The impact of red blood cell transfusions on perioperative outcomes in the contemporary era of liver resection

"The Prognostic Role of Aspartate Transaminase to Platelet Ratio Index (APRI) on Outcomes Following Non-emergent Minor Hepatectomy"

INTRODUCTION

Fibrosis and cirrhosis are associated with worse outcomes after hepatectomy. Aspartate transaminase to platelet ratio index (APRI) is associated with fibrosis and cirrhosis in hepatitis C patients. However, APRI has not been studied to predict outcomes after hepatectomy in patients without viral hepatitis.

METHODS

We reviewed the ACS-NSQIP dataset to identify patients who underwent a minor hepatectomy between 2014 and 2021. We excluded patients with viral hepatitis or ascites as well as patients who underwent emergent operations or biliary reconstruction. APRI was calculated using the following equation: (AST/40)/(platelet count) × 100. APRI ≥0.7 was used to identify significant fibrosis. Univariable analysis was performed to identify factors associated with APRI ≥0.7, transfusion, serious morbidity, overall morbidity, and 30-day mortality. Multivariable logistic regression was performed to identify adjusted predictors of these outcomes.

RESULTS

Of the 18,069 patients who met inclusion criteria, 1630 (9.0%) patients had an APRI ≥0.7. A perioperative blood transfusion was administered to 2139 (11.8%). Overall morbidity, serious morbidity, and mortality were experienced by 3162 (17.5%), 2475 (13.7%), and 131 (.7%) patients, respectively. APRI ≥0.7 was an independent predictor of transfusion (adjusted OR: 1.48 [1.26-1.74], P < .001), overall morbidity (1.17 [1.02-1.33], P = .022), and mortality (1.97 [1.22-3.06], P = .004). Transfusion was an independent predictor of overall morbidity (3.31 [2.99-3.65], P < .001), serious morbidity (3.70 [3.33-4.11], P < .001), and mortality (5.73 [4.01-8.14], P < .001).

CONCLUSIONS

APRI ≥0.7 is associated with perioperative transfusion, overall morbidity, and 30-day mortality. APRI may serve as a noninvasive tool to risk stratify patients prior to elective minor hepatectomy.

A Prospective Analysis of the Effects of a Powder-Type Hemostatic Agent on the Short-Term Outcomes after Liver Resection

Background and Objectives: Postoperative bleeding is a significant cause of morbidity and mortality following liver resection. Therefore, it is crucial to minimize bleeding during liver resection and effectively manage it when it occurs. Arista® AH (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) is a microporous polysaccharide hemosphere (MPH), a new plant-derived polysaccharide powder hemostat that can be applied to the entire surgical field. This study prospectively assessed the effectiveness of Arista for bleeding control when applied intraoperatively to the liver resection surface. Materials and Methods: Data were collected at Seoul National University Bundang Hospital for patients who underwent liver resection owing to malignant hepatocellular carcinoma or benign liver diseases. We compared the outcomes between 45 patients managed with Arista® AH (data were prospectively collected between September 2022 and May 2023) and 156 patients managed without the use of Arista® AH (data were retrospectively collected between January 2021 and December 2021). Results: There were no significant differences in patient characteristics between the two groups. The estimated blood loss (EBL) was significantly lower in the Arista® AH group compared with the control group (495.56 ± 672.7 mL vs. 691.9 ± 777.5 mL, p = 0.049). The mean postoperative hospital stay was significantly shorter in the Arista® AH group (5.93 ± 1.88 days vs. 6.94 ± 4.17 days, p = 0.024). The time to Jackson-Pratt drain removal was also significantly shorter in the Arista® AH group (4.64 ± 1.31 days vs. 5.30 ± 2.87 days, p = 0.030). The patient subgroup was divided into four categories based on the type of resection and the presence or absence of cirrhosis. Within the subgroup of major resections in non-cirrhotic patients, the Arista® AH group demonstrated significantly better outcomes compared to the control group, showed lower EBL, reduced need for blood transfusions, decreased volume of drain fluid collected within 48 h, earlier removal of drains, and shorter hospital stays. In contrast, for the other subgroups such as minor resection (both non-cirrhotic and cirrhotic) and major resection with cirrhosis, the differences between the Arista® AH and control groups in various parameters like EBL, blood transfusion rates, drain fluid volume, time to drain removal, and duration of hospital stay were not statistically significant. Conclusions: Arista® AH significantly improved intraoperative blood management and postoperative recovery in patients undergoing liver resection, particularly in non-cirrhotic patients who underwent major resection.

