University of Groningen Impact of hemostasis and blood ... · blood loss and transfusion requirements in liver transplantation over the years. It is well known that blood transfusions

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Impact of hemostasis and blood loss on outcome after liver surgeryde Boer, Maria Theresia

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Impact of Hemostasis and Blood Loss on Outcome after Liver Surgery

Marieke T. de Boer

© Copyright 2015 M.T. de Boer, GroningenLayout and design: Peter van der Sijde. www.proefschriftgroningen.nlFront cover: FRESCO of Scylla and Charybdis, Banca Toscana, Florence, Italy, reprint from Lessingimages.comPrinting: De Marne, LeensISBN: 978-90-367-7823-7 (Book)ISBN: 978-90-367-7824-4 (Epub)

Impact of Hemostasis and Blood Loss on Outcome after Liver Surgery

Proefschrift

ter verkrijging van de graad van doctor aan deRijksuniversiteit Groningen

op gezag van de rector magnificus prof. dr. E. Sterken

en volgens besluit van het College voor Promoties.

De openbare verdediging zal plaatsvinden op

woensdag 10 juni 2015 om 14.30 uur

door

Maria Theresia de Boer

geboren op 30 april 1973te Heerenveen

Promotores

Prof. dr. R.J. Porte

Prof. dr. T. Lisman

Beoordelingscommissie

Prof. dr. C.M. Lo

Prof. dr. T.M. van Gulik

Prof. dr. E. Heineman

Paranimfen

Dr. J.M.M. Nijboer

Dr. C.I. Buis

Voor heit en mem

Table of contents

Chapter 1 General introduction and outline of this thesis. 9

Part I. Studies in liver resection Chapter 2 Impact of blood loss on outcome after liver resection. 19 Digestive Surgery 2007Chapter 3 Topical hemostatic agents in liver surgery: do we need them? 29 HPB 2009Chapter 4 Role of fibrin sealants in liver surgery. 41 Digestive Surgery 2012Chapter 5 Fibrin sealant for prevention of resection surface-related 55 complications after liver resection. A randomized controlled trial. Annals of Surgery 2012

Part II. Studies in liver transplantationChapter 6 Minimizing blood loss in liver transplantation: progress through 73 research and evolution of techniques. Digestive Surgery 2005Chapter 7 The impact of intraoperative transfusion of platelets and red 91 blood cells on survival after liver transplantation. Anesthesia & Analgesia 2008Chapter 8 Platelet transfusion during liver transplantation is associated 115 with increased postoperative mortality due to acute lung injury. Anesthesia & Analgesia 2009Chapter 9 The Impact of blood transfusion on the incidence of acute rejection 131 in orthotopic liver transplantation. Submitted Chapter 10 Increased post-reperfusion transfusion requirements in liver 145 transplantation with extended criteria donor grafts. Submitted

Chapter 11 Appendix 1 161 Questionnaire used in Chapter 3 Appendix 2 165 Correspondence related to Chapter 5 Letter to the editor and Reply to Letter. Annals of Surgery 2013 Letter to the editor and Reply to Letter. Annals of Surgery 2014 Appendix 3 175 Correspondence related to Chapter 7 Letter to the editor and Reply to Letter. Anesthesia Analgesia 2009

Chapter 12 Summary 179 General conclusions, discussion and future perspectives

Nederlandse samenvatting 195List of publications 205Dankwoord 209Curriculum Vitae 215List of abbreviations 216

9

1General introduction and outline of this thesis

10

Chapter 1

The liver and its role in hemostasis

The liver is a multifunctional, complex organ, playing a key role in metabolism of the human body.

The liver plays a central role in hemostasis, being the producer of the majority of coagulation factors.

In patients with liver disease the production of these coagulation factors can be reduced, which can

lead to disturbed clot formation. On the other hand, the liver produces also many anticoagulant

proteins such as antithrombin (AT), protein C and protein S, leading to a fragile, yet rebalanced

hemostatic system in patients with severe liver disease.1 Operating a patient with end-stage liver

disease is a challenge, because clotting disturbances and portal hypertension can lead to major

blood loss. (Figure 1)

Figure 1: Example of severe blood loss during liver transplantation.

Liver resection in patients with a normal liver function can be complicated by major blood loss

because the densely vascularized, soft structured parenchyma needs to be transected during

resection. Nowadays both liver resection and liver transplantation are generally accepted methods

to treat patients with liver tumors or patients with end-stage liver disease. Although Wendell2

described the first resection of the right side of the liver for a primary tumor in 1911, true anatomical

right hemihepatectomy was first described in 1952 by Lortat-Jacob and Robert.3 The first liver

transplantation was performed by Starzl in 1963.4 Unfortunately, this first patient died of hemorrhage,

illustrating that blood loss during liver transplantation was one of the hurdles to take in improving

outcome in liver transplantation in those early days. As in liver transplantation, hemorrhage was an

important risk factor for mortality in the early days of liver resection.5 Ongoing improvements in

surgical and anesthesiological techniques and postoperative patient management in liver resection

and transplantation have led to a significant improvement in short- and long-term outcome.6 Despite

11

General introduction and outline of this thesis

1these improvements, even nowadays blood loss and blood transfusions remain independent risk

factors for morbidity and mortality after liver resection7-10 and liver transplantation.11-13

Use of hemostatic agents in liver surgery

Although topical hemostatic agents can never replace meticulous surgical hemostasis, they can

be helpful when bleeding problems persist. Hemostatic agents can roughly be divided in matrix

products, only providing a matrix to stimulate clot formation, and in active hemostatic agents.

Active hemostatic agents consist of human or bovine derived coagulation factors, when locally

applied they mimic clot formation or can help to stimulate clot formation.

Outline of this thesis

This thesis focuses on intraoperative blood loss and blood transfusion in liver surgery, and is

subdivided in two parts. Part 1 evaluates the impact of blood loss and blood transfusion on short-

and long-term outcome in liver resections. In this part the use and efficacy of hemostatic agents

in liver surgery is also evaluated. Part 2 focuses on blood loss and transfusion requirements in liver

transplantation and its impact on short- and long-term outcome after liver transplantation.

