胸外科术后静脉血栓栓塞症发生情况的单中心前瞻性队列研究

摘要

目的 探讨胸外科术后静脉血栓栓塞症(VTE)的发生率及发生特点.方法 本研究为单中心前瞻性队列研究.收集2016年7月至2017年3月在首都医科大学附属北京朝阳医院胸外科接受手术治疗的患者资料.除术前常规检查以外,所有患者于手术前后行下肢多普勒超声以明确有无下肢深静脉血栓形成(DVT).如患者出现肺动脉栓塞的典型症状、Caprini评分≥9分或新发DVT,则行CT肺动脉造影除外有无新发肺动脉栓塞(PE).全部患者接受Caprini风险评估.患者术前均未接受过任何形式的VTE预防.分别对定量资料、分类资料等采用t检验、χ2检验或Wilcoxon秩和检验等进行分析.结果 共纳入345例接受胸外科手术的患者,男性207例,女性138例,年龄范围:15~85岁.包括145例良性疾病患者和200例恶性肿瘤患者.手术类型包括285例肺手术、27例食管手术、22例纵隔手术及11例其他手术.全组共48例发生 VTE(13.9%),其中包括39例(81.2%)DVT,1例(2.1%)PE和8例(16.7%)DVT+PE.诊断VTE的中位时间为术后4.5 d.胸部良性疾病术后VTE发生率为9.0%,恶性肿瘤发生率为17.5%(χ2=5.112,P<0.05).肺手术后VTE发生率为12.6%,其中肺良性疾病为7.5%,肺恶性肿瘤为16.4%(χ2=4.946,P<0.05).按Caprini评分分组,低危组(≤4分)发生率为0(0/77)、中危组(5~8分)为15.2%(33/217),高危组(≥9分)为29.4%(15/51)(Z=-12.166,P<0.05).98.2%的肺恶性肿瘤患者为中危或高危组,仅3例为低危组,低至高危组的VTE发生率分别为0、13.4%和32.1%.结论 胸外科大手术术后VTE的总体发生率为13.9%,其中肺恶性肿瘤为16.4%.术后VTE多发生于术后1周内.Caprini评分可有效筛选高危患者.%Objective To evaluate the incidence of postoperative venous thromboembolism(VTE) after thoracic surgery and its characteristic. Methods This was a single-center, prospective cohort study. Patients undergoing major thoracic surgeries between July 2016 and March 2017 at Department of Thoracic Surgery,Beijing Chaoyang Hospital Affiliated to Capital Medical University were enrolled in this study. Besides the routine examination, all patients were screened for deep venous thrombosis(DVT)by using noninvasive duplex lower-extremity ultrasonography after surgery. CT pulmonary angiography(CTPA)was carried out if patients had one of the following conditions including typical symptoms of PE, high Caprini score(>9 points)or new diagnosed postoperative DVT. Caprini risk assessment model was used to detect high risk patients. No patients received any prophylaxis of VTE before surgery. Further data was analyzed for identifying the incidence of postoperative VTE. The t-test, χ2 test or Wilcoxon rank-sum test was used to analyze the quantitative data and classification data, respectively.Results Totally 345 patients who undergoing major thoracic surgery were enrolled in this study including 145 benign diseases and 200 malignant diseases.There were 207 male and 138 female,aging from 15 to 85 years. Surgery procedures included 285 lung surgeries, 27 esophagectomies, 22 mediastinal surgeries and 11 other procedures. The overall incidence of VTE was 13.9%(48 of 345)after major thoracic surgery including 39 patients with newly diagnosed DVT(81.2%),1 patient with PE(2.1%)and 8 patients with DVT+PE(16.7%). The median time of VTE detected was 4.5 days postoperative. There were 89.6%(43/48)VTE cases diagnosed in 1 week. The incidence of VTE was 9.0% in patients with benign diseases, while 17.5% in malignant diseases(χ2=5.112, P<0.05). The incidence of VTE in patients with pulmonary diseases was 12.6%, among that,in patients with lung cancer and benign lung diseases was 16.4% and 7.5%(χ2=4.946,P<0.05), respectively. Regarding to Caprini risk assessment model, the incidence of VTE in low risk patients,moderate risk patients(Caprini score 5 to 8 points)and high risk patients(≥9 points)were 0(0/77),15.2%(33/217)and 29.4%(15/51), respectively(Z=-12.166,P<0.05). In patients with lung cancer,98.2% of patients were moderate risk or high risk;only 3 cases scored low risk. The incidence of VTE in moderate risk and high risk patients was 13.4%(18/134)and 32.1%(9/28), respectively, while it was 0(0/3)in low risk patients. Conclusions The overall incidence of VTE after major thoracic surgeries is 13.9%, and the incidence of VTE after lung cancer surgeries was 16.4%. Most of the VTE cases occurr within one week after the surgery. Caprini risk assessment model can identify high risk patients effectively.