血栓药物对局部麻醉腹股沟疝无张力修补患者的影响

Discussion on effect of antithrombotic drugs on tension-free repair of inguinal hernia under local anesthesia

目的探讨围手术期不停用口服抗血栓药物的腹股沟疝患者行局部麻醉下无张力修补术的临床安全性。方法采用前瞻性队列研究的方法,连续入组2018年9月至2020年3月四川大学华西医院胃肠外科收治的术前长期口服抗血小板药或抗凝药的腹股沟疝患者作为试验组,选取同一时期入院的年龄、性别、身体质量指数(BMI)、腹股沟疝Rutkow分型与试验组相匹配的未服用抗血栓药物的腹股沟疝患者作为对照组。试验组围手术期不停用抗血栓药物治疗,2组患者由同一主刀医生行局部浸润麻醉下无张力疝修补术。对2组患者的手术情况、住院天数和术后30 d内患者切口并发症、出血性及血栓栓塞性并发症发生率进行比较。使用t检验或Mann-Whitney U-检验,卡方检验或Fisher精确检验对结果进行统计分析。结果共纳入148例患者,其中试验组74例(口服华法林14例、口服新型口服抗凝药3例,口服阿司匹林36例口服氯吡格雷13例、口服替格瑞洛1例、联合口服阿司匹林与氯吡格雷7例),对照组74例。试验组与对照组相比年龄、性别、BMI、腹股沟疝Rutkow分型、手术时间、术中出血、住院天数比较,差异无统计学意义(P>0.05),术前凝血酶原时间、部分活化凝血酶原时间、国际标准化比值试验组较对照组明显延长(P<0.05)。试验组术后1例患者出现术区皮下血肿,无需输血及再次手术治疗,4例出现切口愈合不良,1例出现阴囊水肿。对照组术后3例出现切口愈合不良。均保守治疗后愈合,差异无统计学意义(P>0.05)。所有患者围手术期未发现血栓栓塞事件。结论长期口服抗血栓药物的患者可安全地行局部浸润麻醉下腹股沟疝无张力修补术,不中断抗血栓药物治疗与未服用抗血栓药物的患者相比不会增加术中出血及术后出血性事件的发生风险。

Objective To evaluate the clinical safety of tension-free repair of inguinal hernia under local anesthesia in patients without interruption of antithrombotic drugs in perioperative period.Methods A prospective cohort study was conducted to investigate the effects of perioperative continuation of oral antiplatelets or anticoagulants on inguinal hernioplasty patients admitted to West China Hospital of Sichuan University from September 2018 to March 2020.The experimental group continued to take antithrombotic drugs during the perioperative period,whereas the control group consisted of patients who served as age,sex,BMI and the Rutkow classification matched controls underwent inguinal hernia repair without history of oral antithrombotic drugs.The patients of two groups underwent tension-free hernia repair under local infiltration anesthesia by the same surgeon.The surgical situation,length of stay,incision complications,bleeding and thromboembolic complications were compared between the two groups.T-test,Mann-Whitney U-test,Chi-square test or Fisher exact test were used to analyze the results.Results A total of 148 patients were enrolled,including 74 patients in the experimental group(14 patients on warfarin therapy,3 patients on new oral anticoagulant therapy,36 patients on aspirin therapy,13 patients on clopidogrel therapy,1 patient on ticagrelor therapy,and 7 patients on dual aspirin and clopidogrel therapy),and 74 patients in the control group.There was no significant difference in age,gender,BMI,Rutkow classification of inguinal hernia,operation time,intraoperative bleeding and hospitalization days between the experimental group and the control group(P>0.05).Preoperative blood INR,PT and APTT of experimental groups were significantly longer than the control group(P<0.05).In the experimental group,a case had postoperative subcutaneous wound hematoma(without blood transfusion and reoperation),and 4 cases had poor wound healing,one case had scrotal edema,whereas in the control group,3 cases of poor wound healing were observed.They were resolved with basic conservative managements.We have not observed statistically significant difference between the two groups with regards to postoperative complications(P>0.05).No incidences of perioperative thromboembolic events were observed.Conclusion Tension-free inguinal hernioplasty under local anesthesia can be safely performed in patients with long-term oral antithrombotic drugs.Uninterrupted antithrombotic therapy does not increase the risk of intraoperative bleeding and postoperative hemorrhagic events compared with patients without antithrombotic drugs.