Effect of antithrombotic therapy on postoperative outcome of 538 consecutive emergency laparoscopic cholecystectomies for acute cholecystitis: two Italian center’s study

Abstract

The risk of developing hemorrhagic complications during or after emergency cholecystectomy (EC) for acute cholecystitis (AC) in patients with antithrombotic therapy (ATT) remains uncertain. In this double-center study, we evaluated post-operative outcomes in patients with ATT undergoing EC. We retrospectively evaluated 538 patients who underwent laparoscopic EC for AC between May 2015 and December 2019 at two referral centers. 89 of them (17%) were on ATT. We defined postoperative complication rates, including bleeding, as our primary outcome. Mortality was higher in the ATT group. Morbidity was higher in the ATT group as well; however, the difference was not statistically significant. 12 patients (2%) experienced intraoperative blood loss over 500 ml and ten (2%) had postoperative bleeding complications. Two patients (< 1%) experienced both intraoperative and postoperative bleeding. On multivariate analysis, ATT was not significantly associated with worse postoperative outcomes. Antithrombotic therapy is not an independently associated factor of severe postoperative complications (including bleeding) or mortality. However, these patients still represent a challenging group and must be carefully managed to avoid postoperative bleeding complications.

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References

  1. 1.

    Yetkin G, Uludag M, Oba S, Citgez B, Paksoy I (2009) Laparoscopic cholecystectomy in elderly patients. JSLS 13:587–591

    Article  Google Scholar 

  2. 2.

    Tambyraja AL, Kumar S, Nixon SJ (2004) Outcome of laparoscopic cholecystectomy in patients 80 years and older. World J Surg 28:745–748

    Article  Google Scholar 

  3. 3.

    Mita K, Ito H, Murabayashi R, Sueyoshi K, Asakawa H, Nabetani M, Kamasako A, Koizumi K, Hayashi T (2012) Postoperative bleeding complications after gastric cancer surgery in patients receiving anticoagulation and/or antiplatelet agents. Ann Surg Oncol 19:3745–3752

    Article  Google Scholar 

  4. 4.

    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, LuratiBuse G, Xavier D, Chan MT, 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, POISE-2 Investigators (2014) Aspirin in patients undergoing noncardiac surgery. N Engl J Med 370:1494–1503

  5. 5.

    Mita K, Ito H, Takahashi K, Hashimoto M, Nagayasu K, Murabayashi R, Asakawa H, Koizumi K, Hayashi T, Fujino K (2016) Postpancreatectomy hemorrhage after pancreatic surgery in patients receiving anticoagulation or antiplatelet agents. Surg Innov 23:284–290

    Article  Google Scholar 

  6. 6.

    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

    CAS  Article  Google Scholar 

  7. 7.

    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, Stratagem Study Group (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

  8. 8.

    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  Google Scholar 

  9. 9.

    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  Google Scholar 

  10. 10.

    Monden K, Sadamori H, Hioki M, Ohno S, Saneto H, Ueki T, Yabushita K, Sakaguchi K, Takakura N (2017) Safety and feasibility of liver resection with continued antiplatelet therapy using aspirin. J Hepatobiliary Pancreat Sci 24:375–381

    Article  Google Scholar 

  11. 11.

    Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R (2012) Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:E326S-E350S

    CAS  Article  Google Scholar 

  12. 12.

    Joseph B, Rawashdeh B, Aziz H, Kulvatunyou N, Pandit V, Jehangir Q, O’Keeffe T, Tang A, Green DJ, Friese RS, Rhee P (2015) An acute care surgery dilemma: emergent laparoscopic cholecystectomy in patients on aspirin therapy. Am J Surg 209:689–694

    Article  Google Scholar 

  13. 13.

    Akahoshi K, Ochiai T, Takaoka A, Kitamura T, Ban D, Kudo A, Tanaka S, Tanbe M (2017) Emergency cholecystectomy for patients on antiplatelet therapy. Am Surg 83:486–490

    Article  Google Scholar 

  14. 14.

    Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, Kozaka K, Endo I, Deziel DJ, Miura F, Okamoto K, Hwang TL, Huang WS, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Noguchi Y, Shikata S, Ukai T, Higuchi R, Gabata T, Mori Y, Iwashita Y, Hibi T, Jagannath P, Jonas E, Liau KH, Dervenis C, Gouma DJ, Cherqui D, Belli G, Garden OJ, Giménez ME, de Santibañes E, Suzuki K, Umezawa A, Supe AN, Pitt HA, Singh H, Chan ACW, Lau WY, Teoh AYB, Honda G, Sugioka A, Asai K, Gomi H, Itoi T, Kiriyama S, Yoshida M, Mayumi T, Matsumura N, Tokumura H, Kitano S, Hirata K, Inui K, Sumiyama Y, Yamamoto M (2018) Tokyo Guidelines 2018 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 25:41–54

    Article  Google Scholar 

  15. 15.

    Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG, Committee TGR (2013) TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Surg 20:35–46

    Article  Google Scholar 

  16. 16.

    Hirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K, Mayumi T, Yoshida M, Strasberg S, Pitt H, Gadacz TR, de Santibanes E, Gouma DJ, Solomkin JS, Belghiti J, Neuhaus H, Büchler MW, Fan ST, Ker CG, Padbury RT, Liau KH, Hilvano SC, Belli G, Windsor JA, Dervenis C (2007) Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14:78–82

    Article  Google Scholar 

  17. 17.

    Owens WD, Felts JA, Spitznagel EL Jr (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49:239–243

    CAS  Article  Google Scholar 

  18. 18.

    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  Google Scholar 

  19. 19.

