Intractable intraoperative bleeding requiring platelet transfusion during emergent cholecystectomy in a patient with dual antiplatelet therapy after drug-eluting coronary stent implantation (with video)

Impact of preoperative aspirin continuation on bleeding complications during or after liver resection: Propensity score-matched analysis

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.

Risk of postoperative thromboembolic complication after major digestive surgery in patients receiving antiplatelet therapy: Lessons from more than 3,000 operations in a single tertiary referral hospital

BACKGROUND

Although recent studies have suggested that the continuation of preoperative antiplatelet therapy with aspirin does not affect intraoperative or postoperative bleeding in patients undergoing digestive surgery, its preventive effect against thromboembolic complication remains largely unknown.

METHODS

A total of 3,072 patients who underwent major digestive surgery (esophago-gastrointestinal and hepatobiliary-pancreatic resection for malignancy) between 2005 and 2018 at our institution were enrolled in this study. The patients were divided into 3 groups: patients continuing to receive preoperative antiplatelet therapy with aspirin (continued-antiplatelet therapy group, n = 425), those discontinuing preoperative antiplatelet therapy (discontinued-antiplatelet therapy group, n = 549), and those who were not receiving antiplatelet therapy (non-antiplatelet therapy group, n = 2,117). The CHADS₂ and the CHA₂DS₂-VASc scoring system were used to assess potential thromboembolic risk. Surgical outcomes were compared between the groups and the risk factors for thromboembolic complication, bleeding complication, and operative mortality were determined by multivariate analysis.

RESULTS

There was no difference between the discontinued-antiplatelet therapy and continued-antiplatelet therapy groups in the rate of high risk patients categorized by CHADS₂ and CHA₂DS₂-VASc scores; however, the occurrence of thromboembolic complication in the discontinued-antiplatelet therapy group was significantly higher compared with the continued-antiplatelet therapy group (2.8% vs 0.5%; P = .006). In a multivariate analysis using the whole cohort, discontinuation of antiplatelet therapy (odds ratio = 4.39; P < .001), poor performance status (odds ratio = 4.14; P = .001), and hypertension (odds ratio = 3.46; P = .005) were the independent risk factors for thromboembolic complication. In the groups of patients receiving antiplatelet therapy, multivariate analysis showed that preoperative aspirin continuation had a significant negative impact (odds ratio = 0.10, P = .029) on the occurrence of thromboembolic complication, but did not affect either postoperative bleeding complication or operative mortality.

CONCLUSION

Discontinuation of antiplatelet therapy during major digestive surgery is the most significant risk factor for thromboembolic complication, and the continuation of preoperative aspirin therapy significantly reduces the occurrence of thromboembolic complication in patients receiving antiplatelet therapy. It is suggested that the preoperative continuation of aspirin monotherapy is one of the preferred options to prevent severe thromboembolic events during major digestive surgery in patients receiving antiplatelet therapy.

Safety of elective laparoscopic cholecystectomy in patients with antiplatelet therapy: Lessons from more than 800 operations in a single tertiary referral institution

INTRODUCTION

The perioperative antiplatelet management of patients receiving antiplatelet therapy (APT) for elective laparoscopic cholecystectomy (LC) is still controversial.

METHODS

A total of 808 patients who underwent elective LC were reviewed. We classified patients in this cohort into three groups according to thromboembolic risks: patients with no thromboembolic risk (non-APT group, n = 653), patients with low thromboembolic risk (APT-LR group, n = 106), patients with high thromboembolic risk (APT-HR group, n = 49). Our perioperative management of patients with high thrombotic risks included preoperative continuation of single aspirin therapy and early postoperative reinstitution. We assessed intraoperative and postoperative bleeding/thrombotic events among three groups. Primary outcome measures were intraoperative bleeding complications (IBCs, blood loss 200 mL or more) and postoperative bleeding complications (PBCs), and the independent risk factors for increased IBC were determined by multivariate analysis. This study was approved by our institutional review board (#17011804).

RESULTS

In the current cohort, IBC occurred in 17 (2.1%) patients. Postoperatively, there were three PBCs (0.4%) and two thromboembolic complications (TCs, 0.2%), respectively. The occurrences of IBC and TC did not show any significant difference between the three groups, but PBC was more common in the APT-LR group (P = 0.022). Multivariate analysis showed that only chronic cholecystitis was the independent risk factor for IBC (P < 0.001, odds ratio = 12.355), but preoperative continuation of APT or multiple APT use did not affect IBC.