PART 1 Studies on liver resection

Since the first publication of a true anatomical right hemihepatectomy in 1952, the subsequent

early experience in hepatic resections has been discouraging. In major hepatectomy mortality was

reported to be over 20% in a retrospective series of 621 liver resections.5 Death was attributed to

hemorrhage in 20% of these cases. Over the years outcome has improved by evolution in surgical

and anesthesiological techniques and better understanding of segmental liver anatomy. Nowadays

major liver resections can be performed with a mortality rate below 5% in specialized centers, even

though the indications have been extended also to high-risk patients.6 Liver resection has now been

accepted as the standard treatment for most liver tumors. In 2004, Poon et al have described a

gradual reduction in the percentage of transfused patients from around 90% in 1989 to 5% in 2003

in a series of 1,222 consecutive liver resections.6 Despite these improvements blood loss remains

an important predictor of both perioperative morbidity and mortality after liver resection.9,10

Chapter 2 provides a review of the literature on the impact of blood loss and blood transfusion on

postoperative and oncological outcome in liver resections for hepatobiliary malignancies.

Blood loss in liver resection is mainly related to the technical difficulty to transect the liver

parenchyma, which makes blood transfusion sometimes inevitable. Several techniques can be

applied to reduce blood loss: reduction of the central venous pressure (CVP), vascular occlusion

techniques, and the choice of the device to transect the parenchyma. Besides these techniques

several topical agents have been developed to improve hemostasis on the resection surface. The

purpose of Chapter 3 is to describe the use of topical hemostatic agents during liver resections in

the Netherlands and to describe when and for which purpose these agents are used.

12

Chapter 1

Topical hemostatic agents are not only used to achieve hemostasis but are also used with the aim

to reduce postoperative resection surface-related complications, such as bile leakage. In Chapter

4 a study is described in which the evidence for hemostatic and biliostatic capacities of different

fibrin sealants in liver surgery is assessed through a review of the literature. In Chapter 5 the effect

of prophylactic use of fibrin sealants on the liver resection surface is described in a prospective

randomized controlled study including 310 patients.

PART 2 Studies on liver transplantation

After reporting the first successful liver transplantations with prolonged survival in 1968 by Starzl et

al,14 liver transplantation was considered a possible, but hazardous treatment for end stage chronic

liver failure. Many hurdles towards successful liver transplantation have been overcome over the

last decades. The introduction of cyclosporine in the early 1980s and development of the University

of Wisconsin preservation solution in the late 1980s were important steps in improving outcome

after liver transplantation.15,16 However, high morbidity and mortality rates kept being reported,

frequently related to high intraoperative blood loss and transfusion requirements.17,18 In Chapter 6

techniques and developments are described which have contributed to an impressive reduction in

blood loss and transfusion requirements in liver transplantation over the years.

It is well known that blood transfusions have an immunosuppressive effect,19 which may play a role in

the negative correlation between the amount of intraoperative blood transfusion and postoperative

outcome in liver transplantation. In Chapter 7 the impact of transfusion of different blood products

on graft and patient survival after liver transplantation was assessed retrospectively. Chapter 8

focuses on the influence of platelet transfusion on short term outcome after liver transplantation.

Nowadays several centers describe liver transplantation without the need for blood transfusion in

26 up to 80% of cases.13,20,21 Given the immunosuppressive effects of blood transfusion, this raises

the question whether patients who did not require any blood transfusion have an increased risk of

developing acute rejection. In Chapter 9 the relation between blood transfusion and the incidence

of acute rejection after liver transplantation is evaluated.

In an era of organ shortage expanding the donor pool by accepting extended criteria donor

(ECD) grafts is a way to reduce waiting list mortality.22,23 Aim of Chapter 10 is to determine the

impact of implantation of ECD grafts on intraoperative blood transfusion requirements during liver

transplantation.

Chapter 11 consists of 3 appendixes. Appendix 1 is the dutch questionnaire used for the analysis in

Chapter 3; Appendix 2 are letters to the editor and reply, related to Chapter 5; Appendix 3 is a letter

to the editor and reply, related to Chapter 7.

In Chapter 12 the previous chapters are summarized and discussed in a broader perspective. Finally,

this chapter provides directions for future research.

13


1The aims of this thesis were to study:

1. The impact of blood loss and blood transfusion on postoperative and oncological outcome

in liver resections for hepatobiliary malignancies.

2. The use of topical hemostatic agents during liver resections in the Netherlands and

describe when and for which purpose these agents are used.

3. The evidence for hemostatic and biliostatic capacities of different fibrin sealants in liver

surgery.

4. The effect of prophylactic use of fibrin sealants on the liver resection surface in a

multicenter prospective randomized controlled study.

5. Techniques and developments which have contributed to an impressive reduction in

blood loss and transfusion requirements in liver transplantation over the years.

6. The impact of transfusion of different blood products on graft and patient survival after

liver transplantation.

7. The influence of platelet transfusion on short term outcome after liver transplantation.

8. The relation between blood transfusion and the incidence of acute rejection after liver

transplantation.

9. The impact of implantation of ECD liver grafts on intraoperative blood transfusion

requirements during liver transplantation.

14

Chapter 1

REFERENCES

1. Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood 2010;116:878-885.

2. Wendell W. Beitrag zur Chirurgie de Leber. Arch Klin Chir 1911;95:887.

3. Lortat-Jacob JL, Robert HG. Well defined technic for right hepatectomy. Presse Med 1952;60:549-551.

4. Starzl TE, Marchioro TL, Vonkaulla KN, Hermann G, Brittain RS, Waddell WR. Homotransplantation of the Liver in Humans. Surg Gynecol Obstet 1963;117:659-676.

5. Foster JH, Berman MM. Solid liver tumors. Major Probl Clin Surg 1977;22:1-342.

6. Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, et al. Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Ann Surg 2004;240:698-708.

7. Cescon M, Vetrone G, Grazi GL, Ramacciato G, Ercolani G, Ravaioli M, et al. Trends in perioperative outcome after hepatic resection: analysis of 1500 consecutive unselected cases over 20 years. Ann Surg 2009;249:995-1002.

8. Huang ZQ, Xu LN, Yang T, Zhang WZ, Huang XQ, Cai SW, et al. Hepatic resection: an analysis of the impact of operative and perioperative factors on morbidity and mortality rates in 2008 consecutive hepatectomy cases. Chin Med J (Engl) 2009;122:2268-2277.

9. Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397-406.

10. Kooby DA, Stockman J, Ben-Porat L, Gonen M, Jarnagin WR, Dematteo RP, et al. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 2003;237:860-869.

11. Boin IF, Leonardi MI, Luzo AC, Cardoso AR, Caruy CA, Leonardi LS. Intraoperative massive transfusion decreases survival after liver transplantation. Transplant Proc 2008;40:789-791.

12. Dunn LK, Thiele RH, Ma JZ, Sawyer RG, Nemergut EC. Duration of red blood cell storage and outcomes following orthotopic liver transplantation. Liver Transpl 2012;18:475-481.

