Perioperative management of colorectal surgical patients receiving a direct oral anticoagulant: a scoping review, particular emphasis on procedure-specific risks, and pharmacogenomics

Perioperative management of patients on direct oral anticoagulants (DOACs) for preoperative deep vein thrombosis (DVT), pulmonary embolism (PE), or atrial fibrillation (AF), who subsequently undergo elective colorectal surgery, is a frequent clinical scenario with no clear consensus on best practices. Further complicating this issue, venous thromboembolism (VTE) and bleeding rates vary widely, ranging from 4.8% to 12.6% for VTE and 1.1% to 2.4% for bleeding, across different procedures (e.g., abdominoperineal resection, anterior resection, rectopexy, colectomy, and total proctocolectomy), as well as between countries, centers and individual surgeons. Therefore, it is necessary for surgeons to identify strategies to optimize when and how to discontinue and resume anticoagulation. Over the past decade, substantial interpatient variability in DOAC plasma levels has been observed, potentially explaining the frequent incidence of clinically relevant nonmajor bleeding (e.g., anastomotic bleeding and hematochezia) and breakthrough VTE in colorectal surgical patients. Given that pharmacokinetic factors, including genetic variations in metabolizing enzymes and efflux transporters as well as drug plasma levels measured by anti-factor Xa (FXa) activity, are associated with both the efficacy and adverse effects of anticoagulants, genotyping and anti-FXa monitoring could play a valuable role in optimizing perioperative DOAC management or enabling personalized dose adjustments. This scoping review summarizes the current evidence and proposes an integrated, personalized approach for perioperative DOAC management in colorectal surgery, with particular emphasis on procedure-specific risks, pharmacogenomics, and individualized risk prediction.