RU2734271C1 - Method for prevention of venous thromboembolic complications in laparoscopic operations for colonic oncologic diseases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to vascular surgery, and can be used for prevention of venous thromboembolic complications in patients operated laparoscopically for oncologic diseases of large intestine. Overall blood test, a biochemical blood test, a blood coagulogram analysis are performed to determine the following parameters: fibrinogen level, platelet count in plasma, level of D-dimer, amount of soluble fibrin-monomer complexes, thrombin time, prothrombin time. Collecting complete history of the following: previous chemotherapeutic treatment, the presence or absence of venous thromboembolic complications, the use of anticoagulants, antiaggregants, taking into account the findings of ultrasound examination of veins of lower extremities and in the presence of three of the following factors: fibrinogen level > 4 g/l, thrombocyte count > 400 10 × 9 l, level of D-dimer > 0.5 g/l, amount of soluble fibrin-monomer complexes > 4 g/l, thrombin time < 15 seconds, prothrombin time < 8 seconds, diameter of large saphenous vein > 7 mm is high risk of venous thromboembolic complications and 12 hours before performing laparoscopic operation low-molecular heparin is prescribed in dosage 6000 ME.

EFFECT: method improves results of operative treatment by reducing thromboembolic complications in patients with malignant large intestine formations operated laparoscopically.

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Description

The invention relates to medicine, namely to vascular surgery, and can be used for the prevention of venous thromboembolic complications (VTEC) in patients operated on laparoscopically for oncological diseases of the colon.

Laparoscopy is one of the leading directions in surgery and the "gold standard" in the treatment of many diseases of the abdominal cavity. A feature of laparoscopy is the introduction of carbon dioxide into the abdominal cavity, which, in turn, exerts pressure in all directions (see Possibilities of using laparoscopic technologies in the treatment of colon cancer in an oncological clinic / Sidorov D.V., Grishin N.A., Lozhkin M.V., Troitsky A.A., Petrov L.O. // Coloproctology. - 2014. - No. S3. - P. 76).

An important role is played by applying pressure to the posterior wall of the abdominal cavity, since this is where the aorta and inferior vena cava (IVC) are located. According to the data provided by A.S. Gallus, the likelihood of venous thromboembolic complications (VTEC) after laparoscopic interventions in benign formations of the abdominal cavity organs (ABP) and small pelvis is 5.3%. If we consider laparoscopic interventions in cancer patients, the likelihood of VTEC reaches 20% (see Dupras, D. Venous Thromboembolism Diagnosis and treatment / D. Dupras, J. Bluhm, C. Felty [et al.]; Institute for Clinical Systems Improvement. - 2013 Updated January).

The relationship between VTEC and the oncological process has attracted attention for a long time. The first person to prove this pathogenetic connection is the Parisian doctor Armand Trousseau, who presented this fact in his lecture material in 1861. In a later period of time, a Parisian doctor diagnosed himself with a malignant stomach formation, based on the occurrence of distal thrombosis. From that moment on, the combination of migratory thrombosis and tumor is defined as "Trousseau's syndrome".

The occurrence of hypercoagulation in patients with malignant tumors is explained by the interaction of a large number of factors at different levels of hemocoagulation, which include both the patient's body response to the development of oncology and the release of fibrinolysis activators, highly active tissue thromboplastin and certain procoagulants into the systemic circulation (see Howard, LS Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing / LS Howard, RJ Hughes // Thorax. - 2013 Apr. - Vol. 68 (4). - P. 391-393).

It should be noted that all solid formations contribute to an increase in the level of tumor-dependent tissue thromboplastin, which, in turn, is a significant factor in tumor growth. An equally important role in this process is played by fibrinolytic substances (plasminogen, urokinase-type plasminogen activators and its inhibitors - RA-1, alkynin-2) (see The role of the immune system in the pathogenesis of thrombotic complications in cancer patients / Makatsaria A.D., Vorobiev A.V., Chabrov AM, Savchenko A.A., Mishchenko A.L. // Obstetrics, gynecology and reproduction. - 2016. - T. 10. - No. 1. - P. 84-98).

