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Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis

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Abstract

Background

In laparoscopic surgery for colorectal cancer (CRC) for patients who receive antiplatelet therapy (APT), it remains unclear whether APT should be continued or temporarily withdrawn. We investigated the safety of perioperative aspirin continuation, specifically focused on bleeding complications.

Methods

We performed retrospective analysis utilizing propensity score-matching (PSM). In total, 789 patients satisfied the inclusion criteria, and were divided into two groups. Patients in the continued aspirin monotherapy (cAPT) group continued treatment perioperatively with not more than 2 days of withdrawal (n = 140). Patients with more than 3 days withdrawal of aspirin or who did not receive APT at all were assigned to the non-cAPT group (n = 649). After 1:1 PSM, 105 patients were extracted from each group. Perioperative APT management was determined based on our institutional committee-approved guidelines for antithrombotic management.

Results

In PSM cohorts, all patient demographics were comparable between the groups. Regarding intraoperative outcomes, we found no significant difference in operation duration (p = 0.969), blood loss (p = 0.068), and blood transfusion (p = 0.517). Postoperative overall morbidity was 20.0% and 13.3% in the cAPT and non-cAPT groups, respectively (p = 0.195). The incidence of bleeding complications was also comparable between the groups (2.9% vs. 1.0%, p = 0.317). Assessing the 14 cases with bleeding complications overall in the full cohort, all 7 cases in the non-cAPT group had anastomotic bleeding, which was generally observed shortly after surgery [median postoperative day (POD) 1]. All 7 cases in the cAPT group received additional antithrombotics other than aspirin; bleeding occurred at various sites relatively later (median POD 7), mostly after reinstitution of additional antithrombotic agents.

Conclusions

For patients receiving APT, perioperative continuation of aspirin monotherapy could be safe in laparoscopic CRC surgery; however, careful consideration is required at reinstitution of additional antithrombotics where multiple antithrombotic agents are used.

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References

  1. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown JM (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726

    Article  PubMed  Google Scholar 

  2. Veldkamp R, Kuhry E, Hop WCJ, Jeekel J, Kazemier G, Bonjer HJ, Haglind E, Påhlman L, Cuesta MA, Msika S, Morino M, Lacy AM (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484

    Article  PubMed  Google Scholar 

  3. The Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059

    Article  Google Scholar 

  4. Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué JM, Visa J (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229

    Article  PubMed  Google Scholar 

  5. Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW, Hellinger M, Flanagan R, Peters W, Nelson H (2007) Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 246:655–662 (discussion 662-664)

    Article  PubMed  Google Scholar 

  6. Buunen M, Veldkamp R, Hop WCJ, Kuhry E, Jeekel J, Haglind E, Påhlman L, Cuesta MA, Msika S, Morino M, Lacy A, Bonjer HJ (2009) Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 10:44–52

    Article  PubMed  CAS  Google Scholar 

  7. Baron TH, Kamath PS, McBane RD (2013) Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 368:2113–2124

    Article  CAS  PubMed  Google Scholar 

  8. Thachil J, Gatt A, Martlew V (2008) Management of surgical patients receiving anticoagulation and antiplatelet agents. Br J Surg 95:1437–1448

    Article  CAS  PubMed  Google Scholar 

  9. Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, Villar JC, Sigamani A, Biccard BM, Meyhoff CS, Parlow JL, Guyatt G, Robinson A, Garg AX, Rodseth RN, Botto F, Lurati Buse G, Xavier D, Chan MTV, Tiboni M, Cook D, Kumar PA, Forget P, Malaga G, Fleischmann E, Amir M, Eikelboom J, Mizera R, Torres D, Wang CY, VanHelder T, Paniagua P, Berwanger O, Srinathan S, Graham M, Pasin L, Le Manach Y, Gao P, Pogue J, Whitlock R, Lamy A, Kearon C, Baigent C, Chow C, Pettit S, Chrolavicius S, Yusuf S (2014) Aspirin in patients undergoing noncardiac surgery. N Engl J Med 370:1494–1503

    Article  CAS  PubMed  Google Scholar 

  10. Mantz J, Samama CM, Tubach F, Devereaux PJ, Collet JP, Albaladejo P, Cholley B, Nizard R, Barré J, Piriou V, Poirier N, Mignon A, Schlumberger S, Longrois D, Aubrun F, Farèse ME, Ravaud P, Steg PG (2011) Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial. Br J Anaesth 107:899–910

    Article  CAS  PubMed  Google Scholar 

  11. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN (2014) 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary. Circulation 130:2215–2245

