Perioperative Heparin Research Articles

Incidence of Heparin-Induced Thrombocytopenia in Non-Surgical Patients

Introduction: Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin exposure. HIT occurs when Platelet Factor 4 (PF4) forms a complex with heparin, resulting in the formation of autoantibodies. HIT occurs more frequently in surgical patients compared with non-surgical patients due to the inflammatory release of PF4 and perioperative heparin exposure. Previously, unfractionated heparin (UFH) has been compared to low molecular weight heparin (LMWH) solely among surgical patients which has been correlated with a higher incidence of HIT relative to LMWH. However, there is little data regarding UFH versus LMWH in non-surgical patients. The purpose of this study was to determine whether there was a significant difference in the incidence of HIT between these two forms of anticoagulation in non-surgical patients. We also sought to delineate differences in incidence of HIT with respect to BMI, gender, and age. Methods: This is a retrospective study that included all patients admitted to 14 hospitals within Hospital Corporation of America's (HCA) North Florida Division between January 2016 and September 2022. Data was retrieved and analyzed by HCA statisticians. Patient selection was based not only on whether they had been diagnosed with HIT, but various other factors including age, weight, gender and type of anticoagulation (LMWH vs UFH). Patients who had undergone surgery or even been hospitalized within the six months had been excluded. Other excluded conditions include disseminated intravascular coagulation (DIC), hemolytic-uremic syndrome (HUS), immune thrombocytopenic purpura (ITP), drug induced systemic lupus erythematosus (DILE), and systemic lupus erythematosus (SLE). Results: A total of 2,061 patients were included. Unfractionated heparin group was significantly associated with the likelihood of the patient being diagnosed with HIT (χ 2 = 184.06, p < 0.0001). The odds ratio is 0.237, indicating that patients who received unfractionated heparin were 4.219 (1/0.237) times as likely to develop HIT as patients who received LMWH. When controlling for age, sex, and BMI, age was significantly associated with the likelihood of the patient being diagnosed with HIT (χ 2 = 8.423, p < 0.01). The odds ratio was 1.010, indicating that with each additional year of age, patients were 1.010 times as likely to develop HIT. BMI was also significantly associated with likelihood of HIT (χ2 = 4.892, P < 0.03), indicating that obesity was identified as a potential factor associated with the development of HIT. Female were less likely to develop HIT when compared to men overall (χ2 = 7.238, P < 0.05). Conclusions: HIT is a rare but important cause of morbidity and mortality in patients exposed to heparin containing products. This study explored the profile of HIT incidence in non-surgical patients receiving UFH versus LMWH and in young versus older age groups. Here we provide evidence that a long-standing understanding regarding the incidence of HIT in surgical patients holds true in strictly non-surgical patients. Additionally, we have acquired evidence that age may very well play a role in HIT.

Perioperative bridging anticoagulation in patients with oral cancer surgery: a multicenter retrospective study

The number of patients administered oral antithrombotic drugs who require elective surgery has increased. Perioperative heparin bridging needs to be considered for patients at a high risk of thromboembolism. The present study investigated the effects of perioperative heparin bridging therapy on perioperative complications (postoperative bleeding and thrombotic events) in oral cancer surgery. The medical records of 98 patients who underwent oral cancer surgery with perioperative bridging therapy were retrospectively analyzed. Postoperative hemorrhage occurred in 16 patients (16.3%) and thrombotic events (deep venous thrombosis) in 5 (5.1%), which were higher than in other surgeries. A multivariate analysis identified the administration of prostaglandins as the only significant independent risk factor for postoperative hemorrhage, and a longer duration of postoperative heparin bridging therapy was associated with the incidence of deep venous thrombosis. The present results suggest a higher incidence of thrombotic and bleeding events in patients who underwent oral cancer surgery with heparin bridging, and the nature of surgery (such as revascularization and prolonged bed rest) may be a contributing factor. Future studies are needed to establish whether heparin bridging is effective in oral cancer surgery.

Do no harm: the role of perioperative heparin in urethroplasty.

