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BleedingComplicationsinCholecystectomy
ARegisterStudyofOver22000CholecystectomiesinFinland
S.SuuronenA.KivivuoriJ.TuimalaH.Paajanen
BMCSurg.201515(97)

Abstract
Background:Majorbleedingisrarebutamongthemostseriouscomplicationsoflaparoscopicsurgery.Stillverylittleis
knownonbleedingcomplicationsandrelatedbloodcomponentuseinlaparoscopiccholecystectomy(LC).Theaimofthis
studyistocomparebleedingcomplications,transfusionratesandrelatedcostsbetweenLCandopencholecystectomy(OC).
Methods:DataconcerningLCsandOCsandrelatedbloodcomponentusebetween2002and2007werecollectedfrom
existingcomputerizedmedicalrecords(FinnishRedCrossRegister)oftenFinnishhospitaldistricts.
Results:Registerdataincluded17175LCsand4942OCs.IntheLCgroup,1.3%ofthepatientsreceivedredbloodcell(RBC)
transfusioncomparedto13%ofthepatientsintheOCgroup(p<0.001).Similarly,theproportionsofpatientswithplatelet
(0.1%vs.1.2%,p<0.001)andfreshfrozenplasma(FFP)products(0.5%vs.5.8%)transfusionswererespectivelyhigherin
theOCgroupthanintheLCgroup.ThemeantransfuseddoseofRBCs,PTLsandFFPproductOctaplasorthemeancostof
thetransfusedbloodcomponentsdidnotdiffersignificantlybetweentheLCandOCgroups.
Conclusions:Laparoscopiccholecystectomywasassociatedwithlowertransfusionratesofbloodcomponentscomparedto
opensurgery.TheseverityofbleedingcomplicationsmaynotdiffersubstantiallybetweenLCandOC.

Background
Duringthelasttwodecadeslaparoscopiccholecystectomy(LC)hasbecomethegoldenstandardofthetreatmentof
symptomaticgallbladderdisease.Comparedtothetraditionalopencholecystectomy(OC),LCisassociatedwithlower
morbidity [1]andmortality, [2]shorterlengthofhospitalstayandfasterreturntonormalactivities. [3]HoweverLCisassociated
withhigherincidenceofiatrogenicbileductinjuriesthanOC. [46]
Still,accordingtoregisterstudies,some10to30%ofallcholecystectomiesareperformedusingopentechnique,particularly
inelderlypopulation[7]andinacutecholecystitis. [2,8]Inaddition,theopentechniqueisstillneeded,whenthelaparoscopic
operationcannotbecompletedsafelyandtheconversiontoopenprocedureisrequired.Accordingtotheliterature,current
conversionratevariesbetween5and10%. [912]Themajorityofconversionsareperformedbecauseofobscureanatomy
(difficultcholecystitis)orbleedingcomplications.
Theincidenceofbleedingcomplicationsrequiringtransfusionorreoperationhasbeenreportedtoberelativelyrare,occurringin
0.1%inpatientsundergoingLC. [13]Focusintheliterature,however,hasbeenonbiliarycomplicationsofLC.Yet,major
vascularcomplications,eventhoughrare,arealsoseriouscomplicationsoflaparoscopy. [14,15]Inaddition,bleedingremainsa
frequentreasonforconversion. [9,10,16,17]RegardingOC,onlyfewstudieshavereportedtheincidenceofbleedingcomplications
inthelaparoscopicera.Bleedinghasbeenreportedtooccurin0.4%ofpatientsundergoingOC. [4]Thereareverylittledataon
transfusionratesofredbloodcells(RBCs)andhospitalcostsrelatedtobleedingincholecystectomies.
Thepurposeofthisstudyistocomparetransfusionrates,amountsoftransfusionsandrelatedcostsbetweenLCandOCina
largeFinnishregisterbasedcohort.NopriordataofbloodtransfusionandrelatedcostsinLCiscurrentlyavailable.

