Skip to main content
SpringerLink
Log in

Surgery in the Thrombocytopenic and Coagulopathic Patient

  • Chapter
  • First Online:
Surgical Emergencies in the Cancer Patient

  • 933 Accesses

Abstract

Operative therapy in thrombocytopenic or coagulopathic patients, especially those with an underlying malignant condition, remains a challenge in surgical practice today. This chapter provides an overview over causes and treatment options for thrombocytopenia and coagulopathies in cancer patients. Mechanism of action, half-life, and reversibility are discussed for several pharmaceutical anticoagulants including warfarin, heparin, low-molecular-weight heparin, fondaparinux, direct factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), and direct factor IIa inhibitors (dabigatran, argatroban, and bivalirudin). Availability and costs of absorbable matrix products, biologic agents, and energy-based devices as options for intraoperative hemostatic support are being reviewed. Knowledge of physiologic mechanisms and pharmaceutical hemostatic options will complement thoughtful indications and diligent intraoperative techniques applied by the surgeon taking care of cancer patients with increased bleeding risks.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. The 2011 National blood collection and utilization survey report. http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf.

  2. Glance LG, et al. Preoperative thrombocytopenia and postoperative outcomes after noncardiac surgery. Anesthesiology. 2014;120(1):62–75.

    Article  PubMed  Google Scholar 

  3. Williamson DR, et al. Thrombocytopenia in critically ill patients receiving thromboprophylaxis: frequency, risk factors, and outcomes. Chest. 2013;144(4):1207–15.

    Article  PubMed  Google Scholar 

  4. Stasi R. How to approach thrombocytopenia. Hematol Am Soc Hematol Educ Prog. 2012;2012:191–7.

    Google Scholar 

  5. Coppola A, et al. Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery. Cochrane Database Syst Rev. 2015;2, CD009961.

    Google Scholar 

  6. Hermans C, et al. Replacement therapy for invasive procedures in patients with haemophilia: literature review, European survey and recommendations. Haemophilia. 2009;15(3):639–58.

    Article  CAS  PubMed  Google Scholar 

  7. Grottke O, Fries D, Nascimento B. Perioperatively acquired disorders of coagulation. Curr Opin Anaesthesiol. 2015;28(2):113–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Coumadin (warfarin) [prescribing information]. Princeton, NJ: Bristol-Meyers Squibb; October 2011.

    Google Scholar 

  9. Levy JH, Tanaka KA, Dietrich W. Perioperative hemostatic management of patients treated with vitamin K antagonists. Anesthesiology. 2008;109(5):918–26.

    Article  CAS  PubMed  Google Scholar 

  10. Sarode R, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation. 2013;128(11):1234–43.

    CAS  PubMed  Google Scholar 

  11. Aguilar MI, et al. Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion. Mayo Clin Proc. 2007;82(1):82–92.

    Article  CAS  PubMed  Google Scholar 

  12. Heparin sodium in 0.9% sodium chloride [prescribing information]. Lake Forest, IL: Hospira; April 2014.

    Google Scholar 

  13. Cruickshank MK, et al. A standard heparin nomogram for the management of heparin therapy. Arch Intern Med. 1991;151(2):333–7.

    Article  CAS  PubMed  Google Scholar 

  14. de Swart CA, et al. Kinetics of intravenously administered heparin in normal humans. Blood. 1982;60(6):1251–8.

    PubMed  Google Scholar 

  15. Jaques LB. Protamine—antagonist to heparin. Can Med Assoc J. 1973;108(10):1291–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Fragmin® prescribing information. New York, NY: Pfizer Inc.; October 2010.