To examine the safety of single modality mechanical venous thromboembolism (VTE) prophylaxis in patients undergoing urethroplasty. VTE is a perioperative complication with significant morbidity. Routine use of peri-operative VTE prophylaxis is common guideline-driven practice across multiple surgical specialties. There is a discrepancy between guideline recommendations and clinical practice in the administration of peri-operative low-dose unfractionated heparin (LDUH) for urethroplasty. Patients were identified from an IRB-approved database of patients undergoing urethral reconstruction by a single surgeon at MedStar Washington Hospital Center from 2012 to 2020. All patients had sequential compression devices (SCD) prior to anesthesia induction. Select patients received LDUH as dual prophylaxis. Primary endpoint was perioperative VTE within 30days. We identified 345 patients who met inclusion criteria. Sixty-nine patients received peri-operative LDUH. One patient had a deep vein thrombosis in the SCD only group. Routine LDUH administration likely overtreats men undergoing urethroplasty. There may be a subset of men in whom dual prophylaxis with LDUH and SCD is beneficial for prevention of VTE. Current guidelines do not offer adequate criteria to identify these men. We offer clinical considerations to help guide further study to identify these patients.

A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease.

Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements.This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.

32. EVOLUTION OF CLINICAL PRACTICE PATTERNS IN LIPOSUCTION: A SIXTEEN-YEAR REVIEW OF CONTINUOUS CERTIFICATION TRACER DATA FROM THE AMERICAN BOARD OF PLASTIC SURGERY

PURPOSE: A sixteen-year review of liposuction tracer data collected from diplomates of the American Board of Plastic Surgery (ABPS) as part of the Continuous Certification process was performed to evaluate for predominant practice patterns and changes in specific practice patterns over this time. METHODS: Liposuction tracer data were collected from 2005-2021, comparing tracer data from 2005-2014 to those from 2015-2021 using Fisher’s exact test and Student’s t-test. RESULTS: 2810 patients with an average age of 42 years were evaluated, of which 84% were female. In the later cohort (2015-2021), in-office procedures increased significantly. Concerning the body area of liposuction, abdomen, flank, and back have increased, while thighs and knees have decreased. Power-assisted lipectomy has grown in popularity, and significant increases were noted in the volume of wetting solution and lipoaspirate. Surgeons are performing procedures concomitantly with liposuction more often, and more mid-surgical position changes from prone to supine were noted. Perioperative heparin and low-molecular-weight heparin (LMWH) use have significantly increased. CONCLUSION: The present study is the first to objectively assess evolving trends in the clinical practice of liposuction over the last sixteen years. These data illustrate an increase in outpatient procedures, a shift in technique towards power-assisted liposuction, and greater surgical focus on the trunk (abdomen, flanks, and back).

Periop-01: A randomized controlled trial of extended perioperative tinzaparin to improve disease-free survival in patients with resectable colorectal cancer.

124 Background: Cancer patients undergoing surgical resection of their tumor are hypercoagulable beyond the period of hospitalization. Preclinical studies demonstrate that the postoperative hypercoagulable state promotes metastases, an effect that is abrogated by administration of perioperative low molecular-weight heparin (LMWH). Methods: We conducted a randomized, open label clinical trial to determine if extended duration thromboprophylaxis using subcutaneous LMWH (tinzaparin 4,500 IU daily), beginning at decision to operate and continuing for 56 days postoperatively, compared to inpatient postoperative thromboprophylaxis only, increased the 3-year disease-free survival (DSF) in patients undergoing resection for colorectal cancer. Secondary outcomes included 5-year overall survival (OS), postoperative bleeding and venous thromboembolism (VTE). Results: Trial recruitment was stopped prematurely after 614 of the planned 1075 patients were registered, following a pre-defined interim analysis for futility. The intention-to-treat analysis included 602 patients with demographics in the table. The 3-year DFS was 78.9% (63/299 recurrences) in the tinzaparin group and 80.5% (59/303 recurrences) in the control group (hazard ratio (HR) 1.09; [95% CI 0.91,1.31; p=0.3]). The 5-year OS was 91.3% in the tinzaparin group and 92.4% in the control group (HR 1.08; [95% CI 0.66,1.79; p=0.1]). The incidence of postoperative VTE was 1.7% and 1.3% in the tinzaparin and control groups, respectively (HR 1.3; [95% CI 0.30,5.69; p=0.7]. The incidence of major bleeding in the first postoperative week was 0.3% and 2% in the tinzaparin and control groups, respectively (HR 0.16; [95% CI 0.02,1.15; p=0.07]. Conclusions: Extended duration perioperative anticoagulation with tinzaparin did not improve DFS or OS in colorectal cancer patients undergoing surgical resection. The incidences of postoperative bleeding and VTE were low. Funded by Canadian Institute of Health Research and Leo Pharma Clinical trial information: NCT01455831. [Table: see text]

