Highlights from the Literature
Postoperative Bleeding Complications Associated With Novel Oral Anticoagulants in Mohs Micrographic Surgery.
By Ramona Behshad, MD, FACMS
The study investigated postoperative bleeding complications linked to novel oral anticoagulants (NOACs) in Mohs Micrographic Surgery (MMS). Conducted by Fahmy et al. and published in Dermatologic Surgery, it aimed to assess the safety of performing MMS in patients on NOAC therapy. The researchers conducted a retrospective review of patients undergoing MMS at a dermatologic surgery center over a five-year period. The primary objective was to determine if there was a significant difference in the rate of postoperative bleeding complications between patients on NOAC therapy and those not on anticoagulant therapy.
Between January 2017 and July 2022, 2,530 cases of Mohs Micrographic Surgery (MMS) were conducted by a single surgeon. After excluding cases with outside repair and no follow-up, 2,181 MMS cases involving 1,545 unique patients were analyzed. There were 696/2181 cases (31.9%) in which patients were taking at least 1 type of antithrombotic medication. Among these, 22 cases (1.01%) experienced bleeding complications, comprising 19 hemorrhages and 3 hematomas. Age, sex, tumor location, number of stages, repair type, and defect size did not differ significantly between cases with and without bleeding complications.
When using a multivariate analysis that adjusted for age and sex, patients on antithrombotic medications were more likely to experience bleeding, notably those on NOAC and aspirin combination therapy and those on multiple anticoagulants other than NOACs and aspirin combination therapy. NOAC monotherapy (n=149) did NOT significantly increase bleeding risk (OR: 1.70, 95% CI: 0.36-7.97, p = .50), while concomitant NOACs + aspirin use (n=15) significantly elevated bleeding odds (OR 20.5, 95% CI: 3.99-105.7, p < .001). In patients taking anticoagulants other than NOACs, patients on multiple antithrombotic agents had higher odds of experiencing a bleeding event, while patients on antiplatelet medications (aspirin, clopidogrel, prasugrel, or ticagrelor) did NOT see a significantly increased risk of bleeding events. The study suggests NOAC monotherapy may not raise bleeding risk, contrasting with increased risk seen with NOAC and aspirin combination therapy.
Despite the encouraging results, the study has some limitations that warrant consideration. Firstly, the sample size of patients on NOAC therapy was relatively small. Additionally, the retrospective nature of the study introduces the possibility of selection bias and incomplete data collection.
In conclusion, Fahmy et al.'s study suggests that MMS can be safely performed in patients on NOAC monotherapy without an increased risk of postoperative bleeding complications, while those on NOAC and aspirin combination therapy may warrant extra caution. Further research with larger sample sizes and prospective study designs is warranted to confirm these findings and explore potential differences in bleeding risk between specific NOACs.