Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany.
J Gastrointest Surg. 2021 Nov;25(11):2939-2947. doi: 10.1007/s11605-021-04964-9. Epub 2021 Mar 22.
In chronic anticoagulant users undergoing surgery, bleeding and thromboembolism are common and serious complications. Many studies on mainly elective or minor emergency surgical procedures with low associated risks have focused on these outcomes. In comparison, patients undergoing high-risk emergency abdominal surgical procedures have not received sufficient attention. This study aimed to compare outcomes between oral anticoagulant users and nonusers who required emergency laparotomy for high-risk abdominal emergencies.
Patients who underwent surgery for abdominal emergencies at our institution between January 2012 and July 2019 were retrospectively reviewed.
There were 875 patients, including 370 anticoagulant users and 505 nonusers. Of the 370 anticoagulant users, 189 (51.3), 77 (20.8%), 45 (12.2%), and 59 (15.9%) were prescribed antiplatelets, a vitamin k antagonist, a direct oral anticoagulant, and a combination drug regimen, respectively. The most common high-risk emergencies requiring surgery in both groups were perforated viscus (25.7% vs 40.9%), mesenteric ischemia with enteric necrosis (27% vs 12.8%), and bowel obstruction (17.6% vs 28.1%). The overall bleeding rate was higher (29.2% vs 22%, p = 0.015) in anticoagulant users than in nonusers, but the major bleeding rate was similar (17.8% vs 14.1%, p = 0.129) between the two groups. The rates of thromboembolic events and mortality were significantly higher in anticoagulant users than in nonusers (25.7% vs 9.7%, p < 0.0001 and 39.7% vs 31.1%, p = 0.01, respectively). Liver cirrhosis, peripheral arterial diseases, reoperation, and blood product transfusion were independent predictors of the overall risk of bleeding or TEEs, according to the multivariate analysis. In this model, liver cirrhosis had the largest overall effect on mortality, followed by pneumonia, thromboembolism, peripheral arterial disease, blood product transfusion, and atrial fibrillation. The use of oral anticoagulants was not an independent predictor of either bleeding or in-hospital mortality. The use of oral anticoagulants was associated with a decreased risk of all-cause in-hospital mortality.
Based on our results, the continued use of oral anticoagulants is more protective than harmful considering the overall outcomes in this subset of patients.
在接受抗凝治疗的慢性患者中，出血和血栓栓塞是常见且严重的并发症。许多研究主要针对低风险的选择性或小紧急手术，关注这些结果。相比之下，接受高危紧急腹部手术的患者并未得到充分重视。本研究旨在比较口服抗凝药物使用者和非使用者在需要接受高危腹部紧急剖腹手术时的结局。
回顾性分析了 2012 年 1 月至 2019 年 7 月在我院接受腹部急症手术的患者。
共有 875 例患者，其中 370 例为抗凝药物使用者，505 例为非使用者。在 370 例抗凝药物使用者中，分别有 189 例（51.3%）、77 例（20.8%）、45 例（12.2%）和 59 例（15.9%）接受了抗血小板药物、维生素 K 拮抗剂、直接口服抗凝剂和联合药物治疗。两组中最常见的需要手术的高危急症分别为穿孔性内脏（25.7%比 40.9%）、肠系膜缺血伴肠坏死（27%比 12.8%）和肠梗阻（17.6%比 28.1%）。抗凝药物使用者的总体出血率高于非使用者（29.2%比 22%，p=0.015），但两组大出血率相似（17.8%比 14.1%，p=0.129）。抗凝药物使用者的血栓栓塞事件和死亡率明显高于非使用者（25.7%比 9.7%，p<0.0001 和 39.7%比 31.1%，p=0.01）。根据多变量分析，肝硬化、外周动脉疾病、再次手术和血制品输注是出血或 TEE 总体风险的独立预测因素。在该模型中，肝硬化对死亡率的总体影响最大，其次是肺炎、血栓栓塞、外周动脉疾病、血制品输注和心房颤动。口服抗凝剂的使用不是出血或住院死亡率的独立预测因素。口服抗凝剂的使用与全因住院死亡率降低相关。
根据我们的结果，考虑到这部分患者的总体结局，继续使用口服抗凝剂的保护作用大于危害。
