Continuation Of Aspirin Research Articles

Management of antithrombotic agents in dermatologic surgery before and after publication of the corresponding German evidence-based guideline.

A survey in 2012 revealed marked heterogeneity in the management of antithrombotic agents in dermatologic surgery in Germany. An evidence-based guideline on this topic was published for the first time in 2014. Using the same study sample, we conducted an anonymous survey on the management of antithrombotic agents and familiarity with the guideline. We reported the results as relative frequencies and compared them with those from 2012. We analyzed a total of 208 questionnaires (response rate: 36.6 %). A large majority of dermatologists reported performing minor procedures without discontinuing low-dose aspirin (≤ 100 mg), clopidogrel, or direct oral anticoagulants. In contrast, antithrombotic management was still heterogeneous in the context of major procedures, especially among office-based dermatologists. Overall, there was an increase in the proportion of dermatologists who managed phenprocoumon, aspirin, and clopidogrel in compliance with the guideline. For example, while 53.8 % of hospital-based dermatologists and 36.3 % of office-based dermatologists had performed large excisions on continued low-dose aspirin treatment in 2012, these figures showed an increase to 90.2 % and 57.8 %, respectively, by 2017 (phenprocoumon: from 33.8 % and 11.9 % to 63.9 % and 29.9 %, respectively; clopidogrel: from 36.9 % and 23.2 % to 63.9 % and 30.6 %, respectively). Among hospital dermatologists a large proportion was familiar with the guideline and considered it to be useful. Our results suggest that compliance with the German guideline on the perioperative management of antithrombotics in dermatologic surgery has increased for all procedures. Despite this positive development, greater efforts are needed to improve implementation of the guideline and address barriers to its use in everyday practice.

Use of aspirin and bleeding-related complications after hepatic resection.

The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort. Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo-Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality. Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09). This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.

Primary prevention of coronary artery disease: let's start with calcium score.

Primary prevention of coronary artery disease: let's start with calcium score.

Postoperative bleeding risk after gastric endoscopic submucosal dissection during antithrombotic drug therapy.

The safety of gastric endoscopic submucosal dissection (ESD) in the antithrombotic drug users remains controversial. Patients who underwent gastric ESD at Okayama University Hospital between March 2006 and February 2016 were enrolled. This study investigated the risk of post-ESD bleeding according to the management of the antithrombotic drugs. One thousand twenty lesions (872 patients) were enrolled. In a multivariate analysis, heparin replacement (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.8-14), multiple antithrombotic drug use (OR 2.9, 95% CI 1.1-6.9), a resected specimen of ≥33mm in diameter (OR 2.7, 95% CI 1.5-5.4), Helicobacter pylori negativity (OR 2.2, 95% CI 1.3-3.7), and tumors located in the lower third of the stomach (OR 1.7, 95% CI 1.0-2.9) were significant risk factors for post-ESD bleeding, while the continuation of aspirin or cilostazol was not (OR 2.6, 95% CI 0.72-7.8). The bleeding rate of the continuation group was comparable with that of the all cessation group among single antithrombotic drug users (4.5% vs 4.4%, P=1.0); however, the rate of the continuation group was significantly higher than that of the all cessation group among multiple antithrombotic drug users (67% vs 15%, P=0.020). The risk of post-ESD bleeding differed according to the management of the antithrombotic drugs. The gastric ESD under the cessation or continuation of aspirin or cilostazol monotherapy was acceptable. However, multiple antithrombotic drug use or heparin replacement was associated with a higher risk of post-ESD bleeding.

A Broken Heart: A Rare Complication of Hyponatremia

We present a case of a 47-year-old female with a history of anxiety, depression, and alcohol dependence with history of alcohol withdrawal seizures, who presented after a witnessed seizure episode. She admitted to drinking only copious amounts of black tea 1 week prior to presentation in an attempt to quit alcohol. She was subsequently found to be severely hyponatremic with a serum sodium level of 112 mEq/L and was admitted to the intensive care unit. Approximately 48 h after admission, she experienced sudden-onset of dizziness, diaphoresis, and nausea, with a heart rate of 42 beats/min and blood pressure of 70/40 mm Hg. STAT EKG revealed new T-wave inversions in the lateral and precordial leads and troponin was elevated to 5.99 ng/mL. Treatment was initiated for NSTEMI with continuous heparin infusion, aspirin, clopidogrel, carvedilol, and lisinopril. Transthoracic echocardiogram revealed apical and mid ventricular dyskinesia with hyperkinesis of the basal walls, with an estimated left ventricular ejection fraction of 35%. Cardiac catheterization revealed no significant coronary disease with ejection fraction 30-35% and similar areas of hypo and hyperkinesis, classic for apical ballooning syndrome. This case not only illustrates the rare phenomenon of hyponatremia-induced Takotsubo cardiomyopathy, but is one of the only incidents caused by primary polydipsia. J Med Cases. 2018;9(5):147-150 doi: https://doi.org/10.14740/jmc3050e

Continued versus interrupted aspirin use and bleeding risk after endoscopic submucosal dissection of gastric neoplasms: a meta-analysis.

