Intestinal permeability in patients after surgical trauma and effect of enteral nutrition versus parenteral nutrition

AIM: To study the intestinal permeability (IP) following stress of abdominal operation and the different effects on IP of enteral nutrition (EN) and parenteral nutrition (PN).

METHODS: Forty patients undergoing abdominal surgery were randomized into EN group and PN group. Each group received nutritional support of the same nitrogen and calorie from postoperative day (POD) 3 to POD 11. On the day before operation (POD-1), POD 7 and POD 12, 10 g of lactulose and 5 g of mannitol were given orally, and urine was collected for 6 hours. Urine excretion ratios of lactulose and mannitol (L/M) were measured.

RESULTS: L/M ratios of EN group on POD-1, POD 7 and POD 12 were 0.026 ± 0.017, 0.059 ± 0.026, 0.027 ± 0.017, respectively, and those of PN group were 0.025 ± 0.013, 0.080 ± 0.032, 0.047 ± 0.021, respectively. Patients of both groups had elevated L/M ratios on POD 7 vs. POD-1. However the ratio returned toward control level in EN group by POD 12. In contrast, PN group still had elevated L/M ratios on POD 12.

CONCLUSION: L/M ratio increases for a period of time after surgical trauma and the loss of gut mucosal integrity can be reversed by substitution of enteral nutrition.

Gastrointestinal carcinoids. Prognosis and survival

BACKGROUND

Gastrointestinal carcinoid tumors are rare and little is known about factors related to prognosis in patients with carcinoid disease. Aim of this study is to determine the impact of clinical presentation variables on the management and survival.

METHODS

We have evaluated 31 consecutive patients with gastrointestinal carcinoid tu-mours who underwent surgical intervention at the I Department of Surgery of Milano-Bicocca University over 15 years (1985-1999). Tumor distribution, hormone production, prognostic factors and survival were analysed.

RESULTS

Carcinoid syndrome was the only clinical pattern diagnostic of carcinoid tumour. Most common symptoms were abdominal pain (64%), nausea and vomiting (48%). High levels of urinary 5-hydroxyindolacetic acid were significantly associated with carcinoid syndrome and metastatic disease. Tumor size, depth and gender were significant predictors of metastases. Age, gender, tumor size, metastatic spread and location were statistically significant predictors of death.

CONCLUSIONS

Clinical presentation was non specific except for those patients affected by carcinoid syndrome. Ten years overall survival was 43%, with 52% metastatic spread incidence. The extent of surgical resection should be modulated on patient related risk factors. Poor prognostic factors affecting survival were: age, gender, metastatic disease, depth of invasion and tumour size.

Endoscopic ultrasound guided antitumor therapy

This paper will review the possibilities of EUS guided anti-tumor therapy. Ablative energy may be delivered to a tumor under EUS guidance to destruct tumor cells by ultrasound itself, radiofrequency or radiation. Pilot results of endoscopic high intensity focused ultrasound in a human trial have been reported. The feasibility of performing EUS guided radiofrequency ablation has been reported in a swine model. An EUS bases radiation target simulation method has been developed for anal cancer therapy. Targeted delivery of an anti-cancer agent into a tumor under EUS guidance is possible as reported in an early clinical trial of local immunotherapy (Cytoimplant) or modified viruses delivered by EUS guided fine needle injection in patients with advanced pancreatic carcinoma. Image guided injection of alcohol is another approach used for local tumor ablation. Application of other ablation therapies such as laser, microwave and cryo is also conceptually feasible. We will have to wait and see where these initial and ongoing attempts for applying EUS against cancer take us.

Zero mortality after 152 consecutive pancreaticoduodenectomies with pancreaticogastrostomy

BACKGROUND

Since 1968, there have been three published reports in the United States literature of 41, 118, and 145 consecutive patients undergoing pancreaticoduodenectomy without mortality. In all of these series, the pancreatic remnant was anastomosed to the jejunum.

STUDY DESIGN

This study was designed to review 152 consecutive patients who underwent pancreaticoduodenectomy in whom the pancreatic remnant was anastomosed to the stomach (pancreaticogastrostomy).

