The potential role of aprotinin in the perioperative management of malignant tumors

[Surgical Treatment of Refractory Chest Tumors Assisted by Cardiopulmonary Bypass]

背景与目的

回顾性总结体外循环辅助下累及心脏或大血管的难治性胸部肿瘤外科治疗体会。

方法

总结我院2008年1月-2017年5月实施的体外循环下外科手术切除累及心脏或大血管的11例胸部肿瘤患者，分析所有患者的一般情况、临床特征、治疗方法、术后住院时间、并发症及随访结果。

结果

11例患者均在体外循环辅助下手术。肿瘤全部切除者8例，大部分切除者3例，其中1例先行左房内转移性肺平滑肌肉瘤切除，再行右肺中下叶切除术；1例经胸骨正中切口行左肺中央型肺癌切除术；2例同时行肺动脉修补术，3例同时行部分心包切除术，3例同时行肺楔形切除术。所有患者术后症状均得到有效缓解。无院内及术后30天死亡率。3例术后出现肺部感染，于抗生素治疗后恢复。1例淋巴瘤术后6个月复发，1年后死亡；1例心包内纤维肉瘤患者于术后13个月局部复发伴广泛转移，15个月死亡，1例肺平滑肌肉瘤患者于术后15个月发现局部复发灶，予以化疗后缓解。其余8例患者均存活，且计算机断层扫描（computed tomography, CT）检查均未发现明显复发及远处转移。

结论

对于累及心脏或大血管的难治性胸部肿瘤可以实施体外循环辅助下的外科手术治疗，可以提高难治性胸部肿瘤的手术切除率，有效缓解对呼吸、循环功能的影响，明显延长此类患者的生存期。

A possible association between aprotinin and improved survival after radical surgery for mesothelioma

BACKGROUND

Aprotinin has been used to decrease blood loss with complicated cardiac surgery but has not been investigated in extrapleural pneumonectomy, an operation that does not use cardiopulmonary bypass. In this prospective, randomized, placebo-controlled, double-blind trial, the authors investigated whether aprotinin decreased blood loss in patients who underwent this operation.

METHODS

After appropriate statistical design and institutional review board approval, eligible patients who were scheduled for extrapleural pneumonectomy were randomized to receive either aprotinin or placebo during the operation. Blood loss and survival data were obtained from electronic medical records and surgical databases.

RESULTS

Of 20 patients who were enrolled, 16 patients met criteria for blood loss analysis. Four patients were excluded from the blood loss analysis: Three patients were inoperable because of tumor spread and underwent limited surgery, and 1 patient died intraoperatively because of acute, massive hemorrhage. The mean blood loss was 769 mL with aprotinin versus 1832 mL with placebo (P = .05; Wilcoxon test). All 20 patients were included in survival analyses. All 9 patients who received placebo died. In contrast, 7 of 11 patients who received aprotinin remained alive at the time of the current report. Kaplan-Meier survival curves differed significantly between the 2 groups (P = .0004). A Bayesian multivariate survival analysis of 18 patients who had complete data available on 8 prognostic variables indicated a posterior probability of .99 that aprotinin was beneficial.

CONCLUSIONS

Aprotinin decreased blood loss. After accounting for covariate effects, there was a significant comparative benefit with aprotinin in postoperative survival. This finding was unexpected and could not be considered conclusive because of the small size of the current study. A confirmatory study may be warranted.

Influence of ultra-low dose Aprotinin on thoracic surgical operations: a prospective randomized trial

Background

The blood saving effect of aprotinin has been well documented in cardiac surgery. In thoracic surgery, very few recent studies, using rather high doses of aprotinin, have shown a similar result. In a randomized prospective trial, we have tested the influence of aprotinin using an ultra-low dose drug regime.

Methods

Fifty-nine patients, mean age 58 ± 13.25 years (mean ± SD) undergoing general thoracic procedures were randomized into placebo (Group A) and treatment group (Group B). The group B (n = 29) received 500.000 IU of aprotinin after induction to anesthesia and a repeat dose immediately after chest closure. A detailed protocol with several laboratory parameters was recorded. Patients were transfused when perioperative Ht was less than 26%.

Results

The two groups were similar in terms of age, gender, diagnosis, pathology, co-morbidity and operations performed. The mean drainage of the first and second postoperative day in group B was significantly reduced (412.6 ± 199.2 vs. 764.3 ± 213.9 ml, p < 0.000, and 248.3 ± 178.5 vs. 455.0 ± 274.6, p < 0.001). Similarly, the need for fresh frozen plasma transfusion was lower in group B, p < 0.035. Both the operation time and the hospital stay were also less for group B but without reaching statistical significance (84.6 ± 35.2 vs 101.2 ± 52.45 min. and 5.8 ± 1.6 vs 7.2 ± 3.6 days respectively, p < 0.064). The overall transfusion rate did not differ significantly. No side effects of aprotinin were noted.

Conclusion

The perioperative ultra-low dose aprotinin administration was associated with a reduction of total blood losses and blood product requirements. We therefore consider the use of aprotinin safe and effective in major thoracic surgery.

Use of aprotinin in extrapleural pneumonectomy: effect on hemostasis and incidence of complications

BACKGROUND

The purpose of this study was to examine the effect of aprotinin on blood loss in extrapleural pneumonectomy and to identify potential treatment-related complications.

METHODS

Between March 1, 1999, and July 1, 2004, 27 (52%) of 52 patients who underwent extrapleural pneumonectomy received half-dose aprotinin (1 million kallikrein inhibition units load; 250,000 kallikrein inhibition units per hour infusion). A retrospective data review and analysis were performed.

RESULTS

The mean age was 59.8 +/- 11 years, and 45 of 52 patients (87%) were male. Indications for extrapleural pneumonectomy were malignant pleural mesothelioma (n = 50) and pleural-based sarcoma (n = 2). The administration of aprotinin had no significant effect on intraoperative blood loss (1,010 +/- 599 versus 1,182 +/- 688 mL; p = 0.34) or units of packed red blood cells transfused intraoperatively (2.0 +/- 1.7 versus 1.9 +/- 1.7 units; p = 0.86). None of the patients who received aprotinin required the use of non-packed red blood cells blood products, but 4 patients (16%) who did not receive aprotinin required such transfusion (p < 0.05). Postoperative chest tube output at 12 and 24 hours was lower in the aprotinin group (381 +/- 195 and 867 +/- 313 mL, respectively) compared with the control group (725 +/- 527 and 1,221 +/- 442 mL, respectively; p < 0.03). There was no significant difference in incidence of postoperative thromboembolic events between the aprotinin and the control group (5 versus 4 patients; p = 1.0), and 2 patients in each group experienced renal insufficiency (p = 1.0).

CONCLUSIONS

Half-dose aprotinin did not decrease intraoperative blood loss or packed red blood cells transfusion in extrapleural pneumonectomy. However, use of aprotinin was associated with decreased use of non-packed red blood cells blood products and lower postoperative chest tube output. Aprotinin administration was not associated with an increase in incidence of postoperative complications.