摘要
背景与目的:术前长期服用抗血栓药物的患者,围术期如继续服药会增加手术出血风险,而停药则增加血栓栓塞事件发生的风险。对于腹股沟疝手术而言,围术期抗血栓药物的管理尚无共识或高质量临床研究。因此,本研究通过观察长期口服抗血栓药物的腹股沟疝患者围术期不停药行李金斯坦手术的安全性,初步探讨该类患者围术期抗血栓药物的管理策略。方法:采用前瞻性队列研究方法,连续纳入2018年11月—2022年2月间中南大学湘雅医院疝和腹壁外科中心收治的18例因中高血栓风险而长期口服抗血栓药物的腹股沟疝患者,围术期均不停用抗血栓药物,采取神经阻滞联合喉罩全身麻醉行李金斯坦手术。对患者术中及术后出血情况、术后第1天视觉模拟疼痛评分(VAS)、术后主要心脏不良事件(MACEs)、脑血管并发症、切口不良事件、疝复发和病死率进行观察与随访。结果:18例腹股沟疝患者均为男性,其中4例曾行心脏瓣膜置换手术、1例合并房颤、9例曾行冠状动脉支架植入术、1例曾行冠状动脉搭桥术、3例既往发作心肌梗死,均为中高血栓风险患者。其中,长期口服华法林患者5例,长期口服抗血小板药物13例,包括服用阿司匹林8例、服用氯吡格雷3例、服用阿司匹林联合氯吡格雷/吲哚布芬2例。18例患者的平均住院时间(9.61±2.59)d,术中平均失血量为(3.77±2.53)mL,手术平均时长为(70.13±13.44)min。术后1例患者出现伤口明显瘀青,1例患者出现伤口少许瘀青,16例患者伤口无明显出血。无1例需输血或发生需外科处理的出血事件。术后第1天中位VAS评分为1.72分。围术期无MACEs和脑血管并发症发生。所有患者均在术后1~5 d痊愈出院,出院后中位随访19.34个月,随访率为100%。随访期间无伤口不良事件、疝复发、MACEs、脑血管并发症及死亡发生。结论:对于具有中高血栓风险的腹股沟疝患者,在全方位的围术期管理前提下,围术期不停用抗血栓药物行李金斯坦手术这一策略是安全可行的,推荐作为选择。
Background and Aims:In patients receiving long-term antithrombotic prophylaxis who require surgery,the continuation of therapy during perioperative period will raise the risk of surgical bleeding,while the incidence of thromboembolic events will increase after drug discontinuation.For inguinal hernia procedures,there is,at present,no consensus or high-quality evidence regarding the perioperative management of antithrombotic medication.Therefore,this study was designed to observe the safety of performing Lichtenstein hernioplasty in inguinal hernia patients on long-term anticoagulation without antithrombotic treatment withdrawal during the perioperative period,so as to help investigate the strategies for perioperative management of anticoagulation in these patients.Methods:Using a prospective cohort design,18 inguinal hernia patients with moderate or high risk of thromboembolism on long-term anticoagulation admitted to the Department of Hernia and Abdominal Wall Surgery,Xiangya Hospital,Central South University were consecutively enrolled from November 2018 to February 2022.All patients underwent Lichtenstein hernioplasty under nerve block anesthesia combined with laryngeal mask general anesthesia,without interruption of anticoagulation during the perioperative period.The intra-and postoperative bleeding,visual analog pain score(VAS)on postoperative day(POD)1,postoperative major cardiac adverse events(MACEs),cerebrovascular complications,incision-related adverse events,hernia recurrence and mortality of the patients were observed and followed up.Results:The 18 inguinal hernia patients included 4 cases who had previously undergone heart valve replacement surgery,one case with concomitant atrial fibrillation,9 cases who had previously undergone coronary stenting,one case who had previously undergone coronary artery bypass grafting,and 3 cases with previous myocardial infarction.Among them,5 patients received long-term oral warfarin therapy,and 13 patients treated with long-term oral antiplatelet-agent therapy that included aspirin administration in 8 cases,clopidogrel administration in 3 cases,and aspirin plus clopidogrel or indobufen administration in 2 cases.Of the 18 patients,the mean length of hospital stay was(9.61±2.59)d,the mean intraoperative blood loss was(3.77±2.53)mL,and the mean operative duration was(70.13±13.44)min.After surgery,one patient had obvious wound bruising,one patient had mild wound bruising,and 16 patients had no obvious wound bleeding.Blood transfusion or reoperation was required in none of them.The median VAS was 1.72 on POD 1.There was no MACEs and cerebrovascular complications occurred during perioperative period.All patients were discharged from the hospital 15 d after surgery.The median follow-up time after discharge was 19.34 months,and the follow-up rate was 100%.No wound-related adverse events,hernia recurrence,MACEs,cerebrovascular complications,and death occurred during follow-up.Conclusion:For inguinal hernia patients with moderate or high thromboembolic risk,the strategy of continuous use of antithrombotic drugs during the perioperative period of Lichtenstein hernia repair is safe and feasible on the premise of a comprehensive perioperative management.So,it is recommended as an appropriate choice for application.
作者
韦琴
陈璐
朱帅
张韬
孙泽芳
宁彩虹
林嘉晏
李嘉荣
钟巧青
唐朝辉
黄耿文
WEI Qin;CHEN Lu;ZHU Shuai;ZHANG Tao;SUN Zefang;NING Caihong;LIN Jiayan;LI Jiarong;ZHONG Qiaoqing;TANG Zhaohui;HUANG Gengwen(Department of Hernia and Abdominal Wall Surgery,Changsha 410008,China;Department of Cardiovascular Medicine,Changsha 410008,China;Department of Anesthesiology,Xiangya Hospital,Central South University,Changsha 410008,China;National Clinical Research Center for Geriatric Disorders,Changsha 410008,China)
出处
《中国普通外科杂志》
CAS
CSCD
北大核心
2022年第4期490-496,共7页
China Journal of General Surgery
关键词
疝
腹股沟
疝修补术
抗凝药
围手术期
Hernia,Inguinal
Herniorrhaphy
Anticoagulants
Perioperative Period