Continued antiplatelet therapy does not boost bleeding risk in GI procedures

Last Updated: 2016-03-04

By Will Boggs MD

NEW YORK (Reuters Health) - Continuing antiplatelet therapy during the perioperative period does not increase the risk of bleeding in gastrointestinal (GI) procedures, according to a new systematic review.

The risk of intra- and postoperative bleeding in GI surgery has been associated with perioperative antiplatelet therapy, but cessation of these drugs might be unsafe for patients who maintain antiplatelet therapy because of a cardiovascular condition. The American College of Cardiology Foundation/American Heart Association guidelines recommend deferral of procedures that will cause significant postoperative bleeding until patients have completed their course of antiplatelet therapy.

"The question is an important and difficult one - this becomes clear when one looks at the guidelines from various societies outlining how one should treat patients in these types of situations, and their sometimes conflicting opinions," Xiao Fang from the University of Texas Medical Branch, Galveston, Texas told Reuters Health by email.

Fang and colleagues compared the risk of intraoperative or postoperative bleeding among patients who had any type of GI surgery while on continuous antiplatelet therapy to the risk among those not on therapy in their systematic review of 22 studies (one randomized controlled trial, one case-control study, and 20 cohort studies) from eight countries.

Some of the procedures were surgical, and others were endoscopic procedures performed mostly by gastroenterologists.

Five of the 22 studies showed that the risk of intraoperative or postoperative bleeding was higher among patients who had surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy), whereas 17 studies suggested that there was no statistically significant difference between the risks of bleeding with and without continuous antiplatelet therapy.

The randomized controlled trial had an "unclear risk of bias," the researchers note in their report, online February 5 in the Journal of the American College of Surgeons. Among the other studies, nine were deemed to be of high quality, nine of medium quality, and two of low quality.

"Based on this systematic review of the literature, we conclude that the bleeding risk of GI procedures among patients on antiplatelet therapy is not higher than that of patients with no antiplatelet or interrupted antiplatelet therapy," the researchers wrote.

"We encourage investigators to continue to study this area, and make more precise recommendations: the implications of these studies impact not only the decisions that individual surgeons make in individual cases, but also the systemic decisions that health care systems make in terms of overall management," Fang added.

Dr. Bellal Joseph from University of Arizona Medical Center in Tucson, who was not involved in the review, recently showed that laparoscopic cholecystectomy could be safely performed in patients on long-term aspirin therapy.

"Surgeons' decisions to stop anti-platelet/anti-coagulant medication prior to GI surgery should be guided be the risk benefit ratio," he told Reuters Health by email. "The benefit of lower perioperative bleeding comes with a concurrent risk of increased thrombotic events, particularly in individuals with coronary artery disease. This risk benefit should be kept in mind before making the choice between stopping antiplatelet/anticoagulant medication for GI surgery versus delaying the surgery."

"This study is timely and critical because our population is aging and more and more patients are coming in for surgeries on these drugs," Dr. Joseph said. "Future research should be focused on guiding transfusion for patients taking these drugs."

SOURCE: bit.ly/1WZzB0X

J Am Coll Surg 2016.