Fibrinolytic System Changes in Liver Surgery: A Pilot Observational Study

Abstract

Introduction: Bleeding occurs frequently in liver surgery. Unbalance between tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) concentrations might increase bleeding. Our aim was to analyze perioperative fibrinolytic changes during liver surgery.Materials and Methods: We evaluated 15 patients for inclusion into a prospective pilot study of liver surgery. We assessed fibrinolysis by plasma PAI-1 and t-PA: before surgery (T1), before Pringle maneuver (PM;T2), at the end of surgery (T3) and 24 h postoperatively (T4), and registered demographic and laboratory data, extent and duration of surgery, hemodynamic parameters, blood loss, and transfused volumes of blood products. Data presented as mean ± SD. Significance at P < 0.05.Results: After exclusion of six patients only undergoing biopsies, we included six women and three men aged 49.1 ± 19.6 years; two patients with liver metastases of colorectal cancer and hepatocellular carcinoma, respectively, two with focal nodular hyperplasia, two with hepatic hemangioma, and one with angiomyolipoma. Six patients underwent PM. PAI-1 plasma concentration (n = 9) rose from 6.25 ± 2.25 at T1 through 17.30 ± 14.59 ng/ml at T2 and 28.74 ± 20.4 (p = 0.007) and 22.5 ± 16.0 ng/ml (p = 0.04), respectively, at T3 and T4. Correspondingly, t-PA plasma concentration (n = 9) increased from 4.76 ± 3.08 ng/ml at T1 through 8.00 ± 5.10 ng/ml (p = 0.012) at T2 and decreased to 4.25 ± 2.29 ng/ml and 3.04 ± 3.09 at T3 and T4, respectively. Plasma t-PA level at T2 was significantly different from those at T1, T3, and T4 (p < 0.004). In PM patients, t-PA levels increased from T1, peaked at T2 (p = 0.001), and subsequently decreased at T3 and T4 (p = 0.011 and p = 0.037), respectively. Mean blood loss was 1,377.7 ± 1,062.8 ml; seven patients received blood products. Patients with higher PAI-1 levels at T3 received more fresh frozen plasma (r = 0.79; p = 0.01) and red blood cells (r = 0.88; p = 0.002).Conclusions: During liver surgery, fibrinolysis increased, as evidenced by rises in plasma PAI-1and t-PA, especially after start of surgery and following PM. Transfused volumes of blood products correlated with higher plasma concentrations of PAI-1. Confirming this tendency requires a larger cohort of patients.

Combined use of intravenous and topical tranexamic acid efficiently reduces blood loss in patients aged over 60 operated with a 2-level lumbar fusion

“…The blood loss from lumbar spinal fusion surgery could be generally divided into an acute blood loss period (within 6–8 h post-surgery) and chronic blood loss period (within 24 h post-surgery). The accompanying fibrinolysis reaction in vitro could last for 24 h after the surgery [ 28 ]. In the current study, the IV tranexamic acid can maintain the serum antifibrinolytic activity 7 or 8 h, and the topical TXA could keep local antifibrinolytic activity up to around 18 h [ 29 ].…”

Combined Use of Intravenous and Topical Tranexamic Acid Efficiently Reduce Blood Loss in Patients Aged over 60 operated with 2-level lumbar fusion

“…The accompanying fibrinolysis reaction in vitro could last for 24 h after the surgery. [28] In the current study, the IV tranexamic acid can maintain the serum antifibrinolytic activity 7 or 8 h, and the topical TXA could keep local antifibrinolytic activity up to around 18 h. [29] Therefore, the combined use of IV TXA and topical TXA could naturalize the fibrinolysis system in the first critical 24 h after surgery, and thus efficiently reduce blood loss.…”