Removing just 10% of a patient’s blood before liver surgery and returning it afterwards can reduce transfusion rates by half.
This technique also gives surgeons a more explicit view during operations.
This is according to a landmark study in The Lancet Gastroenterology & Hepatology.
Researchers now call for global adoption, predicting it could spare one in 11 patients from transfusions.
Surgeon Dr Guillaume Martel, co-lead author and Arnie Vered Family Chair in Hepato-Pancreato-Biliary Research at The Ottawa Hospital and the University of Ottawa, said: ‘Blood loss is a major concern in liver surgery. Taking out half a litre of blood right before major liver surgery is the best thing we’ve found so far for reducing blood loss and transfusions.’
He explained: ‘It works by lowering the blood pressure in the liver. It’s safe, simple, inexpensive, and should be considered for any liver surgery with a high risk of bleeding.’
A quarter to a third of patients having major liver surgery typically need transfusions.
Cancer, the leading cause of these surgeries, is linked to a higher risk of recurrence when transfusions occur.
Co-lead author Dr François Martin Carrier, anaesthesiologist and Héma-Québec – Bayer Chair in Transfusion Medicine at Université de Montréal, added: ‘Now we’ve proven removing blood before liver surgery reduces transfusions, we’re spreading the word and teaching our colleagues how to do it. It’s simple after the first time and makes a dramatic difference in surgery. It’s now standard of care at the four hospitals in the trial, and others worldwide should adopt it.’
Between 2018 and 2023, the trial recruited 446 patients undergoing major liver surgery at four Canadian hospitals: The Ottawa Hospital, le Centre Hospitalier de l’Université de Montréal, le Centre Hospitalier Universitaire de Sherbrooke, and Vancouver General Hospital.
Under anaesthesia, patients were randomly assigned to either hypovolemic phlebotomy or standard care.
The anaesthetist, the only one aware of the assignment, removed about 450 mL of blood from patients in the hypovolemic phlebotomy group and stored it in a blood bag. If needed, this blood was used during surgery or re-infused before the patient woke up.
Results showed that just 7.6% of patients in the hypovolemic phlebotomy group required a transfusion within 30 days, compared to 16.1% in the standard care group.
Surgeons reported an added benefit: surgeries were easier because less blood obscured the surgical field.
The median blood loss with hypovolemic phlebotomy was 670 mL, compared to 800 mL with standard care. The procedure caused no additional complications.
Rowan Ladd, 44, was diagnosed with colon cancer in 2020. Two years later, it spread to her liver, requiring major surgery.
She said: ‘I signed up for every study I was offered. If I’m going into liver surgery, then why not? I’m a big proponent of research. I thought it was great that researchers were trying to reduce the risks of major bleeding.’
In October 2022, Rowan was randomly selected for hypovolemic phlebotomy. She didn’t need a transfusion and went home just four days later. Now cancer-free, she reflects on the experience:
‘I looked at this surgery like it saved my life. I stopped working, relaxed, and took care of myself. Being part of this trial was a positive experience, and the team was wonderful. I’m so glad I was picked, and I’m glad it will help other people.’
Each blood transfusion costs at least $500 in Canada, primarily for human resources. By comparison, the supplies for hypovolemic phlebotomy cost less than $30.
Dr Martel’s team first demonstrated the safety of hypovolemic phlebotomy in a smaller trial. The technique is now being tested in liver transplants and could potentially be applied in other surgeries prone to significant blood loss.
