Digestive Surgery in Patients Treated with Antiplatelet Agents: How Risky?

B. Menahem¹, L. Plard¹, A. L. Fiant², A. Dugue³, P. Milliez⁴, A. Alves¹, L. Chiche^1*

¹Department of Digestive Surgery, University Hospital of Caen, Caen, France.
²Department of Anesthesiology, University Hospital of Caen, Caen, France.
³Department of Biostatistic, University Hospital of Caen, Caen, France.
⁴Department of Cardiology, University Hospital of Caen, Caen, France.

DOI: 10.4236/oalib.1100474                

Abstract

Purpose: To assess the risks of digestive surgery in patients under antiplatelet therapy. Increasing numbers of patients requiring a surgical digestive procedure are on APT. Several studies have shown that APT interruption during the perioperative period increased thrombotic risks, while in the case of maintaining APT, hemorrhagic complications were not increased. Methods: We included prospectively all patients under APT who were operated on from September 1, 2010 to October 31, 2011. Two groups were defined: patients who interrupted APT and those who maintained APT. Three surgical categories were distinguished, with Group I involving parietal surgery, Group II common abdominal surgery, and Group III complex abdominal surgery. The primary endpoints were hemorrhagic and thrombotic risks. Results: Among the 2047 patients undergoing digestive surgery, 130 (6.5%) were on APT, with 32 in Group APT- and 98 in Group APT+. In the overall series, patients taking APT did not receive significantly more transfusions. APT was significantly associated with a higher rate of bleeding complications and transfusion requirement in patients undergoing complex and major abdominal surgery (0% vs. 28%, p = 0.03). In Group APT-, only one patient out of 32 (3.1%) suffered from a thrombotic event involving a myocardial infarction. Conclusions: This study suggests stopping APT at least 5 - 7 days in patients undergoing complex and major abdominal surgery. In this other case, APT may be maintained without an increased risk of hemorrhage.

