Physiology/Medical Disease LAPAROSCOPIC RENAL-ADRENAL SURGERY IN PATIENTS ON ORAL ANTICOAGULANT THERAPY (2005)

Purpose: Patients requiring chronic anticoagulation are theoretically at increased risk for hemorrhage or thromboembolism perioperatively. Experience with laparoscopic renal/adrenal surgery in patients on chronic warfarin is limited. We assessed hemorrhagic/thromboembolic complications in this group of patients. Materials and Methods: The records of 787 patients undergoing laparoscopic renal/adrenal surgery were retrospectively reviewed. A total of 25 patients on chronic oral anticoagulation with warfarin were identified. The indications for warfarin therapy as well as perioperative management were reviewed. Clinical parameters, including operative time, estimated blood loss, hemorrhagic/thromboembolic complications and transfusions, were documented and compared with those in patients not receiving chronic anticoagulation. Results: Atrial fibrillation (56% of cases) and a prosthetic mitral valve (28%) were the most frequent indications for chronic anticoagulation. Bridging anticoagulation with unfractionated heparin was the most frequent management method (68% of cases). Patients with anticoagulation were older (p 0.001) and hospitalized longer (0.001) than those without anticoagulation. Operative time, estimated blood loss and the conversion rate were not significantly different between the groups. However patients on chronic warfarin significantly more often required transfusion (24% vs 5.2%, p 0.005) and had more postoperative bleeding episodes (8% vs 0.9%, p 0.05) than patients not on chronic anticoagulation. No thromboembolic events occurred in the anticoagulated group, while 3 occurred in the nonanticoagulated group (p 1). Conclusions: Laparoscopic renal/adrenal surgery in patients requiring chronic anticoagulation therapy can be performed safely. The risk of intraoperative bleeding is not increased, although the incidence of postoperative bleeding as well as transfusions is higher. Many patients undergoing elective surgery may be on chronic oral anticoagulant therapy, eg warfarin, because of underlying atrial fibrillation (AF), mechanical prosthetic heart valves, or previous venous thromboembolism (VT) or pulmonary thromboembolism. These patients are at increased risk for perioperative complications. The continuation of full anticoagulation throughout surgery increases bleeding during the procedure, while interrupting of anticoagulant therapy increases the risk of thromboembolism. 1,2 Appropriate management with temporary perioperative interruption of oral anticoagulant therapy and the institution of appropriate bridging anticoagulation therapy, eg unfractionated heparin (UFH) or low molecular weight (LMW) heparin, can decrease complications in patients at high risk. 3 Hemorrhagic complications in patients on chronic anticoagulation undergoing open noncardiac surgery have been evaluated to aid in establishing management strategies. 4 Similar evaluation in patients undergoing laparoscopy is limited and it has been reported only for procedures with a low risk of bleeding, eg cholecystectomy. 5,6 Surgery such as laparoscopic renal/adrenal surgery requires more extensive dissection, thus, conveying a potentially higher risk of hemorrhage. We evaluated bleeding complications associated with laparoscopic renal/adrenal surgery in patients on chronic anticoagulant therapy. METHODS