血栓弹力图评估接受肿瘤细胞减灭术和腹腔热灌注化疗术患者的凝血功能

Application of thrombelastogram in assessing the coagulation function of patients undergoing cytoreductive surgery and hy⁃perthermic perfusion chemotherapy

目的探讨血栓弹力图(TEG)评估接受肿瘤细胞减灭术(CRS)和腹腔热灌注化疗术(HIPEC)患者术中凝血功能的应用价值。方法选择2020年1月至2022年12月接受CRS和HIPEC患者55例,记录患者围手术期的一般情况;记录术前(T1)、CRS时(T2,即肿瘤切除下来的即刻)、HIPEC前(T3)、HIPEC后(T4)、手术结束时(T5)TEG检测参数[包括反应时间(R)、动力学时间(K)、凝固角度(A角)、最大振幅(MA)]并绘制参数变化趋势图,对参数进行Wilcoxon秩和检验。根据R值将患者分为高凝组(29例)和非高凝组(26例),对两组患者围手术期信息进行组间比较并进行多因素logistic回归分析。结果CRS期:与T1比较,T2时K增大、A角减小、MA减小,差异有统计学意义(均P<0.05),R增大,但差异无统计学意义(P>0.05);与T1比较,T3时K增大、A角减小、MA减小,差异有统计学意义(均P<0.05),R减小,但差异无统计学意义(P>0.05)。HIPEC期,与T3比较,T5时R减小、K减小、A角增大、MA增大,差异有统计学意义(均P<0.05)。整个手术期:与T1比较,T5时R减小、MA减小,差异有统计学意义(均P<0.05),K增大,A角减小,但差异无统计学意义(均P>0.05);与T1比较,T4时R减小、K增大、A角减小、MA减小,差异有统计学意义(均P<0.05)。与非高凝组比较,高凝组患者术中白蛋白输注量减少,差异有统计学意义(P<0.05),两组患者其他指标差异均无统计学意义(均P>0.05)。多因素logistic回归分析提示,术中白蛋白输注量、术中血浆输注量、术中红细胞输注量、术中晶体液输注量及出血量均不是高凝的危险因素。结论接受CRS和HIPEC的患者,与术前相比,在肿瘤细胞减灭阶段,纤维蛋白原呈低水平,血小板功能弱;在腹腔热灌注阶段,凝血因子活性增强。

Objective To investigate the application of thrombelastogram(TEG)in assessing the intraoperative coagulation function of patients undergoing cytoreductive surgery(CRS)and hyperthermic intraperitoneal chemotherapy(HIPEC).Methods A total of 55 patients who underwent CRS and HIPEC from January 2020 to December 2022 were selected.Their general conditions during the perioperative period were recorded.The parameters of TEG testing,including reaction time(R),kinetic time(K),coagulation angle,and maximum amplitude(MA),were recorded before surgery(T1),during CRS period(T2,i.e.,immediately after the tumor was re⁃moved),before HIPEC(T3),after HIPEC(T4),and at the end of surgery(T5).Meanwhile,the trend of parameter changes was plotted,and Wilcoxon rank sum test was performed on the parameters.According to the R value,the patients were divided into two groups:a hyperco⁃agulable group(n=29)and a non⁃hypercoagulable group(n=26).Both groups were compared for the perioperative data for multivariate lo⁃gistic regression.Results In the CRS stage,compared with those at T1,K increased,angle decreased,and MA decreased at T2,with statistical differences(all P<0.05),but R increased without statistical differences(P>0.05).Compared with those at T1,K in⁃creased,angle decreased,and MA decreased at T3,with statistical differences(all P<0.05),but R decreased without statistical differ⁃ences(P>0.05).In the HIPEC stage,compared with those at T3,R decreased,K decreased,angle increased,and MA increased at T5,with statistical differences(all P<0.05).Throughout the operation period,compared with those at T1,R decreased and MA decreased at T5,with statistical differences(all P<0.05),but K increased and angle decreased,without statistical differences(all P>0.05).Compared with those at T1,R decreased,K increased,angle decreased,and MA decreased at T4,with statistical differences(all P<0.05).Com⁃pared with the non⁃hypercoagulable group,the hypercoagulable group showed remarkably reduced infusion volume of albumin during operation(P<0.05),and there were no statistical differences in other indicators between the two groups(all P>0.05).According to multi⁃variate logistic regression analysis,the infusion amounts of albumin,plasma,red blood cells and crystalloid during operation and blood loss were not the risk factors of hypercoagulation.Conclusions Patients receiving CRS and HIPEC show low levels of fibrinogen and weak platelet function at the cytoreductive stage and enhanced coagulation factor activity at the peritoneal thermal perfusion stage,compared with the preoperative period.