Skip to main content

Advertisement

SpringerLink
Log in

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery—the APAP trial (ISRCTN45810007)

  • Controlled Clinical Trial
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Purpose

Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery.

Methods

Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery.

Results

A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints.

Conclusions

Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372(9633):139–144

    Article  PubMed  Google Scholar 

  2. Devereaux PJ, Xavier D, Pogue J, Guyatt G, Sigamani A, Garutti I, Leslie K, Rao-Melacini P, Chrolavicius S, Homer Y et al (2011) Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery. Ann Intern Med 154(8):523–528

    PubMed  CAS  Google Scholar 

  3. Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH (2005) Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 173(6):627–634

    Article  PubMed  CAS  Google Scholar 

  4. Devereaux PJ, Goldman L, Yusuf S, Gilbert K, Leslie K, Guyatt GH (2005) Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ 173(7):779–788

    Article  PubMed  CAS  Google Scholar 

  5. Welsch T, Eisele H, Zschäbitz S, Hinz U, Büchler M, Wente M (2011) Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy. Langenbeck's Archiv Surg 396:783–791

    Article  Google Scholar 

  6. Wei AC, Tung-Ping Poon R, Fan ST, Wong J (2003) Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma. Br J Surg 90(1):33–41

    Article  PubMed  CAS  Google Scholar 

  7. Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, Corvera C, Weber S, Blumgart LH (2002) Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 236(4):397–407

    Article  PubMed  Google Scholar 

  8. de Boer MT, Molenaar IQ, Porte RJ (2007) Impact of blood loss on outcome after liver resection. Dig Surg 24(4):259–264

    Article  PubMed  Google Scholar 

  9. Antithrombotic Trialists’ Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324(7329):71–86

    Article  Google Scholar 

  10. Mahla ELT, Vicenzi MN, Werkgartner G, Maier R, Probst C, Metzler H (2001) Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery. Anesth Analg 92(3):572–577

    Article  PubMed  CAS  Google Scholar 

  11. Samama CM, Thiry D, Elalamy I, Diaby M, Guillosson J-J, Kieffer E, Coriat P (2001) Perioperative activation of hemostasis in vascular surgery patients. Anesthesiology 94(1):74–78

    Article  PubMed  CAS  Google Scholar 

  12. Collet JP, Montalescot G, Blanchet B, Tanguy ML, Golmard JL, Choussat R, Beygui F, Payot L, Vignolles N, Metzger JP et al (2004) Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 110(16):2361–2367

    Article  PubMed  CAS  Google Scholar 

  13. Biondi-Zoccai GGL, Lotrionte M, Agostoni P, Abbate A, Fusaro M, Burzotta F, Testa L, Sheiban I, Sangiorgi G (2006) A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease. Eur Heart J 27(22):2667–2674

    Article  PubMed  Google Scholar 

  14. Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J (2005) Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol 62(8):1217–1220

    Article  PubMed  Google Scholar 

  15. ACC/AHA (2004) Guideline update for coronary artery bypass graft surgery. Circulation 110(14):e340–e437

    Google Scholar 

  16. Howard-Alpe GM, de Bono J, Hudsmith L, Orr WP, Foex P, Sear JW (2007) Coronary artery stents and non-cardiac surgery. Br J Anaesth 98(5):560–574

    Article  PubMed  CAS  Google Scholar 

  17. McFadden EP, Stabile E, Regar E, Cheneau E, Ong ATL, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM et al (2004) Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 364(9444):1519–1521

    Article  PubMed  CAS  Google Scholar 

  18. Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35(5):1288–1294

    Article  PubMed  CAS  Google Scholar 

  19. Schouten O, Bax JJ, Poldermans D (2007) Management of patients with cardiac stents undergoing noncardiac surgery. Curr Opin Anesthesiol 20(3):274–278, 210.1097/ACO.1090b1013e328105dac328105

    Article  Google Scholar 

  20. Murphy JT, Fahy BG (2005) Thrombosis of sirolimus-eluting coronary stent in the postanesthesia care unit. Anesth Analg 101(4):971–973

    Article  PubMed  Google Scholar 

  21. Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G, Airoldi F, Chieffo A, Montorfano M, Carlino M et al (2005) Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 293(17):2126–2130

    Article  PubMed  CAS  Google Scholar 

  22. Sharma AK, Ajani AE, Hamwi SM, Maniar P, Lakhani SV, Waksman R, Lindsay J (2004) Major noncardiac surgery following coronary stenting: when is it safe to operate? Catheter Cardiovasc Interv 63(2):141–145

    Article  PubMed  Google Scholar 

  23. Steinhubl SR, Berger PB, Mann JT, Fry ETA, DeLago A, Wilmer C, Topol EJ, Investigators ftC (2002) Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention. JAMA 288(19):2411–2420