Perioperative blood transfusion and resection of colorectal cancer liver metastases: outcomes in routine clinical practice

BACKGROUND

Prior work has shown associations between blood transfusion (BT) and inferior outcomes during resection for colorectal cancer liver metastases (CRLM). Herein, we describe short and long-term outcomes relating to perioperative BT in routine clinical practice.

METHODS

All CRLM resections in Ontario, Canada from 2002 to 2009 were identified using the Ontario Cancer Registry. Log-binomial regression and Cox regression were used to explore factors associated with receipt of BT and the association of BT with 5-year cancer specific (CSS) and overall survival (OS), respectively.

RESULTS

The study included 1310 patients; 31% (403/1310) had perioperative BT. Transfused patients had longer median length of stay (9 vs. 7 days, p < 0.001), higher 90-day mortality (9% vs. 1%, p < 0.001), greater 90-day readmission (28% vs. 16%, p < 0.001), and inferior 5-year CSS (41% vs. 48%, p = <0.001) and OS (38% vs. 47%, p < 0.001). Transfusion was independently associated with inferior CSS (HR = 1.35, 95% CI: 1.11-1.63) and OS (HR = 1.30, 95% CI: 1.10-1.53), however, excluding 90-day postoperative deaths showed these associations were no longer significant.

CONCLUSION

Perioperative BT is common in patients undergoing resection of CRLM. While transfusion is associated with greater morbidity, mortality, and inferior survival, after excluding early postoperative deaths, BT does not appear to be independently associated with CSS or OS.

Using Machine Learning to Predict Postoperative Liver Dysfunction After Aortic Arch Surgery

OBJECTIVES

The study compared machine-learning models with traditional logistic regression to predicting liver outcomes after aortic arch surgery.

DESIGN

Retrospective review from January 2013 to May 2017.

SETTING

Fuwai Hospital.

PARTICIPANTS

The study comprised 672 consecutive patients who had undergone aortic arch surgery.

MEASUREMENTS AND MAIN RESULTS

Three machine-learning methods were compared with logistic regression with regard to the prediction of postoperative liver dysfunction (PLD) after aortic arch surgery. The perioperative characteristics, including the patients' baseline medical condition and intraoperative data, were analyzed. The performance of the models was assessed using the area under the receiver operating characteristic curve. Naïve Bayes had the best discriminative ability for the prediction of PLD (area under the receiver operating characteristic curve = 0.77) compared with random forest (0.76), support vector machine (0.73), and logistic regression (0.72). The primary endpoint of PLD was observed in 185 patients (27.5%). The cardiopulmonary bypass time, long surgery time, long aortic clamp time, high preoperative bilirubin value, and low rectal temperature were strongly associated with the development of PLD after aortic arch surgery.

CONCLUSION

The machine-learning method of naïve Bayes predicts PLD after aortic arch surgery significantly better than traditional logistic regression.

The impact of tranexamic acid on administration of red blood cell transfusions for resection of colorectal liver metastases

BACKGROUND

Red blood cell transfusions (RBCT) remain a concern for patients undergoing hepatectomy. The effect of tranexamic acid (TXA), an anti-fibrinolytic, on receipt of RBCT in colorectal liver metastases (CRLM) resection was examined.

METHODS

Hepatectomies for CRLM over 2009-2014 were included. Primary outcome was 30-day receipt of RBCT. Secondary outcomes were 30-day major morbidity (Clavien-Dindo III-V) and 90-day mortality. Multivariable modelling examined the adjusted association between TXA and outcomes.

RESULTS

Of 433 included patients, 146 (34%) received TXA. TXA patients were more likely to have inflow occlusion (41.8% vs. 23.1%; p < 0.01) and major hepatectomies (56.1% vs. 45.6%; p = 0.0193). TXA was independently associated with lower risk of RBCT (Relative risk (RR) 0.59; 95% confidence interval (95%CI): 0.42-0.85), but not with 30-day major morbidity (adjusted RR 1.02; 95%CI: 0.64-1.60) and 90-day mortality (univariable RR 0.99; 95%CI: 0.95-1.03).