Portal Vein Thrombosis May Be More Strongly Associated With Islet Infusion Than Extreme Thrombocytosis After Total Pancreatectomy With Islet Autotransplantation.

Total pancreatectomy with islet autotransplantation (TPIAT) involves pancreatectomy, splenectomy, and reinjection of the patient's pancreatic islets into the portal vein. This process triggers a local inflammatory reaction and increase in portal pressure, threatening islet survival and potentially causing portal vein thrombosis. Recent research has highlighted a high frequency of extreme thrombocytosis (platelets ≥1000 × 109/L) after TPIAT, but its cause and association with thrombotic risk remain unclear. This retrospective single-site study of a contemporary cohort of 409 pediatric and adult patients analyzed the frequency of thrombocytosis, risk factors for thrombosis, and antiplatelet and anticoagulation strategies. Of 409 patients, 67% developed extreme thrombocytosis, peaking around postoperative day 16. Extreme thrombocytosis was significantly associated with infused islet volumes. Thromboembolic events occurred in 12.2% of patients, with portal vein thromboses occurring significantly earlier than peripheral thromboses. Portal vein thromboses were associated with infused islet volumes and portal pressures but not platelet counts or other measures. Most thromboembolic events (82.7%) occurred before the postoperative day of maximum platelet count. Only 4 of 27 (14.8%) of portal vein thromboses occurred at platelet counts ≥500 × 109/L. Perioperative heparin was given to all patients. Treatment of reactive thrombocytosis using aspirin in adults and hydroxyurea in children was not associated with significantly decreased thromboembolic risk. These results suggest that post-TPIAT thrombocytosis and portal vein thromboses may be linked to the islet infusion inflammation, not directly to each other, and further reducing this inflammation may reduce thrombosis and thrombocytosis frequencies simultaneously.

MP23-11 DO NO HARM: THE ROLE OF PERIOPERATIVE HEPARIN IN ANTERIOR URETHROPLASTY

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making III (MP23)1 Sep 2021MP23-11 DO NO HARM: THE ROLE OF PERIOPERATIVE HEPARIN IN ANTERIOR URETHROPLASTY Harry Lee, Nathan Shaw, Erin Hays, and Krishnan Venkatesan Harry LeeHarry Lee More articles by this author , Nathan ShawNathan Shaw More articles by this author , Erin HaysErin Hays More articles by this author , and Krishnan VenkatesanKrishnan Venkatesan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002014.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Venous thromboembolism (VTE) is a perioperative complication with significant morbidity. Routine use of peri-operative VTE prophylaxis is common guideline-driven practice across multiple surgical specialties. There is a discrepancy between guideline recommendations and clinical practice in the administration of peri-operative heparin for anterior urethroplasty. The purpose of this study was to examine the necessity of peri-operative heparin in patients undergoing anterior urethroplasty. METHODS: Patients were identified from an IRB-approved, prospectively maintained database of patients undergoing anterior urethral reconstruction by a single surgeon at MedStar Washington Hospital Center (MWHC) from 2012-2020. All patients had sequential compression devices (SCDs) prior to anesthesia induction. Patients received heparin based on hospital policy as dual prophylaxis. Primary endpoint was perioperative VTE within 30 days with secondary outcomes of peri-operative complications and stricture recurrence. RESULTS: We identified 342 patients who met inclusion criteria. 68 patients received peri-operative heparin. One patient had a DVT in the SCD only group. There were statistically significant increases in hospital length of stay, stricture recurrence, and post-operative complications in the group that received heparin. CONCLUSIONS: Routine heparin administration likely overtreats men undergoing anterior urethroplasty. There may be a subset of men in whom dual prophylaxis with heparin and SCD is beneficial for prevention of VTE. Currently guidelines do not offer adequate criteria to identify these men. We offer an algorithm to help guide further study to identify these patients. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e405-e406 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Harry Lee More articles by this author Nathan Shaw More articles by this author Erin Hays More articles by this author Krishnan Venkatesan More articles by this author Expand All Advertisement Loading ...