RESULTS

A total of 152 patients underwent pancreaticoduodenectomy with pancreaticogastrostomy between July 1992 and May 2002. There were 85 men and 67 women with a mean age of 65.7 years (range 31 to 90 years). Of the patients, 87 were less than 69 years of age and 65 were more than 69 years. A total of 114 patients had a malignant neoplasm and the remaining 38 had either cystic neoplasms or benign disease. When the two groups were compared, the patients who were more than 69 years of age had a significantly high incidence of hypertension, previous cancer, atrial fibrillation, and coronary artery disease. In addition, patients more than 69 years of age had a significantly high incidence of jaundice and placement of preoperative stents. Patients more than 69 years of age had significantly less operative time but there was no between-group difference in estimated blood loss, transfusion, number of units transfused, and postoperative length of stay. There was no postoperative mortality [corrected] in this series. Pancreatic leak and fistulae were the most common complications, followed by intraabdominal abscess, wound infection, and delayed gastric emptying.

CONCLUSIONS

In this study, 152 consecutive patients underwent pancreaticoduodenectomy with pancreaticogastrostomy without postoperative mortality. Morbidity was mostly because of pancreatic leaks and fistulae, which were successfully treated nonoperatively. With proper selection, careful preoperative preparation, and proper intraoperative conduct of operation, the Whipple procedure can be performed without postoperative mortality.

Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy

BACKGROUND AND STUDY AIMS

The mortality rate for surgical revision of gastroesophageal anastomotic leakage after resection for cancer approximates 60 %. The efficacy of endoscopically placed covered metallic stents for treatment of gastroesophageal leakage was evaluated.

PATIENTS AND METHODS

Between June 1996 and June 2002 we treated 21 patients with proven gastroesophageal leakage; 18 had anastomotic leakage and three patients had perforation for different reasons. The extent of the leaks ranged from one-quarter of the intestinal circumference to its complete dehiscence. The average time from surgery to detection of leakage was 6.1 days (range 3 - 15 days). Mortality, healing rate, length of hospital stay, and complications were assessed.

RESULTS

The insertion of stents was performed endoscopically under radiological guidance without any complication in all patients. In 9.5 % (2/21) of patients complete sealing of the leak was not achieved. The mortality associated with anastomotic leakage was 23.8 % (5/21). In 80.1 % (17/21) patients complete healing of the leakage was achieved. The average hospital stay was 67 days (range 14 - 158 days). Of 23 stents, 13 (56.5 %) were removed, and three patients developed stenosis after removal.

CONCLUSION

The treatment of gastroesophageal leakage with covered stents appears to reduce mortality and the complication rate associated with major leakage. Therefore this technique seems to be a reasonable alternative in the treatment of clinically relevant anastomotic leakage.

Laparoscopic surgery for cancer: are we ready?

Following feasibility studies more and more large prospective reports even randomised trials document the treatment of digestive cancer using a laparoscopic approach. While the spectre of port-site recurrences, once so alarming has faded, it has become a challenge for laparoscopic surgeons to provide long-term follow-up. There is good class II and III evidence that staging laparoscopy (SL) has a value for oesophageal, gastric, pancreatic and hepatobiliary cancer as well as for intra-abdominal lymphomas since it adds to primary staging and often alters the clinical stage of the disease and hence the management of the individual patient. For minimally invasive oesophagectomy and gastric cancer surgery several series have demonstrated shorter perioperative morbidity and hospital stay however at present most studies report smaller numbers of selected patients and long term follow up is rare. The laparoscopic resection of pancreatic malignancies is not reported to be feasible, safe or potentially beneficial for the patient while the curative resection of suspected early gallbladder cancer is a poor indication. Nevertheless laparoscopy is documented to be safe and applicable for small malignant liver lesions and the Lacy trial was significantly in favour of laparoscopy-assisted colectomy, predominantly for stage III disease. Bearing in mind that in many fields of digestive cancer surgery, laparoscopy should still be conducted as part of a trial, it is safe to say that "we are ready" for this revolution to arise.

Factors determining the post-operative hypo-albuminaemia in cancer patients--stepwise regression analysis

AIM

To investigate factors influencing post-operative hypo-albuminaemia in cancer patients, with special reference to low dose albumin and/or immunoglobulins administration.

PATIENTS AND METHODS

In 270 patients with malignant neoplasms, who underwent extensive chest and/or abdominal surgery, albumin concentrations on the first four postoperative days were examined. One hundred and three high-risk patients received human immunoglobulins intravenously; 44 were given albumin. Univariate and multivariate regression analyses were used to determine the factors influencing albuminaemia on the first four postoperative days.

