Hernioplastia inguinal electiva en pacientes con anticoagulación oral. ¿Son candidatos a cirugía ambulatoria?

Do antiplatelets and anticoagulants have an impact on the clinical outcomes of robotic ventral hernia repair?

BACKGROUND

We sought to study the impact of antithrombotics(antiplatelets and anticoagulants) on robotic ventral hernia repair(RVHR).

METHODS

RVHR cases were divided into antithrombotic (AT) (-) and AT (+) groups. After comparing both groups, a logistic regression analysis was performed.

RESULTS

611 patients had no AT-medication. The AT(+) group had 219 patients of which 153 were only on antiplatelets, 52 only on anticoagulants, and 14(6.4%) patients on both antithrombotics. Mean age, American Society of Anesthesiology scores, and comorbidities were significantly higher in the AT(+) group. Intraoperative blood loss was greater in the AT(+) group. Postoperatively, the AT(+) group had greater rates of Clavien-Dindo grade-II and IV-a complications(p=0.001, and p=0.013, respectively), and postoperative hematomas(p=0.013). Mean follow-up was greater than 40 months. Age[Odds Ratio(OR): 1.034] and anticoagulants(OR: 3.121) were associated with increased bleeding-related events.

CONCLUSION

There were no associations between maintained antiplatelet therapy and postoperative bleeding-related events in RVHR whereas age and anticoagulants had the highest association.

Laparoscopic total extraperitoneal inguinal hernia repair is safe and feasible in patients with continuation of antithrombotics

Aims

We aimed to evaluate the safety and feasibility of laparoscopic total extraperitoneal (TEP) inguinal hernia repair in patients with the continuation of their antithrombotic agents.

Settings and Design

This was prospective cohort study.

Materials and Methods

A total of 115 patients who underwent TEP inguinal hernia repair between January 2015 and September 2016 were included in the analysis. Seventeen patients continued their antithrombotics (antithrombotic group); the other 98 had not been on antithrombotics (control group).

Statistical Analysis Used

The analysis was performed by using Mann-Whitney U-test, Chi-square or Fisher's exact test.

Results

The antithrombotic group had a greater mean age (65.9 ± 8.0 vs. 57.7 ± 13.6,P= 0.002) and higher prevalence of hypertension (64.7% vs. 33.7%,P= 0.015), cardiovascular diseases (64.7% vs. 7.1%,P < 0.001), atrial fibrillation (23.5% vs. 0,P < 0.001), ischaemic heart disease (35.3% vs. 0,P < 0.001) and the American Society of Anaesthesiologists ≥2 (94.1% vs. 81.6%,P= 0.005). The operation time for the antithrombotic group was longer than that of the control group (92.06 ± 32.81 min vs. 72.33 ± 20.99 min,P= 0.015). None experienced conversion to open surgery in either group. There was no difference in the post-operative complications (29.4% vs. 28.6%) and sero-haematoma formation (23.5% vs. 11.1%). The analgesic requirement, hospital stays (23.72 ± 7.74 vs. 22.35 ± 10.33 h) and the time for return to normal daily activity (3.56 ± 1.74 vs. 3.63 ± 1.90) were not statistically different between the two groups. None in either group experienced major cardiovascular events within 30 days.

Conclusions

Laparoscopic TEP inguinal hernia repair can be safely performed in patients with the continuation of their antithrombotic agents in experienced hands.

Does coagulopathy, anticoagulant or antithrombotic therapy matter in incisional hernia repair? Data from the Herniamed Registry

BACKGROUND

A considerable number of patients undergoing incisional hernia repair are on anticoagulant or antiplatelet therapy or have existing coagulopathy which may put them at higher risk for postoperative bleeding complications. Data about the optimal treatment of these patients are sparse. This analysis attempts to determine the rate of postoperative bleeding complications following incisional hernia repair and the consecutive rate of reoperation among patients with coagulopathy or receiving antiplatelet and anticoagulant therapy (higher risk group) compared to patients who do not have a higher risk (normal risk group).

METHODS

Out of the 43,101 patients documented in the Herniamed Registry who had an incisional hernia repair, 6668 (15.5%) were on anticoagulant or antithrombotic therapy or had existing coagulopathy. The implication of that higher risk profile for onset of postoperative bleeding was investigated in multivariable analysis. Hence, other influential variables were identified.

RESULTS

The rate of postoperative bleeding in the higher risk group was 3.9% (n = 261) and significantly higher compared to the normal risk group at 1.6% (n = 564) (OR 2.001 [1.699; 2.356]; p < 0.001). Additionally, male gender, use of drains, larger defect size, open incisional hernia repair, lower BMI, and higher ASA score significantly increased the risk of postoperative bleeding. The rate of reoperations due to postoperative bleeding was significantly increased in the higher risk group compared to the normal risk group (2.4 vs. 1.0%; OR 1.217 [1.071; 1.382]; p = 0.003). Likewise, the postoperative general complication rate (6.04 vs. 3.66%; p < 0.001) as well as the mortality rate (0.46 vs. 0.17%; p < 0.001) were significantly higher in the higher risk group.

CONCLUSIONS

Patients with anticoagulant or antiplatelet therapy or existing coagulopathy who undergo incisional hernia repair have a significantly higher risk for onset of postoperative bleeding. The risk of bleeding complications and complication-related reoperations seems to be lower after laparoscopic intraperitoneal onlay mesh.

