664 COMBINATION OF BANDING LIGATION AND MEDICAL INTERVENTION FOR SECONDARY PREVENTION IN ESOPHAGEAL VARICES: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED TRIALS

Abstract

Introduction: Elevation of Prothrombin time (PT) and/or INR following Hepatectomy is a well-known phenomenon and can lead to delays in initiation of thrombo-prophylaxis and epidural catheter removal with administration of prophylactic transfusions of Fresh Frozen Plasma (FFP). Recently, the role of PT-INR has been challenged as this test does not reflect the balance between proand anti-coagulants that is often preserved. Aims: We sought to compare these conventional tests with more global assays of hemostasis such as ROTEMTM, Thrombin Generation and Coagulant Factor activity. Design: We carried out a prospective observational study with full ethical approval in 48 patients undergoing major hepatectomy (>30% resection). Methods: Conventional tests, ROTEM analysis, endogenous thrombin potential (ETP) and proand anti-coagulant activity were measured at baseline, immediately after resection and postoperative days (POD) 1, 2, and 5. Results: Values are mean (±SD). Mean INR peaked at 1.8 (±0.42) on POD 1 and returned to baseline by POD 5. Platelets reached a nadir of 163 (±78) on POD 1 and exceeded baseline by POD 5. Clauss Fibrinogen stayed within normal range but peaked on POD5 at 4.4 g/dL (±1.4). ROTEM EXTEM and INTEM parameters as well as mean ETP values all remained within normal range for the entire study period. Mean levels of factor II, VII, IX and X all stayed above 30iu/dl for the entire study period. Factors VIII and von Willebrand factor (vWf) increased steadily from POD1 onwards. Mean levels of Protein C, Protein S and Anti-Thrombin all dropped to below 50iu/dl by POD1 but only protein S recovered by POD 5. Conclusions: Although PT/INR increased following major hepatic resection, ETP and viscoelastic parameters remained within normal limits and procoagulant factor levels were above the critical threshold of 30% required for normal haemostasis. Levels of endogenous anti-coagulants drop post-operatively and apart from protein S, remain suppressed at POD5. This combined with supranormal levels of factor VIII, vWf may create a hypercoaguable state. This has important healthcare implications if patients are not receiving thromboprophylaxis based on the INR, with inappropriate FFP transfusions and delays in invasive procedures.