Postop bleeding risk guides proctologic anticoagulant management
MedWire News: The risk for bleeding after proctologic surgery is elevated in patients who switch from oral anticoagulation therapy (OAT) to low molecular weight heparin (LMWH) for their procedure, French researchers report.
"Although continuing oral anticoagulant treatment increased the frequency of delayed bleeding, the risk was lower than that following suspension and change to LMWH," say François Pigot (Hôpital Bagatelle, Talence) and co-workers.
The team examined the impact of OAT and platelet inhibitor therapy on the risk for secondary bleeding following in-hospital proctologic surgery performed under general anesthetic at two specialist units over 2010.
In all, 2314 patients, aged an average of 46 years old, were followed up for secondary bleeding after 2513 procedures, including hemorrhoidectomy (n=791), fistula or abscess treatment (n=657), fissurectomy (n=306), pilonidal cyst excision (n=272), and hemorrhoidopexy (n=189).
Bleeding after leaving the operating room occurred in 4.6% of patients. The majority (n=98) experienced just one bleed, and 14% of bleeds were minor, 50% moderate, and 36% severe. Although 97% of bleeds occurred within 17 days of surgery, one major bleed was reported at 32 days.
Bleeding was more common after hemorrhoid surgery, at 7.9% and 6.2% for hemorrhoidopexy and hemorrhoidectomy, respectively, and after transanal excision of rectal tumors, at 6.5%.
The majority (n=2448) of patients were not using any anticoagulant or platelet inhibitors other than aspirin, 34 were using clopidogrel, 34 had uninterrupted OAT, seven switched from OAT to LMWH, and two patients were using LMWH alone. Bleeding occurred in 4.0%, 14.7%, 22.7%, 57.1%, and 100.0% of patients respectively.
In multivariate analysis, adjusting for surgeon and procedure, patients using clopidogrel were 10 times more likely to experience bleeding than nonusers. Furthermore, patients using OAT were six times more likely to develop bleeding than nonusers, but 42 times more likely to develop bleeding if OAT was replaced by LMWH.
"As ever more patients are under antiplatelet or anticoagulant treatment, and as hospital length of stay decreases, exposing patients to late bleeding after they have returned home requires specific recommendations," Pigot et al note in Colorectal Disease.
"Randomised controlled studies are now needed comparing continued oral anticoagulation continuation with suspension and substitution by LMWH. These could include an attempt to determine thrombotic events."
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By Lynda Williams