Methods
Datafrompotentiallytransfusedpatientswascollectedtoaseparate"OptimalUseofBlood"(VOK)registryinajointeffort
betweentheFinnishRedCrossBloodServiceandten(outof21)Finnishhospitaldistricts.Fiveofthehospitaldistrictswere
teachinguniversityconnectedhospitaldistricts(C,F,G,IandJ)andfivecentralhospitaldistricts(A,B,D,EandH)(Fig.1).
Thebleedingregistrywasstartedin2002andcontinuallyupdatedbetween2002and2011,buttheregistryhasbeen
permanentlyterminatedanderasedin2012.ThedatacollectionsystemisdescribedinmoredetailsbyPaloandcoworkers.
[18]Datawerecollectedfromhospitalswhichfulfilledthetechnicalprerequisitesandcoulddelivertherequireddata.Altogether
thesehospitaldistrictshaveabout620000inpatientepisodesannually,constituting63%ofallFinnishpublicinpatienthospital
episodes.Patientdatacamefrompreexistingelectronicmedicalregisters.Computerfilesprovidedinformationonhospital
admissions,diagnoses,surgicaloperations,testresults,andbloodcomponentsaswellasontransfusions.Theoriginally
collected90transfusionrelatedvariableswereprocessedandcombinedinto149variablestodescribeanepisode.Systematic
auditofdatavariablewasdone. [18]
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auditofdatavariablewasdone. [18]

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Figure1.

ParticipatedFinnishhospitaldistricts
Forthisstudy,patientswhovisitedanystudyhospitaldistrictforLCorOCbetweenJanuary1st2002andDecember31st2007
wereextractedfromtheoriginalVOKregistry(20022011).Inthisresearchregistry,datafromthehospitaldistrictJisonly
availablefromJan1st2004toDecember31st2007.
ICD10(InternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,10thRevision,2003)wasusedto
categorizediagnoses.SurgicalprocedurewasdefinedaccordingtotheNCSP(TheNOMESCO,NordicMedicoStatistical
Committee,ClassificationofSurgicalProcedures)classification(NCSPtheNOMESCOClassificationofSurgicalProcedures
version1.7,2005).Allpatientsover15yearsofagewhounderwentLC(JKA21)orOC(JKA20)asaprimarysurgicalprocedure
wereincludedinthisstudy.NCSPdoesnothaveaseparateprocedurecodeforconversionofLCconvertedintoOC.Thus,
conversionscannotbeidentifiedfromthisdataandtheyarereportedintheOCgroup.Cholecystectomiesassociatedwith
biliaryorpancreaticneoplasmswereexcludedbasedonthemaindiagnosisoftheoperationanddiagnosesforthehospital
admission.Allprocedurecodesanddiagnosesweresetbytreatingphysicians.
Thefollowingdatawascollectedforeachpatient:age,sex,AmericanSocietyofAnaesthesiologists(ASA)class,themain
diagnosis,theprimarysurgicalprocedure,secondarysurgicalprocedures,thestatusoftheoperation(either
elective/prescheduledoremergent/acutecase),thelengthoftheoperation,theusageofbloodcomponentsduringthehospital
stay,inhospitalmortality,thelengthofhospitalstay,thehospital,thehospitaldistrictandreoperationsperformedwithin60
daysofthecholecystectomy(notreported).Emergentoperationswereperformedmostlybecauseofacutecholecystitisor
longlastingpainfulbiliarycolic,whichrequiredhospitaladmission.Therecordedusageofbloodcomponentsincludedthe
numberoftransfusedredbloodcell(RBC)units,numberoftransfusedplatelets(PLT),numberoftransfusedfreshfrozen
plasmaproductsandthetotalcostofthetransfusedbloodcomponents.Theseverityofacutecholecystitis
(flegmonous/perforated)wasnotincluded,becausenodetailedoperationfilesorpathologicalreportsfromremovedgallbladders
wereavailable.
TheFinnishRedCrossBloodServicecollectsanddistributesbloodproductsfromnonremunerateddonorsnationwidein
Finland. [19]EachRBCproductisequivalentof1unit.ThePLTproductwaspreparedusingabuffycoatprocedureandmostof
thetransfusedPLTswerebuffycoatderived.ThemeannumberofPLTsperfourdonorproductwas296109andthevolume
wasabout320ml. [20]EachPLTproductisequivalentof(3)4units.
Thefreshfrozenplasmaproductsconsistedoffreshfrozenplasma(FFP)andOctaplas(OctapharmaNordicAB).TheFFP
referstowholebloodrecoveredleukodepletedfreshplasma(volume,approximately270ml).Oneproductwasequalto1unitof
FFP. [21]Duringthestudyperiod,OctaplaswasavailableinFinlandfrom2005untiltheendofthestudy.Theusageofthe
FFPandOctaplasarepresentedseparatelyinthisstudy,becausetheunitsizeandthustheamountofcoagulationfactors
perunitissmallerinOctaplascomparedtoFFP.
ThenumberofallcholecystectomiesperformedinFinlandin20002007wasobtainedfromtheNationalInstituteforHealthand
Welfare(NIHW)registry.
PermissiontousetheBleedingregistrydatawasobtainedfromtheinstitutionalreviewboardoftheFinnishRedCrossBlood
Service.Wedidnotusepatients'identificationdetails(nameorsocialsecuritynumber)inthisregisterstudy.
TheaimsandcontentofthisstudyareinaccordancewiththeHelsinkiDeclaration.Therespectiveethicscommitteeofthe
FinnishRedCrossBloodServiceapprovedthestudyprotocol.
ThedatawasanalyzedusingIBMSPSSStatistics22.0(IBM,USA2015).Theindependenceoftwocategoricalvariableswas
testedforwith 2test.MeanvaluesofcontinuousvariableswerecomparedwitheitherStudent'sttestorMannWhitneyU
testwhereappropriate.Statisticalsignificancewasdefinedasapvaluelessthan0.05.

