Impact of Antithrombotic Agents on Postpancreatectomy Hemorrhage: Results from a Retrospective Multicenter Study

Nakamura, Kota; Sho, Masayuki; Satoi, Sohei; Kosaka, Hisashi; Akahori, Toshikazu; Nagai, Minako; Nakagawa, Kenji; Takagi, Tadataka; Yamamoto, Tomohisa; Yamaki, So

doi:10.1016/j.jamcollsurg.2020.06.017

Cited by 11 publications

(15 citation statements)

References 40 publications

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“…Fourteen out of 19 were observational cohort studies, with only three being prospective in nature. The included articles consisted of 9 studies concerning the management of chronically ATT-received patients[ 10 , 17 - 24 ] (Table 2 ) and 10 studies regarding chemical thromboprophylaxis for VTE (Table 3 )[ 25 - 34 ]. Among the studies on the management of chronically ATT-received patients, one was a multicenter retrospective cohort analysis[ 18 ] and another was an analysis using the propensity score matching method[ 21 ].…”

Section: Resultsmentioning

confidence: 99%

“…In all nine studies concerning the management of chronically ATT-received patients, the authors generally reported the safety and feasibility of pancreatic surgery even in ATT-received patients (Table 2 ). However, three articles investigated the safety of perioperative management using perioperative heparin bridging during or after pancreatectomy, and showed the significant impact of heparin bridging on the increased risk of PPH[ 10 , 17 , 20 ]. Nakamura et al [ 17 ] recently reported a retrospective multicenter study, analyzing 144 chronically ATT-received patients, the patients in the ATT group had a higher frequency of PPH compared with the control (8.3% vs 2.0%), and 75% of ATT-received patients with late-onset PPH were managed by perioperative heparin bridging.…”

Section: Resultsmentioning

confidence: 99%

“…However, three articles investigated the safety of perioperative management using perioperative heparin bridging during or after pancreatectomy, and showed the significant impact of heparin bridging on the increased risk of PPH[ 10 , 17 , 20 ]. Nakamura et al [ 17 ] recently reported a retrospective multicenter study, analyzing 144 chronically ATT-received patients, the patients in the ATT group had a higher frequency of PPH compared with the control (8.3% vs 2.0%), and 75% of ATT-received patients with late-onset PPH were managed by perioperative heparin bridging. They concluded that ATT use was a significant risk factor for PPH, and the use of combined ATT or perioperative heparin bridging may be at particularly high risk for PPH.…”

Section: Resultsmentioning

confidence: 99%

“…Moreover, one recently published large-scale retrospective cohort studies showed that the continuation of preoperative aspirin therapy significantly reduced the occurrence of thromboembolic complication but was not related to bleeding complications or PPH[ 18 ]. In the current systematic review, two recently reported studies demonstrated that in patients receiving chronic antiplatelets or anticoagulants, which were mostly managed by heparin bridging, the risk of PPH was higher compared with those without ATT[ 10 , 17 ]. However, three other studies reported that preoperative continuation of aspirin monotherapy is safe and feasible during hepatobiliary-pancreatic or gastrointestinal surgery[ 18 , 23 , 24 ], and the remaining studies showed no difference in the occurrence of bleeding between ATT-received group and the group without ATT.…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, in one systematic review concerning chemical prophylaxis for VTE in Asian surgical patients[ 48 ], the risk of perioperative VTE in Asian patients is low even in the context of risk factors typically regarded as high risk. The most recently published two large-scale cohort studies (with more than 1000 patients) conducted in Japan also showed that the incidence of clinically relevant VTE during or after pancreatic surgery was 0%-0.3%[ 17 , 18 ]. Currently, the safety and efficacy of chemical thromboprophylaxis with anticoagulants for VTE during pancreatic surgery is still controversial, particularly in Asian populations.…”

Section: Discussionmentioning

confidence: 99%

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

Fujikawa¹,

Naito²

2021

WJCC

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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.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

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

Fujikawa¹,

Naito²

2021

WJCC

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Impact of antithrombotic therapy on postpancreatectomy hemorrhage in 7116 patients: A project study by the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery

Nakamura,

Nagai,

Matsumoto

et al. 2023

J Hepato Biliary Pancreat

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BackgroundWe previously reported an association between antithrombotic therapy and an increased risk of postpancreatectomy hemorrhage (PPH). To validate our findings, we conducted a large‐scale multicenter retrospective study from 63 high‐volume centers in Japan.MethodsBetween 2015 and 2018, 7116 patients who underwent pancreatectomy were enrolled. The antithrombotic group consisted of 920 patients (12.9%) who received preoperative antithrombotic agents including aspirin, clopidogrel, ticlopidine, prasugrel, warfarin, and direct oral anticoagulants.ResultsPPH occurred in 235 (3.3%) of the patients. The incidence of PPH and mortality were significantly higher in the antithrombotic group than in the control group (5.7 vs. 3.0% and 2.2 vs. 0.9%, respectively; both p < .001). In multivariate analysis, a history of antithrombotic use was an independent risk factor for grade C PPH (p = .036). In the antithrombotic group, PPH tended to be delayed in the patients with restarting antithrombotic therapy. Notably, the occurrence of delayed PPH after restarting antithrombotic therapy was observed only when antithrombotic therapy was restarted within 10 days after pancreatectomy.ConclusionsThis multicenter study demonstrated that a history of antithrombotic use was a significant risk factor for PPH and mortality. In particular, the resumption of antithrombotic therapy in the early postoperative period should be done with caution.

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Clinically Relevant Late‐Onset Biliary Complications After Pancreatoduodenectomy

et al. 2022

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Background Late-onset biliary complications (LBC) after pancreatoduodenectomy (PD) can be serious. This study aimed to clarify the frequency and risk factors of severe LBC after PD. Methods We defined LBC as biliary complications occurring 3 months after PD and severe LBC as cases that required intensive care. A total of 318 patients who underwent PD between 2010 and 2018 with at least 1 year of postoperative follow-up were evaluated. Results Hospitalization for severe LBC was required in 59 patients (19%), of whom 20 had liver abscesses (6.3%); 18, acute cholangitis (5.7%); 12, biliary stones (3.8%); and 21, biliary strictures (6.6%). Interventional radiological or endoscopic treatment was required in 32 patients (10%), of whom 9 had a benign primary disease with biliary stones and/or strictures. Thirteen of the remaining 23 patients with a malignant primary disease had liver abscesses and cholangitis. Significant independent risk factors for severe LBC in patients with malignant primary disease were recurrence around the hepaticojejunostomy (odds ratio 6.5, P = 0.013) and chemotherapy (odds ratio 13.5, P \ 0.001). Conclusions Severe LBC after PD may occur regardless of whether the primary disease is benign or malignant. The course of severe LBC differs according to the primary disease, and therefore, appropriate follow-up and optimal treatment should be recommended according to the condition of the patient and the disease state.

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Impact of Antithrombotic Agents on Postpancreatectomy Hemorrhage: Results from a Retrospective Multicenter Study

Cited by 11 publications

References 40 publications

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

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

Impact of antithrombotic therapy on postpancreatectomy hemorrhage in 7116 patients: A project study by the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery

Clinically Relevant Late‐Onset Biliary Complications After Pancreatoduodenectomy

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