CONCLUSION

Intraoperative TXA was associated with a 41% reduction in risk of 30 -day receipt of RBCT after hepatectomy for CRLM. This finding is important to potentially improve healthcare resource allocation and patient outcomes. Pending further evidence, intraoperative TXA may be an effective method of reducing RBCT in hepatectomy for CRLM.

Minimally Invasive Hepatectomy in North America: Laparoscopic Versus Robotic

BACKGROUND

Minimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies.

METHODS

Patients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014-2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias.

RESULTS

Of 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p < 0.01). After matching, 240 were identified in each cohort. Compared with the robotic approach, patients undergoing laparoscopic hepatectomy had a significantly higher conversion rate (23% vs. 7.4%) but had shorter operative time (159 vs. 204 min) (p < 0.001). Laparoscopic cases undergoing an unplanned conversion to open were associated with increased morbidity (p < 0.001), but this difference was not observed in robotic cases. Both MIH approaches had low mortality (1.0%, p = 1.00), overall morbidity (17%, p = 0.47), and very short length of stay (3 days, p = 0.80).

CONCLUSION

Minimally invasive hepatectomy is performed primarily for partial hepatectomies. Laparoscopic hepatectomy is associated with a significantly higher conversion rate, and converted cases have worse outcomes. Both minimally invasive approaches are safe with similar mortality, morbidity, and a very short length of stay. Graphical Abstract.

Minimally Invasive Hepatectomy in North America: Laparoscopic Versus Robotic

BACKGROUND

Minimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies.

METHODS

Patients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014-2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias.

RESULTS

Of 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p < 0.01). After matching, 240 were identified in each cohort. Compared with the robotic approach, patients undergoing laparoscopic hepatectomy had a significantly higher conversion rate (23% vs. 7.4%) but had shorter operative time (159 vs. 204 min) (p < 0.001). Laparoscopic cases undergoing an unplanned conversion to open were associated with increased morbidity (p < 0.001), but this difference was not observed in robotic cases. Both MIH approaches had low mortality (1.0%, p = 1.00), overall morbidity (17%, p = 0.47), and very short length of stay (3 days, p = 0.80).

CONCLUSION

Minimally invasive hepatectomy is performed primarily for partial hepatectomies. Laparoscopic hepatectomy is associated with a significantly higher conversion rate, and converted cases have worse outcomes. Both minimally invasive approaches are safe with similar mortality, morbidity, and a very short length of stay. Graphical Abstract.

Haemostatic Efficacy of Topical Agents During Liver Resection: A Network Meta-Analysis of Randomised Trials

BACKGROUND

Hepatic resection carries a high risk of parenchymal bleeding both intra- and post-operatively. Topical haemostatic agents are frequently used to control bleeding during hepatectomy, with multiple products currently available. However, it remains unknown which of these is most effective for achieving haemostasis and improving peri-operative outcomes.

METHODS

A systematic review and random-effects Bayesian network meta-analysis of randomised trials investigating topical haemostatic agents in hepatic resection was performed. Interventions were analysed by grouping into similar products; fibrin patch, fibrin glue, collagen products, and control. Primary outcomes were the rate of haemostasis at 4 and 10 min.

RESULTS

Twenty randomized controlled trials were included in the network meta-analysis, including a total of 3267 patients and 7 different interventions. Fibrin glue and fibrin patch were the most effective interventions for achieving haemostasis at both 4 and 10 min. There were no significant differences between haemostatic agents with respect to blood loss, transfusion requirements, bile leak, post-operative complications, reoperation, or mortality.

CONCLUSIONS

Amongst the haemostatic agents currently available, fibrin patch and fibrin glue are the most effective methods for reducing time to haemostasis during liver resection, but have no effect on other peri-operative outcomes. Topical haemostatic agents should not be used routinely, but may be a useful adjunct to achieve haemostasis when needed.

Perioperative blood transfusions following hepatic lobectomy: A national analysis of academic medical centers in the modern era

BACKGROUND

The purpose of the study was to characterize the prevalence and impact of perioperative blood use for patients undergoing hepatic lobectomy at academic medical centers.