Results
Thetotalof22117cholecystectomiescomprisethefinaldatasetforthisstudyaccountingfor43%allcholecystectomies(51
094)performedinFinlandin20022007.Oftheincludedcholecystectomies,78%(17175)wereLCsand22%(4942)were
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OCs.ThenumberofLCsandOCsbyhospitaldistrictisshowninFig.2.

Figure2.

Numberoflaparoscopiccholecystectomies(LC)andopencholecystectomies(OC)byhospitaldistrictsin20022007(from
hospitaldistrictJdataavailableonlyfrom2004to2007)
Demographicandperioperativedataofthecholecystectomypatientsisshownin.ComparedtotheOCpatients,theLC
patientswereyounger,moreoftenfemaleandmoreoftenbelongedtothelowerASAclasses.Theyalsounderwentanelective
operationmoreoftenthantheOCpatients(88%vs.38%,p<0.001).ThemeanlengthoftheoperationwasshorterforLCs
thanforOCs.Intraoperativecholangiographies(IOC)andcommonbileductexplorationsweremorecommonintheOCgroup.
Inaddition,themeanlengthofhospitalstaywaslongerandinhospitalmortalitywashigheramongtheOCpatients(2.5%vs.
0.3%,p>0.001).
Table1.Demographicandperioperativedataofpatientswhounderwentopencholecystectomy(OC)orlaparoscopic
cholecystectomy(LC)in20022007

LCn=17175(%)

OCn=4942(%)

Males/females

4702/12473(27/73)

2429/2513(49/51)

<0.001

MeanageSD(range)

5215(1694)

6315(1697)

<0.001

ASAaI

5842(34.0)

673(13.6)

<0.001

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II

6424(38.0)

1564(31.6)

<0.001

III

2753(16.0)

1756(35.5)

<0.001

IV

183(1.1)

409(8.3)

<0.001

0(0.0)

31(0.6)

<0.001

Elective/emergency

15114/2018b(88/12) 1870/3039c(38/62) <0.001

MeanoperativetimeSD(min) 7037

9950

<0.001

Intraoperativecholangiography

862(5.0)

1009(20.0)

<0.001

Commonbileductexploration

156(0.9)

369(7.5)

<0.001

Inhospitalmortality

59(0.3)

122(2.5)

<0.001

8.04.7

<0.001

LengthofhospitalstaySD(d) 2.82.4
aASAAmericanSocietyofAnaesthesiologists,SDStandarddeviation

aDatamissingfrom1974patientsintheLCgroupand509patientsintheOCgroup
bDatamissingfrom43patients
c Datamissingfrom33patients

ThebloodcomponentuseassociatedwithLCandOCisshownin.OftheOCpatients,asmanyas16%ofpatientsreceived
transfusionofanybloodcomponentcomparedto1.6%ofthepatientsintheLCgroup.Similarly,theproportionsofpatientwith
RBC(13%vs.1.3%,p<0.001),PLT(1.2%vs.0.1%,p<0.001),FFP(4.9%vs.0.4%,p<0.001)andOctaplas(0.9%
vs.0.1%,p<0.001)transfusionswererespectivelyhigherinOCgroupcomparedtotheLCgroup.Alsothemeantransfused
doseoftheFFPwassignificantlyhigherintheOCgroupcomparedtotheLCgroups.However,themeantransfuseddoseof
theotherbloodcomponentsandthemeancostofthetransfusedbloodcomponentsdidnotdiffersignificantlybetweenthe
groups().
Table2.Theuseofbloodcomponentsinopencholecystectomies(OC)andlaparoscopiccholecystectomies(LC)in20022007