13. Ramos E, Dalmau A, Sabate A, Lama C, Llado L, Figueras J, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl 2003;9:1320-1327.

14. Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti VA, Moon JB, et al. Orthotopic homotransplantation of the human liver. Ann Surg 1968;168:392-415.

15. Calne RY, Rolles K, White DJ, Thiru S, Evans DB, McMaster P, et al. Cyclosporin A initially as the only immunosuppressant in 34 recipients of cadaveric organs: 32 kidneys, 2 pancreases, and 2 livers. Lancet 1979;2:1033-1036.

16. Belzer FO, Southard JH. Principles of solid-organ preservation by cold storage. Transplantation 1988;45:673-676.

17. Lewis JH, Bontempo FA, Cornell F, Kiss JE, Larson P, Ragni MV, et al. Blood use in liver transplantation. Transfusion 1987;27:222-225.

18. Bismuth H, Castaing D, Ericzon BG, Otte JB, Rolles K, Ringe B, et al. Hepatic transplantation in Europe. First Report of the European Liver Transplant Registry. Lancet 1987;2:674-676.

19. Brand A. Immunological aspects of blood transfusions. Transpl Immunol 2002;10:183-190.

15


120. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S, et al. Primary liver transplantation

without transfusion of red blood cells. Surgery 1996;120:698-704.

21. Massicotte L, Beaulieu D, Thibeault L, Roy JD, Marleau D, Lapointe R, et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008;85:956-962.

22. Barshes NR, Horwitz IB, Franzini L, Vierling JM, Goss JA. Waitlist mortality decreases with increased use of extended criteria donor liver grafts at adult liver transplant centers. Am J Transplant 2007;7:1265-1270.

23. Tector AJ, Mangus RS, Chestovich P, Vianna R, Fridell JA, Milgrom ML, et al. Use of extended criteria livers decreases wait time for liver transplantation without adversely impacting posttransplant survival. Ann Surg 2006;244:439-450.

16

17

Part I. Studies in liver resection

18

19

2Impact of blood loss on outcome after liver resection

Marieke T. de Boer

I. Quintus Molenaar

Robert J. Porte

Digestive Surgery 2007;24:259-264

20

Chapter 2

ABSTRACT

Partial liver resections are the treatment of choice for patients with a malignant liver or bile

duct tumor. The most frequent indications for partial liver resections are colorectal metastasis,

hepatocellular carcinoma (HCC) and cholangiocarcinoma.

Liver resection is the only therapy with a chance for cure in these patients. Refinements in surgical

technique and increasing experience have contributed to a reduction in perioperative morbidity

and mortality in recent years. Despite these improvements, partial liver resections remain a major

surgical procedure and carry the risk for excessive blood loss and a subsequent need for blood

transfusion.

Blood transfusions have been associated with systemic side effects, such as depression of the

immune system. Several studies have suggested that perioperative blood loss or transfusions have

a negative impact on postoperative outcome.

However, it has been debated whether this is due to a real cause-effect relationship or merely the

result of more complicated surgery. We have reviewed the literature concerning studies focusing

on the relationship between blood loss and blood transfusion during liver surgery for malignant

tumors and postoperative outcome. Most studies were based on a retrospective analysis of single

center experiences, using uni- and multivariate statistical methods. Most studies have demonstrated

a significant and clinically relevant association between blood transfusion and postoperative

mortality and morbidity, especially postoperative infectious complications. The effect of blood

transfusions on tumor recurrence and more long-term mortality is much less clear and evidence

varies depending on the type of malignancy. The strongest indication that blood transfusion may

have an impact on tumor recurrence has been found for patients with early stages of HCC. However,

overall, no such effect could be demonstrated for patients undergoing partial liver resection for late

stages of HCC, colorectal liver metastasis or cholangiocarcinoma.

21

Impact of blood loss on outcome after liver resection

2

INTRODUCTION

Liver resection has been accepted as the standard treatment for most benign and malignant liver

tumors. True anatomical right hepatectomy was first described by Lortat-Jacobs in 1952.1 The

subsequent early experience with hepatic resection has been discouraging, showing mortality

figures over 20% for major hepatectomies in a retrospective series of 621 patients operated for a

variety of indications.2 In 20 % of these patients death was attributed to hemorrhage.2

Evolution of surgical and anesthetic techniques, better understanding of the segmental liver

anatomy, new methods to control hemorrhage, and better patient selection have led to

improvement in outcome. Nowadays liver resections are performed in specialized centers with a

perioperative mortality rates of less than 5% even though the indications for liver resections have

been extended, also to high-risk patients.3-9 In a consecutive series of 1222 liver resections Poon et al.

have described a gradual reduction in transfused patients from around 90% in 1989 to 5 % in 2003.3

Despite these improvements, blood loss remains one of the main predictors of both perioperative

morbidity and mortality after liver resection.7,10 The possible negative sequelae of blood transfusions

are well known and include alloimmunization,11-16 transmission of viral diseases,17 graft-versus-host

disease,18 increased postoperative infection rate16,19-21 and increased incidence of tumor recurrence

in certain cancers.16,22-27

In this paper an overview is given on the impact of blood loss and blood transfusion on outcome

after liver resections for the most prevalent malignant tumors of the liver: colorectal metastasis,

hepatocellular carcinoma (HCC) and cholangiocarcinoma.

Evolution of blood transfusions in liver surgery

The hypothesis that transfusion compromises outcome after liver resection has both been

supported and refuted in various studies. Limitations of older studies were the small sample sizes

but also the low numbers of non-transfused patients.28,29 More recent studies with larger numbers

of both transfused and non-transfused patients have been able to confirm the detrimental effects of

transfusion on the development of postoperative complications3,7,8,10 and perioperative death after

liver resections.7,10 Poon et al. have described a series of 1222 consecutive liver resections for benign

and malignant lesions between 1989 and 2003.3 In this time period a doubling of the number

of resections was observed between the first (Group 1: 1989-1996) and last half (Group 2: 1996-

2003) as a result of more liberal patient selection, leading to significantly more elderly patients,

patients with more comorbidity and significantly worse preoperative liver function. Despite this,

the intraoperative blood loss and transfusion requirements, as well as postoperative morbidity and

hospital mortality were significantly lower in group 2, compared to group 1. Transfusion of blood

products was one of the independent predictors of morbidity identified in a multivariate analysis.3

