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Complications Arising From Perioperative Anticoagulant/Antiplatelet Therapy in Major Colorectal and Abdominal Wall Surgery

Cui, Rebecca Bei Jia, B.Med.1,2; Ng, Kheng-Seong, M.B.B.S.(HonsI.), Ph.D.1,2; Young, Christopher J., M.B.B.S., M.S., F.R.A.C.S.1,2

doi: 10.1097/DCR.0000000000001213
Original Contributions: Benign
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BACKGROUND: Postoperative hemorrhage and thromboembolism are recognized complications following colorectal and abdominal wall surgery, but accurate documentation of their incidence, trends, and outcomes is scant. This is relevant given the increasing number of surgical patients with cardiovascular comorbidity on anticoagulant/antiplatelet therapy.

OBJECTIVE: This study aims to characterize trends in the use of anticoagulant/antiplatelet therapy among patients undergoing major colorectal and abdominal wall surgery within the past decade, and to assess rates of, outcomes following, and risk factors for hemorrhagic and thromboembolic complications.

DESIGN AND SETTING: This is a retrospective cross-sectional study conducted at a single quaternary referral center.

PATIENTS: Patients who underwent major colorectal and abdominal wall surgery during three 12-month intervals (2005, 2010, and 2015) were included.

MAIN OUTCOME MEASURES: The primary outcomes measured was the rate of complications relating to postoperative hemorrhage or thromboembolism.

RESULTS: One thousand one hundred twenty-six patients underwent major colorectal and abdominal wall surgery (mean age, 61.4 years (SD 16.3); 575 (51.1%) male). Overall, 229 (21.7%) patients were on anticoagulant/antiplatelet agents; there was an increase in the proportion of patients on clopidogrel, dual antiplatelet therapy, and novel oral anticoagulants over the decade. One hundred seven (9.5%) cases were complicated by hemorrhage/thromboembolism. Aspirin (OR, 2.22; 95% CI, 1.38–3.57), warfarin/enoxaparin (OR, 3.10; 95% CI, 1.67–5.77), and dual antiplatelet therapy (OR, 2.99; 95% CI, 1.37–6.53) were most implicated with complications on univariate analysis. Patients with atrial fibrillation (adjusted OR 2.67; 95% CI, 1.47–4.85), ischemic heart disease (adjusted OR, 2.14; 95% CI, 1.04–4.40), and mechanical valves (adjusted OR, 7.40; 95% CI 1.11–49.29) were at increased risk of complications on multivariate analysis. The severity of these events was mainly limited to Clavien-Dindo 1 (n = 37) and 2 (n = 46) complications.

LIMITATIONS: This is a retrospective study with incomplete documentation of blood loss and operative time in the early study period.

CONCLUSIONS: One in ten patients incurs hemorrhagic/thromboembolic complications following colorectal and abdominal wall surgery. “High-risk” patients are identifiable, and individualized management of these patients concerning multidisciplinary discussion and critical-care monitoring may help improve outcomes. Prospective studies are required to formalize protocols in these “high-risk” patients. See Video Abstract at

1 University of Sydney, NSW, Australia

2 Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia

Earn Continuing Medical Education (CME) credit online at

Funding Support: None reported.

Financial Disclosures: None reported.

Presented at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Christopher J. Young, M.B.B.S., M.S., F.R.A.C.S., RPAH Medical Centre, Suite 415, 100 Carillon Ave, Newtown NSW 2042, Australia. E-mail: Twitter: @ChrisJFYoung.

© 2018 The American Society of Colon and Rectal Surgeons