LCn=17175(%) OCn=4942(%) p

ProportionofpatientswithRBCtransfusion

216(1.3)

641(13)

<0.001

MeantransfusedRBCdose(range)(unit)

3.4(118)

3.6(146)

ns

ProportionofpatientswithPTLtransfusion

15(0.1)

59(1.2)

<0.001

MeantransfusedPTLdose(range)(unit)

16(448)

21(3104)

ns

ProportionofpatientswithFFPtransfusion

74(0.4)

241(4.9)

<0.001

MeantransfusedFFPdose(range)(unit)

3.2(110)

4.3(142)

0.008

ProportionofpatientswithOctaplastransfusion

14(0.1)

43(0.9)

<0.001

MeantransfusedOctaplasdose(range)(unit)

3.2(112)

4.2(115)

ns

Proportionofpatientswithbloodcomponenttransfusion 276(1.6)

774(16)

<0.001

Meancostoftransfusedbloodcomponents(range)()

394(5110607) ns

284(511310)

RBCRedbloodcell,PTLPlatelet,FFPFreshfrozenplasma,nsnotsignificant
Table2.Theuseofbloodcomponentsinopencholecystectomies(OC)andlaparoscopiccholecystectomies(LC)in20022007

LCn=17175(%) OCn=4942(%) p

ProportionofpatientswithRBCtransfusion

216(1.3)

641(13)

<0.001

MeantransfusedRBCdose(range)(unit)

3.4(118)

3.6(146)

ns

ProportionofpatientswithPTLtransfusion

15(0.1)

59(1.2)

<0.001

MeantransfusedPTLdose(range)(unit)

16(448)

21(3104)

ns

ProportionofpatientswithFFPtransfusion

74(0.4)

241(4.9)

<0.001

MeantransfusedFFPdose(range)(unit)

3.2(110)

4.3(142)

0.008

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ProportionofpatientswithOctaplastransfusion

14(0.1)

43(0.9)

<0.001

MeantransfusedOctaplasdose(range)(unit)

3.2(112)

4.2(115)

ns

Proportionofpatientswithbloodcomponenttransfusion 276(1.6)

774(16)

<0.001

Meancostoftransfusedbloodcomponents(range)()

394(5110607) ns

284(511310)

RBCRedbloodcell,PTLPlatelet,FFPFreshfrozenplasma,nsnotsignificant
Massivetransfusionreferstotheadministrationoftenormoreredbloodcellunits.Inthiscohort,48patients(0.002%)
receivedmassivetransfusion.Demographicandoperativedataofthesepatientsispresentedin.Themeanageofthemassive
transfusionpatientswere48yearsand33(69%)ofthemwerefemale.Mostofthecases(81%)wererelatedtoOCand72%
ofthecasestoemergentoperations.InadditiontoRBCs,78%ofthepatientsreceivedfreshfrozenplasmaproducts(FFPor
Octoplas)and46%PLTs.Themassivetransfusionswereassociatedwithmarkedinhospitalmortality(15%).
Table3.Demographicandoperativedata,andtheuseofotherbloodcomponentproductsinpatientswhowereadministered
massiveRBCtransfusion(10units)

PatientswithmassiveRBCtransfusionn=48(%)

Males/females

33/15(69/31)

MeanageSD(range)

4816(3490)

ASAaI

2(4.2)

II

7(15)

III

13(27)

IV

14(29)

7(15)

OC/LC

39/9(81/19)

Elective/emergencyb

13/34(28/72)

MeanoperativetimeSD(min)

12274

Intraoperativecholangiography

8(17)

Commonbileductexploration

6(13)

ProportionofpatientswithPTLtransfusion

22(46)

ProportionofpatientswithFFPtransfusion

30(63)

ProportionofpatientswithOctaplastransfusion 7(15)
Inhospitalmortality

7(15)

LengthofhospitalstaySD(d)

2314

ASAAmericanSocietyofAnaesthesiologists,SDStandarddeviation,RBCRedbloodcell,PTLPlatelet,FFPFreshfrozen
plasma
aDataregardingASAclassmissingfromfivepatients
bDatamissingfromonepatient

