腹腔镜与开腹直肠癌根治术后下肢深静脉血栓形成的对照研究

A comparative study of deep vein thrombosis in lower extremity after radical resection of rectal carcinoma by laparoscopy and laparotomy

目的比较腹腔镜与开腹直肠癌根治术后下肢深静脉血栓形成(DVT)的发生情况,评估两种手术方式对DVT的影响。方法选取2018年6月至2019年6月河北北方学院附属第一医院普外科收诊的术前确诊为进展期直肠癌拟行全直肠系膜切除(TME)手术治疗的患者,依据纳入标准入组76例,其中腹腔镜组(LS)40例,传统开腹组(OS)36例,观察术中相关指标(手术时间、出血量等)、术后相关指标(肛门排气时间、活动时间、住院时间、肺部感染、尿路感染等)、观察比较两组患者不同时间节点的凝血功能指标,检测其血栓弹力图(TEG)及DVT发生情况,分析直肠癌术后DVT的高危因素。结果两组患者的性别、年龄、体质指数、肿瘤分期、术前凝血功能各项指标等一般资料差异均无统计学意义(P>0.05);LS组手术时间明显长于OS组,LS组术后排气时间、术后活动时间及住院时间方面均短于OS组,差异均有统计学意义(P<0.05);LS组DVT发生率(37.5%)明显高于OS组(13.9%),差异有统计学意义(P<0.05),但有症状DVT发生率LS组(12.5%)与OS组(8.3%)比较差异无统计学意义(P>0.05),无症状DVT发生率LS组(25.0%)明显高于OS组(5.6%),差异有统计学意义(P<0.05);LS组PT、APTT术后第1天与术前及OS组术后第1天比较差异均有统计学意义(P<0.05),LS组术后第1、3、5、7天D-D水平均高于术前,且与OS组同一时间节点比较,差异均有统计学意义(P<0.05);血栓弹力图显示:两组α角和MA值,术后第1、3、5、7天均高于术前,差异有统计学意义(P<0.05),LS组与OS组术后同一时间点比较,两组之间差异有统计学意义(P<0.05)。危险因素及OR值统计结果显示:年龄(4.00)、ASA分级(3.48)、吸烟史(3.67)、肿瘤分期(3.34)、手术方式(3.72)、高血压(3.00)是直肠癌根治术术后DVT发生的重要危险因素。结论腹腔镜直肠癌根治术后DVT的发生率较传统开腹手术要高,但两组在有症状的DVT的发生率方面,则无明显差异,同时,要重视DVT的高危因素,做好预防、筛查和监测。

Objective To Compare the incidence of deep vein thrombosis(DVT)in lower extremity after radical resection of rectal cancer by laparoscopy and open,and evaluate the effect of two surgical methods on DVT.Methods 76 Patients with diagnosis of advanced rectal cancer admitted to the Dept of General Surgery of The First Affiliated Hospital of Hebei Northern University from June 2018 to June 2019 according to the inclusion criteria were selected and individed into the laparoscopic surgery group(LS,40 cases)and the open surgery group(OS,36 cases).Relevant intraoperative indicators(operation time,blood loss,etc.)and postoperative indicators(anal exhaust time,activity time,hospital stay,pulmonary infection,urinary tract infection,etc.)were observed and compared between the two groups,and the indicators of coagulation function were observed and compared at different time nodes.TEG and DVT were detected,meanwhile,the risk factors of postoperative DVT were analyzed.Results There were no significant statistical differences in gender,age,body mass index,tumor stage,preoperative coagulation function and other general data between the two groups(P>0.05);The operation time of the LS group was significantly longer than the OS group,while the postoperative exhaust time,postoperative activity time and hospitalization time of the LS group were shorter than the OS group,and there were statistically significant differences(P<0.05);The incidence of DVT in the LS group(37.5%)was significantly higher than in the OS group(13.9%),and there were statistically significant differences(P<0.05),while,there was no statistical difference between the LS group(12.5%)with symptomatic DVT and the OS group(8.3%)(P>0.05),moreover,the incidence of asymptomatic DVT in the LS group(25%)was significantly higher than in the OS group(5.6%),and there was statistically significant differences(P<0.05);There were statistically significant differences of PT and APTT value before and after operation,and postoperative Day 1 between the two groups(P<0.05).The D-D level of the LS group on the 1 st,3 rd,5 th and 7 th day after surgery was higher than that before surgery,and there were statistically significant differences between the two groups at the same time node(P<0.05).The TEG showed that a and MA value of postoperative days 1,3,5 and 7 in two groups were higher than that of preoperative,and there was statistical difference of a and MA value between LS group and OS group at the same postoperative time point(P<0.05).The statistical results of risk factors and OR values showed that age(4.00),ASA grade(3.48),smoking history(3.67),tumor stage(3.34),surgical method(3.72)and hypertension(3.00)were important risk factors for DVT after radical resection of rectal cancer.Conclusion The incidence of DVT after laparoscopic radical resection of rectal cancer is higher than that of traditional laparotomy,but there is no significant difference in the incidence of symptomatic DVT between the two groups.Meanwhile,attention should be paid to the high-risk factors of DVT,and prevention,screening and monitoring should be done.