Peri-Operative Thrombophilia in Patients Undergoing Liver Resection for Colorectal Metastases

Abstract

Introduction: Routine peri-operative chemical venous thromboembolism (VTE) prophylaxis for liver surgery remains controversial, and is often delayed post-operatively until conventional coagulation parameters have normalised, due to perceived risks of bleeding. This study asked whether patients undergoing liver resection for colorectal metastases (CRM) were at risk from VTE pre-operatively, and the impact of liver resection on that risk. Method: A single-centre prospective observational cohort study of patients undergoing open liver resections for CRM, comparing pre-, peri- and post-operative haemostasis variables. Patients with cirrhosis, previous VTE or anticoagulated were excluded. Coagulation assays were measured pre-operatively, peri-operatively (after transection) and first post-operative day. Tissue Factor messenger ribonucleic acid (TFmRNA) activation was measured from peripheral blood mononuclear cells (PBMCs) pre- and post-operatively. Chemical thromboprophylaxis commenced on the first post-operative day after venesection. Results: Of 336 hepatectomies performed October 2017-December 2019, 60 resections in 57 patients were prospectively recruited (Table 1). Patients had raised Factor VIIIC and thrombin generation velocity index pre-operatively, which significantly increased post-operatively. Post-operative Factor VIIIC and von Willebrand Factor (vWF) were higher and Protein C lower following major resections. Longer transections exhibited greater PMBC-TFmRNA expression. Conclusions: These data show the risk of major haemorrhage in elective liver resection in a high-volume unit is low, and administration of chemical thromboprophylaxis within 13-20 hours of surgery is safe and effective. Furthermore, patients with CRM are prothrombotic pre-operatively, an effect exacerbated by liver resection, particularly in patients with longer, more complex resections, suggesting chemical thromboprophylaxis should be considered earlier in the patient pathway.