RESULTS

Mean nadir of hypo-albuminaemia occurred on the third postoperative day. In the multivariate analysis, a positive correlation was found between postoperative albuminaemia and pre-operative albuminaemia (b = 0.4919; p = 0.0000) as well as male gender (b = 2.0939; p = 0.0025). A negative correlation was found with the duration of surgery (b = -0.0416; p = 0.0212), pre-operative plasma protein (b = -0.2118, p = 0.0130) and postoperative immunoglobulin administration (b = -1.8858, p = 0.0074).

CONCLUSIONS

Postoperative albuminaemia is positively correlated with pre-operative albuminaemia and male gender and negatively correlated with the duration of surgery, pre-operative proteinaemia and postoperative Ig administration.

[Limitations of laparoscopic visceral surgery in oncology]

Controversial discussion focuses on the application of laparoscopic curative resection for cancer due to oncologic radicality,tumor cell dissemination, and port site metastases. Considering the limitations of laparoscopic surgery, it is necessary to objectively evaluate whether laparoscopic surgery is associated with an improved quality of curative treatment. Therefore, controlled studies comparing the results of laparoscopic vs conventional cancer surgery are mandatory. To date, comparable findings on short-term outcome of laparoscopy with open resection can only be shown for colorectal cancer. However, long-term data including recurrence and survival are still missing as randomized studies (phase IIIb) are still to be completed. Consequently, laparoscopic curative resection should only be performed within controlled trials. In terms of the upper GI tract, minimally invasive surgery has proven to be technically feasible in expert centers including limited resections for early gastric cancer, left pancreatectomies, or hepatic resections for malignancy. Finally, laparoscopy has gained acceptance in the field of diagnosis (e.g., staging laparoscopy, laparoscopic ultrasound) and palliative treatment (e.g. gastroenterostomy, thermoablation) without the need for controlled studies.

High incidence of colic anastomotic leakage complicating upper abdominal en bloc evisceration for cancer: a 47-patient series

BACKGROUND/AIMS

The purpose of this study was to analyze the early outcome of en bloc extended resection for upper abdominal locally advanced cancer.

METHODOLOGY

A retrospective medical chart review was performed in 47 consecutive patients who underwent an upper abdominal en bloc resection for cancer involving multiple organs or structures at Paoli-Calmettes Institute and Conception Hospital from October 1988 through April 1997. A third of patients underwent a resection of 4 sus mesocolic organs or more.

RESULTS

The postoperative morbidity and mortality rate were respectively, 57% and 19%. Despite a high number of theoretically risky procedures including pancreatic resection and pancreatojejunostomy, total gastrectomy and esophagojejunostomy, total hepatectomy and liver transplantation, the higher percentage of complication was found with colic anastomosis. Five of the 30 patients (17%) who underwent a colic anastomosis developed a colic anastomotic leakage, 4 patients were reoperated and 2 patients died.

CONCLUSIONS

Because of this unacceptably high rate of complications, we propose to systematically perform a protective stoma when an upper abdominal evisceration includes a colic anastomosis.

Dopamine stabilizes milrinone-induced changes in heart rate and arterial pressure during anaesthesia with isoflurane

BACKGROUND AND OBJECTIVE

Phosphodiesterase-III inhibitors and dobutamine effectively improve cardiac function in patients with cardiac failure, but they are limited by possible hypotensive effects. We tested the hypothesis that dopamine contributes to stabilizing milrinone-induced haemodynamic changes.

METHODS

Nine patients undergoing major surgery were anaesthetized using nitrous oxide and oxygen supplemented with isoflurane 1-2%. After baseline haemodynamics were recorded, milrinone (25 or 50 microg kg(-1)) was administered over 10min, followed by a continuous infusion (0.5 microg kg(-1) min(-1). The second set of haemodynamic values was measured 50 min after beginning the continuous infusion of milrinone. Dopamine (4 microg kg(-1) min(-1)) was then administered with milrinone.

RESULTS

Milrinone significantly increased the heart rate from 81 +/- 8 to 102 +/- 16beats min(-1), but it decreased the mean arterial pressure from 83 +/- 10 to 66 +/- 10 mmHg and systemic vascular resistance (P < 0.05 for each). The pulmonary capillary wedge pressure, cardiac index and pulmonary vascular resistance did not change significantly. The addition of dopamine to the milrinone infusion significantly decreased the heart rate (94 +/- 12 beats min(-1)) and increased the mean arterial pressure (82 +/- 11 mmHg). Dopamine and milrinone, but not milrinone alone, significantly increased the cardiac index and the rate-pressure product.