    Article  PubMed  Google Scholar 

  12. Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Solca M, Brichant JF, De Robertis E, Longrois D, Langenecker SK, Wichelewski J (2014) 2014 ESC/ESA Guidelines on non-cardiac surgery: Cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: Cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesth. Eur Heart J 35:2383–2431

    Article  PubMed  Google Scholar 

  13. Fujikawa T, Tanaka A, Abe T, Yoshimoto Y, Tada S, Maekawa H, Shimoike N (2013) Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital. J Am Coll Surg 217:1044–1053

    Article  PubMed  Google Scholar 

  14. Fujikawa T, Tanaka A, Abe T, Yoshimoto Y, Tada S, Maekawa H (2015) Effect of antiplatelet therapy on patients undergoing gastroenterological surgery: thromboembolic risks versus bleeding risks during its perioperative withdrawal. World J Surg 39:139–149

    Article  PubMed  Google Scholar 

  15. Fujikawa T, Kawamoto H, Kawamura Y, Emoto N, Sakamoto Y, Tanaka A (2017) Impact of laparoscopic liver resection on bleeding complications in patients receiving antithrombotics. World J Gastrointest Endosc 9:396–404

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kawamoto Y, Fujikawa T, Sakamoto Y, Emoto N, Takahashi R, Kawamura Y, Tanaka A (2018) Effect of antithrombic therapy on bleeding complications in patients receiving emergency cholecystectomy for acute cholecystitis. J Hepatobiliary Pancreat Sci 25:518–526

    Article  PubMed  Google Scholar 

  17. Sakamoto Y, Fujikawa T, Kawamura Y (2020) Safety of elective laparoscopic cholecystectomy in patients with antiplatelet therapy: lessons from more than 800 operations in a single tertiary referral institution. Asian J Endosc Surg 13:33–38

    Article  PubMed  Google Scholar 

  18. Shimoike N, Fujikawa T, Yoshimoto Y, Tanaka A (2016) Does antiplatelet therapy affect short-term and long-term outcomes of patients undergoing surgery for colorectal cancer? Surgical radicality versus perioperative antiplatelet-related morbidity risks. J Gastroenterol Hepatol Res 5:1962–1969

    Article  Google Scholar 

  19. Yoshimoto Y, Fujikawa T, Tanaka A, Hayashi H, Shimoike N, Kawamoto H, Nakasuga C, Yamamoto T (2019) Optimal use of antiplatelet agents, especially aspirin, in the perioperative management of colorectal cancer patients undergoing laparoscopic colorectal resection. World J Surg Oncol 17:1–8

    Article  Google Scholar 

  20. Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649–655

    Article  CAS  PubMed  Google Scholar 

  21. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  PubMed Central  Google Scholar 

  22. Clifford RE, Fowler H, Govindarajah N, Vimalachandran D, Sutton PA (2019) Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 33:1049–1065

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Malik AH, East JE, Buchanan GN, Kennedy RH (2008) Endoscopic haemostasis of staple-line haemorrhage following colorectal resection. Colorectal Dis 10:616–618

    Article  CAS  PubMed  Google Scholar 

  24. Hébert J, Eltonsy S, Gaudet J, Jose C (2019) Incidence and risk factors for anastomotic bleeding in lower gastrointestinal surgery. BMC Res Notes 12:1–6

    Article  Google Scholar 

  25. Cirocco WC, Golub RW (1995) Endoscopic treatment of postoperative hemorrhage from a stapled colorectal anastomosis. Am Surg 61:460–463

    CAS  PubMed  Google Scholar 

  26. Martínez-Serrano M-A, Parés D, Pera M, Pascual M, Courtier R, Egea MJG, Grande L (2009) Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis. Tech Coloproctol 13:49–53

    Article  PubMed  Google Scholar 

  27. King SB, Smith SC, Hirshfeld JW, Jacobs AK, Morrison DA, Williams DO, Feldman TE, Kern MJ, O’Neill WW, Schaff HV, Whitlow PL, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW, ACC/AHA/SCAI (2008) 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 51:172–209

    Article  PubMed  Google Scholar 

  28. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, Culebras A, Degraba TJ, Gorelick PB, Guyton JR, Hart RG, Howard G, Kelly-Hayes M, Nixon JVI, Sacco RL, Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Counc (2006) Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Counc. Stroke 37:1583–1633

    Article  PubMed  Google Scholar 

  29. Borges JMDM, de Carvalho FO, Gomes IA, Rosa MB, Sousa ACS (2018) Antiplatelet agents in perioperative noncardiac surgeries: to maintain or to suspend? Ther Clin Risk Manag 14:1887–1895

