肝切除术后抗凝治疗对预防静脉血栓形成的作用

doi:10.3969/j.issn.1009-976X.2021.01.006

摘要/Abstract

摘要： 目的评估肝切除术后抗凝治疗对预防静脉血栓栓塞的有效性、安全性及其影响因素。方法采用前瞻性研究方法,选择2018年5月~2020年5月于我院就诊并接受肝切除术的患者作为研究对象,将患者分为常规组（n=96）和抗凝组（n=96）,常规组采用常规治疗,抗凝组在常规组的基础上加用依诺低分子肝素钠抗凝治疗,观察记录静脉血栓发生率、出血率、手术相关指标、术后并发症、凝血功能等并对比分析。结果两组患者基线特征的差异没有统计学意义（P>0.05）。抗凝组与常规组VTE发生率分别为2.1% vs. 5.2%（P=0.441）,两组患者术后出血、术后输血、术后感染、肝功能衰竭发生率以及Clavien-Dindo分级,差异无统计学意义（P>0.05）。抗凝组患者拔管时间和住院时间均高于常规组（P<0.05）。常规组中使用止血患者与未用止血药患者的静脉血栓发生率,差异无统计学意义（P>0.05）。高血压、手术时间≥3 h、术中出血量≥400 mL是肝切除术患者抗凝治疗后出血的独立危险因素。两组患者术后血小板、纤维蛋白原水平差异无统计学意义,抗凝组患者INR、APTT、D-二聚体水平低于常规组。结论肝切术后抗凝治疗有降低静脉血栓发生率的趋势且安全可行。

关键词: 肝切除术, 静脉血栓栓塞, 出血, 低分子肝素

Abstract: Objective To evaluate the effectiveness, safety and influencing factors of anticoagulant therapy in the prevention of venous thromboembolism after hepatectomy. Methods This is a prospective research method. The patients who were treated and underwent hepatectomy May 2018 to May 2020 were selected as research objects. The patients were divided into two groups： conventional group （n=96） and anticoagulant group （n=96）. The conventional group was treated with conventional treatment, and the anticoagulant group was treated with enoxaparin sodium on the basis of the conventional group. The incidence of venous thrombosis, bleeding rate, surgery-related indicators, postoperative complications, and coagulation function were observed and analyzed. Results There was no significant difference in baseline characteristics between two groups（P>0.05）. The incidence of VTE in the anticoagulation group and the routine group were 2.1% and 5.2% （P=0.441）. There was no significant difference in Hemorrhage,blood transfusion, infection, liver failure and the Clavien-Dindo classification between the two groups （P>0.05）. Compared with the conventional group, the drainage tube removal time and hospitalization time of the anticoagulant group were longer. There was no statisticallysignificant difference in the incidence of venous thrombosis between patients with hemostasis and patients without hemostasis in the conventional group （P>0.05）. Hypertension, operation time ≥3 h and intraoperative bleeding volume ≥400 mL are independent risk factors for hemorrhage after hepatectomy. There was no statistically significant difference in the levels of platelets and fibrinogen between two groups. The levels of INR, APTT and D-dimer in anticoagulation group were lower than those in conventional group. Conclusion Anticoagulant therapy after liver resection has a tendency to reduce the incidence of venous thrombosis and is safe and feasible.

Key words: hepatectomy, venous thromboembolism, hemorrhage, low molecular weight heparin

中图分类号:

R657.3

马明磊, 尹雁北, 张红卫. 肝切除术后抗凝治疗对预防静脉血栓形成的作用[J]. 岭南现代临床外科, 2021, 21(01): 29-35.

MA Ming-lei, YIN Yan-bei, ZHANG Hong-wei. Efficacy of postoperative anticoagulation therapy for venous thrombosis after hepatic resection[J]. Lingnan Modern Clinics In Surgery, 2021, 21(01): 29-35.