Another large retrospective study on the improvement of outcome after liver resections has been

reported by Jarnagin et al.7 This group has described a consecutive series of 1803 liver resections

for both benign and malignant lesions performed between 1992 and 2001. Over the years, an

22

Chapter 2

increase in concomitant major procedures was observed, but operative mortality decreased from

approximately 4% in the first 5 years of the study to 1.3% in the last 2 years. In a multivariate analysis,

the number of hepatic segments resected and operative blood loss were the only independent

predictors of both perioperative morbidity and mortality.7

Immunosuppressive effect of blood transfusion

The possibility to store and transfuse blood has been a major advance in medicine in the 20th century,

saving countless lives. One of the side effects of blood transfusion, however, is immunosuppression

which is assumed to cause decreased tumor surveillance and worse outcome.11,16,20 In different

fields of cancer surgery these negative effects have been examined, but also disputed. Even

though the percentage of patients receiving blood transfusion has decreased,3 blood loss remains

a major concern in liver surgery.6,30,31,32,33 The mechanisms underlying the adverse effects of blood

product transfusions with respect to postoperative outcome have been assumed to be related to

the suppressive effects on the immune system. Although the exact mechanism of this is not fully

understood, several studies have suggested that blood transfusions suppress host immunity via

a reduction in natural killer cell function, decreased cytotoxic T-cell function, increased numbers

of suppressor T cells and decreased function of macrophages and monocytes.12,13,16 Many of these

immunosuppressive effects are thought to be related to the number of leukocytes within the

stored blood as well as to the length of blood storage.34 Theoretically these immunosuppressive

effects should be less in leukocyte-depleted blood transfusion, which is standard nowadays in most

western countries.35,36 More and larger studies will be needed to confirm this assumed benefit of

leukocyte-depletion.

Effects of blood loss and blood transfusion in colorectal metastases

Only few studies have focused on the effect of blood transfusions on outcome after partial liver

resections for colorectal metastasis. Kooby et al have retrospectively described a series of 1351

patients who were treated for colorectal liver metastases between 1986 and 2001.10 A total of

55% of these patients received some blood product transfusion (red blood cell (RBC), fresh frozen

plasma (FFP), or platelet concentrate transfusion), 6% received autologues blood and 39% of the

patients did not receive any transfusion. The percentage of patients transfused reduced markedly

over time. Non-transfused patients had significantly fewer complications than patients who needed

blood transfusions (33 vs 46%, P value <0.001). This effect was dose-related. Patients transfused

with autologues blood had complication rates similar to patients receiving one or two allogeneic

transfusions. Patients who received autologues blood transfusions had significantly more

complications than patients who did not require transfusions. In a multivariate analysis, independent

predictors of postoperative complications were blood transfusion (OR 1.5; P value =0.0008), extent

of the resection (OR 2.0; P value =<0.0001) and male gender (OR 1.4; P value =0.002). In addition,

blood transfusion was found to be a predictor for postoperative mortality on multivariate analysis

23


2

(HR 3.7; 95% CI 1.7-8.4; P value =0.001) together with the extent of the resection (HR 4.9; 95% CI

1.8-13.8; P value =0.003). Blood transfusion, however, was not a significant predictor of long-term

survival.10

In another retrospective study, Stephenson et al. have also analyzed the effect of blood transfusion

on tumor recurrence in series of 55 consecutive patients who underwent partial liver resection for

colorectal metastasis.28 In this study, an increase in number of units of blood transfused was found

to be associated with a decreased time to recurrence in a Cox proportional hazards model analysis

(RR 1.05; P value =0.0015).28 In contrast with these studies suggesting a relationship between blood

transfusions and tumor recurrence after partial hepatectomy for colorectal metastasis, Younes et al.

were not able to identify blood transfusion as in independent risk factor for tumor recurrence in a

group of 116 patients.29 Although a significant association between blood transfusion and tumor

recurrence was found in univariate analysis, this could not be confirmed as an independent predictor

in multivariate analysis. These investigators found hypotensive episodes during surgery, the site

of the primary tumor, level of serum CEA, and the number of metastases as the only significant

independent predictors of tumor recurrence.29 Altogether, there is no convincing scientific support

for an effect of perioperative blood transfusions on the risk of tumor recurrence after partial liver

resection of colorectal liver metastases.

Effects of blood loss and blood transfusion in HCC

HCC is mainly found in cirrhotic livers and most studies focusing on this type of malignancy have

focused on partial liver resection in cirrhotic patients. In a series of 155 patients undergoing

extended hemihepatectomy for hepatocellular carcinoma, Wei et al. have analyzed risk factors

for perioperative morbidity and mortality. The overall morbidity rate in this series was 55.5% and

mortality rate was 8.4%.21 These investigators were able to identify perioperative blood transfusion

(P value <0.001) and portal clamping during the resection (P value =0.023) as independent risk

factors for postoperative morbidity. Independent risk factors for perioperative mortality were

perioperative blood transfusion (P value =0.004) and comorbid illness (P value =0.019).21 Outcome

after partial hepatectomy for HCC has also studied by Fan et al. in a large retrospective analysis of 330

patients operated between 1989 and 1997 in a single institution in Hong Kong.5 These investigators

have reported a zero mortality rate in their series. There were no significant changes in the patient

characteristics throughout the 9-year time period, but a significant reduction in intraoperative

blood loss and blood transfusion requirements was observed in this time period. In the most recent

years of this analysis, the median blood transfusion requirement was 0 ml, and 64% of the patients

did not require any blood transfusion. In a univariate analysis, the volume of blood loss, volume

of blood transfusions, and operation time correlated significantly with postoperative morbidity

rates in the most recent two years (1996 and 1997). In a multivariate stepwise logistic regression

analysis, operation time could be identified as the only parameter that correlated significantly with

the postoperative morbidity rate.5

24

Chapter 2

The effects of blood transfusion on recurrence in HCC after partial hepatectomies, has been studied

in several series.22,37,38,39,40 Asahara et al have described 175 patients who underwent a partial liver

resection for HCC between 1986 and 1994. The cumulative cancer-free survival rate for patients

who had received blood transfusion (n=23) was significantly lower than that for patients who

had not received blood transfusions (n=152) (P value =0.003). Multivariate analysis for risk factors

for recurrence in stage I and II of HCC showed significance for blood transfusion (P value =0.006),

extent of resection (P value =0.04), and ICG-clearance (P value =0.04). No significant effect of blood

transfusion was observed on cancer-free survival rates in patients with HCC in stage III-IV. Also, no

significant relation between blood transfusion and the degree of liver cirrhosis was found in this

analysis.22 In another study of 252 patients undergoing partial liver resection for HCC, the incidence

of tumor recurrence was found to be significantly higher in a subgroup of patients who had HCC

without angio-invasion and had received intraoperative blood transfusion.37 These studies suggest

that the impact of blood transfusions on tumor recurrence is most pronounced in patients with

relatively early stages of HCC. These observations are in line with studies suggesting that immune

surveillance is oncologically more relevant in early stages than in the more advanced stages of

HCC.22,37

Effects of blood loss and blood transfusion in cholangiocarcinoma

Very few studies have focused on the impact of blood transfusions on outcome after partial

liver resections for cholangiocarcinoma. Nagino et al. have reported a series of 100 consecutive

patients undergoing combined resections of extrahepatic bile ducts and part of the liver for hilar

cholangiocarcinoma.41 Preoperative blood donation was performed in 73 patients in this series.

