二氧化碳气腹时间对老年腹腔镜胆囊切除术患者凝血-纤溶和血管内皮细胞活性的影响

摘要

目的 观察二氧化碳(CO2)气腹时间对老年人腹腔镜胆囊切除术(LC)患者凝血-纤溶和血管内皮细胞活性的影响.方法 胆石症择期行LC患者45例,年龄＞60岁,术后根据气腹持续时间分组:气腹时间≤60 min组21例;气腹时间＞60 min组24例.于入院检查时(术前)、术毕、术后第1、2、3天抽取静脉血检测凝血酶原时间(PT)、激活部分凝血活酶时间(APTT)、凝血酶原片段1+2(F1+2)浓度、抗凝血酶-Ⅲ(AT-Ⅲ)活性、纤维蛋白原(Fib)浓度、组织纤溶酶原激活物(t-PA)浓度、纤溶酶原激活物抑制物-1(PAI-1)浓度、D-二聚体(D-D)浓度、血管性血友病因子(vWF)活性.结果 (1)凝血指标:术后第3天,＞60 min组的,F1+2为 (1.60±0.26) μg/L,高于≤60 min组的(1.32±0.24) μg/L(P＜0.05);AT-Ⅲ为(84.82±20.21)%,低于≤60 min组的(97.49±16.87)%(P＜0.05);术后第2、3天的Fib分别为(3.87±0.62)、(3.98±0.77)g/L,高于≤60 min组的 (3.42±0.72)、(3.42±0.63)g/L(P＜0.05).(2)纤溶-抗纤溶指标:＞60 min组术后第2 、3天的PAI-1为(33.93±10.42)、(32.90±11.25) μg/L高于≤60 min组的(26.69±9.49)、(26.31±7.06)μg/L(P＜0.05).(3)血管内皮细胞活性指标:＞60 min组术后第2 、3天的vWF为(174.53±44.03)%、(176.31±47.6)%,高于≤60 min组的(134.37±37.74)%、(131.21±36.34)% (P＜0.05).结论 老年LC患者,术后有明显的凝血-纤溶激活和血管内膜损伤;随气腹时间延长,凝血激活和纤溶抑制程度高,凝血-纤溶相对不平衡,血管内膜损伤更明显,可能增加血栓形成风险.%Objective To observe the effect of duration of carbon dioxide pneumoperitoneum on coagulation, fibrinolysis and endothelial activation in elderly patients undergoing laparoscopic cholecystectomy (LC). Methods The 45 elderly patients with cholelithiasis scheduled for LC, aged over 60 yeas, were placed in different groups respectively after surgery according to the duration of pneumoperitoneum. The duration of pneumoperitoneum was ≤60 minutes in group A (n=21),and more than 60 minutes in group B (n=24). Venous blood samples were taken on admission (baseline), at the end of surgery, the 1st, 2nd and 3rd day after surgery for determination of prothrombin time (PT), activated partial thromboplastin time (APTT), prothrombin fragment F1+2 (F1+2), antithrombin 3 (AT-Ⅲ activity), fibrinogen (Fib), tissue plasminogen activator (t-PA), plasminogen activator inhibitor type-1 (PAI-1), D-dimer (D-D), von Willebrand factor (vWF activity). Results Concerning the coagulation activation, at the 3rd postoperative day, the level of F1+2 was significantly higher in group B than in group A [(1.60±0.26) μg/L vs. (1.32±0.24) μg/L, P＜0.05]; AT-III was significantly higher in group B than in group A [(84.82%±20.21%) vs. (97.49%±16.87%), P＜0.05]. At the 2nd and 3rd postoperative day, the levels of Fib were significantly higher in group B than in group A [(3.87±0.62) g/L vs. (3.42±0.72) g/L, (3.98±0.77) g/L vs. (3.42±0.63) g/L, respectively, P＜0.05]. Concerning fibrinolysis, But at the 2nd and 3rd postoperative day, the level of PAI-1 was significantly higher in group B than in group A [(33.93±10.42) μg/L vs. (26.69±9.49) μg/L, (32.90±11.25) μg/L vs. (26.31±7.06) μg/L respectively, P＜0.05]. Concerning endothelial activation, at the 2nd and 3rd postoperative day, vWF was significantly higher in group B than in group A [(174.53%±44.03%) vs. (134.37%±37.74%), (176.31%±47.6%) vs. (131.21%±36.34%), respectively, P＜0.05]. Conclusions Marked activations of coagulation-fibrinolysis and endothelial activation are observed postoperatively in elderly patients undergoing laparoscopic cholecystectomy. Along with prolonged duration of pneumoperitoneum, more pronounced alterations of increased coagulation, reduced fibrinolysis and endothelial activation are observed, which could constitute an imbalanced situation of coagulation-fibrinolysis and increases the risk of venous thrombosis.