Background:Balancing the risk of bleeding and thromboembolic events for patients who use aspirin and need to undergo endoscopic submucosal dissection (ESD) for gastric neoplasms is a delicate process. The current guidelines from different associations provide inconsistent recommendations.Methods:MEDLINE and EMBASE databases were searched through August 2017 for studies that compared the risk of post-ESD bleeding in patients who continued aspirin vs. those who discontinued aspirin preoperatively. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity was quantified using the Q statistic and I2.Results:A total of five studies that included 700 patients were identified. Our meta-analysis could not demonstrate a significantly increased risk of post-ESD bleeding among the aspirin-continued group compared to the aspirin-interrupted group, the pooled OR being 1.81 (95%CI 0.85-3.83). The statistical heterogeneity was insignificant, with an I2 of 25%. Nine thrombotic events occurred in the aspirin-interrupted group whereas none occurred in the aspirin-continued group.Conclusions:This meta-analysis could not demonstrate that continuation of aspirin significantly increases the risk of post-ESD bleeding. However, the analysis was restricted by the small sample size and the observational nature of the primary studies. Randomized controlled trials are still needed to clarify this risk.

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

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.

The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis.

Despite the fact that aspirin is of benefit to patients following coronary artery bypass grafting (CABG), continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the influence of preoperative aspirin administration on patients undergoing cardiac surgery. Medline database was searched using OVID SP interface. Similar searches were performed separately in EMBASE, PubMed, and Cochrane Central Registry of Controlled Trials. Twelve randomized controlled trials and 28 observational studies met our inclusion criteria and were included in the meta-analysis. The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury (AKI). Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI). Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. Despite this effect of preoperative aspirin, it did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC) when preoperative low-dose aspirin (≤160 mg/d) was administered. Preoperative aspirin increases the risk for postoperative bleeding. However, this did not result in an increased need for chest re-exploration and did not increase the rates of PRBC transfusion when preoperative low-dose (≤160 mg/d) aspirin was administered. Aspirin at any dose is associated with decreased mortality and AKI and low-dose aspirin (≤160 mg/d) decreases the incidence of perioperative MI.

Safety of continuing aspirin therapy during spinal surgery: A systematic review and meta-analysis.

Background:Questions whether to continue or discontinue aspirin administration in the perioperative period of spinal surgery has not been systematically evaluated.Objective:The present systematic review is carried out to assess the impact of continuing aspirin administration on the bleeding and cardiovascular events in perispinal surgery period.Methods:Studies were retrieved through MEDLINE, EMBASE, and Springer Link Databases (search terms, aspirin, continue or discontinue, and spinal fusion), bibliographies of the articles retrieved, and the authors’ reference files. We included studies that enrolled patients who underwent spinal surgery who were anticoagulated with aspirin alone and that reported bleeding or cardiovascular events as an outcome. Study quality was assessed using a validated form. 95% confidence interval (95% CI) was pooled to give summary estimates of bleeding and cardiovascular risk.Results:We identified 4 studies assessing bleeding risk associated with aspirin continuation or cardiovascular risk with aspirin discontinuation during spinal surgery. The continuation of aspirin will not increase the risk of blood loss during the spinal surgery (95% CI, −111.72 to −0.59; P = .05). Also, there was no observed increase in the operative time (95% CI, −33.29 to −3.89; P = .01) and postoperative blood transfusion (95% CI, 0.00–0.27; P = .05). But as for the cardiovascular risk without aspirin continuation and mean hospital length of stay with aspirin continuation, we did not get enough samples to make an accurate decision about their relations with aspirin.Conclusion:Patients undergoing spinal surgery with continued aspirin administration do not have an increased risk for bleeding. In addition, there is no observed increase in the operation time and postoperative blood transfusion.

