Case Study: Transfusion-Free Tumor Resection

A 72-year-old man, suffering from cholangiocarcinoma involving the right side of the liver as well as the major right bile duct, was evaluated at a large academic facility in the Midwest for possible resection. He underwent open surgery on April 23, 1999; his surgeons, however, felt uncomfortable performing liver resection for this tumor without the use of blood or blood products. Therefore, a simple cholecystectomy was performed, and the patient was referred for non-surgical treatment.

Unwilling to accept that decision, the patient’s family conducted a search and contacted the USC Transfusion-Free Medicine and Surgery Program. The patient was admitted to the hospital for further evaluation. The preoperative studies were reviewed by Rick Selby, M.D., Nicolas Jabbour, M.D., and Yuri Genyk, M.D. They felt that the surgery could be done safely without the use of blood or blood products.

At that time, the patient had a hemoglobin count of 12.7 grams per decaliter and a hematocrit of 37.9 percent. Prior to the surgery, the patient received erythropoeitin and oral iron to increase his red cell count. This therapy led to an increase of his hemoglobin to 14.4 grams per decaliter and his hematocrit to 43.2 percent.

On May 22, 1999, the patient underwent an exploratory laparotomy that revealed tumor localized to the right lobe of the liver with involvement of the right common bile duct. As part of the protocol for transfusion-free surgery at University Hospital, the patient underwent acute normovolemic hemodilution, a technique that consisted of removing three units of his blood and maintaining it in a continuous circuit with his blood system at the beginning of surgery. The blood was replaced with crystalloid and albumin to maintain normal, central venous pressure and normal blood pressure and heart rate; once the surgery was completed and the potential for blood loss minimal, the blood was reinfused into the patient.

The surgery consisted of right hepatic resection and complete removal of the intrahepatic bile duct along with the lymphatic tissue in the liver hilum. The patient was hemodynamically stable throughout the surgery. He was extubated on the operating table and transferred in stable condition to the intensive care unit. At the end of surgery, his hemoglobin was 14 grams and his hematocrit was 43 percent.

The patient did well postoperatively; he was started on a regular diet on the 5th postoperative day and ambulated on the 6th postoperative day. He was discharged two weeks after the surgery. At discharge, his hemoglobin was 13 grams per decaliter and his hematocrit was 40 percent. He was seen later at the clinic and, to date, is doing well – with no evidence of tumor recurrence.

This patient’s case points out that the inability of even a major, well-thought-of medical center to perform bloodless surgery does not necessarily mean that such an operation cannot be performed. Had the patient not sought care at USC, he would likely have gone on to develop an extensive tumor.

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