Single-incision totally extraperitoneal inguinal hernia repair is feasible and safe in patients on antithrombotic therapy: A single-center experience of 92 procedures

INTRODUCTION

The aim of this study was to evaluate the feasibility and safety of SILS for totally extraperitoneal inguinal hernia repair for patients on antithrombotic therapy.

METHODS

A total of 365 patients who underwent SILS for totally extraperitoneal inguinal hernia repair between January 2011 and November 2015 were analyzed retrospectively. Antithrombotic drugs were stopped preoperatively, and bridging intravenous heparin therapy was given according to the operative risk of each patient. Data on the patients' characteristics and perioperative outcomes were collected from their medical records.

RESULTS

Ninety-two patients (25%, 92/365) were treated with antithrombotic drugs preoperatively. The mean operative times for unilateral and bilateral hernia repairs were 96 min and 94 min (P = 0.5), respectively, in the antithrombotic therapy group and 140 min and 130 min (P = 0.2), respectively, in the control group. Bleeding volume was minimal in all patients. There was no significant difference in the conversion rate. The mean postoperative hospital stay was 2.5 days in the antithrombotic therapy group and 2.1 days in the control group (P = 0.1). Postoperative complications were seen in 16% (15/92) of patients in the antithrombotic therapy group and in 11% (29/273) of patients in the control group (P = 0.2). Pulmonary embolism was seen in one patient (0.4%, 1/273) in the control group.

CONCLUSIONS

SILS for totally extraperitoneal inguinal hernia repair with bridging heparin therapy can be performed safely for patients on antithrombotic therapy.

Risk factors for perioperative complications in inguinal hernia repair - a systematic review

The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.

Has endoscopic (TEP, TAPP) or open inguinal hernia repair a higher risk of bleeding in patients with coagulopathy or antithrombotic therapy? Data from the Herniamed Registry

Introduction

Inguinal hernia operations in the presence of antithrombotic therapy, based on antiplatelet or anticoagulant drugs, or existing coagulopathy are associated with a markedly higher risk for onset of postoperative secondary bleeding. To date, there is a paucity of concrete data on this important clinical aspect of inguinal hernia surgery. Up till now, the endoscopic (TEP, TAPP) techniques have been considered to be more risky because of the extensive dissection involved.

Patients and methods

Out of the 82,911 patients featured in the Herniamed Hernia Registry who had undergone inguinal hernia repair, 9115 (11 %) were operated on while receiving antithrombotic therapy or with existing coagulopathy. The implications of that risk profile for onset of postoperative bleeding were investigated in multivariable analysis. In addition, other influence variables were identified.

Results

The rate of postoperative secondary bleeding, at 3.91 %, was significantly higher in the risk group with coagulopathy or receiving antithrombotic therapy than in the group without that risk profile at 1.12 % (p < 0.001). Multivariable analysis revealed other influence variables which, in addition to coagulopathy or antithrombotic therapy, had a relevant influence on the occurrence of postoperative bleeding. These were open operation, a higher age, a higher ASA score, recurrence, male gender and a large hernia defect.

Summary

Patients receiving antithrombotic therapy or with existing coagulopathy who undergo inguinal hernia operation have a fourfold higher risk for onset of postoperative secondary bleeding. Despite the extensive dissection required for endoscopic (TEP, TAPP) inguinal hernia repair, the risk of bleeding complications and complication-related reoperation appears to be lower.

Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates

BACKGROUND

Periprocedural bridging with unfractionated heparin or low-molecular-weight heparin aims to reduce the risk of thromboembolic events in patients receiving long-term vitamin K antagonists. Optimal periprocedural anticoagulation has not been established.

METHODS AND RESULTS

MEDLINE, EMBASE, and Cochrane databases (2001-2010) were searched for English-language studies including patients receiving heparin bridging during interruption of vitamin K antagonists for elective procedures. Data were independently collected by 2 investigators (κ=0.90). The final review included 34 studies with 1 randomized trial. Thromboembolic events occurred in 73 of 7118 bridged patients (pooled incidence, 0.9%; 95% confidence interval [CI], 0.0.0-3.4) and 32 of 5160 nonbridged patients (pooled incidence, 0.6%; 95% CI, 0.0-1.2). There was no difference in the risk of thromboembolic events in 8 studies comparing bridged and nonbridged groups (odds ratio, 0.80; 95% CI, 0.42-1.54). Bridging was associated with an increased risk of overall bleeding in 13 studies (odds ratio, 5.40; 95% CI, 3.00-9.74) and major bleeding in 5 studies (odds ratio, 3.60; 95% CI, 1.52-8.50) comparing bridged and nonbridged patients. There was no difference in thromboembolic events (odds ratio, 0.30; 95% CI, 0.04-2.09) but an increased risk of overall bleeding (odds ratio, 2.28; 95% CI, 1.27-4.08) with full versus prophylactic/intermediate-dose low-molecular-weight heparin bridging. Low-thromboembolic-risk and/or non-vitamin K antagonist patient groups were used for comparison. Study quality was poor with heterogeneity for some analyses.

CONCLUSIONS

Vitamin K antagonist-treated patients receiving periprocedural heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to nonbridged patients. Randomized trials are needed to define the role of periprocedural heparin bridging.