The safety and efficacy of hypovolemic phlebotomy on blood loss and transfusion in liver surgery: a systematic review and meta-analysis

Abstract

Background: Hypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7-10 mL/kg) without volume replacement. The subsequent central venous pressure (CVP) reduction is hypothesized to decrease blood loss and the need for blood transfusion. The objective was to conduct a systematic assessment of the safety and efficacy of HP on blood loss and transfusion in the liver surgery literature. Methods: MEDLINE, EMBASE, and Cochrane Library databases were searched. Outcomes of interest included blood loss, allogenic red blood cell transfusion, postoperative adverse events, and CVP change. A qualitative synthesis and meta-analysis were performed as appropriate. Results: Four cohort studies, one case series, and three randomized controlled trials involving 2255 patients were included. Meta-analysis of studies involving liver resections for any indication (n = 6) found no difference in transfusion (OR 0.38, p = 0.12) or incidence of adverse events with HP compared to nonuse. Pooling of studies involving liver resections for an underlying pathology (n = 4) revealed HP was associated with significant reduction in transfusion (OR 0.25, p = 0.03) but no differences in blood loss (−173 mL, p = 0.17). Conclusion: This review suggests HP is safe and associated with decreased transfusion in patients undergoing liver surgery. It supports further investigation.

Abdominal Organ Transplantation: Noteworthy Literature in 2020

“…They concluded that hypovolemic phlebotomy is safe and associated with decreased transfusion in patients undergoing liver surgery with underlining pathology. 50 This finding at least supports the safety of this blood conservation technique in donor liver hepatectomy.…”

Effect of intraoperative hypovolemic phlebotomy on transfusion and clinical outcomes in patients undergoing hepatectomy: a retrospective cohort study

“…The use of IOHP was safe, and not associated with more postoperative complications, as supported by a recent meta-analysis. 29 The adversely impacted cancer outcomes observed in transfused patients following hepatectomy 3,[6][7][8] may be due to transfusion-associated immunomodulation (TRIM), characterized by increased regulatory T cells, dysfunctions of natural killer cells and macrophages, and deficient antigen presentation, which in turn may impact healing and anti-cancer immunity. 30,31 Although TRIM may be decreased by depleting allogeneic blood of leukocytes, 32,33 in the modern era, the benefit of Fig.…”

“…The use of IOHP was safe, and not associated with more postoperative complications, as supported by a recent meta-analysis. 29 …”

Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility

“…There have been very few trials comparing HP with the standard of care in patients with primarily oncological indications. An RCT comparing HP with standard of care in living donor procurement procedures reported less blood loss with phlebotomy during liver parenchymal resection (140 versus 230 ml; P = 0·034), but found no significant difference in total intraoperative blood loss (403 versus 440 ml; P = 0·257).…”

“…Seven other studies reporting on the use of HP in liver surgery were identified in a systematic review, including two RCTs, four retrospective cohort studies of patients undergoing liver resection (3) or liver transplantation (1), and one case series of patients undergoing liver resection. Pooled analysis of studies reporting on patients undergoing HP versus standard of care at the time of liver resection for non‐transplant indications reported that HP was protective of blood loss (–173 (95 per cent c.i.…”