Evaluation of the risk of post-operative bleeding complications in skin cancer surgery without interruption of anticoagulant/antithrombotic medication: A prospective cohort study

Perioperative anticoagulation recommendations for cutaneous oncologic surgery: a review of the literature

Consistent perioperative management is important to the practice of dermatologic surgery. With the widespread use of anticoagulant medications such as aspirin, warfarin, clopidogrel, factor Xa inhibitors, and thrombin inhibitors for a number of cardiovascular indications, it is important to standardize the use of these drugs in the setting of skin cancer surgery. Limited literature is available, however, regarding recommendations for dermatological perioperative anticoagulation management. Most published manuscripts involving anticoagulation and skin cancer surgery focus on complications and outcomes rather than providing guidelines for decision-making. In addition, survey studies have largely shown that even with existing recommendations in the literature, many dermatologists continue to have varying management of these medications. Overall, this review finds compelling evidence to support the safety of continuing anticoagulation therapy such as warfarin, aspirin, and clopidogrel throughout treatment for cutaneous malignancies. It is important that dermatologists, while having primary care and cardiology available for consultation, are aware of the safety data and feel comfortable managing their patients perioperatively.

Risk of complications due to antithrombotic agents in cutaneous surgery: a systematic review and meta-analysis

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.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection

SUMMARY

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Hemorrhagic complications of cutaneous surgery for patients taking antithrombotic therapy: a systematic review and meta-analysis

Cutaneous operations are generally safe procedures with minimal major risks. Excessive bleeding occasionally occurs, especially for patients taking antithrombotic medications. Conversely, stopping these medications before cutaneous surgery may increase the risk of a thromboembolic event. We aimed to synthesize the evidence regarding the risk of hemorrhage and thromboembolic events for patients undergoing cutaneous surgery while taking antithrombotic therapy. We performed a comprehensive search to identify randomized controlled trials and cohort studies that compared rates of hemorrhage and/or thromboembolic events between patients receiving antithrombotic therapy at cutaneous surgery and patients not receiving it. Odds ratio (OR) and risk difference for complications were calculated with random-effects models. Of 9214 patients taking anticoagulant or antiplatelet medications, 323 (3.5%) had hemorrhagic complications; of 21,696 control patients, 265 (1.2%) had hemorrhagic complications. Patients taking antithrombotic therapy had increased bleeding risk relative to control patients (OR 2.63 [95% CI 1.90-3.63]; P < 0.001) and an increased but less clinically important risk difference (OR 0.02 [95% CI 0.01-0.03]; P < 0.001) with high heterogeneity. No difference was observed in hemorrhage rates among patients whose antithrombotic therapy was stopped vs continued (OR 1.16 [95% CI 0.73-1.83]; P = 0.54). No difference was seen in rates of thromboembolic events among patients taking antithrombotic therapy vs control patients. However, two serious thromboembolic events were noted in a cohort of 59 patients whose antithrombotic therapy was stopped. Because of potentially devastating effects of thromboembolic events, the current accepted practice is indicated for continuation of antithrombotic therapy for patients undergoing cutaneous surgery.

Efficacy and Safety of Simultaneous Application of HIFEM and Synchronized Radiofrequency for Abdominal Fat Reduction and Muscle Toning: A Multicenter Magnetic Resonance Imaging Evaluation Study

BACKGROUND

Radiofrequency and high-Intensity Focused Electromagnetic (HIFEM) field procedure are well-known, stand-alone, body-shaping modalities, yet their simultaneous application has not been investigated.

OBJECTIVE

The aim is to evaluate the efficacy of a novel device simultaneously delivering HIFEM and radiofrequency for subcutaneous fat reduction and muscle toning.

MATERIALS AND METHODS

Forty-one subjects with an average age of 39.7 ± 11.5 years were recruited. The subjects received 3 abdominal treatments (one per week). Magnetic resonance imaging images of the treated area were evaluated at baseline and at 1-, 3-, and 6-month visits for changes in subcutaneous fat, muscle thickness, and abdominal separation (AS). Anthropometric data and digital photographs were collected. Subject satisfaction and therapy comfort were evaluated.