Creation of an individualized algorithm for venous thromboembolism prophylaxis on a gynecologic oncology service

<h3>Objectives:</h3> To evaluate implementation of a venous thromboembolism (VTE) prophylaxis algorithm on adherence to evidence-based guidelines including the rate of administration of preoperative heparin and the overall VTE rate on the gynecologic-oncology service at a single institution. <h3>Methods:</h3> Prior to 2018, no consensus VTE prophylaxis protocol existed on the gynecologic oncology service at the authors' academic institution. ACOG and Chest guidelines were used to modify a published gynecology VTE risk algorithm. Interventions to improve preoperative heparin administration included: ID badge algorithm attachments, placards in operating rooms, integration of algorithm into the H&P template and order set in the electronic medical record. Surgical, anesthesia, and nursing teams were contacted to investigate cases in which pre-operative heparin was indicated but not administered. In 2020, three retrospective cohorts of 100 patients each (2016-2017, 2018, and 2019) spanning the pre-, intra- and post-QI implementation periods were consecutively identified using cancer and radical surgery-specific CPT codes to evaluate performance in these highest risk cases; cohorts were filled to 100 using randomly selected additional gynecologic oncology cases. Perioperative heparin administration and VTE rates were evaluated. Proportions were compared using chi-square tests; continuous factors were compared using ANOVA or Kruskal-Wallis tests. <h3>Results:</h3> A total of 3 retrospective surgical cohorts totaled 312 patients (2016-2017: 100, 2018: 110, 2019: 102); mean age was 60. Indications for surgery were ovarian (36.9%), endometrial (35.6%), and cervical cancer (11.9%), and benign (15.6%). Minimally invasive cases comprised 52% of the cohort in 2016-7, 42.7% in 2018, and 42.2% in 2019 (p=0.070). The mean (SD) number of risk factors for VTE was similar across cohorts (2016-2017: 3.7 (1.6), 2018: 3.6 (1.4), 2019: 3.5 (1.7); p=0.87). When retrospectively applied to all surgical cases reviewed, adherence to VTE algorithm improved from 31.0% in 2016-2017 to 69.1% in 2018 and 82.4% in 2019 (p<0.001). Appropriate administration of pre-operative heparin in high-risk patients improved over time with each cohort: 34.8% in 2016-2017, 83.3% in 2018, and 92.5% in 2019 (p<0.001). The VTE rate within 30 days of surgery was 5.0% in 2016-2017, 3.6% in 2018, and 1.0% in 2019; this was not statistically significant (p=0.25). Adverse event rates were not significantly different between cohorts; peri-operative blood transfusion was 17.0% in 2016-7, 16.4% in 2017, and 10.8% in 2019 (p=0.385). Superficial and subfascial surgical site infections, hematomas, and vaginal cuff dehiscence were rare across cohorts. <h3>Conclusions:</h3> Implementation of an individualized perioperative VTE prophylaxis algorithm has resulted in improved adherence to evidence-based prophylaxis guidelines and improvement in rates of preoperative heparin administration; observed trends in VTE rates have not achieved significance.

A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service

ObjectiveTo describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution. MethodsPrior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE ‘dashboard’ to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016–2017, 2018, 2019). ResultsCompared to the baseline period, we observed a reduction in VTE rate during the 2018–2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016–2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences. ConclusionsImplementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.

Heparin-Free Lung Transplantation on Venovenous Extracorporeal Membrane Oxygenation Bridge.