A significant factor in the pathogenesis of VTEC in cancer patients is blood stasis, caused by prolonged immobilization of patients, a large volume of surgical intervention and the prevalence of the oncological process, in particular, by tumor growth of the vascular wall.

At present, there is enough information on the frequency of deaths from VTEC in cancer patients. Based on numerous studies, including a group of cancer patients, it was found that VTEC is determined in 10-15% of patients (see Anticoagulants in the practice of a clinical oncologist: prevention and treatment of venous thrombosis / Soloshenko O.S. // News of Medicine and Pharmacy. - 2014 . - No. 17 (513). - S. 16-17_m).

Based on the results of the work done, V.V. Kakkar, it can be concluded that when using izotop jodu 125-labeled fibrinogen in the diagnosis of venous thromboembolic complications, the likelihood of deep vein thrombosis (DVT) in patients with malignant tumors is detected in 41% of cases. In patients without cancer, the probability of DVT is 26%. Studies carried out posthumously in patients with disseminated tumor process revealed that the incidence of VTEC is 40-50%.

It is known that in more than 50 percent of patients, pulmonary embolism remains unrecognized during life. The likelihood of VTEC varies depending on the type of tumor. The highest percentage is observed in patients with mucin-producing adenocarcinomas, as a rule, this type of tumor is localized in the gastrointestinal tract (see Kearon S., Kahn SR, Agnelli G., et al. Antithrombotic Therapy for Venous Thromboembolic Disease. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133: 454S-545S).

Due to the different location of the primary tumor, the likelihood of VTEC is as follows (the data are consonant with the materials of the meta-analysis performed by AS Gallus): the pancreas is 28.5%), the lungs are 26%, the stomach is 13.5%, the colon reaches 3 %, the mammary gland in the premenopausal period is 1-2%, in the postmenopausal period it reaches from 3 to 8%, the likelihood of VTEC in prostate cancer is 2.3%.

Thus, laparoscopic operations, especially in oncopathology, double the risk of developing PE (see Limone, BL Timing of recurrent venous thromboembolism early after the index event: a metaanalysis of randomized controlled trials / BL Limone, AV Hernandez, D. Michalak [et al.] // Thromb Res 2013 Vol 132 (4) P. 420-426).

The main rule for conducting high-quality anti-thrombotic therapy is the development of a complex multifactorial therapy for VTEC, which will take into account all the individual risk factors of the patient, and which will minimize the high incidence of VTEC.

The technical result of the proposed invention is to improve the results of surgical treatment by reducing thromboembolic complications in patients with malignant tumors of the colon, operated laparoscopically.

The technical result is achieved by the fact that at the stage of preoperative preparation, a general blood test, a biochemical blood test, a blood coagulogram analysis are performed with the determination of the following parameters: the level of fibrinogen, the number of platelets in the blood plasma, the level of D-dimer, the number of soluble fibrin-monomer complexes, thrombin time , prothrombin time, collect a full anamnesis: about previous chemotherapeutic treatment, about the presence or absence of venous thromboembolic complications, about taking anticoagulants, antiplatelet agents, taking into account the data of the ultrasound examination of the veins of the lower extremities and in the presence of three of the listed factors: fibrinogen level> 4 g / L, platelet count> 400 10 × 9 L, D-dimer level> 0.5 g / L, amount of soluble fibrin-monomer complexes> 4 g / L, thrombin time <15 seconds, prothrombin time <8 seconds, presence of anticancer therapy , a history of phlebothrombosis and / or thrombophlebitis and / or a thrombus pulmonary embolism, the absence of anticoagulants and / or antiplatelet agents, the diameter of the great saphenous vein> 7 mm determines the high risk of venous thromboembolic complications, and 12 hours before the laparoscopic operation, low molecular weight heparin is prescribed at a dosage of 6000 IU.

The method is as follows. When a patient is admitted to the surgical department, blood is taken for general and biochemical analyzes, blood coagulogram analysis with the determination of the following parameters: fibrinogen level, platelet count in blood plasma, D-dimer level, number of soluble fibrin-monomer complexes (RFMK), thrombin time , prothrombin time. A complete anamnesis is collected: about previous chemotherapy treatment, about the presence or absence of venous thromboembolic complications, about taking anticoagulants, antiplatelet agents, taking into account the data of the ultrasound examination of the veins of the lower extremities.

