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Scherer FD, Nast A, Gaskins M, Werner RN, Dressler C. Perioperatives Management von Antithrombotika in der Dermatochirurgie - Eine Umfrage unter Dermatologen in Deutschland. J Dtsch Dermatol Ges 2022; 20:941-952. [PMID: 35881093 DOI: 10.1111/ddg.14758_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/04/2022] [Indexed: 11/30/2022]
Abstract
Hintergrund und Zielsetzung: Wir haben in zwei Querschnittsumfragen in den Jahren 2012 und 2017 eine erhebliche Heterogenität im perioperativen Management von Antithrombotika unter Dermatologen in Deutschland festgestellt. Die erste deutsche Leitlinie zu diesem Thema wurde 2014 veröffentlicht und im Jahr 2021 aktualisiert. Wir wollten herausfinden, wie sich der Umgang mit Antithrombotika verändert hat. Methodik: Wir haben eine papierbasierte Umfrage an 1115 Dermatologen in ganz Deutschland versandt und sie zu ihrem perioperativen Management von Antithrombotika bei Operationen an der Haut sowie zu ihrer Vertrautheit mit der Leitlinie befragt. Ergebnisse: Wir erhielten Antworten von 65 stationär tätigen und 202 niedergelassenen Dermatologen. Die meisten Dermatologen gaben an, Antithrombotika bei kleineren Operationen fortzuführen. Ein nennenswerter Anteil der Dermatologen gab an, bei invasiveren Operationen die Behandlung mit Phenprocoumon perioperativ zu pausieren und mit Heparin zu überbrücken. Bei Kombinationstherapien war das Fortführen der Behandlung weniger verbreitet. Schlussfolgerungen: Der Anteil der Dermatologen in Deutschland, die angaben, Antithrombotika bei Operationen an der Haut leitlinienkonform zu managen, ist seit 2012 gestiegen. Das Fortführen von Antithrombotika bei großen Exzisionen und Wächterlymphknotenexstirpationen, der Verzicht auf die Überbrückung von Phenprocoumon mit Heparin und das perioperative Fortführen antithrombotischer Kombinationstherapien müssen jedoch weiterhin propagiert werden, insbesondere unter niedergelassenen Dermatologen.
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Affiliation(s)
- Fabian David Scherer
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin, und dem Berlin Institute of Health, Berlin
| | - Alexander Nast
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin, und dem Berlin Institute of Health, Berlin
| | - Matthew Gaskins
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin, und dem Berlin Institute of Health, Berlin
| | - Ricardo Niklas Werner
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin, und dem Berlin Institute of Health, Berlin
| | - Corinna Dressler
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin, und dem Berlin Institute of Health, Berlin
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Scherer FD, Nast A, Gaskins M, Werner RN, Dressler C. Perioperative management of antithrombotic drugs in skin surgery - A survey of dermatologists in Germany. J Dtsch Dermatol Ges 2022; 20:941-950. [PMID: 35748181 DOI: 10.1111/ddg.14758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND We identified substantial heterogeneity in the perioperative management of antithrombotic drugs in skin surgery in Germany in 2012 and 2017 in two cross-sectional surveys. The first national guideline on this subject was published in 2014 and updated in 2021. We sought to identify whether the management of these drugs had changed. METHODS We sent a paper-based survey to 1115 dermatologists throughout Germany asking them about their perioperative management of antithrombotic drugs in skin surgery, as well as their familiarity with the guideline. RESULTS We received responses from 65 hospital- and 202 office-based dermatologists. Most dermatologists reported continuing antithrombotic drugs in their patients when performing minor surgeries. A notable proportion of dermatologists reported discontinuing phenprocoumon treatment perioperatively and bridging patients with heparin when performing more invasive surgeries. Continuation was less common during combination therapies. CONCLUSIONS The proportion of physicians in Germany who reported managing antithrombotic drugs during skin surgery in ways that are in concordance with the national guideline has increased since 2012. However, continuing antithrombotic drugs during large excisions and sentinel lymph node biopsies, abstaining from bridging patients on phenprocoumon with heparin, and continuing antithrombotic combination therapies perioperatively need to be further encouraged, especially among office-based dermatologists.
