12 декабря 2018г.
Evaluation of hemostatic system activation allows to determine the risk of thrombotic and hemorrhagic complications and to make a plan for the correction of these disorders.
Purpose: to study intraoperative shifts and their correction in the hemostatic system in operations of ampullary colon cancer.
Material and methods: The study included 47 men and 37 women aged 54-79 years (mean 58.3 ±1.6 years) with verified ampullary colon cancer and no thrombotic complications in the history. Operation ( anterior low resections of the colon with anastomosis — 33 operations, brunorosetta of exercitii rectum — 51) was carried out in spinal anesthesia with bupivacaine 15-20 mg and sedation midazolama in dozirovke (0,25-0,35 mg/kg body weight). The General criteria for inclusion in the study were the following signs: the lack of localized and systemic inflammation, diabetes, the lack of taking drugs that affect the blood coagulation system. The control group included 30 patients. The study group included 54 patients who underwent hemostatic correction during surgery. The material was taken immediately before the cut of the skin (stage I), at the time of surgical intervention on the tissue (stage II) and immediately after the wound suturing (stage III). Screening parameters: activated partial thrombin time (APT), prothrombin time (PV). Blood for the study by enzyme immunoassay (ELISA) was centrifuged. The content of complexes of thrombin - antithrombin (TAT), plasmin-antiplasmin (PAP), D-dimers, and plasminogen activator (I- RA) were determined by the IFA method. Statistical processing of the results was performed using STATISTICA 7 software. Patients of the study group during the operation in/200.0 ml of 0.9% sodium chloride solution was administered tranexamic acid at a dose of 1 g.
Results: The absence of significant differences in the" screening " indicators in the data confirms their insensitivity, and, consequently, uninformativeness in the diagnosis of hypercoagulation and fibrinolysis pathology. Study the concentration of plasminogen activator was produced only in the control group and was aimed at the determination of the presence or absence of the ejection of the activator of fibrinolysis during manipulation of the rectum. TAT complex is a marker of hemostatic system activation and is a product of interaction of thrombin and antithrombin III. A statistically significant increase in TAT concentrations in stages II and III indicates increased coagulation potential during surgery. For the study of the fibrinolytic system, the level of the plasmin-a-2- antiplasmin complex was determined. This non-active complex is formed by inhibiting plasmin by binding it to a-2- antiplasmin. It should be noted that the concentrations of this complex in this category of patients exceed similar indicators in almost healthy individuals. This may indicate both the presence of reactive (secondary, in response to hypercoagulation) and primary fibrinolysis enhancement. The presence of the latter is evidenced by the increased initial level of urokinase plasminogen activator. A sharp increase in the complex in the postoperative period is most likely due to the release of I-RA, the level of which significantly increased in the postoperative period. The mechanism of the enzyme in the blood is as follows and implies a long-term effect directly on the tumor tissue with a likely constant contact of gaping blood vessels and the possible flow into the blood of the plasma gene that is released from the malignant cells. The level of D-dimer, which is a product of lysis of transversely cross-linked fibrin by plasmin, and accordingly is an indicator reflecting the state of both the coagulation and fibrinolytic link, was lower in the study group (0.178±0.014 µg/ml), which indicates the compensatory state of the homeostasis system against the background of the treatment.
Summary: In patients with ampullary colon cancer, there is an increase in the potential of the blood coagulation system. This is due to the prevalence of the process and the presence of comorbidities. Fibrinolytic system was activated as a second time (response to increased thrombosis) and primary (increased level of I-RA by 23±1,3%, p<0,05). The operation is accompanied by the release of a plasminogen activator, leading to a sharp activation of fibrinolysis. To reduce the activity of the fibrinolytic system, it is advisable to intraoperative administration of tranexamic acid.
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