In the presence of three of the listed factors: fibrinogen level> 4 g / L, platelet count> 400 10 × 9 L, D-dimer level> 0.5 g / L, amount of soluble fibrin-monomer complexes> 4 g / L, thrombin time <15 seconds, prothrombin time <8 seconds, the presence of anticancer therapy, a history of phlebothrombosis and / or thrombophlebitis and / or pulmonary embolism, the absence of anticoagulants and / or antiplatelet agents, the diameter of the great saphenous vein (D BPKV)> 7 mm determines high the risk of venous thromboembolic complications, and 12 hours before laparoscopic surgery, low molecular weight heparin (LMWH) is prescribed at a dosage of 6000 IU.

We give clinical examples of the application of the method:

Example 1:

Patient U., 1955, was admitted to the surgical department of the UOMC FMBA of Russia on 04.12.2017 with a diagnosis of stage IV sigmoid colon cancer (T3N1M1 (HEP)). Body weight 81 kg.

Before the operation, the values of laboratory parameters were:

RFMK - 4.0 g / l (norm 3-4 g / l)

D-dimer - 0.62 g / l (norm 0-0.2 g / l)

Fibrinogen - 5.02 g / l (norm 2-4 g / l)

Platelets - 251 10 × 9 L (120-380 10 × 9 L)

Thrombin time - 18.6 sec (norm 16-26.1 sec)

Prothrombin time - 7.12 seconds (normal 9.1-12.1 seconds)

Anticancer therapy was not prescribed.

There were no venous thromboembolic complications.

Does not take anticoagulants and / or antiplatelet agents.

The diameter of the great saphenous vein is 5 mm.

An increase in the level of D-dimer, fibrinogen, a decrease in the level of prothrombin time, predict a high risk of venous thromboembolic complications. 12 hours before laparoscopic surgery, low molecular weight heparin (LMWH) is prescribed at a dosage of 6000 IU.

Performed laparoscopically - assisted resection of the sigmoid colon. By days 3, 7, 17, 28, clinical manifestations of PE and phlebothrombosis of the upper or lower extremities were not revealed. Ultrasound signs of pathology of the main veins of the lower extremities were not revealed. There were no signs of hemorrhagic complications, the patient was discharged in a satisfactory condition.

Example 2:

Patient S., 1962, was admitted to the surgical department of the UOMC FMBA of Russia on July 27, 2017 with a diagnosis of stage III rectal cancer (T3N0M0 (HEP)). Body weight 77 kg.

Before the operation, the values of laboratory parameters:

RFMK - 3.56 g / l (norm 3-4 g / l)

D-dimer - 0.51 g / l (norm 0-0.2 g / l)

Fibrinogen -3.75 g / l (norm 2-4 g / l)

Platelets - 412 10 × 9 L (120-380 10 × 9 L)

Thrombin time - 14, 2 sec (norm 16-26.1 sec)

Prothrombin time - 11.9 seconds (normal 9.1-12.1 seconds)

Anticancer therapy was not prescribed.

There were no venous thromboembolic complications.

Does not take anticoagulants and / or antiplatelet agents.

The diameter of the great saphenous vein is 5.3 mm.

An increase in the level of D-dimer, platelets, a decrease in the level of thrombin time indicate a high risk of venous thromboembolic complications, therefore, 12 hours before the laparoscopic operation, low molecular weight heparin (LMWH) is prescribed at a dosage of 6000 IU.

Performed laparoscopically - assisted abdominal perineal extirpation of the rectum.

By days 3, 7, 17, 28, clinical manifestations of PE and phlebothrombosis of the upper or lower extremities were not revealed. Ultrasound signs of pathology of the main veins of the lower extremities were not revealed. There were no signs of hemorrhagic complications, the patient was discharged in a satisfactory condition.

Example 3:

Patient F., 1949, was admitted to the surgical department of the UOMC FMBA of Russia on 03.08.2017 with a diagnosis of stage IV rectal cancer (T3N1M0 (HEP)). Body weight 64 kg.