    Google Scholar 

  17. Innohep® prescribing information. Parsippany, NJ: LEO Pharma Inc.; May 2010.

    Google Scholar 

  18. Lovenox ® prescribing information. Bridgewater, NJ: Sanofi-Aventis U.S. LLC; April 2011.

    Google Scholar 

  19. Hirsh J, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed.). Chest. 2008;133(6 Suppl):141s–59s.

    Article  CAS  PubMed  Google Scholar 

  20. Weitz JI. Low-molecular-weight heparins. N Engl J Med. 1997;337(10):688–98.

    Article  CAS  PubMed  Google Scholar 

  21. Garcia DA, et al. Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e24S–43.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Harenberg J, et al. Inhibition of low molecular weight heparin by protamine chloride in vivo. Thromb Res. 1985;38(1):11–20.

    Article  CAS  PubMed  Google Scholar 

  23. Massonnet-Castel S, et al. Partial reversal of low molecular weight heparin (PK 10169) anti-Xa activity by protamine sulfate: in vitro and in vivo study during cardiac surgery with extracorporeal circulation. Haemostasis. 1986;16(2):139–46.

    CAS  PubMed  Google Scholar 

  24. Warkentin TE, et al. Anti-platelet factor 4/heparin antibodies in orthopedic surgery patients receiving antithrombotic prophylaxis with fondaparinux or enoxaparin. Blood. 2005;106(12):3791–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Warkentin TE, Greinacher A, Koster A. Bivalirudin. Thromb Haemost. 2008;99(5):830–9.

    CAS  PubMed  Google Scholar 

  26. Arixtra (fondaparinux) [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline.

    Google Scholar 

  27. Bauer KA. Fondaparinux sodium: a selective inhibitor of factor Xa. Am J Health Syst Pharm. 2001;58 Suppl 2:S14–7.

    CAS  PubMed  Google Scholar 

  28. Buller HR, et al. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379(9811):123–9.

    Article  PubMed  Google Scholar 

  29. Perzborn E, et al. The discovery and development of rivaroxaban, an oral, direct factor Xa inhibitor. Nat Rev Drug Discov. 2011;10(1):61–75.

    Article  CAS  PubMed  Google Scholar 

  30. Wong PC, et al. Apixaban, an oral, direct and highly selective factor Xa inhibitor: in vitro, antithrombotic and antihemostatic studies. J Thromb Haemost. 2008;6(5):820–9.

    Article  CAS  PubMed  Google Scholar 

  31. Camm AJ, Bounameaux H. Edoxaban: a new oral direct factor xa inhibitor. Drugs. 2011;71(12):1503–26.

    Article  CAS  PubMed  Google Scholar 

  32. Schulman S, Crowther MA. How I treat with anticoagulants in 2012: new and old anticoagulants, and when and how to switch. Blood. 2012;119(13):3016–23.

    Article  CAS  PubMed  Google Scholar 

  33. Turpie AG, et al. Management consensus guidance for the use of rivaroxaban—an oral, direct factor Xa inhibitor. Thromb Haemost. 2012;108(5):876–86.

    Article  CAS  PubMed  Google Scholar 

  34. Kubitza D, et al. Safety, pharmacodynamics, and pharmacokinetics of BAY 59-7939—an oral, direct Factor Xa inhibitor—after multiple dosing in healthy male subjects. Eur J Clin Pharmacol. 2005;61(12):873–80.

    Article  CAS  PubMed  Google Scholar 

  35. Frost C, et al. Apixaban, an oral, direct factor Xa inhibitor: single dose safety, pharmacokinetics, pharmacodynamics and food effect in healthy subjects. Br J Clin Pharmacol. 2013;75(2):476–87.

    Article  CAS  PubMed  Google Scholar 

  36. Savaysa (edoxaban) [prescribing information]. Parsippany, NJ: Daiichi Sankyo; January 2015.

    Google Scholar 

  37. Hillarp A, et al. Effects of the oral, direct factor Xa inhibitor rivaroxaban on commonly used coagulation assays. J Thromb Haemost. 2011;9(1):133–9.

