Do we have to stop anticoagulant and platelet-inhibitor treatments during proctological surgery?

Sclerobanding in the treatment of second and third degree hemorrhoidal disease in high risk patients on antiplatelet/anticoagulant therapy without suspension: a pilot study

Introduction

Around 20% of population in western countries is under anticoagulant treatment. However, there is paucity of evidence about the treatment of HD in patients under anticoagulant/antiplatelet therapy, although both suspension and continuation in the perioperative period may increase the risk of severe complications. The aim of this pilot study was to confirm the feasibility and safety of sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy), an office-based procedure, for the treatment of second-and third-degree HD in patients under anticoagulant/antiplatelet therapy without suspension.

Materials and methods

Patients affected by second-third-degree haemorrhoids unresponsive to conservative treatment and under anticoagulant/antiplatelet were enrolled between November 2019 and October 2021. Postoperative complications, readmission, mortality and reintervention during the follow-up were evaluated.

Results

Fifty-one patients were recruited, 23 female (45.1%) and 28 male (54.9%), with an average age of 65 years ± 11.4 SD (range 42-90). Twenty-seven patients (52.9%) had II-degree haemorrhoidal disease, and 24 (47.1%) had grade III-degree. The most frequently taken medications were dual antiplatelet therapy (51%) and new oral anticoagulants (NOACs) (21.6%). The mean follow-up was 23 months. No intraoperative complications were recorded. The rate of complications in the first postoperative month was 13.7%, represented by mild complications: 6 cases of moderate to severe pain and 1 case (2%) of thrombosis of a residual haemorrhoidal nodule, all regressing after conservative therapy. No severe complications were reported. Postoperative complications were not statistically significantly associated with the number of nodules treated (1, 2, or 3), the disease grade (2nd vs. 3rd) or the specific anticoagulant/antiplatelet regimen. During follow-up, 2 patients (4%) required a new procedure for recurrent bleeding: one an infrared photocoagulation as outpatient, and another a haemorrhoidectomy after 3 months. No cases of intraoperative or postoperative mortality occurred.

Conclusions

Sclerobanding is a safe and effective technique in treating intermediate-grade haemorrhoidal disease in patients at high risk on anticoagulant/antiplatelet therapy. Sclerobanding is repeatable, usually does not require anaesthesia, and is cost-effective. Observational multicentre studies with a larger number of patients and controlled clinical trials will be needed to confirm these results.

Bleeding After Hemorrhoidectomy in Patients on Anticoagulation Medications

BACKGROUND

Post-hemorrhoidectomy bleeding is a serious complication after hemorrhoidectomy. In the setting of a new wave of anticoagulants, we aimed to investigate the relationship of post-operative anticoagulation timing and delayed bleeding.

METHODS

We performed a retrospective analysis of all patients undergoing hemorrhoidectomy at a single institution over a 10-year period. Fisher's exact and Wilcoxon Rank Sum tests were utilized to test for association between delayed bleeding and anticoagulation use.

RESULTS

Between January 2011 and October 2020, 1469 hemorrhoidectomies were performed. A total of 216 (14.7%) were taking platelet inhibitors and 56 (3.8%) other anticoagulants. Delayed bleeding occurred in 5.2% (n = 76) of which 47% (n = 36) required operative intervention. Mean time to bleeding was 8.7 days (SD ±5.9). Time to bleeding was longer in those taking antiplatelet inhibitors vs. non-platelet inhibitors vs. none (11 vs. 8 vs. 7 days, P = .05). Among anticoagulants (n = 56), novel oral anticoagulants were more common than warfarin (57% vs 43%) and had a nonsignificant increase in delayed bleeding (31% vs 16%, P = .21). Later restart (>3 days) of novel anticoagulants after surgery was associated with increased bleeding (10.5% vs 61.5%, P=.005). On multivariable analysis, only anticoagulation use (OR 4.5, 95% CI: 2.1-10.0), male sex (OR 1.8, 95% CI: 1.1-2.9), and operative oversewing (OR 3.5, 95% CI: 1.8-6.9) were associated with delayed bleeding.

CONCLUSION

Post-hemorrhoidectomy bleeding is more likely to occur with patients on anticoagulation. Later restart times within the first week after surgery was not associated with a decrease in bleeding.

Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review

BACKGROUND

Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise.

AIM

To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities.

METHODS

We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons.

RESULTS

Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients.

CONCLUSION

Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.

Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery

Introduction Surgery for patients taking antithrombotic drugs for the prevention and treatment of cardiovascular disease, including anticoagulants and antiplatelet drugs, is increasing because of the aging society. In patients with moderate to high risk for cardiovascular events, receiving antiplatelet therapy, and requiring noncardiac surgery continuing antiplatelet drugs perioperatively is recommended. To date, there have been limited reports on the risk of secondary bleeding after proctological surgery in patients who are administered antithrombotic drugs. The purpose of this study was to identify the incidence and severity of secondary bleeding after proctological surgery for patients with or without antithrombotic therapy. Methods We retrospectively identified 113 patients who underwent proctological surgery in our hospital from March 2009 to February 2019. In general, antiplatelet drugs were continued and anticoagulant drugs were either substituted or withdrawn prior to surgery. The severity of secondary bleeding was classified as mild, moderate, or severe. Results Eighteen patients underwent antithrombotic therapy (A group) and 95 patients did not undergo antithrombotic therapy (N group). Secondary bleeding was observed in nine patients (8.0%) and patients in the A group exhibited a significantly higher rate of secondary bleeding than those in the N group (39% vs. 2.4%, P < 0.01). The median interval from surgery to the onset of secondary bleeding was five days (range: 0-11). The severity of bleeding was the highest in patients administered direct oral anticoagulants (DOAC) and was the lowest in those administered aspirin. There was no mortality or cardiovascular event. Conclusion Antithrombotic therapy carries a high risk of secondary bleeding after proctological surgery. Delaying the postoperative resumption of anticoagulants is considered while balancing the risk of postoperative thromboembolic complications against secondary bleeding.

Belgian consensus guideline on the management of hemorrhoidal disease

Introduction

Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking.

Methods

A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020.

Results

Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids.

Conclusions

The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Secondary bleeding following proctological surgery: Rare but potentially severe

PURPOSE

Haemorrhage following proctological surgery is one of the complications with the greatest potential for severity. The aim of this work was to assess the frequency and risk factors of haemorrhage requiring hospitalization during 30-days postoperatively.

METHODS

A retrospective cohort review of all surgeries performed in a Parisian department of medico-surgical proctology between January 2016 and June 2018 was performed. Demographic and surgical data were collected for patients who were hospitalized for postoperative haemorrhage. Their analysis was conducted as a single analysis followed by multivariate analysis.

RESULTS

A total of 7533 surgeries were performed on 6727 patients. The mean patient age was 42.6 (±14.3) years and 67.2% were males. Postoperative haemorrhage occurred in 111 patients (1.5%) with a total of 123 haemorrhagic episodes (12 relapses) within a mean of 6 (±5.5) days. In therapeutic terms, 28.5% of haemorrhages required transfusion, 37.4% required haemostasis in the operating theatre and 14.6% required haemostasis under local anaesthesia. Using multivariate analysis, haemorrhage was more frequent after haemorrhoid surgery and in the case of anticoagulant treatment, particularly direct oral anticoagulants, and if the ASA score was equal to 3. Active smoking was associated with a decreased risk of haemorrhage.

CONCLUSION

Haemorrhage requiring hospitalization occurred in 1.5% of cases following proctological surgery, 52.8% were severe and recurred in 10.8% of cases. The study also specified certain risk factors for haemorrhage and demonstrated the protective effect of active smoking.

Tamponade dressings versus no tamponade after hemorrhoidectomy: study protocol for a randomized controlled trial

Background

Symptomatic hemorrhoids are one of the most common anorectal disorders. Many surgeons use tamponades after open hemorrhoidectomy to manage postoperative bleeding. The question of whether a tamponade is necessary and beneficial after hemorrhoidectomy has not yet been conclusively answered. A previously conducted single-center pilot trial included 100 patients after Milligan–Morgan hemorrhoidectomy. The data indicated that insertion of an anal tamponade after hemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. The findings of this pilot trial are now to be verified by means of a multicenter randomized clinical study called NoTamp.

Methods

We plan to include 953 patients after Milligan-Morgan or Parks hemorrhoidectomy in the NoTamp study. The aim is to demonstrate that using no tamponade dressing after open hemorrhoidectomy is not inferior to using tamponades with respect to postoperative bleeding, and that the patients report less pain. Primary endpoints of the trial are the maximum postoperative pain within 48 h and the incidence of severe postoperative bleeding that requires surgical revision within 7 days after the surgical procedure. Secondary endpoints of the study are the use of analgesics in the postoperative course, the lowest hemoglobin documented within 7 days, quality of life and patient satisfaction. Safety analysis includes all adverse and serious adverse events in relation to the study treatment. Further information can be found in the registration at the German Registry of Clinical Studies (DRKS00011590) and on the study webpage (https://notamp.de/en-GB/trial/main/setLocale/en_GB/). The study is financed by the HELIOS research funding.