Before the operation, laboratory values were:

RFMK - 5.86 g / l (norm 3-4 g / l)

D-dimer - 0.607 g / l (norm 0-0.2 g / l)

Fibrinogen - 5.12 g / l (norm 2-4 g / l)

Platelets - 313 10 × 9 L (120-380 10 × 9 L)

Thrombin time - 17, 9 sec (norm 16-26.1 sec)

Prothrombin veme - 10.04 sec (norm 9.1-12.1 sec)

No anticancer therapy was prescribed

There were no venous thromboembolic complications.

Does not take anticoagulants and / or antiplatelet agents.

An increase in the level of D-dimer, RFMK, fibrinogen indicates a high risk of venous thromboembolic complications. The patient was prescribed low molecular weight heparin (LMWH) at a dosage of 6000 IU 12 hours before the laparoscopic operation.

Performed laparoscopically - assisted abdominal perineal extirpation of the rectum.

By days 3, 7, 17, 28, clinical manifestations of PE and phlebothrombosis of the upper or lower extremities were not revealed. Ultrasound signs of pathology of the main veins of the lower extremities were not revealed. There were no signs of hemorrhagic complications, the patient was discharged in a satisfactory condition.

Example 4:

Patient Ch., 1956, was admitted to the surgical department of the UOMC FMBA of Russia on May 23, 2017 with a diagnosis of stage IV rectal cancer (T3N1M0 (HEP)). Body weight 73 kg.

Before the operation, laboratory values were:

RFMK - 4.89 g / l (norm 3-4 g / l)

D-dimer - 0.754 g / l (norm 0-0.2 g / l)

Fibrinogen -3.87 g / l (norm 2-4 g / l)

Platelets - 258 10 × 9 L (120-380 10 × 9 L)

Thrombin time - 19.2 sec (norm 16-26.1 sec)

Prothrombin time - 11.17 sec (norm 9.1-12.1 sec)

D BPkV left> 8.03 mm

No anticancer therapy was prescribed

There were no venous thromboembolic complications.

Does not take anticoagulants and / or antiplatelet agents.

An increase in the level of D-dimer, RFMK, and an increase in the diameter of the PBV on the left indicate a high risk of venous thromboembolic complications, and low molecular weight heparin (LMWH) is prescribed at a dosage of 6000 IU 12 hours before the laparoscopic operation.

Performed laparoscopically - assisted abdominal perineal extirpation of the rectum.

By days 3, 7, 17, 28, clinical manifestations of PE and phlebothrombosis of the upper or lower extremities were not revealed. Ultrasound signs of pathology of the main veins of the lower extremities were not revealed. There were no signs of hemorrhagic complications, the patient was discharged in a satisfactory condition.

This method was used to prevent venous thromboembolic complications in 120 patients operated on laparoscopically for cancer of the large intestine.

The technical and economic efficiency of the method lies in the fact that its application allows, prior to the laparoscopic operation, to prevent thromboembolic complications in patients operated on for colon cancer.

Claims (1)

A method for the prevention of venous thromboembolic complications during laparoscopic operations for oncological diseases of the large intestine, which consists in the fact that at the stage of preoperative preparation, a general blood test, biochemical blood test, blood coagulogram analysis are performed with the determination of the following parameters: fibrinogen level, number of platelets in blood plasma, the level of D-dimer, the amount of soluble fibrin-monomeric complexes, thrombin time, prothrombin time, a full anamnesis is taken: about previous chemotherapy treatment, about the presence or absence of venous thromboembolic complications, about the use of anticoagulants, antiplatelet agents, take into account the data of the lower veins ultrasound and in the presence of three of the listed factors: fibrinogen level> 4 g / L, platelet count> 400 10 × 9 L, D-dimer level> 0.5 g / L, amount of soluble fibrin-monomer complexes> 4 g / L, thrombin time <15 seconds, pr thrombin time <8 seconds, the diameter of the great saphenous vein> 7 mm determine the high risk of venous thromboembolic complications and 12 hours before the laparoscopic operation, low molecular weight heparin is prescribed at a dosage of 6000 IU.