Only 7 of these 73 patients (10%) required allogeneic blood transfusions. In the remaining 27

patients, 18 (67%) received allogeneic blood transfusion during surgery. During the postoperative

period, 16 patients needed a blood transfusion. The incidence of postoperative complications was

significantly higher in the 35 patients who received a perioperative blood transfusion than in the 65

patients who did not (94% vs 52%; P value <0.0001). No multivariate analysis was done to identify

independent risk factors.41

In a recent publication by Liu et al, a group of 142 patients is described with hilar cholangiocarcinoma

in the period 1989-2004.42 For comparison of outcome patients were divided between two groups:

period 1:1989-1998 and period 2: 1999-2004. Modifications in management resulted in a higher

resection rate in period 2 than in period 1 (45 versus 16 %). In multivariate analysis, resection of

the tumor in period 2 and operative blood loss of 1.5 litres or less were significant independent

determinants of improved overall survival.42

There is no data on the effects of blood transfusion on long-term survival or tumor recurrence after

partial liver resection for cholangiocarcinoma.

25


2

CONCLUSIONS AND PERSPECTIVES FOR THE FUTURE

Recent improvements in the surgical techniques used for hepatic resections as well as optimal

intra- and postoperative patient management have led to a significant improvement in short- and

long-term outcome in patients undergoing partial liver resections.3-10 Blood transfusions have been

identified as an independent predictor of postoperative morbidity and mortality. Unfortunately,

many patients will get recurrent disease, even after complete oncological resection. The impact of

blood transfusions on the risk for tumor recurrence has best been characterized for patients with

early stages of HCC.22,37 Much less evidence exists with respect to the effect of blood transfusion

on the risk of tumor recurrence after resections for colorectal liver metastases.28,29 A similar adverse

effect of blood transfusion on tumor recurrence has been reported for gastric cancer,23 colon

cancer,24,25 lung cancer26 and soft tissue carcinoma.27 The main problem with all these studies

remains their retrospective design, which never allows complete ruling out of the possibility

that blood transfusion and outcome are affected by a common underlying cause, such as more

advanced disease, or more complex surgery. Nevertheless, investigators have tried to overcome

these limitations by performing multivariate regression analyses, including variables that reflect

severity of disease.

Although the exact mechanisms underlying the adverse effects of blood transfusions are not fully

elucidated, residual amounts of donor leukocytes present in transfusions as well as preservation

related changes in erythrocytes are assumed to be critically involved.34-36,43,44 Whether the increasing

use of leukoreduction technologies will lead to a reduction of the negative impact of blood

transfusion on outcome after liver resections needs to be awaited and requires additional studies.

Future studies on blood loss and transfusion in liver surgery should focus on methods to further

reduce blood loss and the need for allogeneic blood transfusion. Strategies to minimize the risks

of allogeneic blood transfusion are leukocyte-depleted transfusions, short storage time and the

use of autologues blood transfusion. Methods for autologues transfusion used in liver surgery

include preoperative blood donation,19,45-47 intraoperative acute normovolemic hemodilution,48

and intraoperative blood salvage.49,50 However, these methods are not common clinical practice

yet because of logistical reasons in preoperative blood donation or the required training of the

operating team in intraoperative hemodilution. Furthermore intraoperative blood salvage

theoretically increases the risk of tumor cell dissemination.

In conclusion, the effects of blood loss and blood transfusions in liver surgery have been studied

extensively. Most studies have demonstrated a significant and clinically relevant association

between blood transfusion and postoperative morbidity, especially postoperative infectious

complications. The effect of blood transfusions on tumor recurrence and more long-term mortality

is much less clear and evidence varies depending on the indication for liver resection and the type

of malignancy. The strongest indication that blood transfusion may have an impact on tumor

recurrence has been found for patients with early stages of HCC, but no such effect could be

demonstrated for patients undergoing partial liver resection for late stages of HCC, colorectal liver

metastasis or cholangiocarcinoma.

26

Chapter 2

REFERENCES

1. Lortat-Jacobs J, Robert H: Hepatectomy droite reglee. Presse Med 1952;60:549-551.

2. Foster JH, Berman MM: Solid liver tumors. Major Probl Clin Surg 1977;22:1-342.

3. Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yeun WK, Yueng C, Wong J: Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases, Analysis of 1222 consecutive patients from a prospective database. Ann Surg 2004;240:698-710.

4. Fortner JG, MacLean BJ, Kim DK, et al: The seventies evolution in liver surgery for cancer. Cancer 1981;47:2162-2166.

5. Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, Wong J. Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths.Ann Surg. 1999 Mar;229:322-330.

6. Belghiti J, Hiramatsu K, Benoist S, et al: Seven hundred fifty-six hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection. J Am Coll Surg 2000;191:38-46.

7. Jarnagin WR, Gonen M, Fong Y, Dematteo RP, Ben-Porat L, Little S, Corvera C, Weber S, Blumgart L: Improvement in perioperative outcome after hepatic resection. Analysis of 1803 consecutive cases over the past decade. Ann Surg 2002;236:397-407.

8. Imamura H, Seyama Y, Kokudo N, et al: One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 2003;138:1198-1206.

9. Heriot AG, Karanjia ND: A review of techniques for liver resection. Ann R Coll Surg Engl 2002;84:371-380.

10. Kooby DA, Stockman J, Ben-Porat L, Gonen M, Jarnagin WR, Dematteo RP, Tuorto S, Wuest D, Blumgart LH, Fong Y: Influence of transfusion on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 2003; 237:860-870.

11. Opelz G, Terasaki PI: Prolongation effect of blood transfusions on kidney graft survival. Transplantation 1976;22:380-383.

