肺癌患者围手术期预防性抗凝的临床价值分析

Clinical Value Evaluation of Perioperative Prophylactic Anticoagulation Therapy for Lung Cancer Patients

背景与目的肺癌患者围手术期肺栓塞(pulmonary embolism, PE)发生率有增高的趋势,预防肺栓塞是加速康复外科的重要组成部分,然而肺癌患者围术期预防性抗凝时机仍存在争议。本研究旨在探讨肺癌患者围手术期应用抗凝药物预防肺栓塞的安全性和有效性。方法连续收集2016年6月-2016年12月,在四川大学华西医院胸外科行胸腔镜肺解剖性肺切除术的肺癌患者共562例,其中56例肺癌患术前12 h开始应用低分子肝素(low molecular weight heparin, LMWH)抗凝直到出院;506例患者术后24 h开始应用直到出院。分析围手术期胸腔引流量、术后出血和肺栓塞发生率、肺部相关并发症等。结果 (1)凝血酶原时间(prothrombin time, PT)、活化部分凝血活酶时间(activated partial thromboplastin time, APTT)和国际标准化比值(international normalized ratio, INR)在术前[(11.5±3.9) s,(27.8±3.5) s,(0.96±0.06) s]与术后抗凝组[(11.4±1.4) s,(28.3±4.0) s,(0.98±0.07) s]均无统计学差异(P=0.796,P=0.250, P=0.137);Caprini评分在术前(3.1±1.8)和术后(3.3±1.5)抗凝组也无统计学差异(P=0.104);(2)麻醉时间和术中出血量在术前抗凝组[(130.2±53.9) min,(76.8±49.3) mL]和术后抗凝组[(142.2±56.5) min,(73.7±41.6)mL]均无统计学差异(P=0.067, P=0.201)。(3)术后72 h总引流量在术前抗凝组[(728.1±505.7) mL]显著高于术后抗凝组[(596.4±373.5) mL](P=0.005),而两组患者术后总引流量[(1,066.8±1,314.6) mL,(907.8±999.8) mL]无差异(P=0.203);(4)肺栓塞和术后出血发生率在术前(1.785%, 1.785%)和术后(0.019%, 0.039%)抗凝组均无显著性差异(P=0.525, P=0.300);(5)皮下气肿和肺部感染发生率在术前(1.785%, 14.285%)和术后(1.581%, 6.324%)抗凝组均无显著性差异(P=0.989, P=0.085)。结论肺癌患者术前或术后预防性应用抗凝药物临床效果相当。

Background and objective The incidence of pulmonary embolism （PE） in lung cancer patients who underwent surgery increased during the perioperative period, and prophylactic anticoagulation therapy was important part of enhanced recovery after surgery （ERAS）. However, the timing of preventive anticoagulation in patients with lung cancer remained controversial This study was designed to investigate the safety and efficacy of perioperative prophylactic antico- agulation therapy for lung cancer patients. Methods Retrospective research was conducted on $62 lung cancer patients who underwent video-assisted thoracoscopic （VATS） anatomic pulmonary resections in West China Hospital from June 2016 to December 2016. 56 patients were treated with low molecular weight heparin （LMWH） anticoagulation 12 hours before op- eration until discharge, while the other 506 patients were treated with LMWH 24 hours after operation until discharge. The postoperative chest drainage volume, postoperative bleeding, pulmonary embolism incidence, and respiratory complications were analyzed. Results （1） There were no significant differences in prothrombin time （PT）, activated partial thromboplastin time （APTT） and international normalized ratio （INR） between the pre-operation prophylactic anticoagulation group （PRE group） [（11.5±3.9） s, （27.8±3.5） s, （0.96±0.06） s] and the post-operation prophylactic anticoagulation group （POST group）[（ 11.4±1.4） s, （28.3±4.0） s, （0.98±0.07） s] （P=0.796, P=0.2S0, P=0.137）, and there was no significant difference in Caprini score between the PRE group （3.1±1.8） and the POST group （3.3±1.5） （P=0.104）. （2） There were no significant differences in anesthesia time and intraoperative bleeding between PRE group [（130.2±53.9） rain, （76.8±49.3） mL] and POST group [（142.2±56.5） min, （73.7±41.6） mL] （P=0.067, P=0.201）. （3） The total drainage volume in 72 hours after operation in PRE group [（728.1±505.7） mL] was significantly higher than that of POST group [（596.4±373.5） mL] （P=0.00S）, while there were no significant differences between the two groups in total postoperative drainage volume [（1,066.8±1,314.6） mL vs （907.8±999.8） mL, P=0.203]. （4） There were no significant differences between the two groups in pulmonary embolism incidence （1.785% vs 0.019%, P=0.525） and postoperative bleeding rates （1.785% vs 0.039%, P=0.300）. （5） There were no significant differences between PRE group and POST group in subcutaneous emphysema incidence （1.785% vs 1.581%, P=0.989） and pulmonary infection rates （14.285% vs 6.324%, P=0.085）. Conclusion The clinical value of preoperative prophylactic antico- agulation is equal to postoperative prophylactic anticoagulation for lung cancer patients.