title: Thromboelastographic changes in liver and pancreatic cancer surgery: hypercoagulability, hypocoagulability or normocoagulability?
abstract: OBJECTIVE
  Despite clinical and laboratory evidence of perioperative hypercoagulability, alterations in haemostasis after potentially haemorrhagic oncologic surgery are difficult to predict. This study aims to evaluate the entity, the extent and the duration of perioperative coagulative alterations following pancreas and liver oncologic surgery, by the use of both routine tests and thromboelastogram (TEG).
  
  
  METHODS
  Fifty-six patients undergoing liver (n = 38) and pancreatic (n = 18) surgery were studied. The coagulation profile was evaluated by platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, antithrombin III and TEG at the beginning, at the end of the operation and on postoperative days 1, 3, 5 and 10.
  
  
  RESULTS
  All preoperative coagulative screening and TEG traces were normal before incision. In the postoperative period of the liver and pancreas groups, despite an increase in prothrombin time-international normalized ratio, a reduction in antithrombin III and platelet count and normal activated partial thromboplastin time and fibrinogen, TEG evidenced a normocoagulability in the liver group, with a major tendency towards hypocoagulability in the pancreas group, as evidenced by a transient increase in R-time and K-time between postoperative days 1 and 3. During the study period, four cases of pulmonary embolism, resolved with heparin infusion, were recorded, in the absence of laboratory and thromboelastographic evidence of hypercoagulability.
  
  
  CONCLUSIONS
  Despite laboratory tests evidencing hypocoagulability in both groups, TEG traces showed a normocoagulability in liver resections, whereas a transient thromboelastographic hypocoagulability was evident in patients undergoing pancreas surgery. The discrepancy between laboratory values and thromboelastographic variables was even more evident in patients undergoing major liver resections compared with minor ones. Our study supports the role of thromboelastography, despite its limitations, as a valuable tool for the evaluation of the perioperative whole coagulation process and hypercoagulability changes and to increase patient safety through better management of antithrombotic therapy.
authors.affiliation: Division of Anaesthesiology, Azienda Ospedaliero-Universitaria di Modena-Policlinico, Modena, Italy. lesley.depietri@yahoo.it
authors.forename: Lesley
authors.initials: L
authors.lastname: De Pietri
authors.forename: Roberto
authors.initials: R
authors.lastname: Montalti
authors.forename: Bruno
authors.initials: B
authors.lastname: Begliomini
authors.forename: Giulia
authors.initials: G
authors.lastname: Scaglioni
authors.forename: Giorgia
authors.initials: G
authors.lastname: Marconi
authors.forename: Alexia
authors.initials: A
authors.lastname: Reggiani
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Di Benedetto
authors.forename: Stefano
authors.initials: S
authors.lastname: Aiello
authors.forename: Alberto
authors.initials: A
authors.lastname: Pasetto
authors.forename: Gianluca
authors.initials: G
authors.lastname: Rompianesi
authors.forename: Giorgio E
authors.initials: GE
authors.lastname: Gerunda
mesh_terms: D000368:Aged; D000990:Antithrombin III / Q000378:metabolism; D001777:Blood Coagulation / Q000187:drug effects; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006498:Hepatectomy / Q000009:adverse effects; D006801:Humans; D019934:International Normalized Ratio; D008113:Liver Neoplasms / Q000097:blood / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000009:adverse effects; D010190:Pancreatic Neoplasms / Q000097:blood / Q000601:surgery*; D010314:Partial Thromboplastin Time; D019990:Perioperative Care; D010976:Platelet Count; D011237:Predictive Value of Tests; D011300:Preoperative Care; D011446:Prospective Studies; D011517:Prothrombin Time; D015203:Reproducibility of Results; D013916:Thrombelastography; D019851:Thrombophilia / Q000097:blood / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors
chemical_list: D005343:Fibrinolytic Agents; D000990:Antithrombin III