- Department of Visceral Surgery and Functional Surgery of the Lower Gastrointestinal Tract (UGI), Evangelisches Klinikum Koeln Weyertal, Weyertal 76, 50931 Cologne, Germany
| | - Claudia Rudroff
- Department of Visceral Surgery and Functional Surgery of the Lower Gastrointestinal Tract (UGI), Evangelisches Klinikum Koeln Weyertal, Weyertal 76, 50931 Cologne, Germany
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Balch JA, Neal D, Crippen C, Johnson-Mann CN, Read TE, Loftus TJ, Al-Mansour MR. Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy. Surg Endosc 2022; 36:9011-9018. [PMID: 35674797 DOI: 10.1007/s00464-022-09360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/16/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION There are a paucity of data regarding the safety of laparoscopic inguinal hernia repair in patients on antiplatelet and anticoagulant therapy (APT/ACT). We aim to compare the postoperative outcomes of laparoscopic (LIHR) vs. open repair of inguinal hernias (OIHR) in patients on APT/ACT. METHOD We conducted a retrospective cohort study using the Vizient Clinical DataBase. We included adults receiving APT/ACT who underwent outpatient, elective, and primary inguinal hernia repair between 2017 and 2019. Subgroup analysis was performed on patients receiving aspirin, non-aspirin antiplatelet, and anticoagulant therapy. Mixed-effects logistic regression was used to assess both the effect of APT/ACT on the probability of receiving LIHR vs OIHR and their respective outcomes. RESULT A total of 142,052 repairs were included, of which 21,441 (15%) were performed on patients receiving APT/ACT. Mean age was 69 years (± 10.5) and 93% were male. 19% of hernias were bilateral. 40% of operations were performed at teaching hospitals. On multivariable analysis, patients on non-aspirin antiplatelet or anticoagulant therapy were more likely to receive an open procedure (Odds Ratio (OR) = 1.2; 95% Confidence Intervals (CI) [1.1, 1.4] and OR = 1.4; CI [1.3, 1.5], respectively). LIHR was associated with a lower rate of length of stay > 1 day (OR = 0.65; CI [0.5, 0.9]). Rates of 30-day postoperative hematoma, transfusions, stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, readmission, and emergency department visits were similar between the two operative approaches. CONCLUSION Patients on APT/ACT represent a substantial proportion of those undergoing inguinal hernia repair. Non-aspirin antiplatelet or anticoagulant therapy are independent predictors of choosing an open repair. Laparoscopic repair appears to be safe in patients receiving APT/ACT under current perioperative management patterns.
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Affiliation(s)
- Jeremy A Balch
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Dan Neal
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Cristina Crippen
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Crystal N Johnson-Mann
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Thomas E Read
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Mazen R Al-Mansour
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA.
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Oji K, Otowa Y, Yamazaki Y, Arai K, Mii Y, Kakinoki K, Nakamura T, Kuroda D. Taking antithrombic therapy during emergency laparoscopic cholecystectomy for acute cholecystitis does not affect the postoperative outcomes: a propensity score matched study. BMC Surg 2022; 22:42. [PMID: 35120469 PMCID: PMC8817483 DOI: 10.1186/s12893-022-01501-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/27/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Continuing antithrombic therapy (ATT) during surgery increases the risk of bleeding. However, it is difficult to discontinue the ATT in emergency surgery. Therefore, safety of emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) is still unclear. We aimed to clarify the affect of ATT during emergency LC for AC. METHODS Patients with AC were classified into ATT group (n = 30) and non-ATT group (n = 120). Postoperative outcomes were compared after propensity score matching (n = 22). RESULTS Higher level of c-reactive protein level and shorter activated partial thromboplastin time (APTT) was observed in ATT group than in non-ATT group after matching. No significant difference was found between other patient characteristics and perioperative results. Blood loss over 100 mL was observed in 8 patients. Multivariate analyze showed that APTT was an independent risk factor for bleeding over 100 mL (P = 0.039), while ACT and APT was not. CONCLUSIONS Taking ATT does not affect the blood loss or complications during emergency LC for AC. Controlling intraoperative bleeding is essential for a safe postoperative outcome.
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Affiliation(s)
- Kentaro Oji
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Yasunori Otowa
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan. .,Radiation Biology Branch, National Cancer Institute, 9000 Rockville Pike, Bethesda, Maryland, 20892, USA.