68 An Urban Fire Department's Experience With Left Ventricular Assist Devices

There has been little literature published describing the nature of out-of-hospital care of patients with implanted left ventricular assist devices (LVADs). Patients sent home from the hospital with these devices pose a unique challenge to the out-of-hospital medical provider. By describing the reasons for their presentations and interventions provided, we hope to contribute to a more understanding of complications of LVADs and which treatments are most appropriate out-of-hospital. This is a retrospective chart review of a level 1 academic center’s LVAD patients transported by the city fire agency to the academic center’s emergency department (ED) from January 2012 to December 2015. We sought to describe the frequency, 911 chief complaint, and interventions provided by the city fire agency. Medical records were queried for LVAD patients presenting to the ED during the study period. We extracted patient demographics (date of birth, sex, race, gender) and the list was then queried against the fire agency’s database to collect the out-of-hospital visits. Chief complaint, vital signs, abnormal physical exam findings, and interventions provided were obtained from the out-of-hospital database. During the study period, 95 LVAD patients presented to the academic university ED. Of these visits, ten were brought in by the fire agency. Of the ten patients, the most common chief complaint was weakness (5/10) followed by chest pain (2/10). In the patients with weakness, one patient had a battery change, another had a stroke scale performed, and all five had their glucose measured. Only 3/5 patients with weakness were documented to have a known LVAD in place. Of note, there was one patient, whom the out-of-hospital providers were unaware of the LVAD, who had shortness of breath and was found to be diaphoretic, had diminished lung sounds, and chest pain. This patient was given continuous positive airway pressure, nitroglycerin and aspirin per chest pain protocol. Another patient, with a known LVAD, received Lidocaine for a pacemaker firing issue. The crew was aware of the LVAD in 6/10 patients and the coordinator was contacted with all 6 patients. Most LVAD patients presenting to the emergency department do not present by ambulance. Of patients that do interact with out-of-hospital providers, the most common presenting symptom is weakness followed by chest pain. Given the LVAD requires coordination and consideration, a focus on how to improve out-of-hospital awareness of LVADs is key. Further research in this area is needed.

Aspirin challenge and desensitization: how, when and why.

To investigate the current approach to aspirin challenge (drug provocation) and/or desensitization in patients with histories of hypersensitivity reactions to it, particularly in those with cardiovascular diseases. The literature indicates that patients with coronary artery disease (CAD), including those with an acute coronary syndrome, may safely undergo low-dose aspirin challenge and/or desensitization. Recently, flowcharts regarding challenge/desensitization procedures with aspirin in patients with CAD and histories of aspirin hypersensitivity reactions have become available. Aspirin desensitization and continuous aspirin therapy constitute an effective option in patients with nonsteroidal anti-inflammatory drug-exacerbated respiratory diseases (NERD) who have suboptimally controlled asthma or rhinosinusitis, or require multiple revision polypectomies. The use of aspirin has proven to reduce morbidity and mortality associated with CAD. There is a general consensus on aspirin's effectiveness in secondary prevention of CAD. Therefore, aspirin desensitization is necessary in patients with CAD and histories of hypersensitivity reactions to it. The effectiveness of aspirin desensitization and continuous therapy in patients with NERD has been shown in numerous studies. However, shared selection criteria of candidates for aspirin challenge/desensitization procedures, and simple and homogeneous protocols are necessary. Moreover, preventive safety measures are still needed in order to reduce the potential risks of these procedures.

Effects of preoperative aspirin on perioperative platelet activation and dysfunction in patients undergoing off-pump coronary artery bypass graft surgery: A prospective randomized study.

The benefit of aspirin use after coronary artery bypass graft surgery has been well proven. However, the effect of preoperative aspirin use in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB) has not been evaluated sufficiently. To evaluate platelet function changes during OPCAB due to preoperative aspirin use, we conducted a randomized controlled trial using flow cytometry and the Multiplate® analyzer. Forty-eight patients scheduled for elective OPCAB were randomized to the aspirin continuation (100 mg/day until operative day) and discontinuation (4 days before the operative day) groups. Platelet function was measured using the platelet activation markers CD62P, CD63, and PAC-1 by flow cytometry, and platelet aggregation was measured using the Multiplate® analyzer, after the induction of anesthesia (baseline), at the end of the operation, and 24 and 48 h postoperatively. Findings of conventional coagulation assays, thromboelastography by ROTEM® assays, and postoperative bleeding—related clinical outcomes were compared between groups. No significant change in CD62P, CD63, or PAC-1 was observed at the end of the operation or 24 or 48 h postoperatively compared with baseline in either group. The area under the curve for arachidonic acid—stimulated platelet aggregation, measured by the Multiplate® analyzer, was significantly smaller in the aspirin continuation group (P < 0.01). However, chest tube drainage and intraoperative and postoperative transfusion requirements did not differ between groups. Our study showed that preoperative use of aspirin for OPCAB did not affect perioperative platelet activation, but it impaired platelet aggregation, which did not affect postoperative bleeding, by arachidonic acid.

Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin: A Systematic Review and Meta-Analysis.

Optimal antiplatelet therapy after an ischemic stroke or transient ischemic attack while on aspirin is uncertain. We, therefore, conducted a systematic review and meta-analysis. We searched PubMed (1966 to August 2016) and bibliographies of relevant published original studies to identify randomized trials and cohort studies reporting patients who were on aspirin at the time of an index ischemic stroke or transient ischemic attack and reported hazard ratio for major adverse cardiovascular events or recurrent stroke associated with a switch to or addition of another antiplatelet agent versus maintaining aspirin monotherapy. Estimates were combined using a random effects model. Five studies with 8723 patients with ischemic stroke or transient ischemic attack were identified. Clopidogrel was used in 4 cohorts, and ticagrelor was used in 1 cohort. Pooling results showed that addition of or a switch to another antiplatelet agent, versus aspirin monotherapy, was associated with reduced risks of major adverse cardiovascular events (hazard ratio, 0.68; 95% confidence interval, 0.54-0.85) and recurrent stroke (hazard ratio, 0.70; 95% confidence interval, 0.54-0.92). Each of the strategies of addition of and switching another antiplatelet agent showed benefit versus continued aspirin monotherapy, and studies with regimen initiation in the first days after index event showed more homogenous evidence of benefit. Among patients who experience an ischemic stroke or transient ischemic attack while on aspirin monotherapy, the addition of or a switch to another antiplatelet agent, especially in the first days after index event, is associated with fewer future vascular events, including stroke.

Cessation or Continuation of Aspirin in Patients Undergoing 20-gauge Pars Plana Vitrectomy due to Diabetic Retinopathy

Background: This study aimed to evaluate the incidence of ocular hemorrhages in patients with proliferative diabetic retinopathy (PDR) undergoing 20-gauge pars plana vitrectomy (PPV) taking aspirin as an antiplatelet agent versus those who did not take any aspirin. Materials and Methods: A total of 180 patients (mean age of 60.5 ± 9.9 years) with PDR referred to Baqiyatallah University Hospital in 2016 were enrolled in aspirin and control groups each group containing 90 patients. All participants underwent a standard 20-gauge diabetic PPV. Laboratory data, including fasting blood sugar, prothrombin time, partial thromboplastin, bleeding time, and platelets count, and intraoperative data, including bleeding and its type (retinal, subretinal, vitreous, conjunctival, sub-conjunctival, and hyphema), were collected and analyzed using SPSS16 software. Results: Bleeding occurred in 56 patients. There were no significant differences in the incidence of bleeding between aspirin (33 patients) and control groups (23patients) (P= 0.1). Likewise, no significant differences were observed in the type of bleeding between the two groups (P= 0.11). Age, gender, hypertension, type of operation, and laboratory findings were not significant between patients with and without bleeding. Conclusion: The results of this study indicated that taking aspirin is not associated with a higher risk of post-PPV surgery bleeding in comparison with the control group. Additionally, the type of bleeding did not significantly differ between the two groups. Hence, there is no urgent need for discontinuation of this medication in diabetic patients undergoing PPV.[GMJ.2017;6(2):95-101]

Morcellation Efficiency in Holmium Laser Enucleation of the Prostate: Oscillating Morcellator Outperforms Reciprocating Morcellator With no Apparent Learning Curve

