Kawanaka Hirofumi, Akahoshi Tomohiko, Itoh Shinji, Iguchi Tomohiro, Harimoto Norifumi, Uchiyama Hideaki, Yoshizumi Tomoharu, Shirabe Ken, Takenaka Kenji, Maehara Yoshihiko
Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
J Am Coll Surg. 2014 Nov;219(5):865-74. doi: 10.1016/j.jamcollsurg.2014.07.939. Epub 2014 Aug 6.
Decreased antithrombin III (ATIII) activity and large splenic vein diameter (SVD) are risk factors for portal vein thrombosis (PVT) after splenectomy in liver cirrhosis with portal hypertension. Antithrombin III concentrates can prevent PVT. This study was designed to stratify risks for PVT after splenectomy in cirrhotic patients and to develop prophylactic protocols for PVT.
In 53 patients (testing cohort), the cutoff level of preoperative ATIII activity (≤60%) was evaluated for administration of ATIII concentrates. Antithrombin III activity and SVD were re-evaluated as criteria for prophylaxis of PVT. In 57 patients (validation cohort), the risk stratification of PVT and prophylactic protocols were validated.
In the testing cohort, 10 (19%) of 53 patients had PVT. Risk level of PVT was stratified and prophylactic protocols were developed. Patients at low risk (ATIII activity ≥70% and SVD <10 mm) were not treated; those at high risk (ATIII activity <70% or SVD ≥10 mm) received ATIII concentrates (1,500 U/day) for 3 days; and those at highest risk (SVD ≥15 mm) received ATIII concentrates for 3 days, followed by danaparoid sodium (2,500 U/day) for 14 days and warfarin. In the validation cohort, 0 of 14 low-risk and 2 of 32 high-risk patients had PVT. Although 8 of 11 patients at highest risk had temporary PVT, it disappeared within 3 months postoperatively. Finally, only 2 (3.5%) of 57 patients had PVT.
Risk stratification of PVT after splenectomy and prophylaxis with ATIII concentrates and danaparoid sodium dramatically reduced the incidence of PVT.
抗凝血酶III（ATIII）活性降低和脾静脉直径（SVD）增大是肝硬化门静脉高压症患者脾切除术后门静脉血栓形成（PVT）的危险因素。抗凝血酶III浓缩剂可预防PVT。本研究旨在对肝硬化患者脾切除术后PVT的风险进行分层，并制定PVT的预防方案。
在53例患者（测试队列）中，评估术前ATIII活性的临界水平（≤60%）以决定是否给予抗凝血酶III浓缩剂。再次评估抗凝血酶III活性和SVD作为PVT预防的标准。在57例患者（验证队列）中，对PVT的风险分层和预防方案进行验证。
在测试队列中，53例患者中有10例（19%）发生PVT。对PVT的风险水平进行分层并制定预防方案。低风险患者（ATIII活性≥70%且SVD<10mm）不进行治疗；高风险患者（ATIII活性<70%或SVD≥10mm）接受抗凝血酶III浓缩剂（1500U/天）治疗3天；最高风险患者（SVD≥15mm）接受抗凝血酶III浓缩剂治疗3天，随后接受达那肝素钠（2500U/天）治疗14天并加用华法林。在验证队列中，14例低风险患者中0例发生PVT，32例高风险患者中有2例发生PVT。尽管11例最高风险患者中有8例发生了暂时性PVT，但在术后3个月内消失。最终，57例患者中只有2例（3.5%）发生PVT。
脾切除术后PVT的风险分层以及使用抗凝血酶III浓缩剂和达那肝素钠进行预防可显著降低PVT的发生率。
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