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

Fujikawa, Takahisa; Kawamura, Y.; Takahashi, Ryo; Naito, Shigetoshi

doi:10.1016/j.surg.2020.01.003

Cited by 9 publications

(22 citation statements)

References 37 publications

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“…The included articles consisted of 9 studies concerning the management of chronically ATT-received patients[ 10 , 17 - 24 ] (Table 2 ) and 10 studies regarding chemical thromboprophylaxis for VTE (Table 3 )[ 25 - 34 ]. Among the studies on the management of chronically ATT-received patients, one was a multicenter retrospective cohort analysis[ 18 ] and another was an analysis using the propensity score matching method[ 21 ]. All 10 articles on chemical thromboprophylaxis for VTE were observational studies, including three prospective and seven retrospective cohort studies.…”

Section: Resultsmentioning

confidence: 99%

“…In contrast, three papers focused on the feasibility of perioperative aspirin continuation during pancreatectomy[ 18 , 23 , 24 ]. Two retrospective cohort studies demonstrated that preoperative aspirin continuation is not associated with increased rates of SBL or PPH in chronically antiplatelet-received patients during or after pancreatic surgery[ 23 , 24 ].…”

Section: Resultsmentioning

confidence: 99%

“…Two retrospective cohort studies demonstrated that preoperative aspirin continuation is not associated with increased rates of SBL or PPH in chronically antiplatelet-received patients during or after pancreatic surgery[ 23 , 24 ]. Another recently published large-scale retrospective cohort studies[ 18 ], reviewing more than 3000 consecutive patients undergoing major digestive malignancy surgery including pancreatectomy, showed that the discontinuation of preoperative antiplatelet therapy is the most significant risk factor for thromboembolic complications and that the continuation of preoperative aspirin therapy significantly reduced the occurrence of thromboembolic complication. However, it was not related to bleeding complications or PPH.…”

Section: Resultsmentioning

confidence: 99%

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Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature

Fujikawa¹,

Naito²

2021

WJCC

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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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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature

Fujikawa¹,

Naito²

2021

WJCC

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“…Actually, another recent analysis of more than 3000 patients who underwent digestive surgery for malignancy (including major hepatobiliary and pancreas surgery) demonstrated that withdrawal of antiplatelet therapy is the most significant risk factor of postoperative thromboembolic complication, and that the preoperative continuation of aspirin significantly reduces the risk of thromboembolism in patients receiving APT. 33 Therefore, we think preoperative aspirin continuation is one of the preferred options for preventing postoperative thromboembolic complication during major digestive surgery including liver resection." Regarding thromboembolic complication, Schroeder et al, 34 demonstrated that the rates of major adverse cardiovascular events and overall thromboembolic complications after liver resection occur at rates of 4.4% and 3.6%, respectively.…”

Section: Discussionmentioning

confidence: 99%

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

Naito

Fujikawa

Hasegawa

2020

J Hepato Biliary Pancreat

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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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“…This scale could be built on the basis of already validated scales ( 16 , 17 ) and should comprehend different parameters. These types of scales have been widely used in general surgery ( 18 ) or cardiosurgery ( 19 ) for evaluation of the risk of postoperative thromboembolic or hemorrhagic complications ( 20 , 21 ). A possible scale could be drafted as follows:…”

Section: Discussionmentioning

confidence: 99%

Low-Dose Acetylsalicylic Acid in Chronic Subdural Hematomas: A Neurosurgeon's Sword of Damocles

Mongardi¹,

Dones²,

Mantovani³

et al. 2020

Front. Neurol.

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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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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

Cited by 9 publications

References 37 publications

Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature

Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature

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

Low-Dose Acetylsalicylic Acid in Chronic Subdural Hematomas: A Neurosurgeon's Sword of Damocles

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