VANCOUVER, B.C. Some patients undergoing Mohs micrographic surgery have undiagnosed bleeding disorders, but careful history taking, vigilance during surgery, and tailored management can prevent complications in most cases, according to results of a study of more than 2,500 patients.
Dr. Carl Vinciullo and his colleague, Dr. Ross Baker, both of Royal Perth Hospital in Australia, prospectively assessed the prevalence of bleeding disorders among 2,517 patients undergoing Mohs surgery between 2003 and 2007. The investigators obtained a detailed bleeding history from all patients and performed a hematologic workup in those who had a positive history or who had unexplained excessive bleeding during their Mohs surgery.
A total of 18 patients (0.7%) had a previously undiagnosed bleeding disorder. Eleven of them had a positive bleeding history, while seven had a negative history but bled excessively during surgery. Dr. Vinciullo noted that most of the affected patients had normal routine coagulation profiles on hematologic testing and that one patient had even undergone general surgery uneventfully 2 years earlier.
The hematologic workup further revealed that 6 of the 18 patients had von Willebrand disease (alone or with other abnormalities), three had acquired platelet abnormalities with myelodysplasia and other abnormalities, two had suspected increased capillary fragility, one had a clopidogrel-like platelet secretion defect, and one had suspected impaired vasoconstriction with hereditary hemorrhagic telangiectasia.
Another two patientsone with refractory immune thrombocytopenia and antiplatelet antibodies, and another with disseminated intravascular coagulation, thrombocytopenia, and cancer-associated fibrinogen deficiencywere treated with radiation therapy instead because their disorders were judged to be contraindications to surgery.
Finally, three of the patients had no definable hematologic abnormality. "This does not mean that they do not have a bleeding abnormality," Dr. Vinciullo said of the last group. "It is quite conceivable that there are bleeding abnormalities which are yet not possible to define with the investigations available to us."
Among the patients who were surgical candidates, those with von Willebrand disease were treated with preoperative desmopressin infusion, oral tranexamic acid, or a combination thereof. Those with platelet function abnormalities were all treated with preoperative platelet infusions; one also received desmopressin, and another also received additional platelet cross-matching, recombinant factor VIIa, and tranexamic acid. The remaining patients were given tranexamic acid or were not treated, Dr. Vinciullo reported at the annual meeting of the American College of Mohs Surgery.
With this management approach, 17 of the 18 patients did not experience initial or additional excessive bleeding and did not require further intervention, according to Dr. Vinciullo. The remaining patient, who had an acquired platelet function abnormality, antiplatelet antibodies, low factor XII levels, and myelodysplasia, was hospitalized for 3 days because of surgery-associated bleeding, despite all measures.
Summing up the study's findings, Dr. Vinciullo said that the incidence of undiagnosed bleeding disorders is low in Mohs surgical patients, but physicians nonetheless should be alert for such disorderseven when a bleeding history is negative and the results of routine coagulation studies are normal.
"Hematology assessment is essential, and specialized prophylactic treatment can prevent the vast majority of bleeding complications," he said.
However, he added, routine preoperative hematologic testing is not warranted in patients with a negative bleeding history. "The most sensitive sign is a positive history, so you must take a detailed bleeding history," he emphasized. (See box.) "The sort of questions I listed are the questions you need to ask. It's absolutely incredible how many of these patients have simply never been asked those questions, or the physician knows they bleed but has never done anything about it."
Finally, Dr. Vinciullo advised, "unexplained excessive bleeding during Mohs surgery should be investigated." He noted that a watery consistency of the blood and bleeding from suture holes can be additional telltale signs of underlying bleeding disorders.
"If you have a patient where you place a stitch and blood comes out of the suture hole, to me, that's a reason to send [that person] off for a hematology investigation," he said.
Dr. Vinciullo reported no conflicts of interest in association with the study.
'Hematology assessment is essential, and specialized prophylactic treatment can prevent' bleeding. DR. VINCIULLO
Take a Detailed Bleeding History
Ask patients if they have had excessive bleeding during any of the following:
▸ Menstrual periods or childbirth?
▸ Nosebleeds?
▸ Skin surgery?
▸ Dental work, tonsillectomy, or general surgery? And also ask:
▸ Have you had to return to a physician's office or hospital because of bleeding?
▸ Do you bruise excessively?
▸ Do you take supplements or complementary products (vitamin E, garlic, ginkgo biloba)?