Discussion
Accordingtothepresentstudy,OCisassociatedwithhighertransfusionrateofbloodcomponentsthanLC.Inthecurrent
data,13%oftheOCpatientsand1.3%ofLCpatientsreceivedRBCtransfusion.Also,fortheotherbloodcomponent
products(PLTs,FFPandOctaplas),thetransfusionratesweresignificantlyhigherintheOCgroup.Inadditiontomore
invasivenatureofOC,thismaybepartlyduetothefactthattheOCpatientswereolderandthusmorelikelytoreceive
anticoagulanttherapy.TheOCpatientsalsounderwentemergentoperationmoreoftenthanLCpatients.
ThelackofsystemicclassificationofbleedingcomplicationsinLCmakesthecomparisonoftheresultsofthecurrentstudyto
theexistingbodyofliteraturechallenging.Someauthorshaveassessedandreportedonlymajorvascularinjuries(usually
includinginjuriestotheaortaanditsmainbranches,venacavaandtheportalvein),whilelifethreateningbleedingmayalso
occurfromtheliverbed. [14]Vascularinjuriesmayalsohavebeenreportedastrocarinjuries.Otherauthorshavedocumented
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occurfromtheliverbed. [14]Vascularinjuriesmayalsohavebeenreportedastrocarinjuries.Otherauthorshavedocumented
bleedingrequiringeithertransfusionorreoperationorlessseriousintraoperativeandpostoperativebleeding.Intraoperativeand
postoperativebleedingmayhavebeenfurtherdividedintointernal(peritonealcavityofretroperitonealspace)andexternal
(abdominalwall)bleedingbasedonthelocalization.
Theincidenceofpostoperativeintraabdominalbleedinghasbeenreportedtobe0.691.05%inLCpatients. [9,16]Inthe
analysisof10174LCsbyZ'graggenandcoworkers, [9]bleedingwasalsothemostfrequentintraoperativecomplication
occurringin1,97%ofthecases.InaFinnishseriesof1581LCs,incidenceofallbleedingcomplicationswas1.1% [22]and
bleedingcomplicationsrequiringreoperationoccurredin0.5%ofthecases. [23]Roslynandcoworkers [4]reportedtheoverall
incidenceofbleedingcomplicationsof0.4%intheanalysisof42474OCs.Intheirseries,intraoperativebleedingwasalso
associatedwithasignificantriskofdeath.Inthecurrentstudy,thedataonmassivetransfusionsindicates,thatmajorbleeding
remainsararebutseriouscomplicationofcholecystectomywithsignificantassociatedmortality.Newadvantagesof
technology,suchasultrasonicdissectionandanticoagulantpadsmaydecreasethebleedingcomplicationsinfutureregister
studies.
PreviousstudieshavehardlyreportedtheneedofbloodtransfusionrelatedtoLCsandOCs.However,fewpublications
reportingtransfusionratesforgenerallaparoscopicoperationsexist.Intheiranalysisof14243generallaparoscopicoperations
(ofwhich59.4%wereLCs),Schferandcoworkers [14]reported33patientswithintraoperativeand63patientswith
postoperativebleedingcomplicationsrequiringbloodtransfusion.Theoverallrateofbleedingcomplicationsrequiringtransfusion
was0.7%intheirseries,theoverallrateofbleedingcomplications(includingminorbleedingsuchaslacerationofminor
vessels)being4.1%.Opitzandcoworkers [15]reportedanoverallbleedingrateof3.3%inanLCdominant(52%)sampleof
43028ofgenerallaparoscopicoperations.Intheirstudy,thehighertransfusionrate(24%)wasobservedinpatientswith
postoperativebleedingcomparedtopatientswithintraoperativebleeding(7%,p<0.0001).
TransfusionratesforLCinthisstudy,1.3%RBCsand1.6%forallbloodcomponentproducts,arehigherthanreportedfor
abovementionedLCdominantgenerallaparoscopysamples. [14,15]About30%ofpatientsinthesetwolaparoscopysamples
underwentherniotomyorappendectomy,bothproceduresthatdonotinvolvethedissectionoftheliverbed,apotentsourceof
bleeding.Thismayexplaininpartthehigherobservedtransfusionrateinthisstudy.Inaddition,apreviousreportshowsthat
therateofRBCusageinFinlandhasbeenratherhighcomparedtothatinotherEuropeancountriespartly,becausethe
