长期口服抗凝药物高龄胃癌患者的围手术期桥联抗凝治疗

Perioperative bridging anticoagulation therapy for elderly patients with gastric cancer those need longterm oral administration of anticoagulants

目的总结长期口服抗凝药物(OAC)的高龄胃癌患者的围手术期处理措施,并探讨高龄胃癌患者围手术期桥联抗凝治疗的可行性和安全性。方法回顾性分析2016年1月—2019年5月本院胃肠外科收治的356例高龄胃癌D2手术患者的临床资料。68例患者术前接受长期OAC治疗,设为OAC组,其余288例患者纳入对照组。对OAC组患者围手术期使用低分子肝素(LMWH)桥联抗凝治疗,比较两组术中出血量、术后引流管引流量和出血量、凝血酶原时间、INR值和近期并发症发生、住院时间、住院费用情况。结果OAC患者年龄比对照组大,OAC组患者体重指数(BMI)比对照组低,住院时间更长,住院费用更多,差异均具有统计学意义(P<0.05);同时,术前OAC组贫血程度重于对照组,差异具有统计学意义(P<0.05)。OAC组和对照组胃癌患者均成功完成胃癌D2手术。两组肿瘤部位、国际抗癌联盟(UICC)分期、分化程度、病理类型比较,差异无统计学意义(P>0.05);术中术后OAC组出血量高于对照组,差异具有统计学意义(P<0.05);术后3天腹腔引流量OAC组显著高于对照组,差异有统计学意义(P<0.05);两组凝血酶原时间和INR值比较,差异无统计学意义(P>0.05)。两组术中术后大出血、吻合口漏、十二指肠残端漏、淋巴漏、肠梗阻、切口感染、深静脉血栓形成、动脉栓塞发生情况比较,差异无统计学意义(P>0.05);OAC组无非计划再手术和围手术期死亡病例。随访6-36个月,6个月内无静脉血栓形成、动脉栓塞、冠状动脉支架狭窄并发症。结论重视高龄OAC胃癌患者的术前评估,通过合理的围手术期桥联抗凝治疗,重视术中止血,胃癌D2手术是安全可行的。

Objective To summarize the perioperative management measure of elderly patients with gastric cancer who took anticoagulants orally for a long time,and to explore the feasibility and safety of perioperative bridging anticoagulation.Methods The clinical data of 356 elderly patients received D2 gastrectomy for advanced gastric cancer those were admitted to the gastrointestinal surgery of the third affiliated hospital of Anhui Medical University from January 2016 to May 2019 were collected for retrospective cohort study.68 patients in the oral anticoagulation(OAC)group received long-term OAC before operation,and the rest 288 patients were enrolled in the control group.Patients in OAC group were treated with low molecular weight heparin(LMWH)for bridge anticoagulation during perioperative period.The intraoperative bleeding volume,postoperative drainage volume and bleeding volume,prothrombin time,INR value,recent complications,hospitalization time and hospitalization cost were compared between the two groups.Results The mean age of OAC group was significantly higher than that of control group.Compared with those in the control group,the BMI of patients in OAC group was lower,the length of hospital stay was longer,and the cost of hospitalization was more expensive,the differences were statistically significant(P<0.05).At the same time,the degree of preoperative anemia in OAC group was significantly worse than that in control group(P<0.05).All the patients in OAC group and control group successfully completed radical gastrectomy D2.There were no significant difference in tumor location,disease stage(stage method of union for international cancer control,UICC),pathological type and differentiation degree between the two groups(P>0.05).The amount of intraoperative bleeding and postoperative drainage within 3 day in the OAC group were significantly higher than those in the control group(P<0.05).There were no significant differences in prothrombin time and INR between the two groups(P>0.05).There were no significant differences between the OAC group and the control group in intraoperative and postoperative hemorrhoea,anastomotic leakage,duodenal stump leakage,lymphatic leakage,intestinal obstruction,incision infection,deep vein thrombosis,arterial embolism(P>0.05).There were no unplanned re-operation or perioperative death in the OAC group.The patients were followed up for 6-36 months,there were no complications of venous thrombosis,artery embolism and coronary stent stenosis.Conclusions It is safe and feasible to carry out D2 gastrectomy for elderly OAC patients suffered with advanced gastric cancer by preoperative evaluation,reasonable perioperative bridging anticoagulation and intraoperative hemostasis.