参考文献

[1] Bahl V, Hu H, Henke P, et al.A validation study of a retrospective venous thromboembolism risk scoring method[J]. Ann Surg, 2010, 251(2): 344-350.
[2] EJAZ A, Spolverato G, Kim Y, et al.Defining incidence and risk factors of venous thromboemolism after hepatectomy[J]. J Gastrointest Surg, 2014, 18(6): 1116-24.
[3] Nathan H, Weiss MJ, Soff GA, et al. Pharmacologic prophylaxis, postoperative INR,risk of venous thromboembolism after hepatectomy [J]. J Gastrointest Surg, 2014, 18(2): 295-302; discussion -3.
[4] Melloul E, Dondero F, Vilgrain V, et al.Pulmonary embolism after elective liver resection: a prospective analysis of risk factors[J]. J Hepatol, 2012, 57(6): 1268-1275.
[5] Turpie A, Bauer K, Caprini J, et al.Fondaparinux combined with intermittent pneumatic compression vs. intermittent pneumatic compression alone for prevention of venous thromboembolism after abdominal surgery: a randomized, double-blind comparison[J]. Thromb Haemost, 2007, 5(9): 1854-1861.
[6] Rausa E, Kelly M, Asti E, et al.Extended versus conventional thromboprophylaxis after major abdominal and pelvic surgery: Systematic review and meta-analysis of randomized clinical trials[J]. Surgery, 2018, 164(6): 1234-1240.
[7] Nair P, Trivedi R, Hu P, et al.Low-molecular weight vs. unfractionated heparin for prevention of venous thromboembolism in general surgery: a meta-analysis[J]. Updates Surg, 2020. doi: 10.1007/s13304-020-00872-w.[Epub ahead of print]
[8] Lisman T.Low molecular weight heparin in management and prevention of portal vein thrombosis[J]. Thromb Res, 2014, 134(4): 761-762.
[9] Baltatzis M, Low R, Stathakis P, et al.Efficacy and safety of pharmacological venous thromboembolism prophylaxis following liver resection: a systematic review and meta-analysis[J]. HPB (Oxford), 2017, 19(4): 289-296.
[10] Poon R, Fan S, Lo C, et al. Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of1222 consecutive patients from a prospective database[J]. Ann Surg, 2004, 240(4): 698-708; discussion -10.
[11] Belghiti J, Hiramatsu K, Benoist S, et al.Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection[J]. Am Coll Surg, 2000, 191(1): 38-46.
[12] Kim BJ, Day RW, Davis CH, et al.Extended pharmacologic thromboprophylaxis in oncologic liver surgery is safe and effective[J]. J Thromb Haemost, 2017, 15(11): 2158-2164.
[13] Hayashi H, Morikawa T, Yoshida H, et al.Safety of postoperative thromboprophylaxis after major hepatobiliary-pancreatic surgery in Japanese patients[J]. Surg Today, 2014, 44(9): 1660-1668.
[14] Reddy SK, Turley RS, Barbas AS, et al.Post-operative pharmacologic thromboprophylaxis after major hepatectomy: does peripheral venous thromboembolism prevention outweigh bleeding risks?[J]. J Gastrointest Surg, 2011, 15(9): 1602-1610.
[15] Vivarelli M, Zanello M, Zanfi C, et al.Prophylaxis for venous thromboembolism after resection of hepatocellular carcinoma on cirrhosis: is it necessary?[J]. World J Gastroenterol, 2010, 16(17): 2146-2150.
[16] Bolliger M, Kroehnert JA, Molineus F, et al.Experiences with the standardized classification of surgical complications (Clavien-Dindo) in general surgery patients[J]. Eur Surg, 2018, 50(6): 256-261.
[17] Rahbari NN, Garden OJ, Padbury R, et al.Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS)[J]. HPB (Oxford), 2011, 13(8): 528-535.
[18] Rahbari NN, Garden OJ, Padbury R, et al.Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS)[J]. Surgery, 2011, 149(5): 713-724.
[19] Newhook TE, Lapar DJ, Walters DM, et al.Impact of Postoperative Venous Thromboembolism on Postoperative Morbidity, Mortality, and Resource Utilization after Hepatectomy[J]. Am Surg, 2015, 81(12): 1216-1223.
[20] Tzeng CW, Katz MH, Fleming JB, et al.Risk of venous thromboembolism outweighs post-hepatectomy bleeding complications: analysis of 5651 National Surgical Quality Improvement Program patients[J]. HPB (Oxford), 2012, 14(8): 506-513.
[21] Yamashita Y, Bekki Y, Imai D, et al.Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer[J]. Thromb Res, 2014, 134(4): 826-831.
[22] Kawaguchi Y, Nomi T, Fuks D, et al.Hemorrhage control for laparoscopic hepatectomy: technical details and predictive factors for intraoperative blood loss[J]. Surg Endosc, 2016, 30(6): 2543-2551.
[23] Barton JS, Riha GM, Differding JA, et al.Coagulopathy after a liver resection: is it over diagnosed and over treated?[J]. HPB (Oxford), 2013, 15(11): 865-871.
[24] Dumitrescu G, Januszkiewicz A, Agren A, et al.The temporal pattern of postoperative coagulation status in patients undergoing major liver surgery[J]. Thromb Res, 2015, 136(2): 402-407.