Thromboelastogram monitoring in the perioperative period of hepatectomy for adult living liver donation

Abstract

Living donor liver transplantation (LDLT) is becoming a widespread procedure. However, the risk of surgical and medical complications in healthy donors is still a major concern. Hypercoagulability contributes to thromboembolic complications after surgery, but alterations of hemostasis after liver resection are difficult to predict. This study aims to define the perioperative coagulation profile of living liver donors by the use of both routine tests and thromboelastogram (TEG). Ten subjects undergoing right hepatectomy for LDLT were studied. A complete coagulation screening was performed before operation. The coagulation profile was evaluated by platelet count, prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT), and TEG at the beginning and at the end of surgery, and on days 1, 3, 5, and 10 after operation, while the donors were under low molecular weight heparin (LMWH) prophylaxis. At preoperative screening, no subject showed evidence of a prothrombotic state. In all cases, TEG was normal at the beginning of surgery. In the postoperative period, despite decreased platelet counts, increased PT-INR, and normal aPTT values, TEG evidenced the progressive development of hypercoagulability in 4 subjects on day 5 and in 6 subjects on day 10. One donor with a definitely hypercoagulable TEG on day 5 experienced deep venous thrombosis (DVT) on day 8, which was resolved with therapeutic doses of LMWH. In conclusion, despite routine tests suggesting hypocoagulability and LMWH prophylaxis, TEG monitoring showed the unexpected occurrence of hypercoagulability in the majority of the subjects after hepatectomy for LDLT. TEG monitoring could be useful in the perioperative management of donors to guide antithrombotic treatment and increase the safety of the procedure. (Liver Transpl 2004;10:289 -294.)

Alterations in coagulation following major liver resection

“…These findings are similar to those reported by other groups [21,24,31]. It is now recognised that conventional coagulation tests have many limitations, in that they are insensitive to endogenous anticoagulant levels and give no information on the presence or absence of hypercoagulability [32].…”

Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery

“…However, the authors emphasize the practical limitations of the original, labor-intensive TEG methodology, which may indicate why many past studies included small sample sizes -often 100 patients or fewer, and sometimes as few as ten patients [15]. Larger studies often examined only patients undergoing a specific operation [16,17].…”

Live liver donors: Are they at a higher risk for post-operative thrombotic complications?

“…In addition, other important functions of the liver include removal of activated clotting factors from the blood and thus keeping and maintaining a balance between anticoagulant/procaogulant mediators [13] . Although, during surgery, bleeding is a major concern for both the surgical and anesthesiology teams, the results from recent study showed that living donors progressively developing hypercoagulable state as shown by thromboelastograph (TEG) even in the presence of anti-thrombotic prophylaxis [14] . In spite of the fact that post-operative coagulopathy in living donors can be easily diagnosed by conventional clotting tests (PTT, PT, INR), the incidence of postsurgical bleeding is extremely low.…”

“…TEG has been used to evaluate acquired and congenital/genetic induced clotting-related problems when compared to healthy reference subjects [14,15] . TEG can demonstrate hypercoagulability by a short R-time, an increased MA and accelerated K-value (Figures 1 and 2).…”