*Andrzej Kluciński
Interventional treatment of haemorrhoids in anticoagulated patients
Leczenie zabiegowe hemoroidów u pacjentów przyjmujących leki przeciwkrzepliwe
Department of General Surgery, St. Ann Hospital in Piaseczno
Streszczenie
Leczenie przeciwkrzepliwe jest obecnie szeroko stosowane u pacjentów z chorobami układu krążenia, jako profilaktyka udarów oraz w innych chorobach naczyń. W codziennej praktyce coraz więcej pacjentów z objawami choroby hemoroidalnej przyjmuje leki rozrzedzające krew. Strategia postępowania okołooperacyjnego u pacjentów przyjmujących leki przeciwkrzepliwe, leczonych zabiegowo z powodu hemoroidów, nie była do tej pory szczegółowo omawiana w literaturze. U pacjentów z hemoroidami w stopniu I-III, u których leczenie zachowawcze było nieskuteczne, zaleca się wykonanie procedur małoinwazyjnych, takich jak podwiązywanie hemoroidów gumowymi podwiązkami (RBL), skleroterapię (SCL) oraz koagulację podczerwienią (IRC). Krwawienie występuje u 0,9-2,8% pacjentów po RBL, u 0-2,7% po SCL i u 5% po IRC. Operacje podwiązania tętnic hemoroidalnych, mukozektomia staplerowa są wskazane w bardziej zaawansowanych stopniach choroby, a krwawienia występują odpowiednio u 1,4-5,9% i 2-7,9% pacjentów. Hemoroidektomia pozostaje najlepszą opcją u pacjentów z hemoroidami w IV stopniu i wiąże się z 6,2-8,4% ryzykiem krwawienia. Profilaktyka krwawień powinna uwzględniać wykonanie zamkniętej hemoroidektomii, użycia Ligasure i tamponu analnego.
Nie zaleca się odstawiania kwasu acetylosalicylowego w procedurach o niskim ryzyku krwawienia, do których zalicza się operację hemoroidów. Jednakże krwawienie po RBL było częstsze w grupie przyjmującej aspirynę. Występowanie krwawienia po skleroterapii nie różniło się w grupie pacjentów leczonych przeciwkrzepliwie w porównaniu z grupą pacjentów, którzy nie przyjmowali leków rozrzedzających krew. Zabieg wycięcia guzków krwawniczych powinien być przełożony o 6 miesięcy u pacjentów na podwójnej terapii przeciwpłytkowej. Chorzy otrzymujący doustne preparaty antagonistów witaminy K powinni je odstawić na 5 dni przed operacją hemoroidów. Zabiegi o bardzo małym ryzyku krwawienia nie wymagają odstawienia leczenia przeciwkrzepliwego, ale wydaje się to niebezpieczne u chorych poddawanych RBL. Skleroterapia nie wymaga odstawienia warfaryny, jeśli INR mieści się w zakresie terapeutycznym. NOACs powinny być odstawiane na dzień przed zabiegami o niskim ryzyku krwawienia, włączając hemoroidektomię, i wznowione dzień po operacji. Podsumowując, poza kwasem acetylosalicylowym pozostałe leki przeciwkrzepliwe powinny zostać odstawione przed operacją. Nie ma jednoznacznych zaleceń postępowania u chorych poddawanych zabiegom małoinwazyjnym.
Summary
Anticoagulants are currently widely used for cardiological reasons, stroke prevention and in other vascular diseases. Colorectal surgeons face patients suffering from haemorrhoids who are put on anticoagulant therapy in their everyday practice. Anticoagulation strategy for patients undergoing interventional treatment of haemorrhoids has not been discussed in detail in the literature so far. Standard management of grade 1-3 haemorrhoids includes rubber band ligation (RBL), sclerotherapy (SCL) and infrared coagulation (IRC) after unsuccessful conservative treatment. The rates of postprocedural bleeding range from 0.9-2.8% after rubber band ligation, 0-2.7% after sclerotherapy and 5% after infrared coagulation. Surgical procedures including dearterialization, haemorrhoidectomy and stapled haemorrhoidopexy are indicated in more advanced degrees as the third line of treatment and are complicated by postoperative bleeding in 1.4-5.9% and 2-7.9% patients, respectively. Haemorrhoidectomy is the best option in grade 4 haemorrhoids and is associated with 6.2-8.4% risk of bleeding. However, closed haemorrhoidectomy, Ligasure technique and/or anal tamponade can reduce this risk. Surgical guidelines recommend continuing acetylsalicylic acid in low bleeding risk procedures, including haemorrhoidal surgery. However, postoperative bleeding after rubber band ligation was more common in the aspirin group. On the other hand, haemorrhage incidence after sclerotherapy did not differ significantly between the group on anticoagulation compared with the group without anticoagulation. Haemorrhoidectomy should be postponed for 6 months in patients receiving dual antiplatelet therapy. According to the guidelines, vitamin K antagonists should be discontinued 5 days before haemorrhoidal surgery. Minimal bleeding risk procedures do not require discontinuation of anticoagulation,but this option seems to be hazardous for patients undertaking rubber band ligation. Sclerotherapy, on the other hand, could not require warfarin discontinuation if the international normalized ratio (INR) is within therapeutic range. Novel oral anticoagulants (NOACs) should be discontinued 1 day before low bleeding risk operations, including haemorrhoidectomy and resumed 1 day after the procedure. In conclusion, all anticoagulants should be ceased prior to operation except for aspirin. There are not clear recommendations on the perioperative protocols for continuation or discontinuation of blood thinners in patients undergoing minimally invasive procedures.
