Which operative techniques minimize blood loss during liver transplantation?

Updated: Apr 19, 2019
  • Author: Vanessa A Olcese, MD, PhD; Chief Editor: Ron Shapiro, MD  more...
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During surgery, technical factors are associated with bleeding and transfusion requirements. Established and innovative surgical techniques to minimize blood loss include the use of venovenous bypass, autologous blood transfusion, volume expansion, and a cell saver.

Surgeons can attend to many technical details in order to minimize blood loss during orthotopic liver transplantation (OLT). The use of split or reduced-size liver grafts results in the successful transplantation of partial adult livers into infants, and, at times, expands the number of recipients who can receive cadaveric grafts.

The experience of the surgical team impacts blood loss, transfusion requirements, and the morbidity of patients undergoing liver transplantation. Additionally, modifications in surgical technique, including the use of cautery, and medical therapy have reduced morbidity during the learning curve of living-donor liver transplantation, as reported for right-lobe living-donor liver transplantation.

OLT involves the explantation of the native liver and replacement with the donor liver. This requires either the use of bypass or clamping of the inferior vena cava and portal vein. A variation of this technique is called piggyback transplantation, whereby the inferior vena cava is preserved and venovenous bypass can be avoided. Several studies have failed to show a benefit in the piggyback technique regarding blood loss or use. [8, 9, 10]

Portosystemic shunting has been used in patients with liver failure in order to decrease preoperative complications associated with portal hypertension (eg, bleeding varices, ascites, sepsis). Traditionally, creation of a shunt could be accomplished only with surgery, but a transjugular intrahepatic portosystemic shunt (TIPS) is now available.

The TIPS procedure is designed to decompress the portal system in order to decrease the risk of variceal rebleeding and minimize ascites. In a comparison of TIPS versus surgical portosystemic shunts before OLT, Menegaux et al reported that patients who underwent TIPS had decreased blood requirements, shorter operative time, shorter intensive care unit stays, and shorter hospital stays. [11]

Central venous pressure (CVP) monitoring is an important aspect of OLT. Patients frequently undergo volume expansion prior to hepatic resection to prevent bleeding complications, but expansion increases CVP. Deliberate lowering of the CVP during liver resection assists in bleeding control by decreasing the blood pressure gradient over which bleeding occurs during dissection.

Melendez and coworkers showed that this anesthesia maneuver decreased median estimated blood loss, morbidity, length of intensive care unit stay, and hospital stay when used with vascular occlusion. [12] Renal failure directly attributable to low CVP was not observed. In this prospective study of 100 hepatic resections, blood loss was significantly less in the low-CVP group and blood transfusions were significantly less frequent (2 vs 25 patients), with no reported increases in morbidity. [12]

Massicotte and colleagues showed that maintenance of a low CVP prior to the anhepatic phase in 100 patients was associated with a decrease in RBC transfusions during liver transplantation. [13] In this group, the mean number of intraoperative RBC units transfused was 0.4 ± 0.8, and no plasma, platelets, albumin, or cryoprecipitate were transfused.

Treatment with recombinant factor VIIa (rFVIIa) may reduce blood loss during OLT. In a pilot study by Hendriks et al, transfusion requirements were significantly lower in 6 adult end-stage liver disease (ESLD) patients who received rFVIIa than in matched controls. [14] Subjects were given 80 mcg/kg of rFVIIa 10 minutes preoperatively (and intraoperatively if the estimated blood loss exceeded the subject's estimated blood volume.

A trial in 20 patients by Pugliese et al found that the units of blood products transfused and total blood loss during OLT were statistically significantly lower in patients receiving a single bolus of 40 mcg/kg of rFVIIa than in controls. In this double-blind, placebo-controlled, prospective, randomized trial, inclusion criteria were hemoglobin level greater than 8 g/dL, international normalized ratio (INR) greater than 1.5, and fibrinogen level greater than 100 mg/dL. [15] Notably, no thromboembolic events occurred in the rFVIIa group. Similar results have been duplicated by several other small pilot trials. [16]

Kalicinski and colleagues at the Warsaw Children's Hospital reported that rFVIIa, given preoperatively to pediatric liver transplant recipients with several risk factors for high intraoperative bleeding, adjusts these patients to a normal risk group. [17] Treatment with rFVIIa, which was given in a bolus just before transplantation, produced immediate correction of coagulopathies, with no increase in thrombotic complications.

As with many other surgical procedures, autologous (cell salvage) blood transfusion can be performed in OLT to reduce the risks associated with allogeneic transfusion. In patients with advanced cirrhosis, the RBC mass may be adequate to support autologous RBC transfusion, but platelet concentrations and clotting factor levels are usually so low that avoidance of platelet and fresh frozen plasma (FFP) transfusion may not be possible.

The use of cell salvage to collect and reinfuse shed, autologous blood is a common practice in surgery with an expected high blood loss. Some question its applicability to cancer surgery, fearing that malignant cells will be redistributed in the salvaged blood.

However, Muscari and colleagues concluded that cell salvage could be used in liver transplantation for hepatocellular malignancy because it does not modify the risk of neoplastic recurrence. [18] On 1-year follow-up of 47 patients, 6.4% of patients operated on with cell salvage experienced recurrence, versus 6.3% of patients in whom cell salvage was not used.

Volume expansion is another method used more frequently in other surgical procedures to decrease the requirement of allogeneic transfusion of PRBCs. The anesthesiologist draws 1 unit of blood from the patient before transplantation and replaces the volume with crystalloid. The number of RBCs lost during the operation is thus lowered, and the unit can be reinfused when needed.

Reports have described liver transplantation in Jehovah's Witness patients who received no transfusions. [19] Jabbour and colleagues continue to lead the field in performing liver transplantation without the use of blood or blood products. In 27 consecutive patients who underwent transfusion-free liver transplantation, this team reported 100% graft and patient survivals in the 19 patients who received living donor grafts and 75% in 8 deceased-donor recipients. [20]

Jabbour and colleagues used a combination of preoperative stimulation of red cell production with recombinant human erythropoietin and iron and intraoperative hemodilution, cell salvage, and tolerance of moderate anemia. This group has also reported on the successful use of rFVIIa at a dose of 80 mcg/kg, administered intravenously just prior to the incision in all patients, with a second intraoperative dose if necessary. [21]

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