Long-term coagulation changes after resection of thoracoabdominal malignancies

Robert M. Van Haren, Evan J. Valle, Chad M. Thorson, Gerardo A. Guarch, Jassin M. Jouria, David Andrews, Danny Sleeman, Joe Levi, Alan Livingstone, Kenneth G Proctor

Research output: Contribution to journalArticle

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Abstract

Background The purpose of this study was to evaluate the long-term coagulation status of patients undergoing malignancy resection. Study Design A prospective observational trial was conducted with informed consent in 52 patients (age 66 ± 10 years and 60% male) with thoracoabdominal tumors (pancreas [n = 18, 35%], esophagus [n = 13, 25%], liver [n = 7, 14%], stomach [n = 6, 12%], bile duct [n = 3, 6%], retroperitoneal [n = 3, 6%], and duodenum [n = 2, 4%]) with 6- to 12-month follow-up. Coagulation was evaluated with rotational thromboelastography (ROTEM) on whole blood and with a panel of hemostatic markers on stored plasma. Results Maximum clot firmness (MCF) in the intrinsic, extrinsic, and fibrinogen pathways increased immediately postoperatively and then decreased by 9.2 ± 4.1 months (p < 0.05). Markers of thrombin generation (prothrombin fragment 1 + 2, fibrinolysis [D-dimer], and endothelial activation [coagulation factor VIII]) were elevated at all time points. The ROTEM pattern depended on histologic type and cancer location. All esophageal tumors were adenocarcinoma and demonstrated similar patterns to the overall population, with MCF differences over time in all 3 pathways (all p < 0.05). Regarding tumors of the pancreas or liver, there were no statistically significant differences when comparing all 3 time periods, but there were time-related differences when evaluating only primary adenocarcinomas of the liver (all p < 0.05). Three patients (6%) developed venous thromboembolism (VTE) and had decreased clot formation time, increased angle, and increased MCF (all p < 0.05). Conclusions Cancer patients at risk for VTE can be identified with a point-of-care ROTEM test and may benefit from additional anticoagulation. Biomarkers reflecting different functional hemostasis activity groups (fibrinolysis, thrombin generation, and endothelial activation) confirm the ongoing prothrombotic state. The ROTEM demonstrated increased hypercoagulability postoperatively, which returned to baseline in long-term follow-up. Reversal of cancer-induced hypercoagulability occurred in some patients and varied with tumor histology and location.

Original languageEnglish
Pages (from-to)846-854
Number of pages9
JournalJournal of the American College of Surgeons
Volume218
Issue number4
DOIs
StatePublished - Jan 1 2014

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Neoplasms
Thrombophilia
Venous Thromboembolism
Fibrinolysis
Thrombin
Pancreas
Liver
Adenocarcinoma
Point-of-Care Systems
Thrombelastography
Factor VIII
Hemostatics
Bile Ducts
Hemostasis
Informed Consent
Duodenum
Fibrinogen
Esophagus
Stomach
Histology

ASJC Scopus subject areas

  • Surgery

Cite this

Long-term coagulation changes after resection of thoracoabdominal malignancies. / Van Haren, Robert M.; Valle, Evan J.; Thorson, Chad M.; Guarch, Gerardo A.; Jouria, Jassin M.; Andrews, David; Sleeman, Danny; Levi, Joe; Livingstone, Alan; Proctor, Kenneth G.

In: Journal of the American College of Surgeons, Vol. 218, No. 4, 01.01.2014, p. 846-854.

Research output: Contribution to journalArticle

Van Haren, Robert M. ; Valle, Evan J. ; Thorson, Chad M. ; Guarch, Gerardo A. ; Jouria, Jassin M. ; Andrews, David ; Sleeman, Danny ; Levi, Joe ; Livingstone, Alan ; Proctor, Kenneth G. / Long-term coagulation changes after resection of thoracoabdominal malignancies. In: Journal of the American College of Surgeons. 2014 ; Vol. 218, No. 4. pp. 846-854.
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title = "Long-term coagulation changes after resection of thoracoabdominal malignancies",
abstract = "Background The purpose of this study was to evaluate the long-term coagulation status of patients undergoing malignancy resection. Study Design A prospective observational trial was conducted with informed consent in 52 patients (age 66 ± 10 years and 60{\%} male) with thoracoabdominal tumors (pancreas [n = 18, 35{\%}], esophagus [n = 13, 25{\%}], liver [n = 7, 14{\%}], stomach [n = 6, 12{\%}], bile duct [n = 3, 6{\%}], retroperitoneal [n = 3, 6{\%}], and duodenum [n = 2, 4{\%}]) with 6- to 12-month follow-up. Coagulation was evaluated with rotational thromboelastography (ROTEM) on whole blood and with a panel of hemostatic markers on stored plasma. Results Maximum clot firmness (MCF) in the intrinsic, extrinsic, and fibrinogen pathways increased immediately postoperatively and then decreased by 9.2 ± 4.1 months (p < 0.05). Markers of thrombin generation (prothrombin fragment 1 + 2, fibrinolysis [D-dimer], and endothelial activation [coagulation factor VIII]) were elevated at all time points. The ROTEM pattern depended on histologic type and cancer location. All esophageal tumors were adenocarcinoma and demonstrated similar patterns to the overall population, with MCF differences over time in all 3 pathways (all p < 0.05). Regarding tumors of the pancreas or liver, there were no statistically significant differences when comparing all 3 time periods, but there were time-related differences when evaluating only primary adenocarcinomas of the liver (all p < 0.05). Three patients (6{\%}) developed venous thromboembolism (VTE) and had decreased clot formation time, increased angle, and increased MCF (all p < 0.05). Conclusions Cancer patients at risk for VTE can be identified with a point-of-care ROTEM test and may benefit from additional anticoagulation. Biomarkers reflecting different functional hemostasis activity groups (fibrinolysis, thrombin generation, and endothelial activation) confirm the ongoing prothrombotic state. The ROTEM demonstrated increased hypercoagulability postoperatively, which returned to baseline in long-term follow-up. Reversal of cancer-induced hypercoagulability occurred in some patients and varied with tumor histology and location.",
author = "{Van Haren}, {Robert M.} and Valle, {Evan J.} and Thorson, {Chad M.} and Guarch, {Gerardo A.} and Jouria, {Jassin M.} and David Andrews and Danny Sleeman and Joe Levi and Alan Livingstone and Proctor, {Kenneth G}",
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T1 - Long-term coagulation changes after resection of thoracoabdominal malignancies