CONCLUSIONS

The combination regimen of milrinone and dopamine improved cardiac function, and changes in heart rate and mean arterial pressure induced by milrinone were attenuated by dopamine. The results suggest that a combination regimen of milrinone and dopamine rather than milrinone alone should be used to maintain arterial pressure.

[A simple method of creation of invaginated esophago-intestinal and esophago-gastric anastomoses]

Creation of invaginated esophageal anastomosis is easier by Tsatsanidi method, but this is accompanied by certain discomforts. In particular, there is inescapable contamination of intestinal serosa by ligature which fixes esophageal stump from inside and is taken out through intestinal wall. The author proposes to put this ligature into the side hole of the thick gastric tube and to fix it there with bougie. The tube is moved deeplier, ligature and esophageal stump are pulled up. This facilitates creation of invaginated anastomosis. Then bougie is removed from the thick tube and fixed ligature is freed. This method was used in 19 patients. There were no lethal outcomes due to insufficiency of esophageal anastomosis. This method permits to simplify creation of invaginated anastomosis, to increase asepsis of surgery and to dicrease the risk of anastomosis insufficiency.

Surgical decision making in upper aerodigestive tract cancer patient follow-up

The objective was to analyze the impact of clinical beliefs on surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer. Clinical beliefs, defined as perceived benefits and risks of surveillance, were examined. All 824 members of the Society of Head and Neck Surgeons (SHNS) and 522 members of the American Society for Head and Neck Surgery, who were not SHNS members, were surveyed using TNM stage-specific clinical vignettes to measure surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer. Controlling for physician demographic and practice characteristics, the relationship between clinical beliefs and diagnostic test ordering practices of surgeons was examined using Poisson and negative binomial regression analysis. Age 50 and over and South Central U.S. practice location were significant predictors of the frequency of surveillance testing in at least three TNM stage I models as was the clinical belief that no survival benefit results from the follow-up of patients with TNM stage I cancers. Less than 15% of the variability in follow-up intensity was explained by the TNM stage I models. Predictive ability was substantially improved for the TNM stage II-IV models by including lower TNM stage practice patterns as an independent variable. Most models predicted at least 50% of the variation in follow-up testing. The two clinical beliefs with the greatest impact on surgical decision making in the posttreatment follow-up of patients with upper aerodigestive tract cancer are that surveillance: i) permits palliative treatment and improves quality of life and ii) provides no survival benefit for patients with TNM stage I cancers. Knowledge of lower TNM stage practice patterns can be used to further improve predictive ability for higher stage models.

Neuroendocrine tumors of the gastro-entero-pancreatic system: the role of early diagnosis, genetic testing and preventive surgery

Surgery is the only curative approach in neuroendocrine gastro-entero-pancreatic (GEP) tumors. As cure is highly dependent of tumor size, early diagnosis is a prerequisite for surgical success. Diagnosis of nonfunctioning tumors of the pancreas or midgut origin is due to symptoms related to the tumor burden, thus early diagnosis is mostly incidental. Functioning pancreatic tumors should be operated early in the course of the disease to provide cure. No genetic screening is available for sporadic GEP tumors. In patients with MEN-1 syndrome genetic screening is recommended to restrict the burden of clinical screening to those with positive test results. Due to the nature of the disease cure may not be achieved, however prevention of cancer may be obtained for one or two decades of life, especially in patients with gastrinoma or nonfunctioning tumors.

The role of surgery in the prevention of familial cancer syndromes of the gastrointestinal tract

Familial predisposition is a well-recognised risk factor in many gastrointestinal cancers. New developments in molecular genetics may contribute to the identification of cancer-prone families. Recognition of familial clustering and genetic testing can identify other members of the family with a high potential risk for cancer development. Appropriate surveillance mechanisms and management protocols may be initiated in order to prevent cancer and/or to detect cancer at an early stage. In the present article, various types of familial cancer of the gastrointestinal tract are reviewed and surgical, diagnostic and therapeutic issues for the management of esophageal, gastric, colorectal, and pancreatic cancer are emphasized.

