Early mobilization, intermittent pneumatic compression devices and pharmacologic agents are used to prevent VTE. While pharmacologic thromboprophylaxis is widely accepted for most general surgery procedures, the fear of bleeding after major hepatectomy has limited its use (55). On the contrary, it is now evident that partial hepatectomy patients are in fact hypercoagulable. This hypercoagulability is a result of many factors including tissue

trauma, decreased synthesis of factors involved in the clotting cascade by the remnant liver, blood loss, hemodilution, increased Inhibitors,research,lifescience,medical acute phase response, malignant diagnosis, prior chemotherapy, Inhibitors,research,lifescience,medical increased age, long anesthetic times, and limited postoperative mobility (26,54,55). The reduced volume of liver not only results in reduced synthesis of procoagulants but the levels of anticoagulants: protein C, S and antithrombin decrease by more than 50%. Von Willebrand factor and factor VIII

levels are increased especially in larger resections likely due to surgical trauma. Prothombotic markers sP-Selectin and thrombin-antithrombin complexes are also significantly increased post hepatectomy. Inhibitors,research,lifescience,medical Decreased anticoagulant levels combined with increased von Willebrand factor and factor VIII produce a prothrombotic milieu that persists on postoperative day 5 when most INR values have normalized (30). Thromboelastogram monitoring also demonstrates a state of postoperative hypercoagulability after living donor hepatectomy Inhibitors,research,lifescience,medical (31). VTE may occur in the presence of elevated

standard measures of anticoagulation such as INR and PTT (56,57). A higher incidence of VTE has been noted in patients not receiving thromboprophylaxis the night of surgery (29). In a retrospective review Inhibitors,research,lifescience,medical of 415 patients undergoing major hepatectomy administration of pharmacologic thromboprophylaxis lowered the rate of VTE but did not increase the rate of red blood cell transfusion post hepatectomy (55). Pharmacologic thromboprophylaxis should be administered first starting the day of surgery unless high risk of bleeding exists. Conclusion Postoperative management after hepatic resection is challenging. Complex resections are being increasingly performed in high risk and older patient population. A well-devised, customized management approach based on patient’s overall condition, liver function, and nutritional status is vital to reduce postoperative complications and to achieve optimal outcomes. Footnotes No potential check details conflict of interest.

In Western countries pancreatic cancer represents the fourth cause of cancer death and its incidence rates, between 6 and 10 per 100000 populations, has increased in the last 30 years.