Thromboelastographic changes during laparoscopic fundoplication

Abstract

Introduction: Thromboelastography (TEG) is a technique that measures coagulation processes and surveys the properties of a viscoelastic blood clot, from its formation to lysis.

Aim: To determine the possible hypercoagulability state and the effect of antithrombotic prophylaxis on thromboelastogram results and development of venous thrombosis during laparoscopic fundoplication.

Material and methods: The study was performed on 106 patients who were randomized into two groups. The first group received low-molecular-weight heparin (LMWH) 12 h before the operation, and 6 and 30 h after it. The second group received LMWH only 1 h before the laparoscopic fundoplication. The TEG profile was collected before LMWH injection, 1 h after the introduction of the laparoscope and 15 min after the surgery was completed.

Results: There was no significant difference in thromboelastography R-time between the groups before low-molecular-weight heparin injection. In group I preoperative R-values significantly decreased 1 h after the introduction of the laparoscope, after the end of surgery and on the third postoperative day. K-time values decreased significantly on the third postoperative day compared with the results before low-molecular-weight heparin injection, and after the operation. In group II, preoperative R-values significantly decreased 1 h after the introduction of the laparoscope, and after surgery. K-time values did not change significantly during or after the laparoscopic operation.

Conclusions: Our study results demonstrated that the hypercoagulation state (according to the TEG results) was observed during and after laparoscopic fundoplication in patients when LMWH was administered 12 h before the operation together with intraoperative intermittent pneumatic compression. The optimal anticoagulation was obtained when LMWH was administered 1 h before fundoplication.

Keywords: hypercoagulability; laparoscopic fundoplication; thromboelastogram.

Figure 1

Characteristic thromboelastographic (TEG) tracings. A – Normal TEG tracing. B – Anticoagulation caused by coagulation factor deficiency or inhibition leading to a prolonged R time. C – Platelet dysfunction or pharmacological inhibition leading to a decreased maximum amplitude (MA). D – Hyperfibrinolysis. E – Hypercoagulability leading to shortened R and K times, with a concomitant elevated and angle

Figure 2

Study design

Figure 3

Technique to perform the TEG test

Figure 4

TEG tracing – normal values of TEG parameters (celite activated whole blood) R-time – reaction time, in minutes (norm: 5.0–10.0 min) – this denotes the time taken from the beginning placement of the blood sample in the cuvette to the initial fibrin formation. K-time – clotting time (norm; 1.0–3.0 min) representing the time of fixed clot formation. &-angle – degrees; closely related to K (norm: 53.0– 72.0°) this represents the rate of clot growth. MA parameter – maximum amplitude, millimeters (norm: 50.0–70.0 mm) – a measurement of maximum strength of the developed clot.

Photo 1

Computed tomography venography revealed v. poplitea dex. thrombosis: A – transverse CT scan, B – coronal CT scan