• intraoperative
• liver transplant
• massive transfusion
• predictors

• Humans
• Male
• Adolescent
• Young Adult
• Adult
• Middle Aged
• Aged
• Female
• Liver Transplantation
• End Stage Liver Disease/surgery
• Blood Loss, Surgical
• Retrospective Studies
• Severity of Illness Index
• Blood Transfusion
• Hemoglobins/analysis

• Blood loss
• Blood transfusion
• Fibrinogen level
• Orthotopic liver transplantation
• Postoperative outcomes

• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Blood Transfusion
• Erythrocyte Transfusion/adverse effects
• Fibrinogen
• End Stage Liver Disease

• Coagulopathy
• Hepatectomy
• Liver splitting
• Massive bleeding
• Transfusion

• bleeding
• hepatectomy
• hepatocellular carcinoma
• prognostic nutritional index
• transfusion

• HI18C2383 Korea Health Industry Development Institute

• SHapley Additive exPlanations
• liver transplantation
• machine learning
• prediction model
• red blood cell transfusion

Liver produces most of the blood coagulation factors, so it is not surprising to see a deranged coagulation profile in patients receiving liver transplants. Besides standard laboratory methods to evaluate coagulation profile, point-of-care assays are being used regularly since their results are rapidly available. However, sparse information is available on the comparability of point-of-care coagulation assays with laboratory coagulation assays in this special setting. In this study, our aim is to observe the changing hemostatic profile during different stages of liver transplant surgery using laboratory-based tests and thromboelastography (TEG).

Fifty patients undergoing living donor liver transplantation surgery were selected. Coagulation tests (prothrombin time [PT], activated partial thromboplastin time [APTT], platelet count, and fibrinogen) and TEG were performed at various intervals during liver transplant surgeries – before induction of anesthesia, 2 h into dissection phase, 30 min into anhepatic phase, 30 min after reperfusion of homograft, postoperative – at closure of surgery, 12 h postoperative, and 24 h postoperative. Statistical analysis and Pearson correlation were performed between laboratory-based coagulation tests and TEG, and their pattern through various stages of the surgery analyzed.

Platelet count and fibrinogen have a significant positive correlation with TEG in almost all phases of liver transplant. PT and APTT have a positive correlation with TEG until uptake of new liver and predominantly negative correlation after that. However, this correlation is significant only before induction of anesthesia and anhepatic phase.

TEG can be used to estimate platelet count and fibrinogen concentrations in all phases but PT and APTT only before induction and anhepatic phase of liver transplant surgery. The decision regarding transfusion of blood products should be based on a combination of the clinical assessment of surgeon and anesthesia personnel combined with results from laboratory and TEG.

• Blood product transfusion
• Hemostasis monitoring
• Liver transplantation
• Patient-centered care
• Thromboelastography
• Viscoelastic tests

• Adult
• End Stage Liver Disease/surgery
• Humans
• Liver Transplantation/adverse effects
• Propensity Score
• Retrospective Studies
• Severity of Illness Index
• Thrombelastography

• High-acuity transplant
• Liver transplantation
• Previous abdominal surgery
• Transplant risk-stratification
• Upper abdominal surgery

• Blood loss
• Living donor liver transplantation
• Nutritional therapy
• Rehabilitation
• Visceral adiposity
• Visceral-to-subcutaneous adipose tissue ratio (VSR)

The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.

• Blood loss
• extracorporeal life support (ECLS)
• lung transplantation
• thoracic surgery

Despite improvements in techniques and management of liver transplant patients, numerous perioperative complications that contribute to perioperative mortality remain. Models to predict intraoperative massive blood transfusion, prolonged mechanical ventilation, or in-hospital mortality in liver transplant recipients have not been identified. In this study we aim to identify preoperative factors associated with the above mentioned complications.

A retrospective observational analysis was conducted on data collected from 124 orthotopic liver transplants performed at a single institution between 2014 and 2017. A multivariable logistic regression using backwards elimination was performed for three defined outcomes (massive transfusion ≥ 10 units packed red blood cells (PRBC), prolonged mechanical ventilation > 24 h, and in-hospital mortality) to identify associations with preoperative characteristics.

Statistically significant (P < 0.05) associations with massive transfusion ≥ 10 units PRBC were hepatocellular carcinoma and preoperative transfusion of PRBC. Significant associations with prolonged mechanical ventilation > 24 h were hepatitis C, alcoholic hepatitis, elevated preoperative alanine aminotransferase, and hepatorenal syndrome. Male gender was protective for requiring prolonged mechanical ventilation. End-stage renal disease and hepatitis B were significantly associated with increased in-hospital mortality.

This study identified risk factors associated with common perioperative complications of liver transplantation. These factors may assist practitioners in risk stratification and may form the basis for further investigations of potential interventions to mitigate these risks.

• Blood transfusion
• Carcinoma, hepatocellular
• Hepatitis C
• Liver cirrhosis
• Liver transplantation
• Mechanical ventilation

• MELD
• bleeding
• liver transplantation
• transfusion

• blood transfusion
• liver transplantation
• living donor
• predictor
• red blood cell
• risk factor

• Adult
• Aged
• Diagnosis
• Erythrocyte Transfusion/methods
• Erythrocyte Transfusion/standards
• Erythrocyte Transfusion/statistics & numerical data
• Female
• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Living Donors
• Male
• Middle Aged
• ROC Curve
• Republic of Korea
• Retrospective Studies
• Risk Factors
• Statistics, Nonparametric
• Treatment Outcome

• atelectasis
• intensive care
• liver transplantation
• pleural effusions
• pneumonia
• pulmonary complications
• pulmonary edema
• risk factors

• Critical Care
• Humans
• Kidney Failure, Chronic/surgery
• Liver Transplantation/adverse effects
• Lung Diseases/diagnosis
• Lung Diseases/therapy
• Pleural Effusion/diagnosis
• Pleural Effusion/therapy
• Pneumonia/diagnosis
• Pneumonia/therapy
• Postoperative Complications/diagnosis
• Postoperative Complications/therapy
• Preoperative Care
• Pulmonary Atelectasis/diagnosis
• Pulmonary Atelectasis/therapy
• Pulmonary Edema/diagnosis
• Pulmonary Edema/therapy
• Risk Factors

This study analyzes the impact of laparoscopic liver resection on intra-abdominal adhesion.

