In a patient with a recent DES stent placement (<3 months) who needs a major non-cardiac operation for colon cancer, what factors might allow for considering the surgery at the 6-month point after DES? At the 3-month mark? The 1-month mark?
If the definitive treatment for colon cancer is surgery, the decision to delay surgery because of the presence of a recent drug eluting stent (DES) must be balanced against the risk of progression of cancer with resultant symptoms, metastases, or change in resectability. Studies using SEER (Surveillance, Epidemiology, and End Results) Medicare data and the Scottish Cancer Registry were unable to demonstrate that delays in treatment of non-emergent colon cancer surgery (e.g., longer than 3 weeks from initial surgical consult or longer than 6 weeks from first diagnostic test) negatively impact operative mortality, disease-specific survival or overall survival. Therefore there is no reason to operate for colon cancer prior to 1 month. If surgery can be performed on dual antiplatelet therapy (DAPT), then performing the operation between 1 and 3 months would be acceptable. If the indication for the DES was stable ischemic heart disease and discontinuation of the P2Y12 inhibitor is required for surgery, then perioperative continuation of aspirin alone at 3 months is reasonable. If the indication for the DES was an acute coronary syndrome and discontinuation of the P2Y12 inhibitor is required for surgery, then DAPT would ideally be continued for 6 months, with perioperative maintenance of aspirin alone at the time of surgery. The decision should in part be dependent on the location of the stent and area of myocardium at risk should stent thrombosis occur. The exact timing of surgery after discontinuation of the P2Y12 inhibitor should be based on consensus by the surgeon, anesthesiologist and cardiologist.
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