Keywords

Antiplatelet, Digestive Surgery, Hemorraghe, Thrombosis

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Mantz, J., Samama, C.M., Tubach, F., Devereaux, P.J., Collet, J.P., Albaladejo, P., Cholley, B., Nizard, R., Barré, J., Piriou, V., Poirier, N., Schlumberger, S., Longrois, D., Aubrun, F., Farèse, M.E., Ravaud, P. and Steg, P.G. (2011) Impact of Preoperative Minteanance or Interruption of Aspirin on Thrombotic and Bleeding Events after Elective Non-Cardiac Surgery: The Multicentre, Randomized, Blinded, Placebo-Controlled, Strategem Trial. British Journal of Anaesthesia, 107, 899-910. http://dx.doi.org/10.1093/bja/aer274
[2]	Samama, C.M., Bartim, O., Forestier, F., Denninger, M.H., Isettra, C., Julian, J.M., et al. (2002) Antiplatelets Agents in the Perioperative Period: Expert Recommendations of the French Society of Anesthesiology and Intensive Care. Canadian Journal of Anesthesia, 49, S26-35.
[3]	Riddell, J.W., Chiche, L., Plaud, B. and Hamon, M. (2007) Coronary Stenting and Noncardiac Surgery. Circulation, 116, e378-382. http://dx.doi.org/10.1161/CIRCULATIONAHA.107.726992
[4]	Korte, W., Cattaneo, M., Chassot, P.G., Eichinger, S., von Heymann, C., Hofmann, N., Rickli, H., Spannagl, M., Ziegler, B., Verheugt, F. and Huber, K. (2011) Peri-Operative Management of Antiplatelet Therapy in Patients with Coronary Artery Disease: Joint Position Paper by Members of the Working Group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the Working Group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESc). Thrombosis and Haemostasis, 105, 743-749. http://dx.doi.org/10.1160/TH10-04-0217
[5]	Albaledjo, P. and Samama, C.-M. (2010) Gestion périopératoire des anciens et nouveaux agents antiplaquettaires. Le Praticien en Anesthésie-Réanimation, 14, 44-50.
[6]	Chassot, P.G., Delabays, A. and Spahn, D.R. (2007) Perioperative Antiplatelet Therapy: The Case for Continuing Therapy in Patients at Risk of Myocardial Infarction. British Journal of Anaesthesia, 99, 316-328. http://dx.doi.org/10.1093/bja/aem209
[7]	Nuttal, G.A., Brown, M.J., Stombaugh, J.W., Michon, P.B., Hathaway, M.F., Lindeen, K.C., et al. (2008) Time and Cardiac Risk of Surgery after Bare-Metal Stent Percutaneous Coronary Intervention. Anesthesiology, 109, 588-595. http://dx.doi.org/10.1097/ALN.0b013e318186ddf8
[8]	Rabbits, J.A., Nuttal, G.A., Brown, M.J., Hanson, A.C., Oliver, W.C., Holmes, D.R., et al. (2008) Cardiac Risk of Non Cardiac Surgery after Percutaneous Coronary Intervention with Drug-Eluting Stents. Anesthesiology, 109, 596-604. http://dx.doi.org/10.1097/ALN.0b013e318186de1c
[9]	Douketis, J.D., Berger, P.B., Dunn, A.S., Jaffer, A.K., Spyropoulos, A.C., Becker, R.C., et al. (2008) The Perioperative Management of Antithrombotic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 133, S299-349.
[10]	Iakovou, I., Schmidt, T., Bonizzoni, E., Ge, L., Sangiorgi, G.M., Stankovic, G., et al. (2005) Incidence, Predictors, and Outcome of Thrombosis after Succesful Implantation of Drug-Eluting Stents. JAMA, 293, 2126-2130. http://dx.doi.org/10.1001/jama.293.17.2126
[11]	Collet, J.P., Montalescot, B., Tanguy, M.L., Goldmard, J.L., Choussat, R., Beygui, F., Payot, L., Vignolles, N., Metzger, J.P. and Thomas, D. (2004) Impact of Priori Use or Recent Withdrawal of Oral Antiplatelet Agents on Acute Coronary Syndromes. Circulation, 110, 2361-2367. http://dx.doi.org/10.1161/01.CIR.0000145171.89690.B4
[12]	Albaledjo, P., Geeraerts, T., Francis, F., Castier, Y., Leseche, G. and Marty, J. (2004) Aspirin Withdrawal and Acute Lower Limb Ischemia. Anesthesia & Analgesia, 99, 440-443. http://dx.doi.org/10.1213/01.ANE.0000131965.61686.BD
[13]	Bachman, D.S. (2002) Discontinuing Chronic Aspirin Therapy: Another Risk Factor of Stroke? Annals of Neurology, 51, 137-138. http://dx.doi.org/10.1002/ana.10023
[14]	Ferrari, E., Benhamou, M., Cerboni, P. and Marcel, B. (2005) Coronary Syndromes Following Aspirin Withdrawal a Special Risk for Late Stent Thrombosis. Journal of the American College of Cardiology, 45, 456-459. http://dx.doi.org/10.1016/j.jacc.2004.11.041
[15]	Maulaz, A.B., Bezerra, D.C., Michel, P. and Bogoulavsky, J. (2005) Effects of Discontinuing Aspirin Therapy on the Risk of Brain Ischemic Stroke. Archives of Neurology, 62, 1217-1220. http://dx.doi.org/10.1001/archneur.62.8.1217
[16]	Sibon, I. and Orgogozo, J.M. (2004) Antiplatelet Drug Discontinuation Is a Risk Factor for Ischemic Stroke. Neurology, 62, 1187-1189. http://dx.doi.org/10.1212/01.WNL.0000118288.04483.02
[17]	Oscarsson, A., Gupta, A., Fredrikson, M., Jarhult, J., Nystrom, M., Pettersson, E., et al. (2010) To Continue or Discontinue Aspirin in the Perioperative Period: A Randomized, Controlled Clinical Trial. British Journal of Anaesthesia, 104, 305-312. http://dx.doi.org/10.1093/bja/aeq003
[18]	Kaluza, G.L., Joseph, J., Lee, J.R., Raizner, M.E. and Raizner, A.E. (2000) Catastrophic Outcomes of Non Cardiac Surgery Soon after Coronary Stenting. Journal of the American College of Cardiology, 35, 1288-1294. http://dx.doi.org/10.1016/S0735-1097(00)00521-0
[19]	Burger, W., Chmnitius, J.M., Kneiss, G.D. and Rucker, G. (2005) Low-Dose of Aspirin for Secondary Cardiovascular Prevention—Cardiovascular Risks after Its Perioperative Withdraal versus Bleeding Risks with Its Continuation—Review and Metanalysis. Journal of Internal Medicine, 257, 399-414. http://dx.doi.org/10.1111/j.1365-2796.2005.01477.x