Perioperative thrombin generation and fibrinolytic activation in patients undergoing major gynaecologic surgery for...

Perioperative coagulation disturbances are common in major gynaecological surgery, yet differences in thrombin generation (TG) and fibrinolytic activation between malignant and benign pathology remain poorly defined. We conducted an exploratory pilot study to characterise perioperative changes in fibrinolysis and TG and to compare trajectories between malignant and benign disease.

In this single-centre exploratory pilot study, 13 patients undergoing major gynaecological surgery were enrolled from June 2024 to November 2024 (malignant n=6; benign n=7). Platelet-poor plasma was sampled preoperatively, after specimen removal (T2), postoperative day 1 (T3), and 4-6 weeks after operation (T4). Fibrinolytic markers (plasminogen, antiplasmin, D-dimer, plasmin-antiplasmin complexes, plasminogen activator inhibitor-1, tissue plasminogen activator antigen) and TG parameters (lag time, endogenous thrombin potential [ETP], peak thrombin) were measured. Linear mixed-effects models were used to describe group differences and temporal changes.

In total, 12 of 13 procedures were laparoscopic; the single open procedure occurred in a patient with benign pathology. Fibrinolytic activation increased intraoperatively and on postoperative day 1 in both groups, characterised by decreased antiplasmin activity at T2 and increased D-dimer and plasmin-antiplasmin complexes at T2-T3. Fibrinolytic markers did not differ significantly between malignant and benign pathology. In contrast, TG kinetics differed by surgical indication: malignancy was associated with a longer lag time (β=3.11 min, 95% confidence interval [CI] 0.67-5.56) and lower peak thrombin (β=-84.1 nM, 95% CI -163.5 to -4.8). ETP decreased intraoperatively in both groups and showed variable recovery at T4.

In this pilot study, perioperative fibrinolytic activation was similar between malignant and benign gynaecological surgery, whereas malignancy was associated with altered TG kinetics. These preliminary findings support further investigation into coagulation phenotypes and potential implications for antifibrinolytic therapy in gynaecological oncology.