    Article  CAS  PubMed  Google Scholar 

  38. Eerenberg ES, et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation. 2011;124(14):1573–9.

    Article  CAS  PubMed  Google Scholar 

  39. Godier A, et al. Evaluation of prothrombin complex concentrate and recombinant activated factor VII to reverse rivaroxaban in a rabbit model. Anesthesiology. 2012;116(1):94–102.

    Article  CAS  PubMed  Google Scholar 

  40. Marlu R, et al. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban: a randomised crossover ex vivo study in healthy volunteers. Thromb Haemost. 2012;108(2):217–24.

    Article  CAS  PubMed  Google Scholar 

  41. Dickneite G, Hoffman M. Reversing the new oral anticoagulants with prothrombin complex concentrates (PCCs): what is the evidence? Thromb Haemost. 2014;111(2):189–98.

    Article  CAS  PubMed  Google Scholar 

  42. Koscielny J, Rutkauskaite E. Rivaroxaban and hemostasis in emergency care. Emerg Med Int. 2014;2014:935474.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Lu G, et al. A specific antidote for reversal of anticoagulation by direct and indirect inhibitors of coagulation factor Xa. Nat Med. 2013;19(4):446–51.

    Article  CAS  PubMed  Google Scholar 

  44. Sullivan Jr DW, et al. Nonclinical safety assessment of PER977: a small molecule reversal agent for new oral anticoagulants and heparins. Int J Toxicol. 2015;34(4):308–17.

    Article  CAS  PubMed  Google Scholar 

  45. Di Nisio M, Middeldorp S, Buller HR. Direct thrombin inhibitors. N Engl J Med. 2005;353(10):1028–40.

    Article  PubMed  Google Scholar 

  46. Laux V, et al. Direct inhibitors of coagulation proteins—the end of the heparin and low-molecular-weight heparin era for anticoagulant therapy? Thromb Haemost. 2009;102(5):892–9.

    CAS  PubMed  Google Scholar 

  47. Swan SK, Hursting MJ. The pharmacokinetics and pharmacodynamics of argatroban: effects of age, gender, and hepatic or renal dysfunction. Pharmacotherapy. 2000;20(3):318–29.

    Article  CAS  PubMed  Google Scholar 

  48. van Ryn J, et al. Dabigatran etexilate—a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost. 2010;103(6):1116–27.

    Article  PubMed  Google Scholar 

  49. Wanek MR, et al. Safe use of hemodialysis for dabigatran removal before cardiac surgery. Ann Pharmacother. 2012;46(9), e21.

    Article  PubMed  Google Scholar 

  50. Khadzhynov D, et al. Effective elimination of dabigatran by haemodialysis. A phase I single-centre study in patients with end-stage renal disease. Thromb Haemost. 2013;109(4):596–605.

    Article  CAS  PubMed  Google Scholar 

  51. Getta B, et al. Intermittent haemodialysis and continuous veno-venous dialysis are effective in mitigating major bleeding due to dabigatran. Br J Haematol. 2015;169(4):603–4.

    Article  CAS  PubMed  Google Scholar 

  52. Schiele F, et al. A specific antidote for dabigatran: functional and structural characterization. Blood. 2013;121(18):3554–62.

    Article  CAS  PubMed  Google Scholar 

  53. Glund S, et al. Safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in healthy male volunteers: a randomised, placebo-controlled, double-blind phase 1 trial. Lancet. 2015;386(9994):680–90.

    Article  CAS  PubMed  Google Scholar 

  54. Pollack Jr CV, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015;373(6):511–20.

    Article  CAS  PubMed  Google Scholar 

  55. Sniecinski RM, Levy JH. Bleeding and management of coagulopathy. J Thorac Cardiovasc Surg. 2011;142(3):662–7.

    Article  PubMed  Google Scholar 

  56. Menkis AH, et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery: a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations (Phila). 2012;7(4):229–41.