METHODS

The University HealthSystem Consortium (UHC) database was queried for hepatic lobectomies performed between 2011 and 2014 (n = 6476). Patients were grouped according to transfusion requirements into high (>5 units, 7%), medium (2-5 units, 6%), low (1 unit, 8%), and none (0 units, 79%) during hospital stay for comparison of outcomes.

RESULTS

Over 20% of patients undergoing hepatic lobectomy received blood perioperatively, of which 35% required more than 5 units. Patients with high transfusion requirements had increased severity of illness (p < 0.01). High transfusion requirements correlated with increased readmission rates (23.4% vs. 19.2% vs. 16.6% vs. 13.5%), total direct costs ($31,982 vs. $20,859 vs. $19,457 vs. $16,934), length of stay (9 days vs. 8 vs. 7 vs. 6), and in-hospital mortality (10.8% vs. 2.0% vs. 0.9% vs. 2.0%) compared to medium, low, and no transfusion amounts (all p < 0.01). Neither center nor surgeon volume were associated with transfusion use.

CONCLUSION

High transfusion requirements after hepatic lobectomy in the United States are associated with worse perioperative quality measures, but may not be influenced by center or surgeon volume.

Patient blood management for liver resection: consensus statements using Delphi methodology

BACKGROUND

Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology.

METHODS

An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement.

RESULTS

The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended.

CONCLUSIONS

PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

Impact of perioperative blood transfusion on clinical outcomes in patients with colorectal liver metastasis after hepatectomy: a meta-analysis

BACKGROUND

Perioperative blood transfusion may be associated with negative clinical outcomes in oncological surgery. A meta-analysis of published studies was conducted to evaluate the impact of blood transfusion on short- and long-term outcomes following liver resection of colorectal liver metastasis (CLM).

MATERIALS AND METHODS

A systematic search was performed to identify relevant articles. Data were pooled for meta-analysis using Review Manager version 5.3.

RESULTS

Twenty-five observational studies containing 10621 patients were subjected to the analysis. Compared with non-transfused patients, transfused patients experienced higher overall morbidity (odds ratio [OR], 1.98; 95% confidence intervals [CI] =1.49-2.33), more major complications (OR, 2.12; 95% CI =1.26-3.58), higher mortality (OR, 4.13; 95% CI =1.96-8.72), and longer length of hospital stay (weighted mean difference, 4.43; 95% CI =1.15-7.69). Transfusion was associated with reduced overall survival (risk ratio [RR], 1.24, 95% CI =1.11-1.38) and disease-free survival (RR, 1.38, 95% CI=1.23-1.56).

CONCLUSION

Perioperative blood transfusion has a detrimental impact on the clinical outcomes of patients undergoing CLM resection.

An update on topical haemostatic agents in liver surgery: systematic review and meta analysis

Mortality and morbidity in hepatic surgery are affected by blood loss and transfusion. Topical haemostatic agents (THA) are composed by a matrix and/or fibrin sealants, and their association known as "carrier-bound fibrin sealant" (CBFS): despite widely used for secondary haemostasis, the level of evidence remains low. To realize a meta-analysis on the results of CBFS on haemostasis and postoperative complications. Searches in PubMed, PubMed Central, Cochrane and Google Scholar using keywords: "topical_haemostasis" OR "haemostatic_agents" OR "sealant_patch" OR "fibrin_sealant" OR "collagen_sealant" AND "liver_surgery" OR "hepatic_surgery" OR "liver_transplantation". Randomized clinical trials, large retrospective cohort studies, case control studies evaluating THA on open/laparoscopic liver surgery and transplantation. From 1993 to 2016 were found 22 studies for qualitative synthesis and 13 for quantitative meta-analysis. The time to haemostasis was lower in the CBFS group (mean difference -2.33 min; P = 0.00001). The risk of receiving blood transfusion, developing collections and bile leak was not influenced by the use of CBFS (OR 0.75; P = 0.25), (OR 0.72; P = 0.52), (OR 0.74; P = 0.30) respectively. The use of CBFS in liver surgery significantly reduce the time to haemostasis, but does not decrease transfusion, postoperative collection and bile leak.