Department of Surgery, Ryhov Hospital, Jönköping, Sweden.
Br J Surg. 2012 Jul;99(7):979-86. doi: 10.1002/bjs.8786. Epub 2012 May 24.
The extent to which systemic perioperative thromboembolic prophylaxis affects peroperative and postoperative bleeding during cholecystectomy is not known. This article reports on risk of bleeding in a national cohort of cholecystectomies.
All cholecystectomies registered in the Swedish Register of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2005 and 2010 were reviewed. Peroperative bleeding was defined as bleeding that could not be controlled by standard surgical techniques, necessitated conversion to an open procedure or required peroperative blood transfusion. Postoperative bleeding was defined as bleeding that necessitated reoperation, transfusion or a prolonged hospital stay. Risk estimates were performed using univariable and multiple logistic regression, and reported as odds ratios (ORs).
A total of 51 621 procedures were registered in GallRiks. Some 48 010 patients were included in the analyses, of whom 21 259 (44·3 per cent) received thromboembolic prophylaxis. Peroperative bleeding complications occurred in 400 (1·9 per cent) and postoperative bleeding in 296 (1·4 per cent) given thromboembolic prophylaxis, compared with 189 (0·7 per cent) and 195 (0·7 per cent) respectively without thromboprophylaxis. After adjusting for age, sex, indication for surgery, American Society of Anesthesiologists grade, mode of admission, operative approach, duration of surgery and hospital volume, the OR for peroperative or postoperative bleeding complications in the group receiving prophylaxis was 1·35 (95 per cent confidence interval 1·17 to 1·55). However, in a subgroup analysis the risk was increased in laparoscopic surgery only. At 30-day follow-up, a total of 74 patients (0·2 per cent) had developed postoperative thromboembolism, 43 (0·2 per cent) of those who received thromboembolic prophylaxis compared with 31 (0·1 per cent) of those who did not.
Thromboprophylaxis in patients undergoing laparoscopic cholecystectomy increased the risk of bleeding, but the occurrence of thromboembolic events was not significantly reduced. Identification of high- and low-risk patients is needed to guide clinical decisions regarding medical thromboprophylaxis.
目前尚不清楚全身围手术期血栓栓塞预防对胆囊切除术围手术期和术后出血的影响程度。本文报告了全国胆囊切除术队列中出血风险。
回顾了 2005 年至 2010 年间在瑞典胆囊结石手术和内镜逆行胰胆管造影术（GallRiks）登记的所有胆囊切除术。术中出血定义为无法通过标准手术技术控制的出血，需要转为开放手术或需要术中输血。术后出血定义为需要再次手术、输血或延长住院时间的出血。使用单变量和多变量逻辑回归进行风险估计，并报告为优势比（ORs）。
GallRiks 共登记了 51621 例手术。在分析中纳入了 48010 例患者，其中 21259 例（44.3%）接受了血栓栓塞预防。接受血栓栓塞预防的患者中，术中出血并发症发生率为 400 例（1.9%），术后出血并发症发生率为 296 例（1.4%），而未接受血栓预防的患者中，术中出血并发症发生率为 189 例（0.7%），术后出血并发症发生率为 195 例（0.7%）。调整年龄、性别、手术指征、美国麻醉医师协会分级、入院方式、手术方式、手术时间和医院容量后，预防组中术中或术后出血并发症的 OR 为 1.35（95%置信区间 1.17 至 1.55）。然而，在亚组分析中，腹腔镜手术的风险增加。在 30 天随访时，共有 74 例（0.2%）患者发生术后血栓栓塞，其中 43 例（0.2%）接受了血栓栓塞预防，31 例（0.1%）未接受。
在接受腹腔镜胆囊切除术的患者中使用血栓预防增加了出血风险，但血栓栓塞事件的发生并未显著减少。需要识别高风险和低风险患者，以指导关于医学血栓预防的临床决策。
