Risk of postoperative thromboembolic complication after major digestive surgery in patients receiving antiplatelet therapy: Lessons from more than 3,000 operations in a single tertiary referral hospital

Abstract

BackgroundAlthough recent studies have suggested that the continuation of preoperative antiplatelet therapy with aspirin does not affect intraoperative or postoperative bleeding in patients undergoing digestive surgery, its preventive effect against thromboembolic complication remains largely unknown. MethodsA total of 3,072 patients who underwent major digestive surgery (esophago-gastrointestinal and hepatobiliary-pancreatic resection for malignancy) between 2005 and 2018 at our institution were enrolled in this study. The patients were divided into 3 groups: patients continuing to receive preoperative antiplatelet therapy with aspirin (continued-antiplatelet therapy group, n = 425), those discontinuing preoperative antiplatelet therapy (discontinued-antiplatelet therapy group, n = 549), and those who were not receiving antiplatelet therapy (non-antiplatelet therapy group, n = 2,117). The CHADS2 and the CHA2DS2-VASc scoring system were used to assess potential thromboembolic risk. Surgical outcomes were compared between the groups and the risk factors for thromboembolic complication, bleeding complication, and operative mortality were determined by multivariate analysis. ResultsThere was no difference between the discontinued-antiplatelet therapy and continued-antiplatelet therapy groups in the rate of high risk patients categorized by CHADS2 and CHA2DS2-VASc scores; however, the occurrence of thromboembolic complication in the discontinued-antiplatelet therapy group was significantly higher compared with the continued-antiplatelet therapy group (2.8% vs 0.5%; P = .006). In a multivariate analysis using the whole cohort, discontinuation of antiplatelet therapy (odds ratio = 4.39; P < .001), poor performance status (odds ratio = 4.14; P = .001), and hypertension (odds ratio = 3.46; P = .005) were the independent risk factors for thromboembolic complication. In the groups of patients receiving antiplatelet therapy, multivariate analysis showed that preoperative aspirin continuation had a significant negative impact (odds ratio = 0.10, P = .029) on the occurrence of thromboembolic complication, but did not affect either postoperative bleeding complication or operative mortality. ConclusionDiscontinuation of antiplatelet therapy during major digestive surgery is the most significant risk factor for thromboembolic complication, and the continuation of preoperative aspirin therapy significantly reduces the occurrence of thromboembolic complication in patients receiving antiplatelet therapy. It is suggested that the preoperative continuation of aspirin monotherapy is one of the preferred options to prevent severe thromboembolic events during major digestive surgery in patients receiving antiplatelet therapy.