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Angelini C, Zangrossi P, Mantovani G, Cavallo MA, De Bonis P, Scerrati A. The effect of antiplatelet and anticoagulant therapies on clinical outcome of patients undergoing decompressive craniectomy: a systematic review. Front Neurol 2024; 15:1336760. [PMID: 38385039 PMCID: PMC10879343 DOI: 10.3389/fneur.2024.1336760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Objective This systematic review aims to investigate a potential correlation between the administration of antiplatelets (APs) or anticoagulants (ACs) and perioperative complications, with a particular focus on hemorrhagic events, in patients undergoing decompressive craniectomy (DC). Additionally, the secondary objective is to assess the neurological outcomes in patients undergoing DC while taking APs/ACs, comparing them to patients not on APs/ACs. Methods The study utilized PubMed and Science Direct as primary online medical databases for the systematic review. Articles underwent screening based on title, abstract, and full-text review. Four studies meeting the inclusion criteria were selected for comprehensive analysis. Results Our findings suggest that the administration of APs/ACs in patients undergoing DC does not significantly impact functional outcomes. Notably, the occurrence of rebleeding within 6 months and other complications, including infections, appears to be less frequent in patients taking APs compared to those not taking APs/ACs. Conclusion Literature-derived data on the association between APs/ACs and DC presented considerable heterogeneity and insufficient volume for robust statistical analysis. Consequently, a definitive conclusion regarding the influence of suspending or continuing these therapies on complications and clinical outcomes cannot be confidently reached at present. To address this, a large-scale prospective study is warranted to gather substantial and precise data, facilitating a nuanced understanding of how to balance the risks and benefits associated with antiplatelet and anticoagulant agents in the context of decompressive craniectomy.
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Affiliation(s)
- Chiara Angelini
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Pietro Zangrossi
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Giorgio Mantovani
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Michele Alessandro Cavallo
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Minimally Invasive Neurosurgery Unit, Ferrara University Hospital, Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Fujikawa T. Perioperative Antithrombotic Management During Gastroenterological Surgery in Patients With Thromboembolic Risks: Current Status and Future Prospects. Cureus 2022; 14:e23471. [PMID: 35494939 PMCID: PMC9038573 DOI: 10.7759/cureus.23471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Fujikawa T, Takahashi R. Impact of Antithrombotic Therapy on the Outcome of Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Systematic Literature Review. Cureus 2022; 14:e23390. [PMID: 35481301 PMCID: PMC9033526 DOI: 10.7759/cureus.23390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/07/2022] Open
Abstract
In recent years, many operations have been performed as laparoscopic surgeries in the field of gastrointestinal surgery, but the effect of antithrombotic therapy (ATT) on hemorrhagic complications in patients who have undergone laparoscopic colorectal cancer surgery remains unknown. In addition, the efficacy and safety of pharmacotherapy for the prevention of venous thromboembolism (VTE) have not yet been concluded. The purpose of this systematic review study is to clarify the effect of ATT on hemorrhagic complications in patients undergoing laparoscopic colorectal cancer surgery. Articles published between 2013 and 2020 were searched on Google Scholar and PubMed, and research regarding ATT and laparoscopic colorectal cancer surgery was included after a thorough examination of each study. Each study yielded information on the study's design, type of surgical procedures, antithrombotic medications used, and surgical outcomes (both thromboembolic and hemorrhagic consequences). This systematic review comprised 20 published papers, including a total of 12,751 patients who received laparoscopic colorectal cancer surgery. Four studies on thrombosis prevention in VTE were randomized clinical trials, and the other 16 were cohort or case-control studies. For the effects of prolonged use of ATT on hemorrhagic complications, most studies demonstrated that laparoscopic colorectal cancer surgery with continued preoperative aspirin could be safely conducted without an increase in the frequency of bleeding complications. On the other hand, most included papers have shown that patients receiving VTE pharmacoprophylaxis may be at an increased risk of bleeding complications, but its effectiveness has not been statistically proven, especially in the Asian patient population. Laparoscopic colorectal cancer surgery in patients on prolonged ATT can be safely conducted with no increase in the incidence of hemorrhagic or thrombotic complications. The efficacy and safety of VTE pharmacoprophylaxis in laparoscopic colorectal surgery is still at issue. It is necessary to establish available protocols or guidelines by validating reliable studies.
