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Ivanics T, Shubert CR, Muaddi H, Claasen MPAW, Yoon P, Hansen BE, McCluskey SA, Sapisochin G. Blood Cell Salvage and Autotransfusion Does Not Worsen Oncologic Outcomes Following Liver Transplantation with Incidental Hepatocellular Carcinoma: A Propensity Score-Matched Analysis. Ann Surg Oncol 2021; 28:6816-6825. [PMID: 33778907 DOI: 10.1245/s10434-021-09863-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intraoperative blood cell salvage and autotransfusion (IBSA) during liver transplantation (LT) for hepatocellular carcinoma (HCC) is controversial for concern regarding adversely impacting oncologic outcomes. OBJECTIVE We aimed to evaluate the long-term oncologic outcomes of patients who underwent LT with incidentally discovered HCC who received IBSA compared with those who did not receive IBSA. METHODS Patients undergoing LT (January 2001-October 2018) with incidental HCC on explant pathology were retrospectively identified. A 1:1 propensity score matching (PSM) was performed. HCC recurrence and patient survival were compared. Kaplan-Meier survival analyses were performed, and univariable Cox proportional hazard analyses were performed for risks of recurrence and death. RESULTS Overall, 110 patients were identified (IBSA, n = 76 [69.1%]; non-IBSA, n = 34 [30.9%]). Before matching, the groups were similar in terms of demographics, transplant, and tumor characteristics. Overall survival was similar for IBSA and non-IBSA at 1, 3, and 5 years (96.0%, 88.4%, 83.0% vs. 97.1%, 91.1%, 87.8%, respectively; p = 0.79). Similarly, the recurrence rate at 1, 3, and 5 years was not statistically different (IBSA 0%, 1.8%, 1.8% vs. non-IBSA 0%, 3.2%, 3.2%, respectively; p = 0.55). After 1:1 matching (26 IBSA, 26 non-IBSA), Cox proportional hazard analysis demonstrated similar risk of death and recurrence between the groups (IBSA hazard ratio [HR] of death 1.26, 95% confidence interval [CI] 0.52-3.05, p = 0.61; and HR of recurrence 2.64, 95% CI 0.28-25.30, p = 0.40). CONCLUSIONS IBSA does not appear to adversely impact oncologic outcomes in patients undergoing LT with incidental HCC. This evidence further supports the need for randomized trials evaluating the impact of IBSA use in LT for HCC.
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Affiliation(s)
- Tommy Ivanics
- HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Christopher R Shubert
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hala Muaddi
- HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marco P A W Claasen
- HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Yoon
- HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Stuart A McCluskey
- HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, University Health Network, Toronto, ON, Canada.
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Costanzo D, Bindi M, Ghinolfi D, Esposito M, Corradi F, Forfori F, De Simone P, De Gasperi A, Biancofiore G. Liver transplantation in Jehovah's witnesses: 13 consecutive cases at a single institution. BMC Anesthesiol 2020; 20:31. [PMID: 32000668 PMCID: PMC6993414 DOI: 10.1186/s12871-020-0945-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background Jehovah’s Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah’s Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures. Methods This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah’s Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. Results In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah’s Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Conclusions Our experience confirms that liver transplantation in selected Jehovah’s Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach.
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Affiliation(s)
- Diego Costanzo
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Maria Bindi
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Davide Ghinolfi
- Liver Transplant Surgery Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Massimo Esposito
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Francesco Corradi
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Francesco Forfori
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Paolo De Simone
- Liver Transplant Surgery Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | - Andrea De Gasperi
- Anesthesia and Critical Care Unit, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Gianni Biancofiore
- Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy.
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Yokoyama APH, Kutner JM, Sakashita AM, Nakazawa CY, de Paula TAO, Zamper RPC, Pedroso PT, de Almeida MD, Meira Filho SP, Orsi FA. Risk Factors for Transfusion after Orthotopic Liver Transplantation. Transfus Med Hemother 2019; 46:431-439. [PMID: 31933573 DOI: 10.1159/000499120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background Transfusion of blood products during orthotopic liver transplantation (OLT) is associated with increased morbidity and mortality. Although risk factors associated with intraoperative transfusion requirements have been widely assessed, published data on the prediction of postoperative transfusion requirements are sparse. Objectives The aim of this study was to evaluate risk factors for postoperative allogeneic transfusion requirements in OLT. Methods Clinical characteristics and intraoperative parameters of 645 consecutive adult patients undergoing OLT were retrospectively reviewed. Multivariate logistic regression was used to determine the main determinants for postoperative transfusion requirements. Results Determinants of postoperative transfusion requirements of any blood product in the postoperative period were the number of blood products transfused in the intraoperative period (OR 1.17, 95% CI 1.08-1.28), warm ischemia time (OR 1.05, 95% CI 1.02-1.08), MELD score (OR 1.05, 95% CI 1.01-1.08) and hepatocellular carcinoma (OR 0.45, 95% CI 0.28-0.72). A dose-dependent effect between the number of units transfused in the intraoperative period and transfusion requirements in the postoperative period was also observed. The relative risk of postoperative allogeneic transfusion of any blood component was 5.9 (95% CI 3.4-10.4) for patients who received 1-2 units in the intraoperative period, 7.3 (95% CI 3.6-14.7) for those who received 3-5 units in the intraoperative period, and 11.1 (95% CI 4.7-26.4) for those who received 6 or more units, when compared to no intraoperative blood transfusion. Conclusion Our study demonstrated an association between intraoperative transfusion and warm ischemia time with postoperative transfusion requirements. The identification of risk factors for transfusion in the postoperative period may improve management of these patients by increasing awareness to bleeding complications in this high-risk population and by expanding hemostasis monitoring to the postoperative period.
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Affiliation(s)
| | - José Mauro Kutner
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Araci Massami Sakashita
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Pamella Tung Pedroso
- Liver Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
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