Discussion

The study received full ethics committee approval. The first patient was enrolled on 3 May 2017. This trial will finally answer the question whether the insertion of a tamponade after open hemorrhoidectomy is necessary and beneficial.

Trial registration

German Clinical Trials Register (Deutsches Register Klinischer Studien (DRKS), DRKS00011590. Registered on 12 April 2017.

Complications Arising From Perioperative Anticoagulant/Antiplatelet Therapy in Major Colorectal and Abdominal Wall Surgery

BACKGROUND

Postoperative hemorrhage and thromboembolism are recognized complications following colorectal and abdominal wall surgery, but accurate documentation of their incidence, trends, and outcomes is scant. This is relevant given the increasing number of surgical patients with cardiovascular comorbidity on anticoagulant/antiplatelet therapy.

OBJECTIVE

This study aims to characterize trends in the use of anticoagulant/antiplatelet therapy among patients undergoing major colorectal and abdominal wall surgery within the past decade, and to assess rates of, outcomes following, and risk factors for hemorrhagic and thromboembolic complications.

DESIGN AND SETTING

This is a retrospective cross-sectional study conducted at a single quaternary referral center.

PATIENTS

Patients who underwent major colorectal and abdominal wall surgery during three 12-month intervals (2005, 2010, and 2015) were included.

MAIN OUTCOME MEASURES

The primary outcomes measured was the rate of complications relating to postoperative hemorrhage or thromboembolism.

RESULTS

One thousand one hundred twenty-six patients underwent major colorectal and abdominal wall surgery (mean age, 61.4 years (SD 16.3); 575 (51.1%) male). Overall, 229 (21.7%) patients were on anticoagulant/antiplatelet agents; there was an increase in the proportion of patients on clopidogrel, dual antiplatelet therapy, and novel oral anticoagulants over the decade. One hundred seven (9.5%) cases were complicated by hemorrhage/thromboembolism. Aspirin (OR, 2.22; 95% CI, 1.38-3.57), warfarin/enoxaparin (OR, 3.10; 95% CI, 1.67-5.77), and dual antiplatelet therapy (OR, 2.99; 95% CI, 1.37-6.53) were most implicated with complications on univariate analysis. Patients with atrial fibrillation (adjusted OR 2.67; 95% CI, 1.47-4.85), ischemic heart disease (adjusted OR, 2.14; 95% CI, 1.04-4.40), and mechanical valves (adjusted OR, 7.40; 95% CI 1.11-49.29) were at increased risk of complications on multivariate analysis. The severity of these events was mainly limited to Clavien-Dindo 1 (n = 37) and 2 (n = 46) complications.

LIMITATIONS

This is a retrospective study with incomplete documentation of blood loss and operative time in the early study period.

CONCLUSIONS

One in ten patients incurs hemorrhagic/thromboembolic complications following colorectal and abdominal wall surgery. "High-risk" patients are identifiable, and individualized management of these patients concerning multidisciplinary discussion and critical-care monitoring may help improve outcomes. Prospective studies are required to formalize protocols in these "high-risk" patients. See Video Abstract at http://links.lww.com/DCR/A747.

Clopidogrel bisulfate (Plavix) does not increase bleeding complications in patients undergoing rubber band ligation for symptomatic hemorrhoids

BACKGROUND

The incidence of postprocedural bleeding in patients undergoing rubber band ligation (RBL) for symptomatic internal hemorrhoids while taking clopidogrel bisulfate is unknown. To determine the postprocedural bleeding risk of RBL for patients taking clopidogrel compared with age- and sex-matched controls.

MATERIALS AND METHODS

This is a retrospective case-controlled cohort study analyzing data from 2005 to 2013 conducted at a single tertiary care academic center. The study included a total of 80 rubber bands placed on 41 patients taking clopidogrel bisulfate and 72 bands placed on 41 control patients not taking clopidogrel matched for age and sex. The 30-d rates of significant and insignificant bleeding events after RBL were recorded. A bleeding event was considered significant if the patient required admission to the hospital, transfusion of blood products, or additional procedures to stop the bleeding. Insignificant bleeding was defined as passage of blood or clots per rectum with spontaneous cessation and no need for additional intervention.

RESULTS

There was no significant difference in the number of bleeding events per band placed in the clopidogrel group when compared with the control group (3.75% versus 2.78%, P = 0.7387). The rate of significant (2.5% versus 1.39%, P = 0.6244) and insignificant bleeding events (1.25% versus 1.39%, P = 0.9399) was also similar between the two groups. Two significant bleeding events occurred in the clopidogrel group requiring intervention: cauterization in one patient and colonoscopy and transfusion in the other.

