Postoperative hemorrhagic complications after elective laparoscopic cholecystectomy in patients receiving long-term
Metin Ercan1, Erdal B Bostanci, Ilter Ozer
1Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Hospital, 06100, Sihhiye, Ankara, Turkey. metinercan66@mynet.com.tr
Insights
Postoperative bleeding complications were significantly higher in patients on chronic oral anticoagulation undergoing laparoscopic cholecystectomy (LC) with bridging anticoagulation. Standard coagulation tests did not predict these bleeding risks.
Area of Science:
- Surgical Oncology
- Hepatobiliary Surgery
- Anticoagulation Management
Background:
- Laparoscopic cholecystectomy (LC) is a common procedure.
- Patients on long-term anticoagulant therapy require careful perioperative management.
- Bleeding complications after LC in anticoagulated patients are not well-studied.
Purpose of the Study:
- To prospectively investigate postoperative bleeding complications in patients undergoing LC while on chronic oral anticoagulation.
- To assess the incidence of bleeding in this patient cohort compared to a control group.
- To identify predictors of postoperative bleeding in anticoagulated patients.
Main Methods:
- Prospective study of 44 patients on warfarin (oral anticoagulant) undergoing LC between 2002-2007.
- Warfarin discontinued 5 days pre-surgery; bridging anticoagulation with enoxaparin (low molecular weight heparin) initiated.
- Comparison with 1,421 patients without comorbidities who underwent LC during the same period.
Main Results:
- Postoperative bleeding occurred in 25% (11/44) of the anticoagulation group versus 1.5% (21/1421) in the control group.
- Bleeding severity ranged from minor oozing to fatal hemorrhage.
- No significant differences in age, gender, BMI, ASA score, INR, or other hemostasis parameters were found between bleeding and non-bleeding patients in the anticoagulation group.
Conclusions:
- Postoperative bleeding is markedly more frequent in patients undergoing LC with bridging anticoagulation than anticipated.
- Standard coagulation parameters (e.g., INR) do not reliably predict bleeding risk in these patients.
- There is a need for improved methods to identify patients at risk for bleeding complications during LC while on anticoagulation.
Background And Aims:
Among patients on long-term anticoagulant therapy who undergo laparoscopic cholecystectomy (LC), bleeding complications have not been extensively investigated. The objective of this study was therefore to investigate postoperative bleeding complications prospectively in patients on chronic oral anticoagulation.
Materials And Methods:
In the period of January 2002 to December 2007, 44 patients on long-term anticoagulation with warfarin, an oral anticoagulant (OAC), underwent LC in our center. Oral anticoagulant was discontinued 5 days before the planned date of surgery, and patients were admitted to the hospital 3 days before. Upon admission, bridging anticoagulation with enoxaparin, a low molecular weight heparin (LMWH), was started. When their international normalized ratio (INR) decreased to <1.5, patients underwent LC. In the absence of postoperative bleeding complications, OAC and LMWH were resumed on the evening of the day of surgery, and LMWH was continued until each patient's target INR was reached. A comparison group was comprised by 1,421 consecutively enrolled patients with no comorbid disease who underwent LC during the same period.
Results:
In the comparison group, postoperative bleeding was encountered in 21 patients (1.5%). In the anticoagulation group, postoperative bleeding was encountered in 11 patients (25%) and ranged from minor oozing from a port incision in one patient to hemorrhage, sepsis, and fatality in one patient. In the anticoagulation group, no significant differences were found between patients with and without postoperative bleeding in terms of age, gender, body mass index, American Society of Anesthesiologists score, INR, or other hemostasis parameters.
Conclusions:
In patients who underwent LC with bridging anticoagulation, postoperative bleeding was markedly more frequent than expected and was not predicted by the usual coagulation parameters. This suggests a need for methods that can indicate which patients on long-term anticoagulation are at risk for postoperative bleeding.
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