12. Gascon P, Zoumbos NC, Young NS: Immunological abnormalities in patients receiving multiple blood transfusions. Ann Intern Med 1984;100:173-177.

13. Kaplan J, Sarnaik S, Gitlin J, et al: Diminished helper/suppressor lymphocyte ratios and natural killer activity in recipients of repeated blood transfusions. Blood 1984;64:308-310.

14. Keown PA, Descamps B: Improved renal allograft survival after blood transfusion: A nonspecific, erythrocyte-mediated immunoregulatory process? Lancet 1979;20-22.

15. Kwon AH, Matsui Y, Kamiyama Y: Perioperative blood transfusion in hepatocellular carcinomas: influence of immunological profile and recurrence free survival. Cancer 2001;91:771-778.

16. Blumberg N, Heal JM: Effects of transfusion on immune function. Cancer recurrence and infection. Arch Pathol Lab Med 1994;118:371-379.

17. Peterman TA, Jaffe HW, Feorino PM, Getchell JP, Warfield DT, Haverk HW, et al: Transfusion-associated acquired immunodeficiency syndromes in the United States. JAMA 1985;254:2913-2917.

18. Arsura EL, Bertelle A, Minkowitz S, Cunningham JN, Grob D: Transfusion-associated graft-vs-host disease in a presumed immunocompetent patient. Arch Intern Med 1988;148:1941-1944.

19. Shinozuka N, Koyama I, Arai T, Numajiri Y, Watanabe T, Nagashima N, et al: Autologous blood transfusion in patients with hepatocellular carcinoma undergoing hepatectomy. Am J Surg 2000;179:42-45.

20. Triulzi DJ, Vanek K, Ryan DH, Blumberg N: A clinical and immunologic study of blood transfusion and postoperative bacterial infection in spinal surgery. Transfusion 1992;32:517-524.

21. Wei AC, Tung-Ping Poon R, Fan ST, Wong J: Risk factors for perioperative morbidity ad mortality after

27


2

extended hepatectomy for hepatocellular carcinoma. Br J Surg 2003;90:33-41.

22. Asahara T, Katayama K, Itamoto T, Yano M, Hino H, Okamoto Y, Nakahara H, Dohi K, Moriwaki K, Yuge O: Perioperative blood transfusion as a prognostic indicator in patients with hepatocellular carcinoma. World J Surg 1999;23:676-680.

23. Kaneda N, Horimi T, Ninomiya M, Nagae S, Mukai K, Takeda I, Shimoyama H, Chohno S, Okabayashi T, Kagawa S, et al. Adverse affect of blood transfusions on survival of patients with gastric cancer.Transfusion 1987;27:375-377

24. Blumberg N, Agarwal MM, Chuang C: Relation between recurrence of cancer of the colon and blood transfusion. BMJ1985;290:1037-1039.

25. Foster RS, Costanza MC, Foster JC, Wanner MC, Foster CB: Adverse relationship between blood transfusions and survival after colectomy for colon cancer. Cancer 1985;55:1195-1201.

26. Hyman NH, Foster JC, DeMeules JE, Costanza MC: Blood transfusion and survival after lung cancer resection. Am J Surg 1985;149:502-507.

27. Rosenberg SA, Seipp CA, White DE, Wesley R. Perioperative blood transfusions are associated with increased rates of recurrence and decreased survival in patients with high-grade soft-tissue sarcomas of the extremities. J Clin Oncol 1985;3:698-709.

28. Stephenson KR, Steinberg SM, Hughes KS, et al: Perioperative blood transfusion are associated with decreased time to recurrence and decreased survival after resection of colorectal liver metastased. Ann Surg 1988;208:679-687.

29. Younes RN, Rogatko A, Brennan MF: The influence of intraoperative hypotension and perioperative blood transfusion on disease-free survival in patients with complete resection of colorectal liver metastases. Ann Surg 1991;214:107-113.

30. Man K, Fan ST, Ng IO, et al: Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Ann Surg 1997;226:704-711.

31. Melendez JA, Arslan V, Fischer ME, et al: Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 1998;187:620-625.

32. Chan AC, Blumgart LH, Wuest DL, et al: Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. Am J Surg 1998;175:461-465.

33. Johnson LB, Plotkin JS, Kuo PC: Reduced transfusion requirements during major hepatic resection with use of intraoperative isovolemic hemodilution. Am J Surg 1998; 176:608-611.

34. Ghio M, Contini P, Mazzei C, et al: Soluble HLA class I, HLA Class II and Fas ligand in blood components: A possible key to explain the immunomodulatory effects of allogeneic blood transfusions.Blood 1999;93:1770-1777.

35. Meryman HT, Hornblower M: The preparation of red cells depleted of leukocytes: review and evaluation. Transfusion 1986;26:101-106.

36. Snyder EL: Prevention of HLA alloimmunization: role of leukocyte depletion and UV-B irradiation. Yale J Biol Med 1990;63:419-427.

37. Yamamoto J, Kosuge T, Takayama T, et al: Perioperative blood transfusion promotes recurrence of hepatocellular carcinoma after hepatectomy. Surgery 1994;115:303-309.

38. Nagasue N, Ono T, Kohno H, El-Assal ON, Taniura H, Uchida M: Prognostic factors and survival after hepatic resection for hepatocellular carcinoma without cirrhosis. Br J Surg 2001; 88: 515–522.

28

Chapter 2

39. Gozetti G, Mazziotti A, Grazi GL, Jovine E, Galluci A, Gruttadauria S, Frena A, Morganti M, Ercolani G, Masetti M, et al: Liver resection without blood transfusion. Br J Surg 1995;82:1105-1110.

40. Makino Y, Yamanoi A, Kimoto T, Nazmy El-Assal O, Kohno H, Nagasue N: The influence of perioperative blood transfusion on intrahepatic recurrence after curative resection of hepatocellular carcinoma. Am J Gastroenterology 2000;95:1294–1300.

41. Nagino M, Kamiya J, Arai T, Nishio H, Ebata T, Nimura Y. One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome. Surgery 2005;137:148-155.

42. Liu CL, Fan ST, Lo CM, Tso WK, Lam CM, Wong J: Improved operative and survival outcomes of surgical treatment for hilar cholangiocarcinoma. Brit J Surg 2006;93:1488-1494.

43. McLellan SA, Walsh TS, McClelland DBL. Should we demand fresh red blood cells for perioperative and critically ill patients? Br J Anaesthesia 2002;44:537-540.

44. Messana I, Ferroni L, Misiti F, et al. Blood bank conditions and RBCs: the progressive loss of metabolic modulation. Transfusion 2000;40:353-360.