    Article  PubMed  Google Scholar 

  57. Bonello VA, et al. Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation. Tech Coloproctol. 2014;18(10):887–93.

    Article  CAS  PubMed  Google Scholar 

  58. Sankaranarayanan G, et al. Common uses and cited complications of energy in surgery. Surg Endosc. 2013;27(9):3056–72.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Garas G, et al. Which hemostatic device in thyroid surgery? A network meta-analysis of surgical technologies. Thyroid. 2013;23(9):1138–50.

    Article  PubMed  Google Scholar 

  60. Vellimana AK, et al. Current technological advances of bipolar coagulation. Neurosurgery. 2009;64(3 Suppl):ons11–8. discussion ons19.

    PubMed  Google Scholar 

  61. Grasso G, Giambartino F, Iacopino DG. Hemostasis in brain tumor surgery using the Aquamantys system. Med Sci Monit. 2014;20:538–43.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Reuter NP, Martin II RC. Microwave energy as a precoagulative device to assist in hepatic resection. Ann Surg Oncol. 2009;16(11):3057–63.

    Article  PubMed  Google Scholar 

  63. Heverhagen AE, et al. Harmonic scalpel versus conventional dissection technique in pylorus-preserving partial duodenopancreatectomy. Dig Surg. 2012;29(5):420–5.

    Article  CAS  PubMed  Google Scholar 

  64. Schwarz RE. Experience with a simple clamp-crush technique devoid of other devices for liver resections in a surgical oncology practice. Am J Surg. 2015;209(3):503–8.

    Article  PubMed  Google Scholar 

  65. Kheirabadi B. Evaluation of topical hemostatic agents for combat wound treatment. US Army Med Dep J 2011:25–37.

    Google Scholar 

  66. Simo KA, et al. Hemostatic agents in hepatobiliary and pancreas surgery: a review of the literature and critical evaluation of a novel carrier-bound fibrin sealant (TachoSil). ISRN Surg. 2012;2012:729086.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Saif R, et al. Use of fibrin-based sealants and gelatin-matrix hemostats in laparoscopic liver surgery. Surg Laparosc Endosc Percutan Tech. 2011;21(3):131–41.

    Article  PubMed  Google Scholar 

  68. Croxtall JD, Scott LJ. Recombinant human thrombin: in surgical hemostasis. BioDrugs. 2009;23(5):333–8.

    Article  CAS  PubMed  Google Scholar 

  69. Maisano F, et al. TachoSil surgical patch versus conventional haemostatic fleece material for control of bleeding in cardiovascular surgery: a randomised controlled trial. Eur J Cardiothorac Surg. 2009;36(4):708–14.

    Article  PubMed  Google Scholar 

  70. Rickenbacher A, et al. Efficacy of TachoSil a fibrin-based haemostat in different fields of surgery—a systematic review. Expert Opin Biol Ther. 2009;9(7):897–907.

    Article  CAS  PubMed  Google Scholar 

  71. Frilling A, et al. Effectiveness of a new carrier-bound fibrin sealant versus argon beamer as haemostatic agent during liver resection: a randomised prospective trial. Langenbecks Arch Surg. 2005;390(2):114–20.

    Article  PubMed  Google Scholar 

  72. Fischer L, et al. Hemostatic efficacy of TachoSil in liver resection compared with argon beam coagulator treatment: an open, randomized, prospective, multicenter, parallel-group trial. Surgery. 2011;149(1):48–55.

    Article  PubMed  Google Scholar 

  73. Matonick JP, Hammond J. Hemostatic efficacy of EVARREST, Fibrin Sealant Patch vs. TachoSil(R) in a heparinized swine spleen incision model. J Invest Surg. 2014;27(6):360–5.

    Article  PubMed  Google Scholar 

  74. Ollinger R, et al. A multicentre, randomized clinical trial comparing the Veriset haemostatic patch with fibrin sealant for the management of bleeding during hepatic surgery. HPB (Oxford). 2013;15(7):548–58.

