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Red blood cell transfusion in liver resection

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Abstract

Background

Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes.

Purpose

Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion.

Results

Following hepatic surgery, 25.2–56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods.

Conclusion

Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.

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Authors and Affiliations

  1. Department of Surgery, University of Toronto, Toronto, Ontario, Canada

    Nicholas Latchana, Dhruvin H. Hirpara, Julie Hallet & Paul J. Karanicolas

  2. Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

    Nicholas Latchana, Dhruvin H. Hirpara, Julie Hallet & Paul J. Karanicolas

  3. Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada

    Paul J. Karanicolas

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  1. Nicholas Latchana
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Correspondence to Paul J. Karanicolas.

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Dr. Karanicolas holds a research grant from Baxter to study Hemopatch in patients undergoing distal pancreatectomy and has received speaker honoraria from Sanofi. Dr. Hallet has received speaking honoraria from Ipsen Biopharmaceuticals Canada and Novartis Oncology. Dr. Latchana and Hirpara have nothing to disclose.

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Latchana, N., Hirpara, D.H., Hallet, J. et al. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 404, 1–9 (2019). https://doi.org/10.1007/s00423-018-1746-2

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