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Fujikawa T, Naito S. Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature. World J Clin Cases 2021; 9:6747-6758. [PMID: 34447821 PMCID: PMC8362514 DOI: 10.12998/wjcc.v9.i23.6747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/27/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu 802-8555, Japan
| | - Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu 802-8555, Japan
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Fujikawa T. Safety of liver resection in patients receiving antithrombotic therapy: A systematic review of the literature. World J Hepatol 2021; 13:804-814. [PMID: 34367501 PMCID: PMC8326165 DOI: 10.4254/wjh.v13.i7.804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/07/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, Fukuoka 802-8555, Japan
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Mongardi L, Dones F, Mantovani G, De Bonis P, Rustemi O, Ricciardi L, Cavallo MA, Scerrati A. Low-Dose Acetylsalicylic Acid in Chronic Subdural Hematomas: A Neurosurgeon's Sword of Damocles. Front Neurol 2020; 11:550084. [PMID: 33133003 PMCID: PMC7550681 DOI: 10.3389/fneur.2020.550084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/21/2020] [Indexed: 01/17/2023] Open
Abstract
Background: The possible influence of different antithrombotic drugs on outcome after neurosurgical treatment of chronic subdural hematoma (CSDH) is still unclear. Nowadays, no randomized clinical trials are available. A metanalysis including 24 studies for a total of 1,812 pooled patients concluded that antiplatelets and anticoagulations present higher risk of recurrences. On the other hand, several studies highlighted that antithrombotic suspension, timing of surgery, and resumption of these drugs are still debated, and patients taking these present higher risk of thromboembolic events with no excess risk of bleed recurrences or worse functional outcome. Our assumption is that the real hemorrhagic risk related to antithrombotic drug continuation in CSDH may be overrated and the thromboembolic risk for discontinuation underestimated, especially in patients with high cardiovascular risk. Methods: A comprehensive literature review with the search terms “acetylsalicylic acid” and “chronic subdural x” was performed. Clinical status, treatment, time of drug discontinuation, complications (in particular, rebleeding or thromboembolic events), and clinical and radiological outcome at follow-up were evaluated. Results: Five retrospective studies were selected for the review, three of them reporting specifically low-dose acetylsalicylic intake and two of them general antithrombotic drugs for a total of 1,226 patients. Only two papers reported the thromboembolic rate after surgery; in one paper, it is not even divided from other cardiac complications. Conclusion: The literature review does not clarify the best management of low-dose acetylsalicylic in CSDH patients, in particular, concerning the balance between thromboembolic event rates and rebleeding risks. We do believe that CSDH precipitates the worsening of comorbidities with a resulting increased mortality. Further studies clearly evaluating the thromboembolic events are strongly needed to clarify this topic. In this perspective paper, we discuss the difficult choice of low-dose acetylsalicylic acid (LDAA) management in patients suffering from chronic subdural hematoma (CSDH). The balance between hemorrhagic and thromboembolic risks often represents a sword of Damocles for neurosurgeons, especially when dealing with patients with high cardiovascular risk. No guidelines are currently available, and a survey by Kamenova et al. showed that most neurosurgeons discontinue LDAA treatment for at least 7 days in the perioperative period of surgical evacuation of CSDH, even though recent studies show that early LDAA resumption might be safe. Thrombosis prophylaxis is administered by only 60%, even though patients with CSDH are at high risk of developing thromboembolic complications. We would like to bring attention to this controversial issue.
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Affiliation(s)
- Lorenzo Mongardi
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Flavia Dones
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Giorgio Mantovani
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Pasquale De Bonis
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | | | - Luca Ricciardi
- Neurosurgery, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Italy
| | - Michele Alessandro Cavallo
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Alba Scerrati
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Takahashi R, Fujikawa T. Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis. Surg Endosc 2020; 35:2075-2083. [PMID: 32372221 DOI: 10.1007/s00464-020-07604-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/28/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Ryo Takahashi
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan
| | - Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan.
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Naito S, Fujikawa T, Hasegawa S. Impact of preoperative aspirin continuation on bleeding complications during or after liver resection: Propensity score-matched analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:830-838. [PMID: 32189437 DOI: 10.1002/jhbp.735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/23/2020] [Accepted: 03/15/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Fukuoka, Japan.,Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | | | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
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