Effect of Antiplatelet Therapy on Surgical Blood Loss and Post-Pancreatectomy Hemorrhage in Patients Undergoing Pancreaticoduodenectomy

Abstract

AIM: The aim of the study was to assess the feasibility and safety of pancreaticoduodenectomy (PD) in patients with preoperative antiplatelet therapy (APT) for arterial thromboembolic risks. METHODS: Consecutive 100 patients receiving PD at our institution between 2005 and 2016 were retrospectively reviewed. APT was regularly used in 31 patients (31%) in this series. Our perioperative management (“Kokura Protocol”) included maintenance of preoperative aspirin monotherapy and early postoperative reinstitution in patients at high thromboembolic risks. Outcome variables of patients with APT (APT group) were compared with those of patients without APT. RESULTS: This series included 31 pancreatic cancer, 27 bile duct cancer, 19 ampullary cancer, 13 intraductal papillary mucinous neoplasms, and 10 others. In APT group, 18 (18%) required preoperative continuation of APT. APT group showed significantly high frequency of history of cerebral infarction and percutaneous coronary intervention. Totally 18 significant pancreatic fistulas (grade B,C, 18%) were observed but no perioperative death was experienced. There was only 1 thromboembolic event (1.0%, cerebral infarction) in a whole cohort, whereas increased surgical blood loss (≥ 1,000 mL) and post-pancreatectomy hemorrhage (PPH) occurred in 11 (11%) and 6 (6.0%, totally grade B), respectively. Multivariate analysis showed that high body mass index (≥ 30 kg/m2) is the only significant risk factor for both increased blood loss and PPH (risk ratio = 13.64 and 27.27, p < 0.05), whereas either APT or preoperative aspirin continuation did not affect perioperative bleeding complications. CONCLUSION: Even in APT-burdened patients with arterial thromboembolic risks, PD is safely performed under the Kokura Protocol without any increase of blood loss and PPH, although this patient population is still challenging and should be rigorously managed to prevent both bleeding and thromboembolic complications.