When can a patient undergo cholecystectomy after Watchman (Left Atrial Appendage Closure) procedure?

From the Guidelines

A patient can undergo cholecystectomy after a Watchman procedure once the anticoagulation therapy is safely discontinued, typically after 6 months, to minimize bleeding risks. The timing of cholecystectomy after a Watchman procedure is crucial to ensure the patient's safety and prevent complications. According to the provided evidence, there is no direct information about the timing of cholecystectomy after a Watchman procedure. However, considering the standard post-Watchman anticoagulation regimen, which includes warfarin plus aspirin for 45 days, followed by dual antiplatelet therapy for an additional 4.5 months 1, it is reasonable to delay elective surgeries like cholecystectomy until this 6-month anticoagulation period is complete.

Some key points to consider when deciding on the timing of cholecystectomy after a Watchman procedure include:

• The risk of bleeding associated with anticoagulation therapy
• The need for endothelialization of the Watchman device
• The potential risks of device-related thrombosis if anticoagulation is stopped prematurely
• The importance of coordinating anticoagulation management between the surgeon, cardiologist, and anesthesiologist

In cases where cholecystectomy is urgently needed before the 6-month mark, a careful risk-benefit assessment should be performed, considering temporary interruption of anticoagulation therapy with appropriate bridging if necessary. For emergency cholecystectomy, a laparoscopic approach with meticulous hemostasis is preferred. It is essential to weigh the risks and benefits of earlier surgery and consider the patient's individual circumstances, such as the severity of their gallbladder disease and their overall health status.

The provided evidence from the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1 emphasizes the importance of early laparoscopic cholecystectomy (ELC) in patients with acute cholecystitis, but it does not directly address the timing of cholecystectomy after a Watchman procedure. However, the principles of minimizing bleeding risks and ensuring proper management of anticoagulation therapy are relevant to both scenarios.

From the Research

Anticoagulation Management After Watchman Procedure

• The WATCHMAN device is used to prevent stroke and systemic embolization in patients with atrial fibrillation, and post-procedural anticoagulation is necessary to avoid device-related thrombosis 2.
• The typical anticoagulation regimen after WATCHMAN implantation includes warfarin and aspirin for 45 days, followed by aspirin and clopidogrel for six months, and then aspirin indefinitely 2.

Timing of Cholecystectomy After Watchman Procedure

• There is no direct evidence on the optimal timing of cholecystectomy after WATCHMAN procedure.
• However, studies suggest that bridging anticoagulation with low-molecular-weight heparin (LMWH) can be used to manage patients who require temporary interruption of warfarin therapy before surgery or a procedure 3, 4.
• The safety and efficacy of LMWH as bridging therapy in the perioperative and periprocedural setting have been demonstrated in several studies 3, 4, 5.

Considerations for Cholecystectomy After Watchman Procedure

• Patients who have undergone WATCHMAN procedure may require anticoagulation therapy to prevent device-related thrombosis, and the timing of cholecystectomy should take into account the patient's anticoagulation status 2.
• The use of LMWH as bridging therapy may be considered to manage patients who require temporary interruption of warfarin therapy before cholecystectomy 3, 4.
• The decision to proceed with cholecystectomy after WATCHMAN procedure should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.