间歇充气装置和低分子肝素预防消化系肿瘤术后下肢深静脉血栓形成的效果

目的探讨间歇充气装置(intermittent pneumatic compression,IPC)和低分子肝素(low molecular weight heparin,LMWH)预防消化系肿瘤术后下肢深静脉血栓形成(deep vein thrombosis,DVT)的效果。方法 2008年1～8月60例因消化系肿瘤行根治性手术,按随机数字表法分为3组,因未完成术后检查或治疗等依从性不好的因素,造成无法判断效果而剔除7例,最终入组53例:20例无预防措施(对照组)、15例术中和术后使用IPC(IPC组)及18例术后使用低分子肝素治疗(LMWH组)。术前和术后3～10 d行双下肢血管超声检查,记录DVT发生情况。对所有患者术前、术后第1、3、7天的血小板(PLT)、凝血酶原时间(PT)和国际标准化比值(INR)、活化的部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、D-二聚体(D-D)进行分析。结果对照组、IPC组、LMWH组DVT发生率分别为30.0%(6/20)、20.0%(3/15)和5.6%(1/18),组间比较差异无显著性(χ2=4.165,P=0.125),LMWH组与对照组比较差异无显著性(Fisher’s检验,P=0.061)。10例发生血栓患者中超重、血栓栓塞病史的发生率显著高于43例未发生血栓患者(χ2=5.106,P=0.024;χ2=5.106,P=0.024)。发生血栓患者术前、术后第1天和第3天血小板明显高于未发生血栓患者(t=2.676,P=0.000;t=2.203,P=0.032;t=3.040,P=0.004),术后第3天D-D也明显高于未发生血栓者(Z=-2.355,P=0.018),其余观察指标均无统计学差异(P>0.05)。术后第3天LMWH组PT较对照组明显延长(P=0.017),INR也较对照组明显升高(P=0.035),3组间手术前后血小板、APTT、FIB、D-D差异无显著性(P>0.05)。结论单一使用IPC和LMWH未能减少消化系肿瘤术后下肢DVT的发生,但使用低分子肝素有减少消化系肿瘤患者术后DVT发生的趋势,超重和血栓栓塞病史可能是发生血栓的危险因素。

Effects of Low Molecular Weight Heparin and Intermittent Pneumatic Compression on the Incidence of Deep Vein Thrombosis after Digestive Cancer Surgery

Objective To investigate the effects of low molecular weight heparin(LMWH) and intermittent pneumatic compression(IPC) on postoperative coagulation and the incidence of deep vein thrombosis(DVT) in patients with digestive cancer.Methods From January to August 2008,60 patients with digestive cancer were enrolled into this study,7 of them were excluded because of low obedience,and the other 53 were randomly divided into three groups: control group(n=20),IPC group(n=15),and LMWH group(n=18).Double lambs vascular ultrasonography was carried out before and 3-10 days after the operation to detect DVT.Blood samples were collected from all the patients before the operation and the 1st,3rd,and 7th day after the operation to determine the levels of platelet,prothrombin time,APTT,INR,FIB and D-dimer(D-D).The data were analyzed and compared among the groups.Results The incidence rate of DVT was 30.0%(6/20) in control group,20.0%(3/15) in IPC group,and 5.6%(1/18) in LMWH group,and no significant difference existed among the groups(χ2=4.165,P=0.125) nor between LMWH group and the control(P=0.061).Thrombosis occurred in 10 of the patients,among whom the incidence rate of obesity and history of thrombosis were significantly higher than those in the other 43 patients(χ2=5.106,P=0.024;χ2=5.106,P=0.024).Compared to the patients without thrombosis,the patients with thrombosis showed significantly higher level of platelet at the 1st and 3rd day postoperation(t=2.676,P=0.000;t=2.203,P=0.032;t=3.040,P=0.004),and higher level of D-D on the 3rd day(Z=-2.355,P=0.018).No statistical difference was observed in other indexes(P>0.05).On the 3rd day after the surgery,LMWH group showed significantly prolonged PT and increased INR compared to the control(P=0.017 and 0.035).No significant difference was detected in the level of platelet,APTT,FIB,and D-D among the three groups both before and after the operation(P>0.05).Conclusions Neither IPC nor LMWH alone reduces DVT in the lower limbs after digestive cancer surgery,however postoperative LMWH can reduce the trend of incidence of DVT after gastrointestinal surgery.Obesity and history of thrombosis can be risk factors of thrombosis.