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

Abstract

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.

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

“…19 Thus, our findings are in keeping with the shift towards more restrictive transfusion practices in liver surgery. 10 Interestingly, the trends in BT for the current study cohort were similar to patients undergoing colon resection for primary colon cancer, where the transfusion rate was roughly 28% and a similar decrease over time was noted. 26 In patients with colorectal cancer, such transfusion rates may, in part, be a consequence of the relatively high prevalence of anemia, ranging between 30 and 70%, typically due to occult tumor bleeding.…”

“…8,9 Recently, a consensus statement was published by the Canadian Hepato-Pancreato-Biliary Association (CHPBA) with the goal of clarifying and standardizing patient blood management around the time of liver resection. 10 While blood transfusions (BT) are often necessary to correct preoperative anemia or help manage perioperative hemorrhage, the trend towards more restrictive transfusion policies has been driven by reported associations with inferior short-term outcomes and long-term survival. [11][12][13] The underlying mechanisms are thought to involve the promotion of further metastatic disease by tumor cell dissemination and inflammation due to the surgical procedure itself, and through various potential immunosuppressive effects induced by allogeneic BT, often referred to as transfusion-related immunomodulation (TRIM).…”

Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

“…In 2019, the Canadian Hepato-Pancreatic-Biliary Association group released a declaration that obtained 70% of consensus about the following recommendations: (1) preoperative evaluation of the risk of transfusion; (2) preoperative administration of iron in case of anemia; (3) restrictive fluid protocol during the clamping of the HH in order to limit the blood loss; (4) general perioperative restrictive transfusion strategies [51]. In the same year, the Liver Intensive Care Group of Europe (LICAGE) addressed the issue of the PBM in chronic liver disease as follows: (1) correction of preoperative anemia; (2) FFP administration only in case of bleeding; (3) in case of bleeding, platelet (PLT) administration if platelet count <50,000/mm 3 ; (4) prothrombin time (PT) and time of partial thromboplastin activation (aPTT) should not be used to guide blood transfusions; conversely, viscoelastic tests are recommended; (5) in the course of bleeding, if fibrinolysis is ruled out and PLTs and fibrinogen are restored, prothrombin complex concentrates (PCCs) could be considered [52].…”