From the Guidelines
Patients undergoing gastrectomy should have their oral anticoagulation managed according to the perioperative bleeding risk, with high bleeding risk procedures requiring withholding of direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) 2-4 days before surgery, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1. The management of oral anticoagulation in gastrectomy patients involves assessing the perioperative bleeding risk and making decisions based on this risk.
Key Considerations
- High bleeding risk procedures, such as gastrectomy, require careful management of oral anticoagulation to minimize the risk of bleeding complications.
- The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline provides recommendations for the perioperative management of DOACs and VKAs, including withholding these medications 2-4 days before high bleeding risk procedures 1.
- The decision to withhold or resume oral anticoagulation should be made on a case-by-case basis, taking into account the individual patient's bleeding and thrombotic risk.
Management Strategies
- For patients on DOACs, such as apixaban, edoxaban, or rivaroxaban, these medications should be withheld 2-4 days before high bleeding risk procedures, as outlined in Table 13 of the guideline 1.
- For patients on VKAs, such as warfarin, these medications should be withheld 4-6 days before high bleeding risk procedures, with bridging anticoagulation considered in high thrombotic risk patients 1.
- In patients with renal impairment, the management of oral anticoagulation should be adjusted according to the degree of impairment, with more frequent monitoring and dose adjustments as needed 1.
Monitoring and Adjunctive Measures
- Regular monitoring for bleeding complications is essential, particularly at surgical sites.
- Mechanical prophylaxis with intermittent pneumatic compression devices should be used alongside pharmacological methods to reduce the risk of venous thromboembolism (VTE).
- Early mobilization, adequate hydration, and close monitoring for signs of VTE are important adjunctive measures to reduce the risk of thrombotic complications.
From the Research
Oral Anticoagulation for Gastrectomy Patients
- The use of oral anticoagulation in patients undergoing gastrectomy is a topic of interest, with several studies investigating the efficacy and safety of different anticoagulants in this population 2, 3.
- A study published in 2021 found that short-term use of enoxaparin (3 days) was effective and safe for venous thromboembolism (VTE) prophylaxis in gastric cancer patients undergoing gastrectomy, with a low incidence of deep vein thrombosis (4.4%) and bleeding-related complications (1.5%) 2.
- Another study published in 2017 highlighted the uncertainty surrounding the use of direct-acting oral anticoagulants (DOACs) in patients with major gastrointestinal resections or bypass, including gastrectomy, due to limited clinical data and potential alterations in drug absorption 3.
- The same study advised against the use of rivaroxaban in patients undergoing gastrectomy, citing concerns about its efficacy in this population 3.
- A network meta-analysis published in 2017 compared the efficacy and safety of different anticoagulants, including enoxaparin, fondaparinux, dabigatran, rivaroxaban, apixaban, and edoxaban, for the prevention of VTE after hip and knee arthroplasty, but not specifically in gastrectomy patients 4.
- The use of low-molecular-weight heparin as bridging therapy during interruption of oral anticoagulation in patients undergoing colonoscopy or gastroscopy was found to be safe and effective in a prospective, observational study published in 2007 5.
- However, the applicability of these findings to gastrectomy patients is unclear, and further studies are needed to determine the optimal oral anticoagulation strategy for this population.
- The available evidence suggests that enoxaparin may be a suitable option for VTE prophylaxis in gastrectomy patients, but the use of DOACs requires further investigation due to concerns about their efficacy and safety in this population 2, 3.