Introduction
Anticoagulants are widely used for cardiological reasons, stroke prevention and other vascular diseases.
Almost 25% of adult population requires a different type of thromboembolic prophylaxis (1). Colorectal surgeons deal with patients suffering from haemorrhoids who are put on anticoagulant therapy on a daily basis. If conservative treatment of haemorrhoids fails to bring improvement, interventional treatment must be considered. First-line treatment is based on outpatient procedures, including Rubber Band Ligation (RBL), Sclerotherapy (SCL) and Infrared Coagulation (IRC). Patients with more advanced disease require surgery. The decision about perioperatice anticoagulation must be made after thorough consideration of possible postoperative bleeding versus thromboembolic risks, comorbidities and surgeon’s preferences. Cuevas et al. (2) showed an off-label use of anticoagulants in patients with atrial fibrillation undergoing elective surgery. This resulted in complications and increased costs. Anticoagulation strategy for patients undergoing interventional treatment for haemorrhoids has not been discussed in detail in the literature so far.
Bleeding after interventional treatment
Symptoms of haemorrhoidal disease include bleeding, prolapse, itching, burning sensation, leakage of mucus or faeces, discomfort and hygiene problems. Bleeding causes anxiety and fear, especially in patients on anticoagulation therapy. Pigot et al. (3) reported 4.6% incidence of postoperative bleeding after a wide range of proctological procedures. Half of the patients required admission to hospital, and further 36% required surgical intervention or blood transfusion. Major bleeding after haemorrhoidal treatment is generally understood as bleeding requiring surgical intervention and/or blood transfusion (3, 4). It is not entirely consistent with the widely used Clavien-Dindo scale based on the type of therapy needed to treat the complication (5). Blood transfusion is considered grade II complication according to this scale, but surgical, endoscopic or radiological intervention is known as grade III complication. Additionally, persistent bleeding after interventional treatment is considered as failure to cure according to Clavien-Dindo scale, because the primary purpose of surgery has not been achieved.
Early postoperative bleeding is almost always associated with surgical technique errors. Late bleeding occurs usually several days after procedure and is caused by infection, ischaemia and necrosis.
Goligher classification of haemorrhoids is currently most widely used. It recognizes haemorrhoidal prolapse seen only in anoscope (grade 1), prolapse during straining with spontaneous (grade 2) or manual reduction (grade 3) and irreducible (grade 4). Standard management of grade 1-3 haemorrhoids includes RBL, SCL and IRC in grade 1-3 after unsuccessful conservative treatment. Surgical procedures including dearterialization, haemorrhoidectomy and stapled haemorrhoidopexy are indicated in more advanced degrees as the third-line treatment (6, 7). Among minimally invasive procedures, RBL is the most effective for grade I-III haemorrhoids (6, 7). Unfortunately, due to the need to repeat procedures several times and the risk of delayed bleeding up to 14 days after the procedure, it carries a high risk for patients on anticoagulants. The incidence of post RBL bleeding range from 0.9 to 2.8% (8-11). No hospital admission or intervention is needed in most of patients. In s randomized study from Great Britain, published in Lancet in 2016, no bleeding complication was reported among 178 patients after RBL (12).
SCL and IRC could be performed in patients with grade 1 and 2 haemorrhoids (6, 7). SCL using polidocanol or aluminium potassium sulfate is mainly complicated by infection and fibrosis. Post-SCL rectal bleeding is reported in 0-2.7% of cases (13, 14). Persistent bleeding after this procedure seen as failure to cure rather than complication occurs in 6.7-8.9% of patients (13, 15). IRC causes local ischaemia of haemorrhoidal cushions due to the use of infrared light. Nikshoar et al. (16) reported 5% incidence of post infrared coagulation bleeding. Transanal haemorrhoidal dearterialisation (THD) with or without mucopexy is an alternative treatment for patients with grade 2 and 3 haemorrhoids (7). Major acute postoperative bleeding was reported in 1.4-5.9% of patients after this procedure (12, 17, 18).
Stapled haemorrhiodopexy is another option for grade 2 and 3 haemorrhoids refractory to outpatient procedures (7). It involves excision of the abnormally enlarged haemorrhoidal tissue by using a circular stapling device. The incidence of postoperative bleeding ranges from 2 to 7.9% (3, 17, 19). Stapled haemorrhoidopexy and haemorrhoidal excision have the highest risk of postoperative bleeding among all proctological procedures (3). Despite common complications including pain, urinary retention and bleeding, haemorrhoidectomy remains the best option for grade 4 hemorrhoids (7). Chen et al. (20) observed only 0.9% incidence of post-hemorrhoidectomy haemorrhage among 4,880 patients. Other trials reported 6.2 and 8.4% delayed bleeding episodes (3, 21).
Anticoagulants increase the risk of postoperative bleeding almost 6 times (OR 5.805; p = 0.001) after various proctological procedures (3). Patients on anticoagulation require additional measures to minimize postoperative bleeding risk. A review of Cochrane Library demonstrated the significant role of phlebotonics in reducing post-haemorrhoidectomy haemorrhage (OR 0.18; 95% CI: 0.06-0.58; P = 0.004) (22). Closed haemorrhoidectomy would be preferred over open haemorrhoidectomy due to its lower incidence of bleeding (7). Furthermore, Ligasure reduces bleeding compared with closed haemorrhoidectomy (7).
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Piśmiennictwo
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