术前不停用阿司匹林对腹腔镜直肠癌前切除术出血影响的前瞻性研究

Effect of perioperative continuous use of aspirin on bleeding in laparoscopic anterior resection for rectal cancer： a prospective study

目的：探讨术前不停用阿司匹林对长期服用阿司匹林直肠癌患者行腹腔镜直肠癌前切除术出血的影响。方法：采用前瞻性研究方法。选取2014年9月至2016年9月中国医科大学附属盛京医院收治的96例长期服用阿司匹林直肠癌患者的临床病理资料。采用随机数字表法将患者随机分为服用阿司匹林组（围术期不停用阿司匹林）和停用阿司匹林组（术前7 d停用阿司匹林，术后3 d开始恢复口服阿司匹林）。由同一组手术医师行腹腔镜直肠癌前切除术。观察指标：（1）两组患者手术及术后情况比较。（2）随访情况。采用门诊和电话方式进行随访，了解患者术后生存情况。随访时间截至2017年1月。正态分布的计量资料以x^-±s表示，组间比较采用t检验。计数资料比较采用χ^2检验或Fisher确切概率法。等级资料比较采用非参数检验。结果：筛选出符合研究条件的患者96例，其中服用阿司匹林组50例，停用阿司匹林组46例。（1）两组患者手术及术后情况比较：96例患者均顺利完成直肠癌前切除术，1例患者中转开腹，其余95例患者均行腹腔镜直肠癌前切除术，无围术期死亡、术后输血和再次手术患者。服用阿司匹林组患者中转开腹、手术时间、术中出血量、术后Hb降低值、术后肛门首次排气时间、术后前3 d腹腔引流量、术后鲜血便、术后心脑血管并发症、术后总体并发症（含术后鲜血便和术后心脑血管并发症）、术后住院时间、住院费用、肿瘤术后病理学TNM分期（Ⅰ、Ⅱ、Ⅲ期）、术后凝血指标（PLT、PT、国际标准化比值、凝血酶原活动度、活化部分凝血活酶时间、凝血酶时间、纤维蛋白原）分别为0、（112±18）min、（39±18）mL、（4.3±2.8）g/L、（57±24）h、（22±9）mL/d、6例、0、10例、（8.6±2.5）d、（6 739±481）元、11例、35例、4例、（236±80）×109/L、（12.7±1.1）s、1.00±0.08、101%±15%、（28±4）s、（15.5±1.9）s、（3.2±1.0）g/L，停用阿司匹林组患者分别为1例、（118±16）min、（38±22）mL、（3.5±3.0）g/L、（55±29）h、（20±8）mL/d、4例、1例、 8例、（9.1±2.3）d、（6 606±510）元、5例、36例、5例、（211±49）×109/L、（12.5±0.7）s、1.00±0.06、103%±11%、（29±3）s、（15.3±1.7）s、（3.1±0.7）g/L，两组患者上述指标比较，差异均无统计学意义（t=-1.737，0.204，1.416，0.380，1.365， χ^2=0.038，0.107，t=-1.082，1.322，Z=-1.370，t=1.850，0.978，0.872， -0.712，-1.291，0.311，0.585，P〉0.05）。两组共10例术后鲜血便患者未经特殊处理，均顺利痊愈。术后心脑血管并发症方面，停用阿司匹林组患者术后发生下肢深静脉血栓1例，予单纯抗凝药物治疗后痊愈。其余并发症方面，服用阿司匹林组患者术后发生尿潴留2例、尿路感染2例，停用阿司匹林组患者术后发生炎性肠梗阻1例、尿潴留1例、尿路感染1例，均经保守治疗后痊愈。（2）随访情况：96例患者中， 95例获得术后随访，随访时间为4～27个月，中位随访时间为13个月。随访期间，3例患者死亡，其余92例患者生存。结论：术前不停用阿司匹林不增加长期服用阿司匹林直肠癌患者行腹腔镜直肠癌前切除术出血风险。

