Hemostatic Complications in Hepatobiliary Surgery

Abstract

Hepatobiliary surgery is a well-known risk factor for thrombotic complications but is also associated with substantial perioperative blood loss. Given the central role of the liver in hemostasis, hepatobiliary surgery is frequently accompanied by complex changes in the hemostatic system. Increasing knowledge of these changes has resulted in an improved understanding of the etiology of some of the hemostatic complications. In the early postoperative period a prolongation of conventional coagulation test times, such as the prothrombin time, is frequently seen. Together with a decreased platelet count, this suggests a hypocoagulable state. The concomitant decline of anticoagulant factors and development of a von Willebrand factor/ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) imbalance, however, suggest a hypercoagulable state, potentially contributing to the risk of thromboembolism. Postoperative thromboprophylaxis should be initiated early to avoid thrombosis, and intensified prophylaxis might benefit high-risk patients. The risk of hemorrhagic complications during hepatobiliary surgery has diminished over time, mainly due to improved surgical and anesthesiological techniques. However, bleeding can still be profound in individual patients and is difficult to predict using (global) hemostasis tests. A restrictive transfusion and fluid infusion policy to maintain a low central venous pressure is crucial in prevention of perioperative bleeding. However, when active bleeding occurs, proactive prohemostatic management is required.

Computed Tomography-Assessed Sarcopenia Indexes Predict Major Complications following Surgery for Hepatopancreatobiliary Malignancy: A Meta-Analysis

“…With the developments in surgical technique and concept of perioperative management, the postoperative incidences of morbidity and mortality have greatly decreased; however, the condition is still not satisfactory, and the incidence of major complications after hepatopancreatobiliary surgery is still high [48][49][50]. The prevention and treatment of major complications have remained of paramount significance in improving the outcomes of patients, and the preoperative risk evaluation and clinical intervention are effective measures to prevent the occurrence of major complications.…”

Platelets as Modulators of Liver Diseases

“…In surgical procedures involving the liver, notably partial liver resections and liver transplantation, substantial perioperative changes in hemostatic components may occur. 31 These changes may occur in patients who had a normal preoperative hemostatic status, such as in the noncirrhotic patient undergoing partial hepatectomy for metastatic disease or the patient with a disorder such as familial amyloid polyneuropathy requiring a liver transplant. Perioperative hemostatic changes may also occur in patients who had cirrhosis-related hemostatic changes preoperatively.…”

Viscoelastic Tests as Point-of-Care Tests in the Assessment and Management of Bleeding and Thrombosis in Liver Disease

“…As a result, these patients have often been considered to be at an increased risk of postoperative bleeding, leading to frequent administration of blood components, and delayed thromboprophylaxis, despite evidence that postoperative VTE is more common than postoperative bleeding in this setting. 45 VETs have been used to assess whether or not a true coagulopathy exists in this setting. In a study of 40 patients undergoing hepatectomy, the authors showed that despite significant elevations in INR/PT postoperatively, TEG parameters suggested an initial hypercoagulable postoperative state, which quickly transitioned back to normal.…”