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Affiliation(s)
- Fabian David Scherer
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexander Nast
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Matthew Gaskins
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ricardo Niklas Werner
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Corinna Dressler
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Nast A, Häfner HM, Kolk A, Koscielny J, Kunte C, Löser C, Meissner M, Pokrywka A, Schirmer S, Scherer FD, Strömer K, Wetzig T, Dressler C. S3 guideline: Management of anticoagulants and antiplatelet agents in cutaneous surgery. J Dtsch Dermatol Ges 2021; 19:1531-1546. [PMID: 34661365 DOI: 10.1111/ddg.14522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander Nast
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Hans-Martin Häfner
- University Hospital for Dermatology, University Hospital Tübingen, Germany
| | - Andreas Kolk
- University Hospital for Oral and Maxillo-facial Surgery, Medical University of Innsbruck, Austria
| | - Jürgen Koscielny
- MVZ Coagulation Clinic with Hemophilia Center at Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Kunte
- Artemed Fachklinik München GmbH & Co. KG, Munich, Germany, Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians Universität München
| | - Christoph Löser
- Department of Dermatology and Center for Skin Tumors, Hospital Ludwigshafen, Germany
| | - Markus Meissner
- Dermatology, Venereology and Allergology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Anna Pokrywka
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Steffen Schirmer
- Plastic, Esthetic and Reconstructive Microsurgery, Hand Surgery, St. Marien Hospital, Berlin, Germany
| | - Fabian David Scherer
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Tino Wetzig
- Dermatology, Dermatosurgery and Allergology, ASKLEPIOS Hospital, Weißenfels, Germany
| | - Corinna Dressler
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Scherer FD, Dressler C, Avila Valles G, Nast A. Komplikationsrisiken im Zusammenhang mit Antithrombotika bei Hautoperationen: Systematischer Review und Metaanalyse. J Dtsch Dermatol Ges 2021; 19:1421-1433. [PMID: 34661363 DOI: 10.1111/ddg.14579_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Fabian David Scherer
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
| | - Corinna Dressler
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
| | - Gabriela Avila Valles
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
| | - Alexander Nast
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
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Nast A, Häfner HM, Kolk A, Koscielny J, Kunte C, Löser C, Meissner M, Pokrywka A, Schirmer S, Scherer FD, Strömer K, Wetzig T, Dressler C. S3‐Leitlinie: Umgang mit Antikoagulanzien und Thrombozytenaggregationshemmern bei Operationen an der Haut. J Dtsch Dermatol Ges 2021; 19:1531-1547. [PMID: 34661348 DOI: 10.1111/ddg.14522_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Alexander Nast
- Division of Evidence-Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | | | - Andreas Kolk
- Universitätsklinik für Mund-, Kiefer- und Gesichtschirurgie, Medizinische Universität Innsbruck
| | - Jürgen Koscielny
- MVZ Gerinnungsambulanz mit Hämophiliezentrum am Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Christian Kunte
- Artemed Fachklinik München GmbH & Co. KG, München, Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians Universität München
| | | | - Markus Meissner
- Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt am Main
| | - Anna Pokrywka
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Steffen Schirmer
- Plastische, Ästhetische und Rekonstruktive Mikrochirurgie, Handchirurgie, St. Marien Krankenhaus, Berlin
| | - Fabian David Scherer
- Division of Evidence-Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | | | - Tino Wetzig
- Dermatologie, Dermatochirurgie und Allergologie, ASKLEPIOS Klinik, Weißenfels
| | - Corinna Dressler
- Division of Evidence-Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
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Scherer FD, Dressler C, Valles GA, Nast A. Risk of complications due to antithrombotic agents in cutaneous surgery: a systematic review and meta-analysis. J Dtsch Dermatol Ges 2021; 19:1421-1432. [PMID: 34596345 DOI: 10.1111/ddg.14579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/01/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine the risk of complications during cutaneous surgery for the perioperative discontinuation in comparison to the continuation of antithrombotic agents and the bridging of vitamin K antagonists with heparin in comparison to their continuation. METHODS We conducted a systematic review, searching three databases for eligible studies. Methods followed the Cochrane Handbook. We used RoB 2 and ROBINS-I to assess risk of bias. The quality of evidence was judged (GRADE). Fixed-effect