| | - Yuta Yamazaki
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Keisuke Arai
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Yasuhiko Mii
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Keitaro Kakinoki
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Tetsu Nakamura
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
| | - Daisuke Kuroda
- Department of Surgery, Kita-Harima Medical Center, 926-250 Ichiba-cho, Ono, Hyogo, 675-1392, Japan
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Ghaffari Hamedani SMM, Akbari A, Sayaydi S, Zakariaei Z, Moosazadeh M, Boskabadi J, Naserifar M, Kargar Soliemanabad S. The topical application of tranexamic acid to control bleeding in inguinal hernia surgery candidate patients: A randomized controlled trial. Ann Med Surg (Lond) 2021; 69:102683. [PMID: 34429952 PMCID: PMC8365320 DOI: 10.1016/j.amsu.2021.102683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background and objectives Inguinal hernia surgery is a common procedure, especially for the elderly, who usually use anticoagulants and antiplatelet drugs. In this study, we evaluated the effectiveness of tranexamic acid (TXA) on the complications of inguinal hernia repair in patients using antiplatelets. Patients and methods This study is a randomized controlled trial that was performed during the 2018-2019 years. Forty patients with inguinal hernia and antiplatelet use were enrolled randomly into the two groups. In the intervention group, the patients received two injectable form (500mg/5 mL) of TXA, totally 10 mL as a topical application at the surgical site, and then the patient's surgical site was seen every 8 h for 48 h, and the patient was examined daily for one week. Results The mean length of hospitalization, seroma, hematoma and infection in the two groups were not statistically significant (P > 0.05). However, the duration of surgery in the TXA group was significantly shorter than in the control group (54.85 vs. 68.72 min) (P < 0.001). The mean bleeding during surgery was significantly lower in the TXA group than in the control group (P < 0.001). Conclusion The findings of present study indicate that topical TXA has a high ability to control bleeding. As a result, TXA is beneficial in terms of reducing bleeding and increasing the surgeon's satisfaction. Therefore, it is recommended that TXA be prescribed for patients requiring inguinal hernia surgery with a high risk of bleeding.
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Affiliation(s)
- Seyed Muhammad Mehdi Ghaffari Hamedani
- Department of Surgery, Toxoplasmosis Research Center, Communicable Diseases Institute, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Akbari
- Department of Surgery, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sohrab Sayaydi
- Department of Surgery, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zakaria Zakariaei
- Toxicology and Forensic Medicine Division, Toxoplasmosis Research Center, Communicable Diseases Institute, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahmood Moosazadeh
- Health Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Javad Boskabadi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahshid Naserifar
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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Bruzzone P, Bini F, Lancia M, Popivanov G, Giustozzi M, Marinozzi F, D'Andrea V, Cirocchi R. The role of computed tomography angiography 3D imaging in postoperative hemorrhage after groin mesh hernioplasty during anticoagulation therapy. Minerva Surg 2021; 76:286-287. [PMID: 33855375 DOI: 10.23736/s2724-5691.21.08704-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paolo Bruzzone
- Paride Stefanini Department of General and Specialist Surgery, Sapienza University, Rome, Italy -
| | - Fabiano Bini
- Department of Mechanical and Aerospace Engineering, Sapienza University, Rome, Italy
| | - Massimo Lancia
- Department of General Surgery, Hospital of Terni, University of Perugia, Terni, Italy
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - Michela Giustozzi
- Unit of Internal Vascular and Emergency Medicine and Stroke, University of Perugia, Perugia, Italy
| | - Franco Marinozzi
- Department of Mechanical and Aerospace Engineering, Sapienza University, Rome, Italy
| | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Roberto Cirocchi
- Department of General Surgery, Hospital of Terni, University of Perugia, Terni, Italy
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Abstract
PURPOSE OF REVIEW Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks. RECENT FINDINGS Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management. SUMMARY Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.
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Prather JC, Montgomery TP, Crowther D, McGwin G, Ghavam C, Theiss SM. Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community. J Clin Orthop Trauma 2020; 11:928-931. [PMID: 32879582 PMCID: PMC7452213 DOI: 10.1016/j.jcot.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE This retrospective study aimed to assess the feasibility of continuing clopidogrel therapy during the perioperative period in elective cervical and thoracolumbar surgery. METHODS After IRB approval, medical records of patients requiring one or two-level surgery over a two-year period (2015-2017) while receiving clopidogrel were reviewed for relevant outcomes. Over the same period, a control group of patients not receiving clopidogrel perioperatively was formed. RESULT In total, 136 patients were included: 37 clopidogrel and 99 control, with a mean age of 64.8 years. Between clopidogrel and control respectively, operative time was 86.7 min and 86.7 min (p = 0.620); blood loss was 127.0 cc and 117.5 cc (p = 0.480); drain output was 171.2 cc and 190.7 cc (p = 0.354); length of stay was 1.8 days and 1.5 days (p = 0.103). Two clopidogrel patients and 1 control patient had complications. Two clopidogrel patients and 1 control patient were readmitted within 30 days. CONCLUSIONS Remaining on clopidogrel therapy during elective spine surgery results in no difference in operative time, blood loss, drain output, length of stay, or readmission. Precaution should be taken in cervical procedures as the drain output in clopidogrel patients was increased and complications in this region can be severe.
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Affiliation(s)
- John C. Prather
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Tyler P. Montgomery
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Doug Crowther
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Gerald McGwin
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Cyrus Ghavam
- Franciscan Orthopaedic Associates 16259 SW Sylvester Rd suite 301 Burien, WA 98166 USA
| | - Steven M. Theiss
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA,Corresponding author. 1313 13th Street South, Birmingham, AL, 35205, USA
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