Extracorporeal membrane oxygenation (ECMO) bridge to lung transplantation (LuTX) exposes the patients to a high risk of perioperative bleeding secondary to systemic anticoagulation and coagulation factors deficiency. With this case series, we propose innovative "no-heparin" management of ECMO-bridge support during LuTX, based upon 1) control heparin resistance with antithrombin III in the preoperative period; 2) relying upon a fully functional, brand new heparinized ECMO circuit; 3) completely avoiding perioperative heparin; 4) hampering fibrinolysis with tranexamic acid; and 5) limiting venoarterial (VA) ECMO escalation, and the following need for full anticoagulation. Following the application of this new approach, we carried out three challenging clinical cases of bilateral ECMO-bridged LuTX effectively, with limited intraoperative blood requirement and no major postoperative bleeding or thromboembolic events. Of note, two of them had an extremely high risk for hemorrhage due to complete right lung anatomic derangement in case number 2 and surgical adhesion following first LuTX in case number 3, while for the case number 1, no blood products were administered during surgery. Despite the limited patient population, such an approach relies on a strong rationale and may be beneficial for managing ECMO bridging to LuTX. Prospective studies are necessary to confirm the validity of our strategy.

Safety of Hepatobiliary and Pancreatic Surgery in Patients Receiving Direct Oral Anticoaulants (DOACs)

Introduction: The safety and optimal perioperative management of patients receiving direct oral anticoagulants (DOACs) during hepatobiliary and pancreatic (HBP) surgery is still controversial. Methods: Between 2012 and 2018, 115 anticoagulant-prescribed patients who underwent elective HBP surgery (65 benign and 50 malignant diseases, 69 laparoscopic and 46 open-fashioned operations) in our department were enrolled in this study. Patients undergoing emergency operations were excluded from the study. The patients were divided into two groups; patients receiving DOACs (DOAC group, n = 35) and patients undergoing warfarin therapy (WF group, n = 80). Background characteristics, surgical blood loss, and postoperative complications, including bleeding and thrombotic complications, were compared between the groups. Results: In the DOAC group, dabigatran, apixaban, rivaroxaban, and edoxaban were used in 10, 8, 10, and 7 patients, respectively, and only 11 patients (31.4%) received perioperative heparin bridging. There were no differences in patients´ background characteristics and mode of surgery (open or laparoscopic). The duration of operation (p = 0.148), surgical blood loss (p = 0.782), and the rate of intraoperative red blood cell transfusion (p = 1.000) were similar between the groups. Overall, any thromboembolic complications were not observed in the current cohort, and only 1 patient (2.9%) suffered from postoperative bleeding complication in the DOAC group. The mortality was zero, and the length of postoperative stay was also identical between the groups (p = 0.998). Conclusion: HBP surgery is safely performed in patients receiving DOAC therapy, without increase in bleeding or thromboembolic complications compared with warfarin therapy.

A comparative analysis of four activated clotting time measurement devices in cardiac surgery with cardiopulmonary bypass

In cardiac surgery on cardiopulmonary bypass (CPB), heparin anticoagulation is monitored by point-of-care measurement of activated clotting time (ACT). The objective of this study was to compare four ACT systems in cardiac surgery in terms of their reproducibility, agreement and potential clinical impact at relevant medical decision points. The study included 40 cardiac surgery patients. Samples were taken at five time points before (T1), after heparinization for CPB (T2, T3, T4), and after heparin reversal (T5). The reproducibility, correlation, and differences in ACT values were assessed with two devices from each of the four ACT systems: Instrumentation Laboratory Hemochron Elite (Hmch), Medtronic HMS Plus (HMS), Abbott i-STAT, and Helena Abrazo. Subrange analyses were performed for low ACT values (results from T1, T5) and high ACT values (results from T2, T3, T4). Within-system analysis showed strong linear correlation between paired measurements (R = 0.968-0.993). However, Hmch showed poorer reproducibility with highest proportion of values that exceed a difference of 10% and highest overall standard error of 74 seconds across the measurement range compared to that of the others (range 39-47 seconds, respectively). For inter-system comparison, using Hmch as reference, ACTs were strongly correlated as follows: HMS (R = 0.938), i-STAT (R = 0.911), and Abrazo (R = 0.911). Agreement analysis in the high ACT range showed HMS tended to have higher ACT values with +11% bias over Hmch, whereas i-STAT (-8% bias) and Abrazo (-13% bias) tended to underestimate. Post-protamine ACT results were dependent on device type where Hmch yielded highest post-protamine ACT (+13% higher than baseline) compared to -16% for HMS, -10% for iSTAT and 0% for Abrazo. Each device had individual reproducibility and biases, which may impact peri-operative heparin management. Careful validation must be undertaken when adopting a different method as decision limits would be affected. Clinicians should also be cautious using ACT as the only indicator for full heparin reversal.