To compare the morcellation efficiency of the Wolf Piranha oscillating morcellator with the Lumenis VersaCut reciprocating morcellator. After institutional review board approval, we conducted a retrospective analysis of patients undergoing holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia. The first 41 cases of HoLEP with morcellation performed with the oscillating morcellator were matched by weight of resected tissue to 41 control patients from our historic data set who underwent morcellation with the reciprocating system. The primary outcome of interest was morcellation efficiency. We also evaluated surgeon experience level to assess for a learning curve with the oscillating morcellator. The 41 patients from each group were comparable in terms of age, prostate size, continuation of aspirin, and catheter status. The oscillating morcellation efficiency was nearly double that of the reciprocating morcellator (8.6 g/min [range: 3.0-18.3] vs 3.8 g/min [range: 0.9-10.1], P <.0001). Mean resected weights for cases with the oscillating and reciprocating instruments were 69 g (range: 17-224 g) and 69 g (range: 17-213 g), respectively (P = .9). The total operative time and complication rates did not significantly differ. For the oscillating system, morcellation efficiency for cases performed by staff alone was 9.8 g/min compared with 8.1 g/min when trainees were involved (P = .2), and there was no correlation between morcellation efficiency and number of cases performed (R = 0.01). The oscillating morcellation system resulted in a morcellation efficiency double that of the reciprocating system for tissue retrieval after HoLEP. Achieving efficiency with the oscillating system was not associated with a significant learning curve and was not impacted by trainee involvement.

Extended Duration Dual Antiplatelet Therapy After Coronary Stenting Among Patients With Peripheral Arterial Disease: A Subanalysis of the Dual Antiplatelet Therapy Study

ObjectivesThis study sought to determine whether patients with peripheral arterial disease (PAD) experience different reductions in ischemic event and increases in bleeding events with extended duration dual antiplatelet therapy versus those without PAD. BackgroundPatients with PAD have increased ischemic and bleeding risks after coronary stenting. MethodsThe DAPT (Dual Antiplatelet Therapy) study randomized 11,648 patients free from ischemic and bleeding events 12 months after coronary stenting to continued thienopyridine plus aspirin therapy for an additional 18 months versus aspirin therapy alone. The effects of continued thienopyridine on myocardial infarction (MI) or stent thrombosis, major adverse cardiovascular and cerebrovascular events (death, MI, or stroke) and bleeding (GUSTO [Global Utilization of t-PA and Streptokinase for Occluded Coronary Arteries] moderate or severe) were assessed among those with versus without PAD. ResultsAmong 11,648 randomized patients, 649 (5.57%) had PAD. Between 12 and 30 months, randomized patients with PAD had higher rates of MI/stent thrombosis (6.03% vs. 2.92%; p < 0.001), major adverse cardiovascular and cerebrovascular events (11.65% vs. 4.62%; p < 0.001), and bleeding (4.86% vs. 1.74%; p < 0.001). Continued thienopyridine versus placebo was associated with consistent treatment effects for MI/stent thrombosis (with PAD, HR: 0.63; 95% CI: 0.32 to 1.22; without PAD, HR: 0.53; 95% CI: 0.42, 0.66; interaction p = 0.631), major adverse cardiovascular and cerebrovascular events (with PAD, HR: 1.06; 95% CI: 0.67 to 1.67; without PAD, HR: 0.70; 95% CI: 0.59 to 0.84; interaction p = 0.103), and bleeding (with PAD, HR, 1.82; 95% CI: 0.87 to 3.83; without PAD, HR: 1.66; 95% CI: 1.23 to 2.24; interaction p = 0.811). ConclusionsAmong patients undergoing coronary stenting, those with PAD have more ischemic and bleeding events versus those without PAD. Extended duration dual antiplatelet therapy is associated with consistent ischemic benefit and bleeding harm among patients with and without PAD.

672 - A Double-Blind, Randomized Trial of Misoprostol for Healing of Small Bowel Bleeding Ulcers in Patients on Continuous Aspirin

672 - A Double-Blind, Randomized Trial of Misoprostol for Healing of Small Bowel Bleeding Ulcers in Patients on Continuous Aspirin

Continuous Aspirin Use Does Not Increase Bleeding Risk of Split-Thickness Skin Transplantation Repair to Chronic Wounds.

Discontinuation of aspirin therapy before cutaneous surgery may cause serious complications. The aim of this prospective study was to evaluate the bleeding risk of split-thickness skin transplantation repair to chronic wounds in patients on aspirin therapy. A total of 97 patients who underwent split-thickness skin transplantation surgery of chronic wounds during a 2-year period were enrolled. They were categorized on the basis of aspirin therapies. The primary outcome was postoperative bleeding and bleeding complications. Univariate analysis was performed to examine the association between aspirin and bleeding complications. Among the 26 patients taking aspirin continuously in group A, there were 5 bleeding complications (19.23%). Among the 55 nonusers in group B, there were 10 bleeding complications (18.18%). Among the 16 discontinuous patients in group C, there were 3 bleeding complications (18.75%). No statistical differences were found among the groups ( P = .956). Univariate analysis showed that continuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.933; 95% confidence interval, 0.283-3.074; P = .910 in the aspirin and control groups) and that discontinuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.963; 95% confidence interval, 0.230-4.025; P = .959 in the aspirin and control groups; odds ratio, 0.969; 95% confidence interval, 0.198-4.752; P = .969 in the aspirin and discontinuous groups). Continuous aspirin use does not produce an additional bleeding risk in patients who undergo split-thickness skin transplantation repair of chronic wounds.

