Warfarin Institute of America
DEDICATED TO YOUR HEALTH SINCE 2000
HERNIA REPAIR SURGERY WHILE FULLY ANTICOAGULATED
Surgeons at the Mayo Clinic in Scottsdale, Arizona report that they have had success doing inguinal hernia repairs without stopping warfarin. The study involved 88 people who were on warfarin. Warfarin was discontinued without bridging in 54 patients. Their hospital stay was about 1/2 day. About 2% of them developed hematomas. The 19 people who continued warfarin throughout the procedure stayed about 3/4 day. About 11% of them developed hematomas. The 15 people who discontinued warfarin and had bridging with a heparin product stayed an average of 3-1/3 days. About 13% of them developed hematomas. The difference in the rate of hematomas was not statistically significant.
Reference: McLemore EC et al. The safety of open inguinal herniorraphy in patients on chronic warfarin therapy. Am J Surg 2006;192:860-4.
One of my students looked at this study and summed up the decisions to be made in the article below
Continue or Discontinue Warfarin for a Non-major Open Hernia Surgery?
Kendra Gorby PharmD Candidate Ohio Northern University.
Issues for patients on warfarin therapy that undergo elective surgery are complex as the surgeon attempts to manage the anticoagulation therapy of the patient and at the same time attempts to prevent major blood loss. The primary concern with patients on warfarin undergoing surgery is their increased risk of bleeding during surgery; however with patients at high risk for clotting, it may be imperative to keep patients on their warfarin therapy during non-major surgeries like the open hernia repair.
In preparation for elective open hernia repair, warfarin patients have either simply discontinued their warfarin therapy or stopped warfarin and initiated bridge therapy with a short-acting anticoagulation agent such as un-fractionated or low-molecular-weight heparin. A recent study looked at the safety of patients continuing their warfarin therapy while undergoing non-major open hernia repair. While performing open hernia repair patients that discontinue the warfarin therapy are at high risk for developing a clot. This study looked at an additional option: continuing warfarin therapy for moderate to high risk patients during open hernia repair compared with those patients that discontinue warfarin and those patients that discontinue and start bridge therapy.
High risk patients were classified in this study as patients with atrial fibrillation and prior heart attack, systemic embolism or stroke, history of high blood pressure, clinical evidence of rheumatic mitral valve disease or heart valve replacement, heart failure or impaired left ventricular function on echocardiography, diabetes mellitus, or over the age of 75. Moderate-risk patients are those with atrial fibrillation from ages 65-75, and Mild-risk patients are those with atrial fibrillation under the age of 65 with no other risk factors.
In this study, the groups of patients that continue warfarin and those who discontinue warfarin with bridge therapy had more moderate to high risk individuals than did the discontinue warfarin therapy group. There were no statistically significant differences in operative time or complications after surgery between the three groups. The length of hospital stay was increased for the discontinue warfarin with bridge therapy due to the need to monitor the bridge therapy as well as the length of time it takes to reinitiate the warfarin to reach effective doses, (about 5-7 days). The incidence of large bruising after surgery was increased in the discontinue warfarin with bridge therapy and the continue warfarin groups. The bruises resolved over time with appropriate management.
The absolute risk of a patient developing a clot and having a stroke upon the discontinuation of warfarin prior to and during surgery is less than 1% and the risk of a major bleed with the continued use of warfarin during surgery is estimated at 0-3% for non-major surgeries of this type. When comparing these two risks the risk of developing a clot and having a stroke appears to be less risky; however, the repercussion can be devastating with 70% of the cases experiencing extensive neurological injury secondary to the embolic stroke with a 15% death rate.
When you take time to think about the consequences of each of these risks, the small risk of having a major bleed seems less risky and more manageable as there are reversible treatments such as blood transfusions, where as a majority of the time the neurological damage experienced during an embolic stroke is irreversible and life altering. The suggestion for non-major surgeries is for patients with low risk of developing a clot to discontinue their warfarin therapy prior to surgery whereas moderate to high risk patients continue warfarin therapy when the risk of developing a clot outweighs the risk of complications due to bleeding following surgery. It is extremely important that whatever the decision about the anticoagulation therapy prior to and during surgery that the patient’s INR level be determined the day of surgery. The INR should be below 3.0 the day of surgery. If the INR is greater than 3.0 the surgery should be rescheduled. This will reduce the risk of a major bleed after the surgery. It is important to discuss all the risk factors during this non-major open hernia repair with your physician whether you remain on the warfarin or discontinue the warfarin, with or without bridge therapy.
©2007 Kendra Gorby Used by Permission
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Last updated September 3, 2007
