Effect of Antiplatelet Therapy on Patients Undergoing Gastroenterological Surgery: Thromboembolic Risks Versus Bleeding Risks During Its Perioperative Withdrawal
Effect of Antiplatelet Therapy on Patients Undergoing Gastroenterological Surgery: Thromboembolic Risks Versus Bleeding Risks During Its Perioperative Withdrawal
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DOI：
10.1007/s00268-014-2760-3
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发表时间：
2015-01-01
影响因子：
2.6
通讯作者：
Maekawa, Hisatsugu
中科院分区：
文献类型：
--
作者：
Fujikawa, Takahisa;Tanaka, Akira;Maekawa, Hisatsugu
用于预防血栓栓塞性疾病的抗血小板药物经常在手术前停用，以减少出血并发症。这一行动可能会增加患者的血栓栓塞发病率和死亡率。本研究回顾了2005年1月至2010年6月在我院接受胃肠外科手术的2012例患者。在该队列中，519例患者（25.8%）使用了抗血小板治疗（APT）。围手术期治疗包括在低血栓栓塞风险患者术前1周中断APT治疗和术后早期重新住院，而高血栓栓塞风险患者则维持APT治疗至手术。在519例APT患者中，99例（19.1%）接受了多药APT治疗，其中124例（23.9%）需要术前继续APT治疗，没有一例患者出现术中大出血。整个队列中有19例血栓栓塞事件（0.9%）。术后出血并发症37例（1.8%）。多因素分析显示，术后出血并发症增加与多药APT[危险比（HR） 4.3, p = 0.014]、高危手术（HR 3.5, p = 0.003）和围手术期肝素桥接（HR 2.8, p = 0.029）独立相关。高危手术（HR 8.3, p < 0.001）和不良表现状态(HR 4.9, p = 0.005)-但APT和抗凝治疗均不是血栓栓塞并发症的重要预后因素。在严格的围手术期管理下，包括在高血栓栓塞风险患者中继续使用单药APT，胃肠外科手术获得了满意的结果。然而，接受多药APT治疗的患者仍然是一个具有挑战性的群体，需要仔细管理以防止围手术期并发症。
Antiplatelet agents given to prevent thromboembolic disease are frequently withdrawn prior to surgical procedures to reduce bleeding complications.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.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.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.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.