What preoperative factors affect bleeding during hepatectomy?

Preoperative Factors Affecting Bleeding During Hepatectomy

Several key preoperative factors significantly impact bleeding risk during hepatectomy, including cirrhosis, kidney dysfunction, medication use, and technical considerations related to the tumor. 1

Patient-Related Factors

Liver Function and Structure

• Presence of cirrhosis, especially Child-Turcotte-Pugh class C, significantly increases bleeding risk during hepatectomy 1
• Preoperative international normalized ratio (INR) is an independent predictor of postoperative coagulopathy, which may reflect underlying liver synthetic function 2
• Traditional coagulation tests (INR, PT) often overestimate bleeding risk and do not reliably predict procedural bleeding in hepatectomy patients 1

Hematologic Parameters

• Preoperative platelet count <100 × 10^9/L is an independent risk factor for both postoperative morbidity and mortality 3
• Preoperative prothrombin time >14 seconds is an independent risk factor for significant hospital mortality 3
• Despite common practice, there is no specific INR or platelet cutoff that reliably predicts increased bleeding risk, according to the American Association for the Study of Liver Diseases 4

Kidney Function

• Acute kidney injury significantly increases bleeding risk during hepatectomy 1
• Addressing acute and/or chronic kidney dysfunction before elective procedures is strongly recommended to reduce bleeding risk 4

Concurrent Medical Conditions

• Bacterial infections can significantly worsen bleeding risk and should be treated before surgery 1
• Hypofibrinogenemia has been identified as an independent predictor of bleeding in patients with liver disease 1

Medication-Related Factors

Antiplatelet and Anticoagulant Medications

• Medications, particularly antiplatelet therapy and anticoagulation, alter bleeding risk and should be carefully managed in the preoperative period 4
• For patients on clopidogrel, discontinuation is recommended five days prior to surgery with major bleeding risk 5
• Concomitant use of NSAIDs, anticoagulants, and other antiplatelet agents increases bleeding risk and should be discontinued when possible 5

Thromboprophylaxis Considerations

• Chemical thromboprophylaxis with low molecular weight heparin or unfragmented heparin should be started postoperatively rather than preoperatively to balance bleeding and thrombotic risks 4
• Intermittent pneumatic compression devices should be applied prior to anesthesia induction to reduce thrombotic risk without increasing bleeding 4

Tumor-Related Factors

Tumor Characteristics

• Tumor size significantly impacts bleeding risk - tumors larger than 15 cm are associated with massive bleeding (>5000 mL) compared to smaller tumors (7.9 cm average) 6
• Tumor compression of the inferior vena cava on preoperative CT scans is strongly associated with massive bleeding during hepatectomy 6
• The extent of planned liver resection correlates with bleeding risk - right major hepatectomy for primary liver cancer carries higher bleeding risk 6

Surgical Approach Considerations

• Laparoscopic approach may affect bleeding control - single-port major hepatectomy has been associated with more difficult bleeding control resulting in more transfusions compared to multiport approaches 7
• The inability to use liver-hanging maneuver during right major hepatectomy is associated with increased bleeding risk 6
• Resected liver weight is an independent predictor of coagulopathy, which may contribute to bleeding 2

Practical Recommendations

• Preoperatively identify and correct modifiable risk factors including kidney dysfunction, infections, and discontinuation of medications affecting hemostasis 4, 1
• Carefully evaluate tumor size and relationship to major vascular structures on preoperative imaging 6
• For patients with preoperative platelet count <100 × 10^9/L or prothrombin time >14 seconds, prepare for potential increased blood loss and transfusion requirements 3
• Consider surgical approach and technique based on tumor characteristics - avoid anterior approach without liver-hanging maneuver for large tumors compressing the IVC 6
• Prepare rapid infusion devices for cases with high bleeding risk factors to avoid prolonged hypotension 6

Common Pitfalls to Avoid

• Overreliance on INR/PT values to predict bleeding risk, as these parameters often overestimate coagulopathy 1
• Unnecessary prophylactic blood product transfusions based solely on laboratory values, which may increase complications without reducing bleeding 1
• Failure to discontinue antiplatelet medications with adequate lead time before surgery (5 days for clopidogrel) 5
• Neglecting to treat underlying conditions like infections or acute kidney injury that may contribute more to bleeding risk than coagulation abnormalities 4, 1