RESULTS

The muscle mass increase peaked at 3 months, showing 26.1% thickening. The fat thickness reduction was most prominent at 3 months, showing a 30.8% reduction. The AS decreased by 18.8% at 3 months after treatment. The waist circumference reduced by 5.87 ± 3.64 cm at a 3-month follow-up. Six-month data showed maintenance of these outcomes. The treatment was considered as comfortable with high patient satisfaction.

CONCLUSION

The analysis of magnetic resonance imaging images and waist measurements showed that the therapy combining HIFEM and radiofrequency is highly effective in reducing subcutaneous fat and muscle thickening.

Evidence-based clinical practice guideline: Reconstruction after skin cancer resection

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection

SUMMARY

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

[Evaluation of the risk of postoperative bleeding complications in hand surgery without interruption of anticoagulant Vitamin K Antagonist (VKA), a retrospective study]

OBJECTIVE

The management of patients on Vitamine K Antagonist (VKA) anticoagulation is a public health issue with surgery being the primary cause of VKA interruption. The aim of this study was to evaluate the bleeding risk in patients operated on hand surgery without interruption of VKA treatment.

PATIENTS AND METHODS

This retrospective, monocentric study was conducted between 2013 and 2015. The inclusion criteria were, as follows: patients on VKA over 18 years of age who had emergency or scheduled surgery without interruption of VKA treatment; INR inferior to 3 analyzed less than 24h before surgery. Exclusion criteria were, as follows: INR superior to 3; interruption of VKA treatment with or without switch to heparin treatment. The primary evaluation parameter was any form of bleeding that occurred during the first 7 post-operative days. The secondary criteria were other surgical complications.

RESULTS

There were 93 patients and 104 procedures. The mean age was 74.36 years (from 27 to 90) with a sex ratio male-to-female of 2.47. The scheduled surgeries were 61.5% against 36.5% for the emergency cases. The mean INR was 2.29 (from 1.07 to 3). One patient presented a postoperative hematoma on the 4th postoperative day, which did not require any revision surgery. There were no other complications reported.

CONCLUSION

The results of this series suggest a small bleeding risk in hand surgery without interruption of VKA treatment provided that IRN is inferior to 3 less than 24hours before the procedure.

Safety of Anticoagulation Interruption in Patients Undergoing Surgery or Invasive Procedures: A Systematic Review and Meta-analyses of Randomized Controlled Trials and Non-randomized Studies

BACKGROUND

The safety of anticoagulation interruption in patients requiring surgical or invasive procedures remains unclear. We thus performed a systematic review and meta-analyses of randomized controlled trials (RCTs) and non-randomized studies (NRS).

METHODS

MEDLINE, Embase and Central databases were searched to March 2017 without date or language restrictions. We considered RCTs and NRS comparing anticoagulation interruption with any anticoagulation (continuation or heparin bridging) in adult surgical patients taking oral anticoagulation. Data were independently extracted. The quality of the evidence was assessed following recommendations from the Cochrane collaboration (GRADE approach). Risk ratios were calculated for 30-day events: thromboembolic (TE) events, major bleeding and mortality. Additional analyses explored the effects of different anticoagulation strategies.

RESULTS

Twelve reports were included: 4 RCTs (2190 participants) and 8 NRS (18993 participants). Trials included mostly participants with atrial fibrillation. Interrupting anticoagulation did not seem to increase TE events (RR 0.65, 95% CI [0.33, 1.30]-4 studies, 2190 participants) and resulted in less bleeding (RR 0.41, 95% CI [0.22, 0.78]-3 studies, 2126 participants) compared to anticoagulation continuation or heparin bridging. The GRADE assessment was moderate. Similar results were found in non-randomized studies, but the quality of the evidence was low. Possible strategy-specific effects were identified: forgoing heparin bridging seemed beneficial, but these effects were less clear with other strategies.

CONCLUSION

Interrupting anticoagulation in patients requiring invasive procedures did not seem to result in harm and protected against major bleeding. Uncertainty remains regarding the safety of this strategy in indications other than atrial fibrillation and in moderate- to high-risk surgery.

STUDY REGISTRATION

http://www.en.anaesthesie.usz.ch/research/Pages/Study-protocols.aspx.