    Levy JH (2014) Role of coagulation factor concentrates for reversing dabigatran-related anticoagulation. Anesthesiology 120:1316–1318

    Article  Google Scholar 

  20. 20.

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

    CAS  Article  Google Scholar 

  21. 21.

    Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35:1288–1294

    Article  Google Scholar 

  22. 22.

    Wilson SH, Fasseas P, Orford JL, Lennon RJ, Horlocker T, Charnoff NE, Melby S, Berger PB (2003) Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 42:234–240

    Article  Google Scholar 

  23. 23.

    Chávez KV, Márquez-González H, Aguirre I, Orellana JC (2018) Prognostic risk factors for conversion in laparoscopic cholecystectomy. Updates Surg 70:67–72

    Article  Google Scholar 

  24. 24.

    Ho HS, Mathiesen KA, Wolfe BM (1996) The impact of laparoscopic cholecystectomy on the treatment of symptomatic cholelithiasis. Surg Endosc 10:746–750

    CAS  Article  Google Scholar 

  25. 25.

    Brodsky A, Matter I, Sabo E, Cohen A, Abrahamson J, Eldar S (2000) Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study. Surg Endosc 14:755–760

    CAS  Article  Google Scholar 

  26. 26.

    Hadad SM, Vaidya JS, Baker L, Koh HC, Heron TP, Hussain K, Thompson AM (2007) Delay from symptom onset increases the conversion rate in laparoscopic cholecystectomy for acute cholecystitis. World J Surg 31:1298–1303

    Article  Google Scholar 

  27. 27.

    Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, Mayumi T, Miura F, Gouma DJ, Garden OJ, Büchler MW, Kiriyama S, Yokoe M, Kimura Y, Tsuyuguchi T, Itoi T, Gabata T, Higuchi R, Okamoto K, Hata J, Murata A, Kusachi S, Windsor JA, Supe AN, Lee S, Chen XP, Yamashita Y, Hirata K, Inui K, Sumiyama Y, Committee TGR (2013) TG13: Updated Tokyo guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20:1–7

    Article  Google Scholar 

  28. 28.

    Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN, Committee TGR (2013) TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 20:89–96

    Article  Google Scholar 

  29. 29.

    Vaccari S, Lauro A, Cervellera M, Casella G, D’Andrea V, Di Matteo FM, Santoro A, Panarese A, Gulotta E, Cirocchi R, Ussia A, Brighi M, Romano A, Tonini V (2018) Early versus delayed approach in cholecystectomy after admission to an emergency department. A multicenter retrospective study. G Chir 39:232–238

    CAS  PubMed  Google Scholar 

  30. 30.

    Kwon AH, Matsui Y (2006) Laparoscopic cholecystectomy in patients aged 80 years and over. World J Surg 30:1204–1210

    Article  Google Scholar 

  31. 31.

    Kuy S, Sosa JA, Roman SA, Desai R, Rosenthal RA (2011) Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans. Am J Surg 201:789–796

    Article  Google Scholar 

  32. 32.

    Tucker JJ, Yanagawa F, Grim R, Bell T, Ahuja V (2011) Laparoscopic cholecystectomy is safe but underused in the elderly. Am Surg 77:1014–1020

    Article  Google Scholar 

  33. 33.

    Hazzan D, Geron N, Golijanin D, Reissman P, Shiloni E (2003) Laparoscopic cholecystectomy in octogenarians. Surg Endosc 17:773–776

    CAS  Article  Google Scholar 

  34. 34.

    Tambyraja AL, Kumar S, Nixon SJ (2005) POSSUM scoring for laparoscopic cholecystectomy in the elderly. ANZ J Surg 75:550–552

    Article  Google Scholar 

  35. 35.

    Uecker J, Adams M, Skipper K, Dunn E (2001) Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach? Am Surg 67:637–640

    CAS  PubMed  Google Scholar 

  36. 36.

    Yasuda H, Matsuo Y, Sato Y, Ozawa S-I, Ishigooka S, Yamashita M, Yamamoto H, Itoh F (2015) Treatment and prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. World J Crit 4:40–46

    Article  Google Scholar 

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Acknowledgements

We wish to thank Ms. Claudia CIRILLO (M.A. in English and Consultant for Thomas Jefferson University-Philadelphia-PA-USA) for her English language editing of our text.

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SV, AL, MC, GP, RC, VDA, and VT conceptualized and designed the study, acquired, and analyzed data, interpreted the study results, drafted the manuscript, and critically revised the manuscript for important intellectual content. EG, APP, RB, DDN, and AU acquired and analyzed data, and interpreted the study results.

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Correspondence to Augusto Lauro.

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All authors declared that they have no potential conflict of interest.

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All authors declared that they no receive financial support and sponsorship.

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All procedures performed in the participants of our study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study received approval from the hospital’s institutional review board (156/2018/Oss/AOUBo, 18/04/18).

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Our study received approval from the hospital’s institutional review board (156/2018/Oss/AOUBo, 18/04/18). Informed consent was obtained from every patient included in this cohort of study.

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Vaccari, S., Lauro, A., Cervellera, M. et al. Effect of antithrombotic therapy on postoperative outcome of 538 consecutive emergency laparoscopic cholecystectomies for acute cholecystitis: two Italian center’s study. Updates Surg (2021). https://doi.org/10.1007/s13304-021-00994-9

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Keywords

  • Acute cholecystitis
  • Anticoagulation therapy
  • Antiplatelet therapy
  • Antithrombotic therapy
  • Bleeding complication
  • Emergency cholecystectomy
  • Laparoscopy