    Article  PubMed  CAS  Google Scholar 

  24. Chassot P-G, Delabays A, Spahn DR (2007) Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 99(3):316–328

    Article  PubMed  CAS  Google Scholar 

  25. Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H (2006) Coronary artery stenting and non-cardiac surgery—a prospective outcome study. Br J Anaesth 96(6):686–693

    Article  PubMed  CAS  Google Scholar 

  26. Korte W, Cattaneo M, Chassot PG, Eichinger S, von Heymann C, Hofmann N, Rickli H, Spannagl M, Ziegler B, Verheugt F, Huber K (2011) Peri-operative management of antiplatelet therapy in patients with coronary artery disease. Joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb Haemost 105(5):743–749

    Article  PubMed  CAS  Google Scholar 

  27. Burger W, Chemnitius JM, Kneissl GD, Rücker G (2005) Low-dose aspirin for secondary cardiovascular prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med 257(5):399–414

    Article  PubMed  CAS  Google Scholar 

  28. O’Brien JR (1968) Effect of salicylates on human platelets. Lancet 1:779–783

    Article  PubMed  Google Scholar 

  29. Beving H, Zhao C, Albage A, Ivert T (1996) Abnormally high platelet activity after discontinuation of acetylsalicylic acid treatment. Blood Coagul Fibrinolysis 7(1):80–84

    Article  PubMed  CAS  Google Scholar 

  30. Colwell JA (2004) Antiplatelet agents for the prevention of cardiovascular disease in diabetes mellitus. Am J Cardiovasc Drugs 4(2):87–106

    Article  PubMed  CAS  Google Scholar 

  31. Drouet L, Balditsollier C, Henry P (2010) Antiagrégants plaquettaires et diabète. Ann Cardiol Angeiol 59(Supplement 2):S56–S64

    Article  Google Scholar 

  32. Butalia S, Leung A, Ghali W, Rabi D (2011) Aspirin effect on the incidence of major adverse cardiovascular events in patients with diabetes mellitus: a systematic review and meta-analysis. Cardiovasc Diabetol 10(1):25

    Article  PubMed  CAS  Google Scholar 

  33. Horowitz N, Brenner B (2007) Thrombophilia and cancer. Pathophysiol Haemost Thromb 36(3–4):131–136

    Article  CAS  Google Scholar 

  34. Rickles FR, Shoji M, Abe K (2001) The role of the hemostatic system in tumor growth, metastases and angiogenesis: tissue factor is a bifunctional molecule capable of inducing both fibrin deposition and angiogenesis in cancer. Int J Hematol 73:145–150

    Article  PubMed  CAS  Google Scholar 

  35. POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P (2008) Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371(9627):1839–1847

    Article  PubMed  CAS  Google Scholar 

  36. Landesberg G, Shatz V, Akopnik I, Wolf YG, Mayer M, Berlatzky Y, Weissman C, Mosseri M (2003) Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol 42(9):1547–1554

    Article  PubMed  CAS  Google Scholar 

  37. Fleischmann KE, Goldman L, Young B, Lee TH (2003) Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay. Am J Med 115(7):515–520

    Article  PubMed  Google Scholar 

  38. Mackey WC, Fleisher LA, Haider S, Sheikh S, Cappelleri JC, Lee WC, Wang Q, Stephens JM (2006) Perioperative myocardial ischemic injury in high-risk vascular surgery patients: incidence and clinical significance in a prospective clinical trial. J Vasc Surg: Official Publ Soc Vasc Surg Int Soc Cardiovasc Surg, North Am Chapter 43(3):533–538

    Google Scholar 

  39. Kumar R, McKinney WP, Raj G, Heudebert GR, Heller HJ, Koetting M, McIntire DD (2001) Adverse cardiac events after surgery. J Gen Intern Med 16(8):507–518

    Article  PubMed  CAS  Google Scholar 

  40. Shah KB, Kleinman BS, Rao TLK, Jacobs HK, Mestan K, Schaafsma M (1990) Angina and other risk factors in patients with cardiac diseases undergoing noncardiac operations. Anesth Analg 70(3):240–247

    Article  PubMed  CAS  Google Scholar 

  41. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW (1998) Myocardial infarction after noncardiac surgery. Anesthesiology 88(3):572–578

    Article  PubMed  CAS  Google Scholar 

  42. Oscarsson A, Gupta A, Fredrikson M, Järhult J, Nyström M, Pettersson E, Darvish B, Krook H, Swahn E, Eintrei C (2010) To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth 104(3):305–312

    Article  PubMed  CAS  Google Scholar 

  43. Thachil J, Gatt A, Martlew V (2008) Management of surgical patients receiving anticoagulation and antiplatelet agents. Br J Surg 95(12):1437–1448

    Article  PubMed  CAS  Google Scholar 

  44. Di Minno M, Prisco D, Ruocco A, Mastronardi P, Massa S, Di Minno G (2009) Perioperative handling of patients on antiplatelet therapy with need for surgery. Intern Emerg Med 4(4):279–288