45. Cunningham J, Fong Y, Shriver C, Melendez J, Mar WL, Blumgart LH: One hundred consecutive hepatic resections: blood loss, transfusion and operative technique. Arch Surg 1994;129:1050-1056.

46. Chan ACW, Blumgart LH, Wuest DL, Melendez JA, Fong Y: Use of preoperative autologous blood donation in liver resections for colorectal metastases. Am J Surg 1998;175:461-465.

47. Kajikawa M, Nonami T, Kurokawa T, Hashimoto S, Harada A, Nakao A, et al: Autologous blood transfusion for hepatectomy in patients with cirrhosis and hepatocellular carcinoma: use of recombinant human erythropoietin. Surgery 1994;115:727-734.

48. Sejourne P, Poirier A, Meakins JL, Chamieh F, Smadja C, Grange D, et al.: Effect of hemodilution on transfusion requirements in liver resection. Lancet 1989;315:1380-1382.

49. Zulim RA, Rocco M, Goodnight JE, Smith GJ, Krag DN, Schneider PD: Intraoperative autotransfusion in hepatic resection for malignancy: is it safe? Arch Surg 1993;128:206-211.

50. Fujimoto J, Okamoto E, Yamanaka N, Oriyama T, Furikawa E, et al: Efficacy of autotransfusion in hepatectomy for hepatocellular carcinoma. Arch Surg 1993;128:1065-1069.

29

Topical hemostatic agents in liver surgery: do we need them?

Elizabeth A. Boonstra

I. Quintus Molenaar

Robert J. Porte

Marieke T. de Boer

HPB 2009;11:306-310

3

30

Chapter 3

ABSTRACT

Background: Worldwide, partial liver resections are increasingly performed for primary or secondary

hepatic malignancies. There are various techniques to reduce blood loss during liver surgery. Several

topical hemostatic agents have been developed to improve hemostasis of the resection surface and

these agents are used more and more, even although the true effects remain unclear.

Methods: The present literature about the use of topical hemostatic agents in liver surgery was

reviewed. Futhermore we conducted a Dutch national survey tot explore the use of and belief in

these agents in liver surgery.

Results: The Dutch national survey among surgeons showed that topical hemostatic agents are

frequently used not only to lower intraoperative blood loss or shorten time to hemostasis, but

even more importantly, to reduce resection surface related complications such as bile leakage,

postoperative hemorrhage and abscess formation. Although various topical hemostatic agents

have been shown to reduce intraoperative time to hemostasis at the resection surface after liver

resections, there is no scientific proof that these topical haemostatic agents really reduce resection

surface related complications.

Conclusion: This review highlights the need for more randomized clinical trials to investigate the

efficacy of topical haemostatic agents in reducing resection surface related complications.

31


3

INTRODUCTION

Worldwide, partial liver resections are being performed for primary or secondary hepatic

malignancies with increasing frequency. Although recent reports have shown improvement

in operative morbidity and mortality associated with hepatic resection there is no uniformity

between centers in the surgical, anesthesiological and hemostatic techniques used. Specific

factors contributing to the improvement in operative risks have not been clearly defined. Several

studies have shown intraoperative blood loss and transfusion requirements to be risk factors

for postoperative morbidity and mortality.1-4 According to these results a main focus in hepatic

resections should be reduction of blood loss and transfusion requirements.

There are several techniques to reduce blood loss during liver surgery. Reduction of the central

venous pressure during transection of the liver parenchyma has been shown to significantly reduce

blood loss.5,6 Vascular occlusion techniques, such as inflow occlusion and total vascular occlusion,

have also been shown to potentially reduce blood loss during hepatic resection.7 The device used

for transection of the liver parenchyma might also influence blood loss,8 even though none of these

devices or techniques have gained unanimous acceptance among liver surgeons.

Besides techniques applied during resection, several topical hemostatic agents are developed to

improve hemostasis of the resection surface. Apart from their hemostatic potential, these hemostatic

agents are also used with the aim to prevent bile leakage, which is still a clinically important

complication after liver surgery. Bile leakage from the resection surface has been reported in up to

15% of the patients after partial liver resections. Only a few clinical trials on the use of hemostatic

agents have focused on resection surface related complications after liver resection. Hemostatic

agents are used more and more, even though the true effects remain unclear.

This article will focus on the use of topical hemostatic agents in liver surgery. The rationale of

different topical agents will be discussed followed by the results of a Dutch national survey on the

use of topical hemostatic agents by liver surgeons in The Netherlands.

Topical hemostatic agents

Topical hemostatic agents can be divided into two groups.(Table 1) The first group consists of

agents that only provide a matrix for endogenous coagulation. Available matrices are those that are

made of collagen, cellulose or gelatine. These agents do not contain active components. The second

group consists of agents that do contain active components, the fibrin sealants. These agents mimic

endogenous coagulation. A few products available combine a matrix for coagulation with active

hemostatic components, the so-called “carrier-bound fibrin sealants”.

The final step in the normal coagulation cascade, the formation of fibrin out of fibrinogen under

the influence of thrombin, is mimicked by fibrin sealants.(Figure 1). These agents contain separated,

virus inactivated, human fibrinogen and thrombin. The composition of the available sealants differs

mainly in the concentration of fibrin and thrombin and the addition of calcium or antifibrinolytic

components, such as aprotinin. When applied, for example to a resected liver surface, the two

32

Chapter 3

components mix and reproduce the last step of the coagulation cascade. This leads to the gradual

polymerization of fibrinogen by hydrogen bonding and electrostatic reactions into fibrin fibers.

These fibers form a three-dimensional structure with the appearance of a gel. Factor XIII (fibrin

stabilizing factor), activated by thrombin in the presence of calcium ions, converts the bonds

between the fibrin monomers into covalent bonds. This cross linking leads to the formation of a

stable and insoluble fibrin clot. Most fibrin sealants also contain an antifibrinolytic agents, usually

aprotinin or tranexamic acid. These agents inhibit the degradation of the fibrin clot by proteolytic

enzymes.9

Most fibrin sealants are packed in a dual syringe system. Hereby thrombin and fibrinogen are

separated. They mix at the end of the syringes or in a connector just before contact with the resection

Table 1. Different topical hemostatic agents used in surgery. Examples of agents between brackets

Agents providing a matrix for coagulation Collagen (Tissufleece®, Novacol® Lyostipt®, Antema®, Avitene®, Duracol®)

Gelatine(Gelfoam®, Spongostan® Gelita®)

Cellulose (Nu-knit®, Surgicell®)

Agents that mimic coagulation Fibrin sealants (Tisseel® or Tissucol®, Quixil® or Crosseal®, Vivostat®, Beriplast®, Biocol® Bolheal®, Hemaseel®))

Carrier-bound fibrin sealants (FloSeal ® Tachosil®, Costasis®)

Figure 1: The final step in the normal coagulation cascade, the formation of fibrin out of fibrinogen under the influence of thrombin, is mimicked by fibrin sealants.

