Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovahs witnesses

Safety and feasibility of urological procedures in Jehovah's Witness patients

OBJECTIVES

To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients.

METHODS

An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported.

RESULTS

A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively).

CONCLUSIONS

Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.

Central hepatectomy for hepatocellular carcinoma in a patient with anti-Gerbich antibody

Background

Anti-Gerbich (Ge) alloantibody against high-frequency erythrocyte antigen is extremely rare. Owing to incomplete evidence regarding the degree and severity of adverse events induced by hemolytic transfusion reactions, the transfusion management often remains cumbersome in these patients. We report an anti-Ge alloantibody positive patient with hepatocellular carcinoma (HCC) who underwent central hepatectomy (CH) without the need for an allogeneic blood transfusion.

Case presentation

A 76-year-old Japanese woman was diagnosed with HCC measuring 9.5 × 8.0 cm in segments 4, 5, and 8 of the liver. This patient with anti-Ge alloantibody had a history of two pregnancies without transfusion. CH was planned, and based on the suggestion from the multidisciplinary team meeting, preoperative autologous donation (PAD) and acute normovolemic hemodilution (ANH) were performed. CH was successfully performed by using CUSA and Thunderbeat® with Pringle maneuver and infra-hepatic inferior vena cava clamping without perioperative need for an allogeneic blood transfusion. She has been alive without recurrence after a follow-up period of 45 months.

Conclusion

To our knowledge, this is the first case report of hepatectomy in a patient with anti-Ge alloantibody. A multidisciplinary team approach, PAD and ANH, and bloodless liver surgical techniques appear to be useful for major hepatectomy in patients with extremely rare blood type.

Holmium laser enucleation of the prostate in Jehovah's Witness patients

PURPOSE

To evaluate if HoLEP is a viable option for male patients with medication-refractory urinary symptoms due to an enlarged prostate who are surgical candidates, but do not accept blood product transfusion.

MATERIALS AND METHODS

Between August 2008 and March 2019, nine Jehovah's Witness patients were undergoing HoLEP for relief of lower urinary tract symptoms and urinary retention. We described change in hemoglobin, change in PSA, enucleated prostate weight, enucleation and morcellation times, length of stay, and postoperative retention rate.

RESULTS

The average age was 71.4 years (range 53-87). Urinary retention requiring catheterization was present in seven patients (78%). Two patients had a known diagnosis of prostate cancer preoperatively. The mean preoperative PSA on average was 21.6 ng/dL. Patients had a wide range of gland sizes, with a mean enucleated weight of 141 g (range 18-344 g). Mean reduction in hemoglobin was 16.9% following HoLEP. All patients managed to void postoperatively. All but one patient went home on postoperative day 1, and this patient went home on postoperative day 2. No patients required blood product transfusion or return to the operating room for clot irrigation postoperatively.

CONCLUSION

HoLEP is a reasonable option for Jehovah's Witness and other patients with contraindications to blood product transfusion requiring surgical management of urinary symptoms due to enlarged prostate.

[Cell salvage : Scientific evidence, clinical practice and legal framework]

Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.

Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer

Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients' biological status, disease and its aggressiveness, and physician and centres' expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians' understanding of their own patients' preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians' recommendation.

Major abdominal surgery in Jehovah's Witnesses

Introduction Patients who are Jehovah's Witnesses pose difficult ethical and moral dilemmas for surgeons because of their refusal to receive blood and blood products. This article outlines the personal experiences of six Jehovah's Witnesses who underwent major abdominal surgery at a single institution and also summarises the literature on the perioperative care of these patients. Methods The patients recorded their thoughts and the dilemmas they faced during their surgical journey. We also reviewed the recent literature on the ethical principles involved in treating such patients and strategies recommended to make surgery safer. Results All patients were supported in their decision making by the clinical team and the Hospital Liaison Committee for Jehovah's Witnesses. The patients recognised the ethical and moral difficulties experienced by clinicians in this setting. However, they described taking strength from their belief in Jehovah. A multitude of techniques are available to minimise the risk associated with major surgery in Jehovah's Witness patients, many of which have been adopted to minimise unnecessary use of blood products in general. Nevertheless, the risks of catastrophic haemorrhage and consequent mortality remain an unresolved issue for the treating team. Conclusions Respect for a patient's autonomy in this setting is the overriding ethical principle, with detailed discussion forming an important part of the preparation of a Jehovah's Witness for major abdominal surgery. Clinicians must be diligent in the documentation of the patient's wishes to ensure all members of the team can abide by these.

