肺叶切除术后严重出血的发生率、病因及预后

Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy.

作者信息

Udelsman Brooks V, Soni Monica, Madariaga Maria Lucia, Fintelmann Florian J, Best Till D, Li Selena Shi-Yao, Chang David C, Gaissert Henning A

机构信息

Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.

Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA.

出版信息

Eur J Cardiothorac Surg. 2020 Mar 1;57(3):462-470. doi: 10.1093/ejcts/ezz266.

DOI:10.1093/ejcts/ezz266

PMID:31562514

Abstract

OBJECTIVES

Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management.

METHODS

We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days.

RESULTS

Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group.

CONCLUSIONS

Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.

摘要

目的

肺叶切除术后出血并不常见，且很少被研究。在本研究中，我们旨在确定肺叶切除术后出血的发生率，并比较再次手术和非手术治疗的结果。

方法

我们对2009年至2018年期间的肺叶切除病例进行了单机构回顾性研究。根据术后出血的治疗方法，将患者分为两组：再次手术组或输注浓缩红细胞并观察组。排除用于纠正术中失血的输血情况。术后出血由以下一项或多项标准定义：（i）血细胞比容下降≥10%；或（ii）胸腔闭式引流管持续明显出血，伴或不伴有低血压。协变量包括人口统计学、合并症和手术特征。观察指标包括手术死亡率、并发症、住院时间和30天内再入院情况。

结果

在1960例肺叶切除术（92%为恶性疾病，8%为非恶性疾病）后，42例（2.1%）发生出血，其中27例（1.4%）需要再次手术，15例（0.8%）接受非手术治疗。再次手术的中位时间为17小时。44%的再次探查未发现出血源。术后出血患者男性更常见（64.3%对41.2%；P<0.01），术前贫血的可能性更大（45.2%对26.5%；P=0.01），既往正中开胸手术史更常见（14.3%对6.0%；P=0.04），有感染指征更常见（7.1%对1.8%；P=0.01），手术粘连松解更常见（45.2%对25.8%；P=0.01）。与非手术治疗相比，再次手术输注的浓缩红细胞单位数更少（0.4对1.9；P<0.001），而两组并发症发生率相似，且均无30天死亡率。