Comparative effectiveness evaluation of the improved and conventional perioperative antithrombotic therapy in patients with acute calculous cholecystitis and concomitant ischemic heart disease

Abstract

The aim — to evaluate the efficacy of improved perioperative antithrombotic therapy in patients who underwent laparoscopic cholecystectomy for acute calculous cholecystitis (ACH) with concomitant ischemic heart disease (IHD).Materials and methods. 168 patients with ACH and IHD who received anticoagulant (ACT) or antiplatelet therapy (APT) before admission to the surgical department of the hospital in Kyiv took part in the study. The comparison group included 95 patients who underwent conventional perioperative antithrombotic therapy, the main group included 73 patients who had bridging therapy according to the developed algorithms. Groups of patients were representative by the functional class of heart failure, angina class, severity and histological form of ACH, the frequency of ACT and APT variants. The target points of the study were the frequency of International Normalized Ratio (INR) therapeutic value achieving or bleeding time (BT) by Lee‑White in the preoperative and early postoperative period and the frequency of hemorrhagic complications.Results and discussion. Immediately before the operation in patients assigned to the main group, the mean INR values were greater than in the comparison group: 2.93 ± 0.18 versus 1.96 ± 0.18. The target values of INR > 2 in the main group were in 18 (90 %) of 20 patients who received warfarin prior to admission, and 11 (52.4 %) of 21 in the comparison group (p = 0.008). Target values of BT > 12 min in the main group were in 48 (90.6 %) of 53 patients who received APT before admission, in the comparison group — in 46 (62.2 %) of 74 (p = 0.001). Statistically significant differences between groups relative to the proportion of patients with therapeutic values of INR and BT were found on the first 3 and 4 days of the postoperative period, respectively. Increased bleeding of the tissues (the bed of the gallbladder), in which stable haemostasis required more than 10 minutes, was observed in 19 (26.0 %) patients in the main group and 20 (21.1 %) in the comparison group (p = 0.449). The need for a tamponade of the gallbladder bed arose respectively in 13 (17.8 %) and 11 (11.6 %) patients (p = 0.253). A decrease in haemoglobin level below 100 g/l, but not lower than 86 g/L, was noted in 4 and 6 patients (all p < 0.05).Conclusions. The improved algorithm of bridging therapy in patients with ACH and concomitant IHD demonstrated a statistically significant increase in the proportion of patients with the target values of the prophylaxis of thromboembolism in the perioperative period (in comparison with the conventional approach) without significant haemorrhagic complications, as in the case of taking anticoagulant or antiplatelet drugs in anamnesis.