CONCLUSION

We performed elective LC safely in patients receiving APT under rigorous perioperative management of APT. Continuation of aspirin monotherapy is considered in patients with APT during elective LC.

Impact of laparoscopic liver resection on bleeding complications in patients receiving antithrombotics

AIM

To assess the impact of laparoscopic liver resection (LLR) on surgical blood loss (SBL), especially in patients with antithrombotics for thromboembolic risks.

METHODS

Consecutive 258 patients receiving liver resection at our institution between 2010 and 2016 were retrospectively reviewed. Preoperative antithrombotic therapy (ATT; antiplatelets and/or anticoagulation) was regularly used in 100 patients (ATT group, 38.8%) whereas not used in 158 (non-ATT group, 61.2%). Our perioperative management of high thromboembolic risk patients included maintenance of preoperative aspirin monotherapy for patients with antiplatelet therapy and bridging heparin for patients with anticoagulation. In both ATT and non-ATT groups, outcome variables of patients undergoing LLR were compared with those of patients receiving open liver resection (OLR), and the independent risk factors for increased SBL were determined by multivariate analysis.

RESULTS

This series included 77 LLR and 181 OLR. There were 3 thromboembolic events (1.2%) in a whole cohort, whereas increased SBL (≥ 500 mL) and postoperative bleeding complications (BCs) occurred in 66 patients (25.6%) and 8 (3.1%), respectively. Both in the ATT and non-ATT groups, LLR was significantly related to reduced SBL and low incidence of BCs, although LLR was less performed as anatomical resection. Multivariate analysis showed that anatomical liver resection was the most significant risk factor for increased SBL [risk ratio (RR) = 6.54, P < 0.001] in the whole cohort, and LLR also had the significant negative impact (RR = 1/10.0, P < 0.001). The same effects of anatomical resection (RR = 15.77, P < 0.001) and LLR (RR = 1/5.88, P = 0.019) were observed when analyzing the patients in the ATT group.

CONCLUSION

LLR using the two-surgeon technique is feasible and safely performed even in the ATT-burdened patients with thromboembolic risks. Independent from the extent of liver resection, LLR is significantly associated with reduced SBL, both in the ATT and non-ATT groups.

Effect of antiplatelet therapy on patients undergoing gastroenterological surgery: thromboembolic risks versus bleeding risks during its perioperative withdrawal

BACKGROUND

Antiplatelet agents given to prevent thromboembolic disease are frequently withdrawn prior to surgical procedures to reduce bleeding complications. This action may expose patients to increased thromboembolic morbidity and mortality.

METHODS

A series of 2012 patients who had undergone gastroenterologic surgery between January 2005 and June 2010 at our institution were reviewed. Among this cohort, antiplatelet therapy (APT) was used in 519 patients (25.8 %). The perioperative management included interruption of APT 1 week before surgery and early postoperative reinstitution in patients at low thromboembolic risk, although APT was maintained until surgery in those at high thromboembolic risk. Bleeding and thromboembolic complications, as well as other outcome variables, were assessed in patients with and without APT.

RESULTS

Among 519 patients with APT, 99 (19.1 %) underwent multidrug APT. Among them, 124 (23.9 %) required preoperative continuation of APT. None suffered from excessive bleeding intraoperatively. There were 19 thromboembolic events (0.9 %) in the whole cohort. Postoperative bleeding complications occurred in 37 patients (1.8 %). Multivariate analysis showed that increased postoperative bleeding complications were independently associated with multidrug APT [hazard ratio (HR) 4.3, p = 0.014], high-risk surgical procedures (HR 3.5, p = 0.003), and perioperative heparin bridging (HR 2.8, p = 0.029). High-risk surgery (HR 8.3, p < 0.001) and poor performance status (HR 4.9, p = 0.005)--but neither APT nor anticoagulation use--were significant prognostic factors for thromboembolic complications.

CONCLUSIONS

Satisfactory outcomes were obtained during gastroenterologic surgery under rigorous perioperative management, including single-agent APT continuation in patients at high thromboembolic risk. Patients treated with multidrug APT still represent a challenging group, however, and need to be carefully managed to prevent perioperative complications.

