Factors affecting the fibrinolytic response to surgery

The stress of injury and surgical operation results in an initial increase in the spontaneous fibrinolytic activity of the blood which is followed by a period of reduced activity in the postinjury or postoperative period. This 'fibrinolytic shutdown' is particularly marked in patients with malignant disease and occurs irrespective of whether or not they develop a deep venous thrombosis. It also occurs in patients with benign disease and in these patients is greater, though only on the first postoperative day, in those who develop deep venous thrombosis. Venous occlusion studies suggest that this reduction in spontaneous fibrinolytic activity may be the results of a reduction in the fibrinolytic capacity of the vascular endothelium resulting either from a deficiency of the enzyme plasminogen activator or an inability to release the enzyme from the endothelium. Changes in antiplasmins, the inhibitors of the fibrinolytic system, also occur as a result of the stress of operation. Plasma levels of alpha2-macroglobulin fall while those of alpha1-antitrypsin rise. These changes occur irrespective of the presence of malignant or benign disease and do not appear to influence the development of deep venous thrombosis.