CONCLUSIONS

The risk of a bleeding complication after RBL for hemorrhoids does not appear to be increased in patients taking clopidogrel. Our results support the practice of continuing clopidogrel bisulfate in the periprocedural period as the associated risk of thrombosis is greater than the risk of bleeding.

Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016

This paper outlines the recommendations from the Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016. It includes diagnosis and management of haemorrhoids including dietary, non-surgical, and surgical techniques. These guidelines are intended for the use of general practitioners, general surgeons, colorectal surgeons, and gastrointestinal surgeons in India.

Classical treatment of hemorrhoids

Radical and definitive surgical treatment is indicated in approximately one out of ten patients with hemorrhoidal disease. The Milligan and Morgan hemorrhoidectomy technique is the most widely performed in France: the technique is well-codified and results are satisfactory and durable if the indications and the post-operative follow-up are appropriately respected. Post-operative pain can be adequately controlled.

Tamponade dressings may be unnecessary after haemorrhoidectomy: a randomised controlled clinical trial

PURPOSE

Bleeding after haemorrhoidectomy is common. Many surgical textbooks recommend insertion of an anal tampon in order to reduce postoperative bleeding. This practice, however, is bothersome and probably painful for patients. The effect of using a tamponade has not been validated in randomised controlled trials.

METHODS

The study included 100 patients who were scheduled for Milligan-Morgan haemorrhoidectomy. During surgery, patients were randomly assigned to receive or not to receive an anal tampon at the end of the procedure. Data on pain, complications and wound care were collected. The trial was registered (DRKS00003116) and all analyses were by intention-to-treat.

RESULTS

There were 48 patients in the group with tamponade, and 52 patients were left without tamponade. The trial's primary outcome and maximum pain intensity, averaged 6.1 and 4.2 in the two groups (P = 0.001). In the group with tamponade, a complication was recorded in seven patients (15 %), which was similar to the group without tamponade (21 %). Severe anal bleeding occurred in two and five patients, respectively. Bandage changes were less necessary often in the group treated without tamponade (P = 0.013). Hospital stay was 4 days in both groups.

CONCLUSIONS

Data indicate that insertion of an anal tampon after haemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. After haemorrhoidectomy, anal tampons should not be used routinely but may be considered when specific indications justify its use.

One-year outcome of haemorrhoidectomy: a prospective multicentre French study

AIM

An evaluation was performed of the 1-year outcome of open haemorrhoidectomy (Milligan and Morgan alone or with posterior mucosal anoplasty [the Leopold Bellan procedure]).

METHOD

A prospective, multicentre, observational study included all patients having a planned haemorrhoidectomy from January 2007 to June 2008. Data were collected before surgery, and at 3 months and 1 year after surgery. Patients assessed their anal symptoms and quality of life (SF-36).

RESULTS

Six-hundred and thirty-three patients (median age = 48 years, 56.5% women) underwent haemorrhoidectomy either by the Milligan and Morgan procedure alone (n = 231, 36.5%) or together with the Leopold Bellan procedure (posterior mucosal anoplasty) for resection of a fourth haemorrhoid (n = 345, 54.5%), anal fissure (n = 56, 8.9%) or low anal fistula (n = 1, 0.16%). The median healing time was 6 weeks. Early complications included urinary retention (n = 3), bleeding (n = 11), local infection (n = 7) and faecal impaction (n = 9). At 1 year, the main complications included skin tags (n = 2) and anal stenosis (n = 23). There were three recurrences requiring a second haemorrhoidectomy. On a visual analogue scale, anal pain at 1 year had fallen from a median of 5.5/10 before treatment to 0.1/10 (p < 0.001), anal discomfort from 5.5/10 to 0.1/10 (P < 0.001) and the Knowles-Eckersley-Scott Symptom (KESS) constipation score from 9/45 to 6/45 (P < 0.001). The median Wexner score for anal incontinence was unchanged (2/20). De-novo anal incontinence (a Wexner score of >5) affected 8.5% of patients at 1 year, but preoperative incontinence disappeared in 16.7% of patients with this symptom. All physical and mental domains of quality of life significantly improved, and 88% of patients were satisfied or very satisfied.

CONCLUSION

Complications of open haemorrhoidectomy were infrequent. Anal continence was not altered. Comfort and well-being were significantly improved at 1 year after surgery. Patient satisfaction was high despite residual anal symptoms.