Effect of preoperative biliary drainage on coagulation and fibrinolysis in severe obstructive cholestasis.
OBJECTIVE
To evaluate the function of coagulation and fibrinolysis in cholestatic patients before and after preoperative biliary drainage (PBD).


BACKGROUND
Cholestasis owing to an obstructive biliary malignancy is associated with postoperative complications related to a proinflammatory state, an impaired hepatic synthesis function, and a potential derangement of hemostasis. Hence, PBD is advocated for cholestatic patients undergoing major surgery.


METHODS
Plasma coagulation and fibrinolytic parameters were assessed in 24 cholestatic patients and 10 controls. In 9 cholestatic patients, the parameters were reassessed at least 4 weeks after PBD.


RESULTS
Compared with controls, cholestatic patients showed lower concentrations (P<0.001) of plasma vitamin K-dependent factors II and VII, whereas prothrombin time, activated partial thromboplastin time, and factor V were unaltered. Thrombin generation was increased in cholestatic patients, as reflected by higher plasma concentrations of thrombin-antithrombin complexes and D-dimers. Fibrinolysis was significantly impaired as evidenced by low plasminogen activator activity (PAA) owing to an increase in plasminogen activator inhibitor -1). Elevated markers for thrombin generation thrombin-antithrombin decreased after PBD from 10.7±1.2 to 5.7±0.7 ng/mL (P<0.05). Additionally, impairment of fibrinolysis in cholestatic patients resolved after PBD (plasminogen activator inhibitor-1 levels decreased from 19±1 to 10±1 IU/mL and plasminogen activator activity increased from 82±3 to 110±4%, respectively). D-dimers remained unaltered after PBD, likely because of normalization of coagulation and fibrinolytic activity.


CONCLUSIONS
Obstructive cholestasis is associated with a procoagulant state, despite an impaired vitamin K-dependent coagulation factor synthesis. Virtually all alterations in coagulation and fibrinolysis were reversed by biliary drainage.
Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands. jaap.kloek@amc.uva.nl
Jaap J
JJ
Kloek
Michal
M
Heger
Niels A
NA
van der Gaag
Ulrich
U
Beuers
Thomas M
TM
van Gulik
Dirk J
DJ
Gouma
Marcel
M
Levi
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001777:Blood Coagulation; D001779:Blood Coagulation Factors / Q000096:biosynthesis; D002779:Cholestasis / Q000601:surgery*; D004322:Drainage / Q000379:methods*; D005260:Female; D005342:Fibrinolysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D011300:Preoperative Care / Q000379:methods; D012720:Severity of Illness Index
D001779:Blood Coagulation Factors