Sarah Bos

128 CHAPTER 7 Concluding remarks The intricate balance of hemostasis in patients with cirrhosis and in patients undergoing HPB-surgery is difficult to depict in an overall hemostasis test. For all parts of hemostasis there are various tests available, all with their own advantages and disadvantages. Targeting therapy on a test that does not provide an accurate reflection of hemostasis is troublesome. Since there is no gold standard to test hemostasis, local preferences occur and pro-and anticoagulant strategies might differ between countries, hospitals, and even inside hospitals itself. This thesis is a step forward in providing rationale for further clinical studies on the use of pro-and anticoagulant therapies in patients with cirrhosis and in patients undergoing HPB-surgery. Future perspectives Future studies will have to address whether enhanced thrombin generation in patients with cirrhosis contributes to the elevated risk of important clinical outcomes, such as venous thrombosis and/or PVT, and what steps should be taken to safely decrease the hypercoagulable state to avoid thrombotic events in this patient population. To establish which of the currently available anticoagulants is the best option in the treatment of any kind of thrombosis in cirrhosis, more long term safety and efficacy data is required. Long-term cohort studies on the use of anticoagulants in this patient population will lead to better answers. Peri-operative hemostatic management still needs further optimizing. This thesis provides solid in vitro results to further explore the options of in vivo hemostatic management.