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hawn MT, Graham LA, Richman JR, Itani KMF, Plomondon ME, Altom LK, Henderson WG, Bryson CL, Maddox TM (2012) The incidence and timing of noncardiac surgery after cardiac stent implantation. J Am Coll Surg 214:658–666 (discussion 666-667)

    Article  PubMed  Google Scholar 

  31. Gerstein NS, Carey MC, Cigarroa JE, Schulman PM (2015) Perioperative aspirin management after POISE-2: some answers, but questions remain. Anesth Analg 120:570–575

    Article  CAS  PubMed  Google Scholar 

  32. Ekeloef S, Alamili M, Devereaux PJ, Gögenur I (2016) Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis. Br J Anaesth 117:559–568

    Article  CAS  PubMed  Google Scholar 

  33. Oscarsson A, Gupta A, Fredrikson M, Jarhult J, Nystrom M, Pettersson E, Darvish B, Krook H, Swahn E, Eintrei C (2010) To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth 104:305–312

    Article  CAS  PubMed  Google Scholar 

  34. Fujikawa T, Ando K (2018) Safety of laparoscopic surgery in digestive diseases with special reference to antithrombotic therapy: a systematic review of the literature. World J Clin cases 6:767–775

    Article  PubMed  PubMed Central  Google Scholar 

  35. Taguchi K, Shimomura M, Egi H, Hattori M, Mukai S, Kochi M, Sada H, Sumi Y, Nakashima I, Akabane S, Sato K, Ohdan H (2019) Is laparoscopic colorectal surgery with continuation of antiplatelet therapy safe without increasing bleeding complications? Surg Today 49:948–957

    Article  PubMed  PubMed Central  Google Scholar 

  36. Priebe HJ (2004) Triggers of perioperative myocardial ischaemia and infarction. Br J Anaesth 93:9–20

    Article  PubMed  Google Scholar 

  37. Anderson K, Jupiter DC, Abernathy SW, Frazee RC (2014) Should clopidogrel be discontinued before laparoscopic cholecystectomy? Am J Surg 208:926–931

    Article  PubMed  Google Scholar 

  38. Noda T, Hatano H, Dono K, Shimizu J, Oshima K, Tanida T, Miyake M, Komori T, Kawanishi K, Morita S, Imamura H, Iwazawa T, Akagi K, Kitada M (2014) Safety of early laparoscopic cholecystectomy for patients with acute cholecystitis undergoing antiplatelet or anticoagulation therapy: a single-institution experience. Hepatogastroenterology 61:1501–1506

    PubMed  Google Scholar 

  39. Song JW, Soh S, Shim JK (2017) Dual antiplatelet therapy and non-cardiac surgery: evolving issues and anesthetic implications. Korean J Anesthesiol 70:13–21

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, Garcia DA, Jacobson A, Jaffer AK, Kong DF, Schulman S, Turpie AGG, Hasselblad V, Ortel TL (2015) Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 373:823–833

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Macle L, Cairns J, Leblanc K, Tsang T, Skanes A, Cox JL, Healey JS, Bell A, Pilote L, Andrade JG, Mitchell LB, Atzema C, Gladstone D, Sharma M, Verma S, Connolly S, Dorian P, Parkash R, Talajic M, Nattel S, Verma A, Atrial Fibrillation Guidelines Committee CCS (2016) 2016 Focused update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 32:1170–1185

    Article  PubMed  Google Scholar 

  42. Douketis JD, Spyropoulos AC, Duncan J, Carrier M, Le Gal G, Tafur AJ, Vanassche T, Verhamme P, Shivakumar S, Gross PL, Lee AYY, Yeo E, Solymoss S, Kassis J, Le Templier G, Kowalski S, Blostein M, Shah V, MacKay E, Wu C, Clark NP, Bates SM, Spencer FA, Arnaoutoglou E, Coppens M, Arnold DM, Caprini JA, Li N, Moffat KA, Syed S, Schulman S (2019) Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med 179(11):1469–1478

    Article  PubMed Central  PubMed  Google Scholar 

  43. Fujikawa T, Kawamura Y, Takahashi R, Naito S (2020) 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. Surgery 167(5):859–867

    Article  PubMed  Google Scholar 

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  1. Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan

    Ryo Takahashi & Takahisa Fujikawa

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  1. Ryo Takahashi
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  2. Takahisa Fujikawa
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Correspondence to Takahisa Fujikawa.

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Drs. Takahashi and Fujikawa have no conflicts of interest or financial ties to disclose.

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Takahashi, R., Fujikawa, T. Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis. Surg Endosc 35, 2075–2083 (2021). https://doi.org/10.1007/s00464-020-07604-6

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