作者：广东省肺癌研究所 杨学宁 & LAMP

肺癌围术期肝素增加因出血而再次手术的风险

在中国，一般不做预防性的术前肝素，只是在术后有发现才使用。

213. Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding

Robert M. Van Haren1, Ravi Rajaram2, Arlene M. Correa2, *Reza J. Mehran2, Mara B. Antonoff2, *Wayne L. Hofstetter2, Boris Sepesi2, *Stephen G. Swisher2, *Ara A. Vaporciyan2, *Garrett L. Walsh2, *David C. Rice2, *Jack A. Roth2
1University of Cincinnati, Cincinnati, OH; 2MD Anderson Cancer Center, Houston, TX

Invited Discussant: *Virginia R. Litle

Objective: Lung cancer patients are at risk for venous thromboembolism (VTE); however, there are limited studies on thromboprophylaxis in thoracic surgery. Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate the effect of preoperative heparin administration on rates of venous thromboembolism and reoperation for bleeding.
Methods: We performed a retrospective review comparing outcomes for all patients undergoing pulmonary resection for primary lung cancer from January 2006 until April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between those who received preoperative subcutaneous heparin (5000 U) and those who did not. Postoperative medications such as heparin, aspirin, clopidogrel, low-molecular weight heparin (LMWH), and therapeutic anticoagulation agents were reviewed. Statistical analyses were performed with univariate analysis and multivariate logistic regression.
Results: 3,325 lung resections were reviewed, and 1.4% (n=48) required reoperation for bleeding. VTE occurred in 1.1% (n=38): 0.4% (n=12) deep vein thrombosis, 0.2% (n=7) pulmonary emboli, and 0.6% (n=21) outpatient pulmonary emboli. 465 patients (14.0%) did not receive preoperative heparin. The preoperative heparin vs. no heparin groups were similar in terms of age, neoadjuvant therapy, and pathologic stage. However, the preoperative heparin group had more frequent weight loss in prior 3 months (9.2% [n=263] vs. 4.9% [n=23], p=0.003), redo operations (6.1% [n=174] vs. 1.9% [n=9], p=0.001), VATS approach (39.8% [n=1137] vs. 10.3% [n=48], p<0.001), and sublobar resections (18.5% [n=528] vs. 10.3% [n=48], p<0.001). The preoperative heparin group was more likely to receive postoperative heparin (99.6% [n=2829] vs. 97.7% [n=422], p<0.001), however there were no differences in usage of aspirin, clopidogrel,LMWH, or therapeutic anticoagulation. There were no differences in estimated blood loss (EBL) or transfusion requirements.Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n=46] vs. 0.2% [n=1], p=0.017), and there were no differences in VTE (1.5% [n=7] vs. 1.1% [n=31], p=0.424). On logistic regression, preoperative heparin was independently associated with increased risk of reoperation for bleeding (OR 8.417, p=0.042), however preoperative heparin was not independently associated with VTE (Table).
Conclusions: The administration of preoperative heparin was associated with increased risk of reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.