Coagulopathy after a liver resection: is it over diagnosed and over treated?

Abstract

In spite of an elevation in PT-INR, patients undergoing a liver resection demonstrated a brief hypercoagulable state, followed by normal coagulation function based on TEG. These data call into question the practice of utilizing PT-INR to guide plasma transfusion and timing of prophylactic anticoagulation after a liver resection.

Alterations in coagulation following major liver resection

“…These findings are similar to those reported by other groups [21,24,31]. It is now recognised that conventional coagulation tests have many limitations, in that they are insensitive to endogenous anticoagulant levels and give no information on the presence or absence of hypercoagulability [32].…”

“…That these changes are specific to hepatic resection, and are not mirrored by other abdominal surgery, has been demonstrated in a number of other studies [21,22,30,31]. Following other types of major surgery, there is a small (20%) initial reduction in pro-and anticoagulant levels up to day 2, and only modest increases in VWF and factor VIII [30].…”

Liver failure after hepatocellular carcinoma surgery

“…Previous studies have shown that increased values of these parameters accurately predicted liver-related death and occurrence of severe complications after hepatectomy [18,19]. Several previous reports have identified the following risk factors for elevated serum bilirubin and INR after hepatic resection: advanced age, underlying hepatic steatosis, significant intraoperative blood loss, and prolonged operation time [17,[20][21][22]. However, it is difficult to accurately interpret these results because the patient populations in these analyses have been heterogeneous, and have included healthy living liver donors and patients with benign liver diseases.…”

“…Serum bilirubin and international normalized ratio (INR) are well-known indices of liver function [14][15][16][17]. Previous studies have shown that increased values of these parameters accurately predicted liver-related death and occurrence of severe complications after hepatectomy [18,19].…”

Malignancy does not dictate the hypercoagulable state following liver resection

“…10,11 However, our laboratory has used thromboelastography (TEG) to show that a hypercoagulable state exists following liver resection. 12,13 This test uses whole blood to provide a comprehensive assessment of the coagulation profile.…”