Sarah Bos

77 Hemostatic complications in hepatobiliary surgery 5 association of CMV with an increased risk of HAT,(109,110) screening, and early thromboprophylaxis and/or antiviral treatment should be considered. Another possibility in the prevention of HAT is treatment with platelet inhibitors. Two independent studies have shown a significant incidence reduction of HAT by aspirin.(111,112) One of the studies reported a reduction in the overall incidence of HAT from 4.6 to 3.0%,(111)the second study reported an incidence reduction of late HAT from 3.6 to 0.6%.(112) Even though these studies are limited by their retrospective design and study populations are heterogeneous; there was a clear benefit of antiplatelet use without an increase in bleeding events. A further well- designed randomized study to explore safety and efficacy of aspirin to prevent HAT would be indicated. Next, to prophylaxis, early detection of HAT via screening with the regular use of Doppler ultrasound or contrast enhanced ultrasound could be considered.(73,75,78,113) Conclusion Laboratory studies and clinical observations have changed the insights in the hemostatic status during and following hepatobiliary surgery. Whereas conventional hemostasis tests (platelet count, PT/INR) are suggestive of a perioperative- bleeding tendency, more advanced hemostatic tests indicate a balanced hemostasis with hypercoagulable features. The concept of maintenance of hemostatic balance with hypercoagulable features is reflected in the thrombotic risk following liver surgery. Nevertheless, intraoperative bleeding remains a concern, and further refinements in hemostatic management are required to decrease (excessive) blood loss in individual patients. Our management strategies include avoidance of prophylactic correction of abnormal hemostasis tests since they do not predict bleeding events. Blood loss can be minimized through surgical techniques and anesthesiological interventions including a restrictive fluid infusion policy. We advise to use blood products wisely and preferably only when active bleeding occurs. The use of blood products should be guided by conventional hemostasis tests or point-of-care testing, based on the local experience. Because of a hypercoagulable postoperative state following liver surgery, we suggest initiating pharmacological thromboprophylaxis with low molecular weight heparin as soon as possible. We routinely start thromboprophylaxis at 6 hours after surgery unless active bleeding occurs. It is plausible that a higher dosage of postoperative thromboprophylaxis is needed for specific patient populations with increased risk of thrombotic complications. The prevalence of VTE in hepatobiliary surgery patients, even in those that receive early thromboprophylaxis, stresses the need for further research to optimize thromboprophylaxis in these patients.