Heparin Induced Thrombocytopenia for the Perioperative and Critical Care Clinician.

Purpose of ReviewThis review will illustrate the importance of heparin-induced thrombocytopenia in the intraoperative and critical care settings.Recent FindingsHeparin-induced thrombocytopenia (HIT) occurs more frequently in surgical patients compared with medical patients due to the inflammatory release of platelet factor 4 and perioperative heparin exposure. Recognition of this disease requires a high index of suspicion. Diagnostic tools and therapeutic strategies have been expanded and refined in recent years.SummaryHIT is a condition where antibodies against the heparin/platelet factor 4 complex interact with platelet receptors to promote platelet activation, aggregation, and thrombus formation. Our review will focus on intraoperative and postoperative considerations related to HIT to help the clinician better manage this rare but often devastating hypercoagulable disease process.

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Impact of antithrombotic therapy on the outcomes with focus on bleeding and thromboembolic events in patients undergoing pancreticoduodenectomy.

We investigated perioperative outcomes of pancreaticoduodenectomy (PD) in patients receiving antithrombotic therapy (ATT) with a focus on the incidence of perioperative bleeding and thromboembolic complications. A total of 77 patients who underwent PD at our institution between 2013 and 2019 were retrospectively reviewed. Clinical findings and surgical outcomes including bleeding and thromboembolic complications were compared in patients with or without ATT. Interruption of ATT and perioperative heparin bridging were based on our hospital protocol. Among ATT (30) and non-ATT (47) groups, ATT group had a significantly higher age and history of cardiocerebrovascular diseases. No significant difference was observed in intraoperative and post-pancreatectomy haemorrhage (PPH) between the groups. ATT group was associated with a significantly higher rate of post-operative complications, Clavien-Dindo classification ≥II and thromboembolic events. Operative mortality in ATT and non-ATT groups was 2 (6.7%) and 1 (2.1%), respectively. There was no significant association between ATT and excessive intraoperative blood loss (≥1000 mL), PPH (≥grade B) and thromboembolic complications (Clavien-Dindo classification ≥II). In patients with ATT, PD is a feasible procedure with no major impact on intraoperative bleeding or PPH.

Perioperative antithrombotic management of patients who receive direct oral anticoagulants during gastroenterological surgery.

AimWe investigated the effect of perioperative management of direct oral anticoagulants (DOACs) on bleeding and thromboembolic complications during gastroenterological (GE) surgery.MethodsA total of 334 patients receiving anticoagulants and undergoing elective GE surgery between 2012 and 2018 were enrolled. The patients were divided into three groups: patients receiving warfarin (WF, n = 231), patients receiving DOACs with heparin bridging (DOAC‐HB, n = 34), and patients receiving DOAC without heparin bridging (DOAC‐NHB, n = 69). Outcome variables were compared between the groups and the risk factors of postoperative bleeding were assessed using logistic multivariate analysis.ResultsNo significant differences were observed in background characteristics between the groups. There were similarities between the groups in surgical blood loss (P = .772) and rate of intraoperative transfusion (P = .952). Thromboembolic complications only occurred in two patients in the WF group (0.9%), and no thromboembolism occurred in the DOAC groups. The incidence of major postoperative bleeding was significantly higher in DOAC‐HB group than in the other groups (14.7% vs 4.8% vs 1.4%, P = .011). Multivariate analysis showed DOAC with heparin bridging to be the most significant risk factor of major postoperative bleeding (odds ratio = 11.60, P = .028).ConclusionsElective GE surgery can be safely performed in patients receiving DOACs without heparin bridging. Perioperative heparin bridging during DOAC interruption is not recommended even for patients undergoing major GE surgery due to increased postoperative bleeding.