Intraoperative cell salvage in radical prostatectomy does not appear to increase long-term biochemical recurrence, metastases, or mortality

BACKGROUND

Blood management strategies help to conserve allogeneic red blood cells, a finite resource. Intraoperative cell salvage (ICS) is an effective method of allogeneic avoidance. However, concerns persist about the safety of ICS in surgical oncology cases, including radical prostatectomy (RP). Previous findings do not support these concerns. We hypothesized that ICS would not increase rates of long-term prostate cancer recurrence characterized by biochemical failure, disease dissemination, or mortality.

STUDY DESIGN AND METHODS

Consecutive patients undergoing RP by a single urologist over two 3-month periods 1 year apart were analyzed retrospectively. Patients in the first period had preoperative autologous donation (PAD) but not ICS (PAD group), whereas those in the second period had ICS only (ICS group). Variables assessed included patient demographics, prostate-specific antigen levels at surgery and end of follow-up, clinical stage, operative time, surgical margin status, pathologic stage and grade, Gleason score sum, length of hospital stay, biochemical recurrence, metastases, and mortality.

RESULTS

A total of 116 consecutive patients were analyzed. Of these, 32 patients in the PAD group and 42 patients in the ICS group had follow-up of at least 4.75 years. There was a significantly higher rate of biochemical failure (34.4% vs. 9.5%; p = 0.02) and metastases (12.5% vs. 0%; p = 0.03) in the PAD group versus the ICS group; there was no significant difference in mortality (9.4% vs. 0%; p = 0.08).

CONCLUSION

ICS appears to be a safe and effective method of allogeneic blood conservation in patients undergoing RP. The findings suggest that there is no increased risk of biochemical failure, disease dissemination, or mortality at 5 years post-RP as a result of ICS use.

Cell salvage as part of a blood conservation strategy in anaesthesia

The use of intraoperative cell salvage and autologous blood transfusion has become an important method of blood conservation. The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion and its associated complications. Allogeneic blood transfusion has been associated with increased risk of tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low-output cardiac failure, and increased mortality. We have reviewed the current evidence for cell salvage in modern surgical practice and examined the controversial issues, such as the use of cell salvage in obstetrics, and in patients with malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to be safe and effective at reducing allogeneic blood transfusion requirements in adult elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use. Cell salvage should be considered in all cases where significant blood loss (>1000 ml) is expected or possible, where patients refuse allogeneic blood products or they are anaemic. The use of cell salvage in combination with a leucocyte depletion filter appears to be safe in obstetrics and cases of malignancy; however, further trials are required before definitive guidance may be provided. The only absolute contraindication to the use of cell salvage and autologous blood transfusion is patient refusal.

Management of Jehovah's Witnesses in otolaryngology, head and neck surgery

It is imperative that surgeons should have some knowledge and understanding of the beliefs of Jehovah's Witnesses to respect the patient's wishes and effectively minimize and manage blood loss. The objective of this review was to provide a management strategy for Jehovah's Witness patients undergoing otolaryngology, head and neck surgery, because there is paucity of information regarding this within our literature. A systematic review of medical literature was conducted. Articles were identified using MEDLINE (1966-2007). The search strategy used Medical Subject Heading terms Jehovah's Witnesses, Beliefs, Ethical and Legal issues, Blood transfusion alternatives, ENT, Head and Neck surgery in Jehovah' witnesses. There is a broad range of nonblood surgical management strategies available in other specialities, making major surgery possible within this population. This review suggests recommendations in elective surgery, trauma, and emergencies.

Right trisectionectomy of the liver for intrahepatic cholangiocarcinoma with bile duct invasion in a Jehovah's Witness

Intrahepatic cholangiocarcinoma (ICC) is well known to have a very poor prognosis. Aggressive surgical strategies in the treatment of ICC, including major hepatectomy, have been reported to afford patients the best chance for significant survival. Recent advancements in surgical techniques concerning live donor liver transplantation have dramatically improved the results of major hepatectomy. However, surgical treatment of biliary malignancy is complex and is known to increase the likelihood of blood transfusion. We describe a Jehovah's Witness patient with ICC and concomitant bile duct invasion who had a successful right trisectionectomy with bile duct resection, lymph node dissection, and Rouxen-Y hepatico-jejunostomy without blood transfusion. A multidisciplinary preparation was crucial in obtaining this positive outcome. Importantly, bloodless liver transection techniques with inflow clamping, meticulous dissection, and hemostasis should be utilized for major hepatectomy in a Jehovah's Witness. The success of this case may alert clinicians to consider a hepatectomy as a possible option in the treatment of ICC in a Jehovah's Witness.