Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
J Clin Gastroenterol. 2010 Oct;44(9):646-52. doi: 10.1097/MCG.0b013e3181ce5b36.
To evaluate the function of coagulation and fibrinolysis in cholestatic patients before and after preoperative biliary drainage (PBD).
Cholestasis owing to an obstructive biliary malignancy is associated with postoperative complications related to a proinflammatory state, an impaired hepatic synthesis function, and a potential derangement of hemostasis. Hence, PBD is advocated for cholestatic patients undergoing major surgery.
Plasma coagulation and fibrinolytic parameters were assessed in 24 cholestatic patients and 10 controls. In 9 cholestatic patients, the parameters were reassessed at least 4 weeks after PBD.
Compared with controls, cholestatic patients showed lower concentrations (P<0.001) of plasma vitamin K-dependent factors II and VII, whereas prothrombin time, activated partial thromboplastin time, and factor V were unaltered. Thrombin generation was increased in cholestatic patients, as reflected by higher plasma concentrations of thrombin-antithrombin complexes and D-dimers. Fibrinolysis was significantly impaired as evidenced by low plasminogen activator activity (PAA) owing to an increase in plasminogen activator inhibitor -1). Elevated markers for thrombin generation thrombin-antithrombin decreased after PBD from 10.7±1.2 to 5.7±0.7 ng/mL (P<0.05). Additionally, impairment of fibrinolysis in cholestatic patients resolved after PBD (plasminogen activator inhibitor-1 levels decreased from 19±1 to 10±1 IU/mL and plasminogen activator activity increased from 82±3 to 110±4%, respectively). D-dimers remained unaltered after PBD, likely because of normalization of coagulation and fibrinolytic activity.
Obstructive cholestasis is associated with a procoagulant state, despite an impaired vitamin K-dependent coagulation factor synthesis. Virtually all alterations in coagulation and fibrinolysis were reversed by biliary drainage.
评估术前胆道引流（PBD）前后胆汁淤积患者的凝血和纤溶功能。
由于胆道恶性肿瘤引起的胆汁淤积与术后炎症状态、肝合成功能受损以及潜在的止血功能紊乱相关的并发症有关。因此，对于接受重大手术的胆汁淤积患者，提倡进行 PBD。
评估了 24 例胆汁淤积患者和 10 例对照者的血浆凝血和纤溶参数。在 9 例胆汁淤积患者中，至少在 PBD 后 4 周再次评估这些参数。
与对照组相比，胆汁淤积患者的血浆维生素 K 依赖性因子 II 和 VII 浓度较低（P<0.001），而凝血酶原时间、活化部分凝血活酶时间和因子 V 无变化。凝血酶生成增加，反映在胆汁淤积患者的血浆凝血酶-抗凝血酶复合物和 D-二聚体浓度较高。纤溶明显受损，表现为纤溶酶原激活物活性（PAA）降低，原因是纤溶酶原激活物抑制剂-1 增加。在 PBD 后，由于凝血酶生成标志物（凝血酶-抗凝血酶复合物）从 10.7±1.2 降至 5.7±0.7 ng/mL（P<0.05），因此升高。此外，PBD 后胆汁淤积患者的纤溶功能障碍得到解决（纤溶酶原激活物抑制剂-1 水平从 19±1 降至 10±1 IU/mL，纤溶酶原激活物活性从 82±3 增加至 110±4%）。D-二聚体在 PBD 后无变化，可能是由于凝血和纤溶活性的正常化。
尽管维生素 K 依赖性凝血因子合成受损，但阻塞性胆汁淤积与促凝状态相关。几乎所有的凝血和纤溶变化都可以通过胆道引流来逆转。
