Abstract
Background: Perioperative management of antiplatelet therapy in colorectal surgery requires balancing the risk of surgical bleeding against cardiovascular and cerebrovascular complications after treatment withdrawal. This meta-analysis assessed the safety of continuing antiplatelet therapy compared with preoperative discontinuation. Methods: PubMed and Embase were searched through 30 May 2026 for comparative studies of adults undergoing colorectal surgery. Random-effects models were used to pool odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. The clinically relevant analysis was restricted to patients already receiving antiplatelet therapy with separately reported continuation and discontinuation groups. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE. Results: Seven observational studies were included in the systematic review, of which four (505 patients; 209 continuation and 296 discontinuation) contributed to the primary analysis. Continuation was not associated with statistically significant differences in postoperative bleeding (OR 2.65, 95% CI 0.78–8.99), thrombotic events (OR 0.29, 95% CI 0.06–1.32), transfusion (OR 1.39, 95% CI 0.35–5.51), overall morbidity (OR 2.08, 95% CI 0.97–4.48), intraoperative blood loss (MD −2.74 mL, 95% CI −13.07 to 7.59), or operative time (MD 0.72 min, 95% CI −11.83 to 13.27). Hospital stay was longer with continuation (MD 0.65 days, 95% CI 0.40–0.91). In the broader secondary analysis, continuation was associated with increased postoperative bleeding (OR 3.30, 95% CI 1.40–7.78). GRADE certainty was very low for all outcomes. Conclusions: Among established antiplatelet users undergoing colorectal surgery, continuation was not associated with statistically significant differences in bleeding or thrombotic outcomes compared with discontinuation. However, sparse events, imprecise estimates, and very low certainty of evidence preclude definitive safety conclusions. Perioperative management should be individualized according to thrombotic risk, anticipated bleeding risk, and surgical complexity.