An acute care surgery dilemma: emergent laparoscopic cholecystectomy in patients on aspirin therapy

BACKGROUND

The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on prehospital aspirin (ASP) therapy undergoing emergent cholecystectomy.

METHODS

We performed a 1-year retrospective analysis of our prospectively maintained acute care surgery database. The 2 groups (ASP group vs No ASP group) were matched in a 1:1 ratio for age, sex, previous abdominal surgeries, and comorbidities. Primary outcome measures were intraoperative hemorrhage, postoperative anemia, need for blood transfusion, and conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of ≥ 100 mL; postoperative anemia was defined by ≥ 2 g/dL drop in hemoglobin.

RESULTS

A total of 112 (ASP: 56, no ASP: 56) patients were included in the analysis. The mean age was 65.9 ± 10 years, and 50% were male. There was no difference in age (P = .9), sex (P = .9), and comorbidities (P = .7) between the 2 groups. There was no difference in intraoperative blood loss >100 mL (P = .5), postoperative anemia (P = .8), blood transfusion requirement (P = .9), and conversion to open surgery (P = .7) between patients on American Society of Anesthesiologists therapy and patients not on American Society of Anesthesiologists therapy.

CONCLUSIONS

Emergent laparoscopic cholecystectomy is a safe procedure in patients on long-term ASP. Prehospital use of ASP as an independent factor should not be used to delay emergent cholecystectomy.

Successful multidisciplinary treatment of hilar cholangiocarcinoma in a patient with complicated new-onset coronary artery disease

We report a 69-year-old man suffering from hilar cholangiocarcinoma and concurrent new-onset complicated coronary artery disease. After implanting non-drug-eluting coronary stents, combination chemotherapy with gemcitabine and S-1 under continuation of dual antiplatelet therapy was carried out and partial tumour response was achieved. Subsequently, extended right hepatectomy with partial resection of the Spiegel lobe and left hepaticojejunostomy was performed while continuing preoperative single antiplatelet therapy with aspirin. The patient recovered well without any thromboembolic or bleeding complications. Like the current case, neoadjuvant chemotherapy and subsequent curative resection under continuation of antiplatelet therapy, followed by preceding coronary intervention, is one of the preferred options for the treatment of hepatobiliary malignancy in patients with concurrent new-onset coronary artery disease.

Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital

BACKGROUND

The effect of antiplatelet therapy (APT) on surgical blood loss and perioperative complications in patients receiving abdominal laparoscopic surgery still remains unclear.

STUDY DESIGN

A total of 1,075 consecutive patients undergoing abdominal laparoscopic surgery between 2005 and 2011 were reviewed. Our perioperative management protocol consisted of interruption of APT 1 week before surgery and early postoperative reinstitution in low thromboembolic risk patients (n = 160, iAPT group). Preoperative APT was maintained in patients with high thromboembolic risk or emergent situation (n = 52, cAPT group). Perioperative and outcomes variables of cAPT and iAPT groups, including bleeding and thromboembolic complications, were compared with those of patients without APT (non-APT group, n = 863).

RESULTS

In this cohort, 715 basic and 360 advanced laparoscopic operations were included. No patient suffering excessive intraoperative bleeding due to continuation of APT was observed. There were 10 postoperative bleeding complications (0.9%) and 3 thromboembolic events (0.3%), but the surgery was free of both complications in the cAPT group. No significant differences were found between the groups in operative blood loss, blood transfusion rate, and the occurrence of bleeding and thromboembolic complications. Multivariable analyses showed that multiple antiplatelet agents (p = 0.015) and intraoperative blood transfusion (p = 0.046) were significant prognostic factors for postoperative bleeding complications. Increased thromboembolic complications were independently associated with high New York Heart Association class (p = 0.019) and history of cerebral infarction (p = 0.048), but not associated with APT use.

CONCLUSIONS

Abdominal laparoscopic operations were successfully performed without any increase in severe complications in patients with APT compared with the non-APT group under our rigorous perioperative assessment and management. Maintenance of single APT should be considered in patients with high thromboembolic risk, even when an abdominal laparoscopic approach is considered.