[Video-assisted surgery in oncology. From diagnostic applications to therapeutic possibilities]

The growing use of laparoscopic techniques in general surgery over the last decade has also involved the oncological sector where it is not only used for diagnostic purposes but also for therapeutic procedures, unfortunately in the latter instance, with controversial results owing to its indiscriminate use. Where there are no contraindications, the mini-invasive approach has undoubtedly become the gold standard for the treatment of benign pathologies, such as biliary lithiasis or gastroesophageal reflux. However, video-assisted surgery is not yet sufficiently radical, and in some cases lacks the feasibility to legitimate its unqualified use in oncological practice as a valid alternative to open surgery. In the case of malignant tumours its role is hampered by major drawbacks which restrict its use to carefully selected patients. The persistent lack of randomised clinical trials in many cases still exposes the comparison between traditional laparotomy and mini-invasive procedures open to the risk of subjective opinion, unless backed up by immediate clinical evidence. It is certainly a very exciting field of surgery and this review aims to offer an extremely concise panorama of the application of these methods to oncological pathologies affecting individual organs.

A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice

OBJECTIVE

To review the effectiveness of preoperative biliary drainage (PBD) in patients with obstructive jaundice resulting from tumors.

SUMMARY BACKGROUND DATA

This was a systematic review, including a meta-analysis, of randomized controlled trials and comparative cohort studies conducted worldwide and published between 1966 and September 2001, classified on methodologic strength and subdivided into level 1 (randomized controlled trials) and level 2 (comparative cohort studies).

METHODS

Comparison was made of PBD versus no PBD in jaundiced patients undergoing resection of a tumor. Outcome measures were in-hospital death rate, overall complications resulting from the treatment modality (drainage- and surgery-related complications), and hospital stay. Effect sizes were calculated and combined in meta-analyses. Relative differences (%) were calculated to compare effects on outcome measures.

RESULTS

Five randomized controlled studies comprising 302 patients met the inclusion criteria for level 1 studies, and 18 cohort studies comprising 2,853 patients met the criteria for level 2 studies. Meta-analysis of level 1 studies showed no difference in the overall death rate between patients who had PBD and those who had surgery without PBD. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. At level 2, there was no difference in the death rate between the two treatment modalities. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. If PBD had been without complications, then complications would be in favor of drainage based on level 1 studies, and no difference based on level 2 studies. Further, PBD was not able to reduce the length of postoperative hospital stay compared with surgery without PBD; instead, it prolonged the stay.

CONCLUSIONS

This meta-analysis shows that PBD with current standards for patients with obstructive jaundice resulting from tumors carries no benefit and should not be performed routinely. The potential benefit of PBD in terms of postoperative rates of death and complications does not outweigh the disadvantage of the drainage procedure. Only if PBD-related complications could be reduced by 27% and consequently diminish hospital stay could PBD be beneficial. Further randomized controlled trials with improved PBD techniques are necessary.

Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract

BACKGROUND

Alcoholics are at risk of developing major complications in the postoperative period. Adequate prophylactic treatment, as well as preoperative abstinence, can significantly decrease the rate of complications. However, the preoperative diagnosis of alcoholism is difficult to establish. The purpose of this study was to assess whether three preoperative visits, an alcohol-related questionnaire (CAGE), and the laboratory markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) would increase the rate of detection of chronic alcoholics.

METHODS

The study included the Departments of ENT, Facial and Maxillofacial Surgery, and General Surgery of a university hospital; 705 male patients were assessed for tumor surgery of the upper digestive tract and were allocated to 5 different groups. All patients were seen three times, and five different strategies were used to detect chronic alcoholics. The gold standard was the diagnosis of alcohol misuse made by an experienced (blinded) investigator according to the DSM-III-R. The main outcome measurements were the detection rates of the different test strategies.

RESULTS

By clinical routine alone, only 16% were detected during the first visit and 34% after three visits. If the CAGE questionnaire was added, sensitivity increased to 64%. The further addition of GGT or CDT led to 80 and 85% detections, respectively. A combination of all tests had a sensitivity of 91%.

CONCLUSIONS

To detect more alcoholic patients at risk for major complications, patients should be seen more often, and additional diagnostic tools such as the CAGE, CDT, and GGT should be used before surgery.