    Article  Google Scholar 

  75. Moench C, et al. Randomized controlled multicenter trial on the effectiveness of the collagen hemostat Sangustop(R) compared with a carrier-bound fibrin sealant during liver resection (ESSCALIVER study, NCT00918619). Langenbecks Arch Surg. 2014;399(6):725–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. Verhoef C, et al. Fibrocaps for surgical hemostasis: two randomized, controlled phase II trials. J Surg Res. 2015;194(2):679–87.

    Article  PubMed  Google Scholar 

  77. Johansson PI, Ostrowski SR, Secher NH. Management of major blood loss: an update. Acta Anaesthesiol Scand. 2010;54(9):1039–49.

    Article  CAS  PubMed  Google Scholar 

  78. Colombo GL, et al. Economic and outcomes consequences of TachoSil(R): a systematic review. Vasc Health Risk Manag. 2014;10:569–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Krishna SG, et al. Safety of endoscopic interventions in patients with thrombocytopenia. Gastrointest Endosc. 2014;80(3):425–34.

    Article  PubMed  Google Scholar 

  80. Yap FY, et al. Transcatheter embolotherapy for gastrointestinal bleeding: a single center review of safety, efficacy, and clinical outcomes. Dig Dis Sci. 2013;58(7):1976–84.

    Article  CAS  PubMed  Google Scholar 

  81. Albeniz Arbizu E, et al. Fibrin-glue sealed liver biopsy in patients with a liver transplantation or in liver transplantation waiting list: preliminary results. Transplant Proc. 2003;35(5):1911–2.

    Article  CAS  PubMed  Google Scholar 

  82. Gaba RC, et al. Safety and efficacy of StarClose SE Vascular Closure System in high-risk liver interventional oncology patients. J Vasc Access. 2012;13(4):415–20.

    PubMed  Google Scholar 

  83. Prajapati HJ, et al. Safety and efficacy of a circumferential clip-based vascular closure device in cirrhotic and coagulopathic patients with hepatocellular carcinoma after doxorubicin drug-eluting beads transarterial chemoembolization. Cardiovasc Intervent Radiol. 2014;37(3):664–70.

    Article  PubMed  Google Scholar 

  84. Federici AB, Vanelli C, Arrigoni L. Transfusion issues in cancer patients. Thromb Res. 2012;129 Suppl 1:S60–5.

    Article  CAS  PubMed  Google Scholar 

  85. Carson JL, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012;157(1):49–58.

    Article  PubMed  Google Scholar 

  86. Kaufman RM, et al. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2015;162(3):205–13.

    Article  PubMed  Google Scholar 

  87. Slichter SJ. Relationship between platelet count and bleeding risk in thrombocytopenic patients. Transfus Med Rev. 2004;18(3):153–67.

    Article  PubMed  Google Scholar 

  88. Nahirniak S, et al. Guidance on platelet transfusion for patients with hypoproliferative thrombocytopenia. Transfus Med Rev. 2015;29(1):3–13.

    Article  PubMed  Google Scholar 

  89. Shehata N, et al. ABO-identical versus nonidentical platelet transfusion: a systematic review. Transfusion. 2009;49(11):2442–53.

    Article  PubMed  Google Scholar 

  90. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev. 2007;21(6):327–48.

    Article  PubMed  Google Scholar 

  91. Seth R, et al. Surgical stress promotes the development of cancer metastases by a coagulation-dependent mechanism involving natural killer cells in a murine model. Ann Surg. 2013;258(1):158–68.

    Article  PubMed  Google Scholar 

  92. Hallet J, et al. The impact of perioperative red blood cell transfusions on long-term outcomes after hepatectomy for colorectal liver metastases. Ann Surg Oncol. 2015;22:4038–45.