Patients who underwent salvage liver transplantation after liver resection for hepatocellular carcinoma from January 2012 to October 2017 at our institution were included. Information about the severity of intra-abdominal adhesions was collected from a prospectively maintained database. Intra-abdominal adhesions were graded after the agreement of 2 surgeons who participated in the salvage liver transplantation based on predetermined criteria. Adhesion severity and demographic, operative, and postoperative data were compared between the laparoscopic group and the open group. Multivariate logistic regression was performed to consider potential factors related to severe adhesion during salvage transplantation.

Sixty-two patients who underwent salvage liver transplantation after liver resection were included in this study. Among them, 52 patients underwent open surgery, and 10 patients underwent laparoscopy. Adhesion was significantly more severe in the open group than in the laparoscopy group (P = 0.029). A multivariate logistic regression model including potential factors related to severe adhesion showed that laparoscopy (odds ratio, 0.168; 95% confidence interval, 0.029–0.970; P = 0.048) was the only significant factor.

Laparoscopic liver resection for hepatocellular carcinoma can minimize intra-abdominal adhesion during salvage liver transplantation.

• H epatocellular carcinoma
• Laparoscopy
• Liver transplantation
• Surgical adhesion

Massive blood loss has been a dreaded complication of liver transplantation, and the accompanying transfusion is associated with adverse outcomes in the form of decreased patient and graft survival. With advances in both surgical techniques and anesthetic management during transplantation, blood and blood products requirements reduced significantly. However, transfusion practices vary among different centers. The altered coagulation parameters in patients with liver cirrhosis results in a state of “rebalanced hemostasis” and patients are just as likely to clot as they are to bleed. Commonly used coagulation tests do not always reflect this new state and can, therefore, be misleading. Transfusion of blood products solely to correct abnormal parameters may worsen the coagulation status, thus adversely affecting patient outcome. Point-of-care tests such as thromboelastometry more reliably predict the risk of bleeding in these patients and in addition may provide quicker turnaround times compared to routine tests. Perioperative management should also include the possibility of thrombosis in these patients, and the use of low-molecular-weight heparin correlates with better patient survival. This review article aims to highlight the concept of rebalanced hemostasis, limitation of routine coagulation tests, and harmful effect of empiric transfusion of blood products.

• Hepatic anesthesia
• liver transplant coagulation
• liver transplantation
• point-of-care tests
• rebalanced hemostasis
• transfusion

• clot formation
• liver transplantation
• thrombin generation
• viscoelastic assays

• liver transplantation
• massive transfusion
• pRBC utilization
• patient blood management
• predictive model

• Bleeding complication
• Central venous catheter
• Platelet count
• Thrombocytopenia

• anticoagulants
• antifibrinolytics
• cardiac arrest
• cardiovascular collapse
• inotropic support
• intracardiac thrombosis
• liver transplantation
• multidisciplinary management
• postreperfusion syndrome
• procoagulants
• pulmonary embolism
• right ventricle
• selective pulmonary vasodilation
• transesophageal echocardiography
• venovenous bypass
• von Willebrand factor

• Crohn’s disease
• Primary sclerosing cholangitis
• cholangiocarcinoma
• colorectal cancer
• inflammatory bowel disease
• liver transplantation
• ulcerative colitis

• hemorrhage
• pediatric liver transplantation
• predictive factors
• surgery
• transfusion

From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.

• Liver transplantation
• Massive transfusion
• Coagulopathy

• carboxipeptidase b2
• fibrinolysis
• liver transplantation
• hemorrhage
• fibrinogen
• meld

• Aged
• Blood Loss, Surgical
• Carboxypeptidase B2/metabolism
• Female
• Fibrinogen/metabolism
• Humans
• Linear Models
• Liver Transplantation/methods
• Liver Transplantation/mortality
• Male
• Middle Aged
• Pilot Projects
• Postoperative Period
• Preoperative Period
• Time Factors

Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.

• Liver transplantation
• Transfusion
• Blood conservation
• Patient blood management
• Coagulation

• Chronic liver disease
• convention coagulation parameters
• ultrasound guided central vein cannulation

• anesthesia
• live donor
• liver transplantation
• review

• ABO Blood-Group System
• Anesthesia, General/methods
• Blood Coagulation Disorders/therapy
• Blood Transfusion
• Female
• Hemodynamics
• Humans
• Intraoperative Complications
• Liver Transplantation
• Living Donors
• Pregnancy

There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.

• Liver disease
• Transplantation
• Coagulation
• Transfusion
• Patient blood management
• Thromboelastography
• Cell salvage

• Blood Coagulation
• Blood Transfusion
• Elasticity
• End Stage Liver Disease/therapy
• Humans
• Liver Transplantation
• Platelet Transfusion
• Postoperative Complications
• Risk Factors
• Thrombelastography
• Treatment Outcome
• Viscosity

• cause of death
• liver transplantation
• risk factors
• survival