Transcatheter microcoil embolotherapy for ruptured pseudoaneurysm following pancreatic and biliary surgery

PURPOSE

To evaluate the outcome of transcatheter microcoil embolotherapy for bleeding pseudoaneurysms complicating major pancreatic and biliary surgery.

MATERIALS AND METHODS

Over an 8-year period, 8 patients were encountered who developed massive bleeding from pseudoaneurysms 15-64 days (mean 31 days) following major pancreatic and biliary surgery. Urgent transcatheter microcoil embolotherapy was performed in all 8 patients.

RESULTS

Transcatheter embolotherapy was successful in 7 of 8 patients (88%) but failed in one due to development of disseminated intravascular coagulation. One patient developed recurrent bleeding 36 days after the first embolotherapy from a newly developed pseudoaneurysm, which was again treated successfully with embolization. Two patients subsequently underwent additional surgery for residual pathology. Three of the 7 patients with successful embolotherapy were alive at 10-96 months, 4 patients died of associated malignancies 4-20 months after embolotherapy.

CONCLUSION

Transcatheter microcoil embolotherapy is effective for bleeding pseudoaneurysms complicating pancreatic and biliary surgery, and should be considered the first treatment of choice.

Technical modifications and strategies for stenting gastric outlet strictures using esophageal endoprostheses

BACKGROUND AND STUDY AIMS

The outcome of stenting gastric outlet stricture is favorable compared with a bypass operation which has significant morbidity and mortality. In Japan, this procedure is particularly complicated by a lack of enteral stents. We report some technical stratagems for stent placement for gastric outlet strictures.

PATIENTS AND METHODS

Between February 1993 and July 2001, 23 patients with gastric outlet strictures (14 men, nine women; mean age 72 years) underwent stent placement using an esophageal stent system. The Ultraflex or Z-stents were used in 18 or five patients, respectively. With the Ultraflex, we increased the length of the delivery system. Some patients underwent stent placement with the help of endoscopic assistance with a grasping forceps or a home-made sheath.

RESULTS

The metal stent was successfully inserted in all patients. There were no complications during the procedure. Migration occurred in two out of five patients treated with the Z-stent, whereas there was no migration in patients treated with the Ultraflex stent. In two patients, curable pancreatitis was caused by pressure on the duodenal papilla. One of these patients also experienced bile stasis which required biliary decompression. There were three cases of obstruction, caused by tumor ingrowth (1), hyperplasia (1) and stent fracture (1); recanalization by an additional stent placement and/or cutting stent filaments was successful. All the patients died, with a median survival period of 52 days. There was no procedure-related mortality.

CONCLUSIONS

With some technical modification, stent placement for gastric outlet stricture, even using an esophageal stent, is feasible. This procedure offers good palliation with no major complications.

In vivo effect of haemodilution with saline on coagulation: a randomized controlled trial

BACKGROUND

Previous studies have shown that 10-30% haemodilution with crystalloid may induce a hypercoagulable state demonstrable by using the Thrombelastograph (TEG). While most are in vitro studies, the few in vivo studies are limited by confounding surgical or 'environmental' factors. We conducted this randomized controlled study to evaluate the coagulation changes associated with in vivo haemodilution.

METHODS

Twenty patients undergoing major hepatobiliary surgery were randomly allocated to one of two study groups. Group H (n = 10) had 30% blood volume withdrawn over 30 min and replaced with saline. Group C (n = 10) did not have any blood withdrawn. Blood samples were taken in both groups at 10, 20 and 30 min. Native TEG, complete blood count, coagulation profile, fibrinogen, antithrombin III, protein C and thrombin-antithrombin complex concentrations were measured.

RESULTS

Compared with Group C, Group H patients had significantly greater shortening of r-time at 30 min (-30% vs +36%), greater shortening of k-time at all time points (-36% vs +17% at 10 min; -37% vs +44% at 20 min; -45% vs +49% at 30 min), and greater widening of alpha at 30 min (+71% vs +4%). The decrease in antithrombin III and other natural procoagulants and anticoagulants closely followed that of haematocrit, with the exception of thrombin-antithrombin complex.

CONCLUSION

In vivo haemodilution of up to 30% with saline can induce a hypercoagulable state. The mechanism remains unclear as disproportionate dilution of natural anticoagulants was not detected. Thrombin-antithrombin complex concentration remained stable despite haemodilution in Group H, which may suggest increased thrombin generation.