    Article  PubMed  Google Scholar 

  93. Velasquez JF, Cata JP. Transfusions of blood products and cancer outcomes. Rev Esp Anestesiol Reanim. 2015;62:461–7.

    Article  CAS  PubMed  Google Scholar 

  94. Cai Y, Liu X, Peng B. Should we routinely transfuse platelet for immune thrombocytopenia patients with platelet count less than 10 x 10(9)/L who underwent laparoscopic splenectomy? World J Surg. 2014;38(9):2267–72.

    Article  PubMed  Google Scholar 

  95. Weitz J, et al. Interaction of splenectomy and perioperative blood transfusions on prognosis of patients with proximal gastric and gastroesophageal junction cancer. J Clin Oncol. 2003;21(24):4597–603.

    Article  PubMed  Google Scholar 

  96. Stewart JH, Castaldi PA. Uraemic bleeding: a reversible platelet defect corrected by dialysis. Q J Med. 1967;36(143):409–23.

    CAS  PubMed  Google Scholar 

  97. Lindsay RM, et al. Improvement of platelet function by increased frequency of hemodialysis. Clin Nephrol. 1978;10(2):67–70.

    CAS  PubMed  Google Scholar 

  98. Watson AJ, Keogh JA. 1-Deamino-8-D-arginine vasopressin as a therapy for the bleeding diathesis of renal failure. Am J Nephrol. 1984;4(1):49–51.

    Article  CAS  PubMed  Google Scholar 

  99. Mannucci PM, et al. Deamino-8-D-arginine vasopressin shortens the bleeding time in uremia. N Engl J Med. 1983;308(1):8–12.

    Article  CAS  PubMed  Google Scholar 

  100. Byrnes JJ, Larcada A, Moake JL. Thrombosis following desmopressin for uremic bleeding. Am J Hematol. 1988;28(1):63–5.

    Article  CAS  PubMed  Google Scholar 

  101. Janson PA, et al. Treatment of the bleeding tendency in uremia with cryoprecipitate. N Engl J Med. 1980;303(23):1318–22.

    Article  CAS  PubMed  Google Scholar 

  102. Sileshi B, et al. Application of energy-based technologies and topical hemostatic agents in the management of surgical hemostasis. Vascular. 2010;18(4):197–204.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgical Oncology, Indiana University Health Goshen Center for Cancer Care, 200 High Park Avenue, Goshen, IN, 46526, USA

    Urs W. von Holzen M.D.

  2. Department of Medical Oncology, Indiana University Health Goshen Center for Cancer Care, Goshen, IN, USA

    Sachin Agarwal M.D. & Roderich Egbert Schwarz M.D., Ph.D., F.A.C.S.

Authors
  1. Urs W. von Holzen M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sachin Agarwal M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Roderich Egbert Schwarz M.D., Ph.D., F.A.C.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roderich Egbert Schwarz M.D., Ph.D., F.A.C.S. .

Editor information

Editors and Affiliations

  1. Department of Surgery, City of Hope Medical Center, Duarte, California, USA

    Yuman Fong

  2. Department of Surgery, City of Hope Medical Center, Duarte, California, USA

    Rondi Marie Kauffmann

  3. Surgical Oncology Hepatobiliary Surgery, City of Hope Medical Center, Duarte, California, USA

    Emily Marcinkowski

  4. Department of Surgery, City of Hope Medical Center, Durate, California, USA

    Gagandeep Singh

  5. Department of Surgery, City of Hope Medical Center, Duarte, California, USA

    Hans F. Schoellhammer

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

von Holzen, U.W., Agarwal, S., Schwarz, R.E. (2017). Surgery in the Thrombocytopenic and Coagulopathic Patient. In: Fong, Y., Kauffmann, R., Marcinkowski, E., Singh, G., Schoellhammer, H. (eds) Surgical Emergencies in the Cancer Patient. Springer, Cham. https://doi.org/10.1007/978-3-319-44025-5_4

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-44025-5_4

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-44023-1

  • Online ISBN: 978-3-319-44025-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation