Changes in homeostasis during surgical liver resection

Abstract

To assess changes in haemostasis during liver resection and to discuss the indications for antifibrinolytic therapy. Open prospective study. The study included 39 consecutive non-cirrhotic patients presenting for liver resection under portal triad clamping. General anaesthesia was obtained with thiopentone, fentanyl, vecuronium and isoflurane. Transfusion scheme was standardized. Aprotinin (5,000 kIU.kg-1 BW) was administered in case of unexplained bleeding in the operative field. Coagulation pattern was assessed by routine tests and thrombelastrography before surgery, before portal triad clamping, 5 min after reperfusion and at completion of surgery. Patients requiring aprotinin intraoperatively were compared to others. In 32 patients no significant bleeding occurred. Their coagulation pattern was moderately changed and remained within the normal range. In seven patients severe bleeding occurred which was treated with aprotinin. Their coagulation tests were significantly modified, especially after reperfusion, associating an increase in aPTT, TT, FDP, DDim, r + k and a decreased platelet count. These changes were more in favour of a dilution coagulopathy or a DIC than hyperfibrinolysis. Therefore substitutive therapy with coagulation factors should be preferred to an antifibrinolytic agent. A systematic administration of the latter for liver resection in non-cirrhotic patients is debatable, considering the allergic risk (reoperation for cancer recurrence), thrombosis facilitation (pedicle clamping) and high cost.