Evidence for a rebalanced hemostatic system in pediatric liver transplantation: A prospective cohort study.

In adults with end‐stage liver disease concurrent changes in pro‐ and antihemostatic pathways result in a rebalanced hemostasis. Children though, have a developing hemostatic system, different disease etiologies, and increased risk of thrombosis. This study aimed to assess the hemostatic state of children during and after liver transplantation. Serial blood samples were obtained from 20 children (≤16 years) undergoing primary liver transplantation (September 2017‐October 2018). Routine hemostasis tests, thrombomodulin‐modified thrombin generation, clot lysis times, and hemostatic proteins were measured. Reference values were established using an age‐matched control group of 30 children. Thrombocytopenia was present in study patients. Von Willebrand factors were doubled and ADAMTS13 levels decreased during and after transplantation up until day 30, when platelet count had normalized. Whereas prothrombin time and activated partial thromboplastin time were prolonged during transplantation, thrombin generation was within normal ranges, except during perioperative heparin administration. Fibrinogen, factor VIII levels, and clot lysis time were elevated up until day 30. In conclusion, children with end‐stage liver disease are in tight hemostatic balance. During transplantation a temporary heparin‐dependent hypocoagulable state is present, which rapidly converts to a hemostatic balance with distinct hypercoagulable features that persist until at least day 30. This hypercoagulable state may contribute to the risk of posttransplant thrombosis.

The impact of perioperative heparin bridging therapy in lung cancer surgery.

The impact of perioperative heparin bridging (HB) for lung surgery in patients on anti-clotting drugs remains unclear. We performed a retrospective study to assess its effect on surgical safety by comparing HB and non-HB groups. This study included 274 consecutive patients on anti-clotting drugs who underwent surgery for lung cancer. Of these, 77 received HB and 197 did not. Propensity score matching extracted 124 patients, consisting of 62 patients with HB and 62 patients without HB. Endpoints were surgical safety. There was no statistically significant difference in the outcomes of surgical safety outcomes between the HB and non-HB group after propensity-score matching, operative time (172 vs. 203min, p = 0.131), volume of blood loss (60 vs. 70ml, p = 0.335), need for intraoperative RBC transfusion (3.2 vs. 6.5%, p = 0.680), chest tube drainage volume on the 1st postoperative day (200 vs. 200ml, p = 0.796), and chest tube placement duration (3 vs. 3days, p = 0.606). The influence of perioperative HB on postoperative thromboembolic or bleeding events in lung cancer surgery is not obvious, but its surgical safety appears to be acceptable.

Low-Dose Aspirin Reduces the Rate of Renal Allograft Thrombosis in Pediatric Renal Transplant Recipients.

Renal allograft thrombosis is an important cause of early renal allograft loss. A previous study from our unit showed thrombosis rates in patients who received heparin that were similar to those who did not receive any thromboprophylaxis. This study evaluated the impact of aspirin prophylaxis on renal allograft thrombosis rates in pediatric renal transplant recipients. We conducted a retrospective study of 456 consecutive pediatric allografts from deceased and living related donors over age 22 years in a single center. Routine perioperative heparin was introduced in 1994 and was subsequently changed to aspirin prophylaxis in 2000. Group 1 comprised 126 patients who did not receive any thromboprophylaxis, group 2 comprised 128 patients who received heparin, and group 3 comprised 202 patients who received aspirin therapy. Variables associated with increased risk of renal allograft loss were examined using multivariable logistic regression. Thrombosis occurred in 11% (14/126) of grafts in group 1, 9% (11/128) of grafts in group 2, and 1% (2/202) of grafts in group 3 (odds ratio for aspirin group = 0.38, 95% confidence interval, 0.22-0.64; P = .02). In patients who received aspirin (group 3), there was only one renal allograft loss secondary to hemorrhage, and no grafts were lost in patients younger than 5 years of age. After our center introduced a change from heparin to aspirin prophylaxis, the thrombosis rate in pediatric renal allografts fell from 9% to 1%. Although there are a number of possible confounding variables, the introduction of aspirin has led to a reduced rate of renal allograft thrombosis.