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

Abstract

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.

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper-Gastrointestinal and Hepatopancreatobiliary Surgery

“…The wide variability in the use of thromboprophylaxis in general abdominal, colorectal, UGI, and HPB surgeries, both within and between countries, centers, and surgeons, reflects a lack of consensus regarding optimal practice 12,19,20,22,23,56 . As no systematic reviews of procedure-specific risks of VTE and bleeding for general abdominal, colorectal, UGI, and HPB surgeries have heretofore been available, this variability is unsurprising 12,15–17 . Summaries presented—and visually summarized in Infographics (Figs.…”

“…12,19,20,22,23,56 As no systematic reviews of procedure-specific risks of VTE and bleeding for general abdominal, colorectal, UGI, and HPB surgeries have heretofore been available, this variability is unsurprising. 12,[15][16][17] Summaries presented-and visually summarized in Infographics (Figs. 1-3)-important implications for surgery practice and will help rationalize the use of thromboprophylaxis worldwide.…”

“…General abdominal, colorectal, upper gastrointestinal (UGI), and hepatopancreatobiliary (HPB) surgery guidelines have failed to provide patient and procedure-specific guidance on pharmacological thromboprophylaxis, 7,12–17 at least in part due to uncertainty regarding baseline risks that vary with patient and procedure-specific factors 18 . The absence of procedure-specific recommendations contributes to substantial practice variation within and between centers and countries 12,19–25 .…”

Assessing the use of Extended Venous Thromboembolism Prophylaxis on the Rates of Venous Thromboembolism and Postpancreatectomy Hemorrhage Following Pancreatectomy for Malignancy

“…17,18 PPH usually presents in delayed manner [19][20][21] and is associated with a mortality rate of 10% to 38%. 12,17,[21][22][23][24][25] Several studies of abdominal and pelvic surgery have examined the associations between extended VTE prophylaxis, development of VTEs, and postoperative hemorrhage. These studies report that extended VTE prophylaxis may be associated with a decrease in VTE rate with no increase in postoperative hemorrhage.…”

“…The rate of PPH is ~6% to 8% 17,18. PPH usually presents in delayed manner19–21 and is associated with a mortality rate of 10% to 38% 12,17,21–25. Several studies of abdominal and pelvic surgery have examined the associations between extended VTE prophylaxis, development of VTEs, and postoperative hemorrhage.…”