Background

The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies.

Methods

All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002–2010) and anticoagulated patients in the NOAC era (2010–2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion.

Results

Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R² = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57–0.88) and transfusions (OR 0.71 95%CI 0.64–0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14–1.39).

Conclusion

Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed.

中文翻译：

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NOAC 时代的急诊结肠切除术：一项显示并发症增加的全国性分析

背景

自 2010 年引入以来，非维生素 K 拮抗剂口服抗凝剂 (NOAC) 的使用大幅增加。缺乏现成的逆转剂给围手术期管理带来了挑战。本研究的目的是评估 NOACs 对急诊结肠切除术结局的影响。

方法

从 2002 年至 2018 年的全国住院患者样本 (NIS) 数据库中确定了接受急诊结肠切除术并接受长期抗凝治疗的所有成年患者。使用 ICD-9/10 代码定义了长期抗凝治疗。比较了两个队列：前 NOAC 时代（2002-2010）的抗凝患者和 NOAC 时代（2010-2018）的抗凝患者。感兴趣的结果是术后手术并发症、死亡率和输血需求。

结果

在 13,218 名长期抗凝患者中，3,264 名患者在前 NOAC 时代接受治疗，9,954 名患者在 NOAC 时代接受治疗。在研究期间，接受急诊结肠切除术的抗凝患者比例显着增加 (R ²  = 0.91)。在单变量分析中，NOAC 时代接受抗凝治疗的患者合并症更多，术后并发症发生率更高（73.3% 对 60.3%，p  < 0.001）和死亡率（8.2% 对 6.7%，p  = 0.006），但较低的术后出血率（3.5% 对 4.4%，p  = 0.002）和输血率（38.1% 对 45.4%，p < 0.001)。在多变量回归分析中，考虑到具有临床意义的协变量后，NOAC 时代的抗凝治疗与术后出血率 (OR 0.70, 95%CI 0.57–0.88) 和输血率 (OR 0.71 95%CI 0.64–0.77) 的降低有关，但仍然是总体术后并发症增加的独立预测因子（OR 1.26，95%CI 1.14–1.39）。

结论

接受紧急结肠切除术的患者长期抗凝的流行率正在增加。尽管与较低的术后出血和输血率相关，但 NOAC 时代的抗凝与较高的总体术后并发症发生率相关。急诊结直肠手术环境下使用 NOACs 患者的围手术期管理需要循证指南。