Is breast cancer surgery safely performed in patients receiving antithrombotic therapy?

Aim:The aim of the study was to assess the safety of surgery for breast cancer in patients with antithrombotic therapy (ATT), including antiplatelet therapy (APT) and anticoagulation therapy (ACT) for thromboembolic risks.Methods:One hundred ninety-three consecutive patients receiving breast surgery for breast cancer at our institution between 2010 and 2015 were retrospectively reviewed. Among them, ATT was regularly used in 50 patients (25.9%). Our perioperative management included maintenance of preoperative aspirin monotherapy for APT and bridging heparin for ACT in patients at high thromboembolic risks and early postoperative reinstitution in all ATT cases. The outcome variables of patients with ATT (ATT group) were compared to those of patients without ATT (non-ATT group), and the significant risk factors for postoperative complications were determined by multivariate analysis.Results:This series included 127 mastectomy and 66 breast-conserving surgery. ATT group showed significantly high frequency of history of cerebral infarction and percutaneous coronary intervention (PCI). In the ATT group, 32 patients (16.6%) were categorized as high risk for thromboembolism, but there was neither thromboembolic event nor perioperative death in the whole cohort. Surgical blood loss and rates of intraoperative transfusion were identical between the groups. Whereas overall postoperative bleeding complication was more frequently observed in the ATT group compared to the non-ATT group (12.0% vs. 3.5%, p=0.360) in univariate analyses, multivariate analysis showed that neither ATT nor preoperative aspirin continuation affected postoperative bleeding complications.Conclusion:Even in patients undergoing ATT, surgery for breast cancer is safely performed without any increase in blood loss or postoperative bleeding, and no thromboembolism was experienced in the series. Our perioperative management of ATT patients is valid during breast surgery, although this patient population is still challenging and should be rigorously managed.

Aspirin use in robot-assisted radical prostatectomy? Systematic review and metanalysis.

e553 Background: Low dose aspirin (81-100mg) used as secondary prevention in cardiovascular diseases is correlated with increased bleeding and overall complications in surgical procedures. However, the suspension of this medication can increase the risk of cerebrovascular accident and myocardial infarction. Robot-assisted radical prostatectomy (RARP) has significantly decreased the surgical morbidity and the peri-operative bleeding. Our aim was to analyze whether RARP is feasible and safe in patients with low dose aspirin intake. Methods: Systematic review of the literature using MEDLINE, ESCOPUS, Lilacs, Scielo and Cohcrane articles published until June 2016. We included prospective trials and large cohorts that evaluated patients with (Group A) or without the maintenance of aspirin (Group B). Results: 5 trials (n = 1481 men) were included. One thousand and thirteen men stopped the use of the medication and 168 kept it during the peri-operatory setting, including the procedure. For the analyses of overall complications 3 articles with 458 men were included. The overall complication rate was 19%, without statistically significant difference between groups (Group A: 10.5%; Group B: 21.8% - OR: 0.70 IC:0.31- 1.56; I2= 0%). In a sub analysis evaluating major complications (Clavien &gt; 2), cardiovascular events were similar between groups (Group A: 10.5%; Group B: 19% OR: 0.67 IC: 0.34- 1.70; I2= 0%). There were 5 trials included to evaluate blood loss, with 1481 patients (168 Group A and 1313 Group B). The overall transfusion rate was 1.9%, without difference between groups (Group A = 3,5% and Group B = 1.7% - OR:3.24 IC:0.87- 12.06; I2= 0%). The estimate perioperative bleeding rate was significantly lower in patients using aspirin during surgery (OR:-33.74 IC:-44.99, -22.49, I2= 92%). The hospital stay length was similar between groups (OR:0 IC:-0.04, 0.04; I2= 0%). Conclusions: Low dose aspirin does not correlate with larger peri-operatory surgical morbidity, transfusion rate or hospital stay. The blood loss was lower in the aspirin intake group, but this fact should be interpreted with caution due to the high heterogeneity among studies. RARP in patients under continuous aspirin intake was feasible and safe.