sufficientbloodsupplyhasnotlimitedtheavailabilityofbloodcomponentproductsandbecauseofthelowriskfortransfusion
transmittedviralinfectionsinFinland. [19]
Bleedingdataofourtransfusionregisterandparticularplatelettransfusionsinthepatientsundergoinggeneralsurgeryhasbeen
publishedearlier. [20]Onefourth(27.1%)ofthesurgeryrelatedplatelettransfusionswenttopatientswhohadalimentarytract
operations,11%inorthopedicsurgery,butmainlytopatientsundergoingcardiacoperations.Surgeryrelatedbleeding
complicationsandplatelettransfusionsoccurredmostfrequentlybetweentheagegroups50and79years,andmoreoftenin
malesthanfemales. [20]Inobstetricprocedures,plateletswereusedin267/17916(1.5%)operations.
Thereareseverallimitationsinthisstudy.Oneistheregisterbasednatureofthisstudy.First,thecurrentdatacoversonlythe
transfusionsassociatedwiththehospitalstayduringwhichthecholecystectomytookplace,andthuscasesofdelayed
postoperativebleedingrequiringtransfusionmayhavebeenmissed.Second,reoperationsarenotreported.Majorbleedingis
oftendefinedasableedingcomplicationrequiringtransfusionorareoperation.However,therewasasubstantialnumberof
missingdiagnosiscodesfor60dayreoperationsinthedata.Combinedwiththelackofuniformpracticefordiagnosisand
procedurecodeentries,whenacomplicationoccurs,itwouldhavebeenhighlybiasedtoreporttherateofreoperations,
especiallythoseperformedbecauseofbleeding.Third,conversionscouldnotbeidentifiedfromthedataduetothelackofa
separateprocedurecodeforconversioninNCSP.Consequently,casesofLCconvertedintoOCareincludedintheOCgroupin
thisstudy.Sincebleedingisafrequentreasonforconversion, [9,10,16,17]conversionswouldhavebeendeservedtobeanalyzed
asagroupofitsown.
Inaddition,becauseoftheregisterbasednatureofthisstudy,patientspecificpredisposingfactorsforbleedingcomplications,
suchasanticoagulantorantiplatelettherapyorlivercirrhosis,couldnotbeidentifiedfromtheavailabledata.Ahighincidence
ofpostoperativebleedinghasbeenreportedinpatientsonlongtermanticoagulanttherapyundergoingLC,evenwhenthe
anticoagulanttherapywasdiscontinuedlongenoughfortheinternationalnormalizedratiotobenormalized. [24]Additionally,ina
Swedishregisterstudy,systemicthromboprophylaxisincreasedtheriskofbleedingcomplicationsinLC,buttheincidenceof
thromboemboliccomplicationwasnotsignificantlyreduced. [25]Ontheotherhand,theassociationbetweenantiplatelet
therapyandbleedingcomplicationsiscontroversial,especiallyinthecaseofemergencysurgery.Inarecentretrospective
casecontrolstudy,longtermaspirinantiplatelettherapywasnotassociatedwithincreasedriskofbleedingcomplicationsin
emergentLCforacutecholecystitis. [26]Basedontheresults,theauthorsconcludedthatlongtermaspirinuseshouldnotbe
usedasanindependentfactortodelayanemergentLC.TheimpactofthenewnonvitaminKantagonistoralanticoagulantson
theincidenceofbleedingcomplicationsassociatedwithLCremainsaninterestingtopicforfutureresearch.

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Conclusions
Thepresentstudyshowsthat,inadditionstoothervirtues,LCisassociatedwithlowertransfusionratesofRBCs,PLTsand
FFPproductscomparedtoOC.ThemeantransfuseddoseforRBCs,PLTsorOctaplasandthemeancostoftransfused
bloodcomponentproductspertransfusedpatientdidnotdiffersignificantlybetweenLCsandOCsindicatingtheseverityof
bleedingcomplicationmaynotvarysubstantiallybetweenOCandLC.Nevertheless,theobservedhighertransfusionrateinOC
increasestheaveragecostsofOCcomparedtoLC.
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Acknowledgements
WeacknowledgeMrs.LisaKivelaforrevisingEnglish.Noexternalfundingwasreceivedforthismanuscript.
BMCSurg.201515(97)2015BioMedCentral,Ltd.
19992006BioMedCentralLtd
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