General Surgeons and Tranexamic Acid

Tranexamic acid is a synthetic derivative of the amino acid lysine that competitively inhibits the activation of plasminogen to plasmin and tissue plasminogen activator and thus interferes with fibrin binding to plasminogen and subsequent fibrinolysis. As a result of this fibrinolysis inhibition, the agent has received broad interest in surgery and has proven to be of benefit in many kinds of procedures. As for its perioperative use in general surgery, as the article by Delgado and coauthors addresses, it is a mixed bag. Most general surgeons do not perform head and neck procedures, at least not the kind included in this meta-analysis (tonsillectomies, for example) and in which, according to the authors, TXA shows promise. Of course, any neck surgery is of interest if only to avoid the formation of hematoma that might compromise airways. What about the types of trauma that many general surgeons still see? TXA is of questionable benefit, at least in the large randomized CRASH (yes) and PATCH (no) studies. Other large databases give confusing results. For example, in the POISE-3 subgroup analysis for general surgery, life-threatening and critical organ bleeding between TXA and placebo groups were not statistically different. Now, general surgeons might be most concerned about the hemorrhagic consequences of elective hepatic surgery. Few elective general surgery procedures carry the potential for life-threatening hemorrhage as liver resection does. Certainly, an agent such as TXA would be of keen interest as bleeding can be onerous, even with careful technique, proper inflow control, and use of cell-saving devices. A meta-analysis by Hashmi and coauthors found no difference in blood loss or mortality with the use of TXA and did report a higher incidence of thromboembolic events. And, of course, in the HeLiX randomized clinical trial published in JAMA in 2024, use of TXA did not reduce blood loss even for major hepatic resections and with a comparable use of blood-reducing techniques (such as the Pringle maneuver) in each group. Delgado et al found similar results. Blood loss in intra-abdominal operations, including liver resections, was not reduced by use of TXA. General surgeons beware. It seems safe to say that, for the usual general surgery operations, TXA is not a critical element in the operator’s toolbox.