    Article  PubMed  Google Scholar 

  45. Brotman DJ, Bakhru M, Saber W, Aneja A, Bhatt DL, Tillan-Martinez K, Jaffer AK (2007) Discontinuation of antiplatelet therapy prior to low-risk noncardiac surgery in patients with drug-eluting stents: a retrospective cohort study. J Hosp Med 2(6):378–384

    Article  PubMed  Google Scholar 

  46. O’Riordan JM, Margey RJ, Blake G, O’Connell PR (2009) Antiplatelet agents in the perioperative period. Arch Surg 144(1):69–76

    Article  PubMed  Google Scholar 

  47. Metzler H, Kozek-Langenecker S, Huber K (2008) Antiplatelet therapy and coronary stents in perioperative medicine—the two sides of the coin. Best Pract Res Clin Anaesthesiol 22(1):81–94

    Article  PubMed  CAS  Google Scholar 

  48. Servin F (2007) Low-dose aspirin and clopidogrel: how to act in patients scheduled for day surgery. Curr Opin Anesthesiol 20(6):531–534, 510.1097/ACO.1090b1013e3282f1015f1095

    Article  Google Scholar 

  49. Merritt JC, Bhatt DL (2004) The efficacy and safety of perioperative antiplatelet therapy. J Thromb Thrombolysis 17(1):21–27

    Article  PubMed  CAS  Google Scholar 

  50. DA Chassot PG, Spahn DR (2007) Perioperative use of anti-platelet drugs. Best Pract Res Clin Anaesthesiol 21(2):241–256

    Article  PubMed  CAS  Google Scholar 

  51. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR et al (2007) ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 50(17):1707–1732

    Article  PubMed  Google Scholar 

  52. Collins R, Scrimgeour A, Yusuf S, Peto R (1988) Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. N Engl J Med 318(18):1162–1173

    Article  PubMed  CAS  Google Scholar 

  53. Tuman KJ, McCarthy RJ, O’Connor CJ, McCarthy WE, Ivankovich AD (1996) Aspirin does not increase allogeneic blood transfusion in reoperative coronary artery surgery. Anesth Analg 83(6):1178–1184

    PubMed  CAS  Google Scholar 

  54. Reich DL, Patel GC, Vela-Cantos F, Bodian C, Lansman S (1994) Aspirin does not increase homologous blood requirements in elective coronary bypass surgery. Anesth Analg 79(1):4–8

    Article  PubMed  CAS  Google Scholar 

  55. Michlig C, Vu DH, Wasserfallen JB, Spahn DR, Schneider P, Tissot JD (2003) Three years of haemovigilance in a general university hospital. Transfus Med 13(2):63–72

    Article  PubMed  CAS  Google Scholar 

  56. Lindblad B, Persson N, Takolander R, Bergqvist D (1993) Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial. Stroke 24(8):1125–1128

    Article  PubMed  CAS  Google Scholar 

  57. Neilipovitz DT, Bryson GL, Nichol G (2001) The effect of perioperative aspirin therapy in peripheral vascular surgery: a decision analysis. Anesth Analg 93(3):573–580

    Article  PubMed  CAS  Google Scholar 

  58. Manning BJ, O’Brien N, Aravindan S, Cahill RA, McGreal G, Redmond HP (2004) The effect of aspirin on blood loss and transfusion requirements in patients with femoral neck fractures. Injury 35(2):121–124

    Article  PubMed  Google Scholar 

  59. Nuttall GA, Santrach PJ, Oliver WC, Horlocker TT, Shaughnessy WJ, Cabanela ME, Bryant S (1996) The predictors of red cell transfusions in total hip arthroplasties. Transfusion 36(2):144–149

    Article  PubMed  CAS  Google Scholar 

  60. Palmer JD, Sparrow OC, Iannotti F (1994) Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery 35(6):1061–1065

    Article  PubMed  CAS  Google Scholar 

  61. Belisle S, Hardy J-F (1996) Hemorrhage and the use of blood products after adult cardiac operations: myths and realities. Ann Thorac Surg 62(6):1908–1917

    Article  PubMed  CAS  Google Scholar 

Download references

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany

    D. Antolovic, A. Rakow, P. Contin, A. Ulrich, N. N. Rahbari, M. W. Büchler, J. Weitz & M. Koch

Authors
  1. D. Antolovic
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Rakow
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. P. Contin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Ulrich
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. N. N. Rahbari
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. W. Büchler
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. J. Weitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. M. Koch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Koch.

Additional information

D. Antolovic and A. Rakow contributed equally to the study.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Antolovic, D., Rakow, A., Contin, P. et al. A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery—the APAP trial (ISRCTN45810007). Langenbecks Arch Surg 397, 297–306 (2012). https://doi.org/10.1007/s00423-011-0867-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-011-0867-7

Keywords

Search

Navigation