meta-analyses were performed. RESULTS Two randomized-controlled trials and 19 prospective cohort studies were included. It is uncertain whether, compared to its discontinuation, continuing acetylsalicylic acid (risk difference (RD) 0.004, 95 % confidence interval (CI) -0.003 to 0.019) perioperatively increases the risk of significant postoperative bleedings (SPB). Compared to its discontinuation, continuing phenprocoumon perioperatively may increase the risk of SPB (RD 0.02, 95 % CI 0.00 to 0.05). Bridging phenprocoumon with heparin perioperatively may increase the risk of SPB when compared to its continuation (RD 0.07, 95 % CI 0.01 to 0.22). No evidence was found regarding bleeding risks for direct oral anticoagulants. CONCLUSIONS No clear indications of major risks of bleedings when continuing antithrombotic agents during minor skin surgeries were identified. However, the quality of evidence was very low.
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Affiliation(s)
- Fabian David Scherer
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Corinna Dressler
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gabriela Avila Valles
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexander Nast
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Abstract
Current guidelines generally recommend continuation of blood thinning drugs in dermatologic surgery and the previously used "bridging" with subcutaneous or intravenous heparin is obsolete. While the guidelines are increasingly implemented in daily practice, there is still uncertainty concerning the use of the novel direct oral anticoagulants (NOAC = DOAC). In this review, we analyze current developments and formulate concise recommendations for continuation during skin surgery under consideration of individual risk.
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Abstract
In ophthalmology many patients undergo surgical treatment who need to take anticoagulant medication due to cardiovascular diseases. The proper handling of these drugs requires both correct assessment of the risk of thromboembolism as well as the rating of the risk of surgery-related hemorrhages. While there are established recommendations for estimation of the risk of thromboembolism based on a large body of prospective randomized trials, data regarding the evaluation of the related complications secondary to ophthalmic surgery are limited. In comparison to other surgical procedures, most interventions in ophthalmic surgery tend to have a relatively low risk of bleeding; therefore, in general there is no need to convert or discontinue anticoagulant drugs in patients undergoing opthalmic surgery. The sparse data available justifying the abrupt termination of anticoagulation are contrary to the approach currently widely distributed in clinical practice. This overview covers the relevant knowledge of the perioperative use of anticoagulant drugs. In addition, the data on the risk of hemorrhage in ophthalmological procedures are presented and discussed.
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Abstract
Basal cell carcinoma (BCC) represents the most common malignant skin tumour in fair-skinned people. Despite low metastatic potential, BCC can cause decisive tissue destruction and disfigurement by invasive growth. In addition to clinical and histologic diagnosis modern imaging techniques as optical coherence tomography and confocal laser microscopy have been introduced. BCCs with aggressive growth pattern and/or increased risk of relapse are preferentially treated surgically. For superficial BCCs various topical treatments and photodynamic therapy are available. Inhibitors of the sonic hedgehog pathway have been approved for symptomatic treatment of metastatic BCC and locally advanced BCC inappropriate for surgery or radiotherapy. Detailed knowledge of the clinical spectrum of BCC and an appropriate choice of therapy are mandatory for the successful treatment of BCC.
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Abstract
In recent decades, the portion of elderly has increased substantially due to demographic changes in developed countries. Dermatological surgery is particularly affected by this development, because a large proportion of the elderly suffer from skin tumors, which are primarily treated surgically. Physiological changes of age and multimorbidity, often associated with polypharmacy, present the treating physician with enormous challenges. What aspects of care are important? What must be considered? What are possible complications and how can they be prevented? These important questions are answered. Finally, selected surgical approaches for the care of very old patients are also described.
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Affiliation(s)
- M Meissner
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
| | - R Kaufmann
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
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