AU - Van Haren, Robert M.

AU - Valle, Evan J.

AU - Thorson, Chad M.

AU - Guarch, Gerardo A.

AU - Jouria, Jassin M.

AU - Andrews, David

AU - Sleeman, Danny

AU - Levi, Joe

AU - Livingstone, Alan

AU - Proctor, Kenneth G

PY - 2014/1/1

Y1 - 2014/1/1

N2 - Background The purpose of this study was to evaluate the long-term coagulation status of patients undergoing malignancy resection. Study Design A prospective observational trial was conducted with informed consent in 52 patients (age 66 ± 10 years and 60% male) with thoracoabdominal tumors (pancreas [n = 18, 35%], esophagus [n = 13, 25%], liver [n = 7, 14%], stomach [n = 6, 12%], bile duct [n = 3, 6%], retroperitoneal [n = 3, 6%], and duodenum [n = 2, 4%]) with 6- to 12-month follow-up. Coagulation was evaluated with rotational thromboelastography (ROTEM) on whole blood and with a panel of hemostatic markers on stored plasma. Results Maximum clot firmness (MCF) in the intrinsic, extrinsic, and fibrinogen pathways increased immediately postoperatively and then decreased by 9.2 ± 4.1 months (p < 0.05). Markers of thrombin generation (prothrombin fragment 1 + 2, fibrinolysis [D-dimer], and endothelial activation [coagulation factor VIII]) were elevated at all time points. The ROTEM pattern depended on histologic type and cancer location. All esophageal tumors were adenocarcinoma and demonstrated similar patterns to the overall population, with MCF differences over time in all 3 pathways (all p < 0.05). Regarding tumors of the pancreas or liver, there were no statistically significant differences when comparing all 3 time periods, but there were time-related differences when evaluating only primary adenocarcinomas of the liver (all p < 0.05). Three patients (6%) developed venous thromboembolism (VTE) and had decreased clot formation time, increased angle, and increased MCF (all p < 0.05). Conclusions Cancer patients at risk for VTE can be identified with a point-of-care ROTEM test and may benefit from additional anticoagulation. Biomarkers reflecting different functional hemostasis activity groups (fibrinolysis, thrombin generation, and endothelial activation) confirm the ongoing prothrombotic state. The ROTEM demonstrated increased hypercoagulability postoperatively, which returned to baseline in long-term follow-up. Reversal of cancer-induced hypercoagulability occurred in some patients and varied with tumor histology and location.

AB - Background The purpose of this study was to evaluate the long-term coagulation status of patients undergoing malignancy resection. Study Design A prospective observational trial was conducted with informed consent in 52 patients (age 66 ± 10 years and 60% male) with thoracoabdominal tumors (pancreas [n = 18, 35%], esophagus [n = 13, 25%], liver [n = 7, 14%], stomach [n = 6, 12%], bile duct [n = 3, 6%], retroperitoneal [n = 3, 6%], and duodenum [n = 2, 4%]) with 6- to 12-month follow-up. Coagulation was evaluated with rotational thromboelastography (ROTEM) on whole blood and with a panel of hemostatic markers on stored plasma. Results Maximum clot firmness (MCF) in the intrinsic, extrinsic, and fibrinogen pathways increased immediately postoperatively and then decreased by 9.2 ± 4.1 months (p < 0.05). Markers of thrombin generation (prothrombin fragment 1 + 2, fibrinolysis [D-dimer], and endothelial activation [coagulation factor VIII]) were elevated at all time points. The ROTEM pattern depended on histologic type and cancer location. All esophageal tumors were adenocarcinoma and demonstrated similar patterns to the overall population, with MCF differences over time in all 3 pathways (all p < 0.05). Regarding tumors of the pancreas or liver, there were no statistically significant differences when comparing all 3 time periods, but there were time-related differences when evaluating only primary adenocarcinomas of the liver (all p < 0.05). Three patients (6%) developed venous thromboembolism (VTE) and had decreased clot formation time, increased angle, and increased MCF (all p < 0.05). Conclusions Cancer patients at risk for VTE can be identified with a point-of-care ROTEM test and may benefit from additional anticoagulation. Biomarkers reflecting different functional hemostasis activity groups (fibrinolysis, thrombin generation, and endothelial activation) confirm the ongoing prothrombotic state. The ROTEM demonstrated increased hypercoagulability postoperatively, which returned to baseline in long-term follow-up. Reversal of cancer-induced hypercoagulability occurred in some patients and varied with tumor histology and location.

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