Objective：To explore the effect of perioperative continuous use of aspirin on bleeding in laparoscopic anterior resection for rectal cancer （RC） in patients taking low dose aspirin. Methods：The prospective study was conducted. The clinicopathological data of 96 RC patients taking low dose aspirin who were admitted to the Shengjing Hospital of China Medical University from September 2014 to September 2016 were collected. All the 96 patients were divided into the aspirin group （perioperative continuous use of aspirin） and nonaspirin group （discontinuation of aspirin at 7 days preoperatively and taking aspirin at 3 days postoperatively） by random number table. Laparoscopic anterior resection for RC was applied to patients by the same team of doctors. Observation indicators： （1） comparison of surgical and postoperative situations between the 2 groups; （2） followup situations. Followup using outpatient examination and telephone interview was performed to detect the postoperative survival of patients up to January 2017. Measurement data with normal distribution were represented as x^-±s. Comparisons between groups were evaluated with the t test. Comparisons of count data were analyzed using the chisquare test and Fisher exact probability. Comparison of ordinal data was analyzed using the nonparametric test. Results：All the 96 patients were enrolled into the study, including 50 in the aspirin group and 46 in the nonaspirin group. （1） Comparison of surgical and postoperative situations between the 2 groups： 96 patients underwent successful laparoscopic anterior resection for RC, including 1 with conversion to open surgery and 95 undergoing laparoscopic anterior resection for RC, without perioperative death, postoperative blood transfusion and reoperation. Cases with conversion to open surgery, operation time, volume of intraoperative blood loss, decreasing value of postoperative hemoglobin （Hb）, time to anal exsufflation, peritoneal drainage volume from 1-3 days postoperatively, cases with postoperative hematochezia, cardiocerebrovascular complications and overall complications （including postoperative hematochezia and cardiocerebrovascular complications）, duration of hospital stay, hospital expenses, cases in stageⅠ,Ⅱ and Ⅲof postoperative TNM stage, postoperative coagulation indexes of platelet, prothrombin time, international normalized ratio, prothrombin activity, activated partial thromboplastin time, thrombin time and fibrinogen were 0, （112±18）minutes, （39±18）mL, （4.3± 2.8）g/L, （57±24）hours, （22±9）mL/d, 6, 0, 10, （8.6±2.5）days, （6 739±481）yuan, 11, 35, 4, （236±80）×109/L, （12.7±1.1）seconds, 1.00±0.08, 101%±15%, （28±4）seconds, （15.5±1.9）seconds, （3.2± 1.0）g/L in the aspirin group and 1, （118±16）minutes, （38±22）mL, （3.5±3.0）g/L, （55±29）hours, （20± 8）mL/d, 4, 1, 8, （9.1±2.3）days, （6 606±510）yuan, 5, 36, 5, （211±49）×109/L, （12.5±0.7）seconds, 1.00±0.06, 103%±11%, （29±3）seconds, （15.3±1.7）seconds, （3.1±0.7）g/L in the nonaspirin group, respectively, with no statistically significant difference between the 2 groups （t=-1.737, 0.204, 1.416, 0.380, 1.365, χ^2=0.038, 0.107, t=-1.082, 1.322, Z=-1.370, t=1.850, 0.978, 0.872, -0.712, -1.291, 0.311, 0.585, P〉0.05）. Ten patients with postoperative hematochezia in the 2 groups were cured, without special treatment. One patient in the nonaspirin group was complicated with deep venous thrombosis and then was cured by single anticoagulant drug. Two and 2 patients in the aspirin group were respectively complicated with urinary retention and urinary tract infection. One, 1 and 1 patients in the nonaspirin group were respectively complicated with inflammatory intestinal obstruction, urinary retention and urinary tract infection, and then were cured by conservative treatment. （2） Followup situations： of 96 patients, 95 were followedup for 4-27 months, with a median time of 13 months. During the followup, 3 patients died and 92 had survival. Conclusion：The perioperative continuous use of aspirin cannot increase risk of bleeding in laparoscopic anterior resection for RC in patients taking low dose aspirin.