Transfusion-Free Strategy in Liver and Pancreatic Surgery: A Predictive Model of Blood Conservation for Transfusion Avoidance in Mainstream Populations

Abstract

INTRODUCTION: Major liver and pancreatic resection often requires operative transfusion. This limits surgical options for patients who do not accept major blood component-transfusion. There is also growing recognition of the negative impact of allogenic blood transfusion. The objectives of this study are to: (1) Describe the techniques and prove the feasibility of performing complex hepatobiliary and pancreatic surgery on a Jehovah’s Witness (JW) population. (2) Describe a strategy that offsets operative blood loss by the manipulation of circulating blood volume to create reserve whole blood on anesthesia induction. METHODS: A 23-year, single-center, retrospective review of JW patients undergoing liver and pancreatic resection was performed. We describe perioperative management and patient outcomes. Acute normovolemic hemodilution (ANH) is proposed as an important strategy for offsetting blood loss and preventing the need for blood transfusion. A quantitative mathematical formula is developed to provide guidance for its use. RESULTS: One hundred one major resections were analyzed (liver n = 57, pancreas n = 44). ANH was used in 72 patients (liver n = 38, pancreas n = 34) with median removal of 2 units that were returned for hemorrhage as needed or at the completion of operation. There were no perioperative mortalities. Morbidity classified as Clavien grade 3 or higher occurred in 7.0% of liver resection and 15.9% of pancreatic resection patients. CONCLUSION: Deliberate perioperative management makes transfusion-free liver and pancreatic resection feasible. Intraoperative whole blood removal with ANH specifically preserves red blood cell mass, platelets, and coagulation factors for timely reinfusion. Application of the described JW transfusion-free strategy to a broader general population could lessen blood use cost and morbidity.