Original Research Article| Volume 224, ISSUE 1, P69-74, July 2022

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The vexing triad of obesity, alcohol, and coagulopathy predicts the need for multiple operations in liver transplantation

Published:February 18, 2022DOI:


      • Liver transplant recipient BMI greater than 30 and donor history of heavy alcohol use is associated with an 80% return rate to the operating room.
      • During liver transplantation, clot strength less than 45 mm during the anheptic and early reperfusion is associated with greater than 20 units of intraoperative blood loss and 80% return rate to the operating room.
      • The combination of coagulopathy, obesity, and donor alcohol heavy use is associated with an 100% rate of return to the operating room.



      One in four liver transplants (LT) require return to the operating room(R-OR) within 48 h of surgery. We hypothesize that donor, recipient, and intraoperative factors will predict R-OR.


      LT recipients were enrolled in an observational study to measure coagulation with thrombelastography (TEG) were assessed with transplant recipient and donor variables for risk of R-OR.


      160 recipients with a median age of 55 years and a MELD-Na of 22 were analyzed. R-OR occurred in 22%. Recipient BMI (p = 0.006), donor heavy alcohol use (p = 0.017), TEG MA (p = 0.013) during the anhepatic phase of surgery, TEG MA at anhepatic and 30-min after reperfusion (p < 0.05), and red blood cell transfusions (p < 0.001) were associated with R-OR.


      The vexing triad of recipient obesity, heavy donor alcohol use, and low TEG MA were associated with a high rate of R-OR. Strategies to reduce this sub-optimal combination of risk factors could reduce the frequency of unplanned re-operations.


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