Patients With Bleeding Disorders Face Similar Surgery Risks to Healthy Controls

With sufficient preoperative planning and comprehensive care, individuals with bleeding disorders can safely undergo major surgical procedures, because risks of bleeding complications are similar to those of the general population, new research suggests.

Findings of the retrospective study carried out at a single hemophilia treatment center were published in Clinical and Applied Thrombosis/Hemostasis.

Although patients with bleeding disorders are at high risk for bleeding stemming from invasive procedures, little is known about the risk of bleeding in this patient population undergoing major surgery and the outcomes of those managed perioperatively at hemophilia treatment centers.

Previous research has shown that prior to routine use of factor replacement therapy, “perioperative mortality was high in [people with bleeding disorders], with a series of reports finding mortality rates of 60% in hemophilia A patients prior to 1966 and 3% to 5% by 1980.”

To carry out the current study, the researchers assessed surgical outcomes of patients who underwent major surgery between January 1, 2017, and December 31, 2019 at Cardeza Foundation Hemophilia and Thrombosis Center in Philadelphia, Pennsylvania. The study’s primary outcome was postoperative bleeding, and secondary outcomes included use of unplanned postoperative hemostatic therapy, length of stay, and 30-day readmission rate.

All planned surgeries that required general anesthesia for more than 30 minutes, in addition to any orthopedic and neurologic surgeries, were assessed.

Fifty patients with bleeding disorders who underwent 63 major surgeries were included in the analysis. Twenty percent of patients had hemophilia, and 64% had von Willebrand disease. The latter disease is the most common congenital bleeding disorder, affecting 0.0023% to 0.01% of the population.

For patients with hemophilia, “bleeding can range from spontaneous hemarthrosis and soft tissue bleeds in patients with severe deficiency to no spontaneous bleeding in patients with mild deficiency, but all are at risk for hemorrhage with invasive procedures or trauma,” the authors wrote.

Orthopedic surgical procedures were the most common among patients included in the study. The researchers also compared outcomes to individuals without bleeding disorders.

Data showed:

• Preoperative hemostatic therapy was recommended in 58 (92.1%) surgeries and planned postoperative therapy in 34 (54.0%)
• Postoperatively, 4.8% of procedures were complicated by major bleeding and 1.6% by nonmajor bleeding
• Mean length of stay was 1.65 days
• 30-day readmission rate was 1.6%
• Compared with patients without bleeding disorders undergoing the same procedures, study patients had a similar rate of bleeding complications per procedure (5.0% vs 1.04%; P = .071)

Hospital readmission rates were also similar between the 2 groups. The mean patient age at the time of surgery was around 51 years, and most patients were female. The fact that more than half of patients were female serves as a study strength, given most early analyses of this patient population included men with hemophilia, the researchers said.

“Gynecologic and breast surgeries—which represented 15/63 (23.8%) of surgeries in our study—are common and carried the highest risk of bleeding among [National Surgical Quality Improvement Program (control)] patients included in our study,” they added.

To the authors’ knowledge, the study marks one of the largest description analyses of outcomes of patients with bleeding disorders undergoing major surgery.

Limitations include the small number of patients and retrospective design. In addition, only 3 patients with severe disease were included.

“We observed few bleeding complications or inpatient readmissions, and while [length of stay] was significantly longer in [patients with bleeding disorders] than control patients, overall it remained relatively short despite most patients being planned for postoperative hemostatic therapy,” the authors concluded.

Reference:

Rhoades R, French Z, Yang A, Walsh K, Drelich DA, and McKenzie SE. Perioperative outcomes of patients with bleeding disorders undergoing major surgery at an academic hemophilia treatment center. Clin Appl Thromb Hemost. Published online March 27, 2023. doi:10.1177/10760296231165056