33


3

surface. Another method for applying fibrin sealant is as a spray. The earlier mentioned carrier-

bound fibrin sealants combine the active agents in the fibrin sealant with a matrix for coagulation.

Instead of using ready-to-use carrier-bound fibrin sealants, it is also possible to combine a fibrin

sealant with a matrix of choice, in this way creating a carrier- bound fibrin sealant. The ideal topical

agent should have the capacity to seal small vessels and bile ducts of the resection surface, be safe

and easy to use.

Little is known about the effect of bile on the active substances of topical hemostatic agents. In the

past, experimental research is performed to show the effect of bile on blood clotting. These studies

have shown that bile salts, especially taurocholate or desoxycholate, are responsible for delaying

blood clotting by counteracting the activities of thrombin and prothrombin.10,11

Use of hemostatic agents in liver surgery: Results of a Dutch survey

Topical haemostatic agents are increasingly used in liver surgery. In a Japanese survey it was found

that 60% of surgeons performing liver surgery routinely use hemostatic materials such as fibrin

sealants.12

In 2004 we conducted a web-based nation-wide survey to explore the surgical attitudes and

preferences regarding hepatic resections among Dutch surgeons, focusing on hemostasis. In

our survey, the following parameters were assumed to be of importance: anesthesia techniques,

vascular occlusion techniques, hemostatic techniques and the use hemostatic agents. One of our

goals was to determine whether surgeons believe in the effect of hemostatic agents in reducing

resection surface related complications. Questionnaires were sent by e-mail to all practicing

surgeons in the Netherlands. E-mail addresses were obtained from the Dutch Surgery Association

(“Nederlandse Vereniging voor Heelkunde”). The response rate was 69% (590/859). Hepatic

resections were performed by 96 of the 590 responding surgeons, of whom 24 only performed

wedge or segmental resections. Seven surgeons sometimes performed larger liver resections

but never hemihepatectomies. Sixty-seven (11%) surgeons in the Netherlands reported that they

Figure 2: Results of a Dutch survey. Use of surgical devices among 67 surgeons who regularly perform major liver resections. Multiple answers were possible.

53

3223

15 11 92 3

0102030405060

Num

ber o

f sur

geon

s

What surgical devices for transsection of parenchyma do you use?

34

Chapter 3

regularly perform major partial liver resections (e.g. hemihepatectomies). All of these surgeons were

working in a teaching hospital (n=31) or in a university medical center (n=36). We here report only

on the surgical practice of those 67 surgeons performing major liver resections.

The estimated number of liver resections in the Netherlands is around 500 per year, but there are no

valid data on complete numbers. In our survey 41 (69%) surgeons performed less than 10 resections

per year, while 26 (31%) surgeons performed more than 10 per year. Data on surgical methods used

for transection of the hepatic parenchyma are presented in figure 2. The most frequently used

methods were CUSA, Argon beam coagulation and clamp crush technique.

The majority of surgeons (58/67; 87%) used hemostatic agents after resection of the liver

parenchyma. More than half of them used hemostatic agents routinely (57%), the rest of these

surgeons used hemostatic agents only when indicated. The most frequently used products were

fibrin sealants. (Figure 3 and 4)

Forty-five percent of the surgeons believed that fibrin sealants reduce resection surface related

complications, 12% disagree and 43% were not sure about the effect of fibrin sealants on resection

Figure 3: Results of a Dutch survey. Use of topical hemostatic agents among 67 surgeons who regularly perform major liver resections.

Figure 4: Results of a Dutch survey. Use of various types of topical hemostatic agents among 58 of 67 surgeons who use topical hemostatic agents when performing liver resections. Multiple answers were possible.

35


3

surface related complications. (Figure 5)

From this nation-wide survey, we conclude that hemostatic agents are frequently used in major

liver surgery, not only for hemostasis, but also with the aim to reduce resection surface related

complications

45%

12%

43%

Do you believe that topical hemostatic agents reduce resection surface related complications?

Yes

No

Do not know

Evidence for the use of topical hemostatic agents in liver surgery

In 2002 a systematic review was performed to examine the efficacy of fibrin sealants in reducing

intraoperative blood loss and red cell transfusion in adult elective surgery. Types of surgery involved

in this study were prostatectomy, pulmonary, cardiac, vascular, arthroplasty and liver surgery.

Overall these results suggested efficacy of fibrin sealants. For the trials that were conducted in the

setting of liver surgery the use of fibrin sealants did not show a significant reduction of intra- and

postoperative blood loss. A lack of blinding in the majority of the studies reviewed raised concern

about taking blood transfusion practice as a response variable. The authors conclude that there

were inadequate data provided to draw firm conclusions about the impact of fibrin sealant use on

clinically important endpoints.13

In liver surgery, hemostatic agents have shown to be effective in improving time to hemostasis of

the resection surface. Although several products show statistically significant reduction in time to

hemostasis the question remains whether this is clinically relevant. Also in liver surgery intraoperative

blood loss or blood transfusion might not be a relevant endpoint for the use of hemostatic agents,

because these agents are mainly used after transection of the parenchyma, to seal the resection

surface, while blood loss is usually a problem during transection and not so much thereafter.

Apart from intraoperative hemostasis, resection surface related complications, such as bile leakage

and abscess formation, are a major concern after liver resection. Patients suffering from a biliary

leakage after partial liver resection often require prolonged hospitalization, additional interventions

and have a worse prognosis. The reported incidence of biliary leakage varies between 3,6 and 12

%.14-16

Figure 5: Results of a Dutch survey. Perception about the efficacy of topical hemostatic agents among 67 surgeons who perform liver resections.

36

Chapter 3

In a prospective randomized trial, Frilling et al. compared a carrier-bound fibrin sealant (Tachosil,

Nycomed, Copenhagen, Denmark) (n=59) with argon beam coagulation (n=62) as a hemostatic

agent in liver resection. Time to hemostasis was significantly shorter in the group treated with the

carrier bound fibrin sealant (3,9 min vs 6,3 min p= 0,0007). Although the incidence of bile leakage

was slightly higher in the sealant group (7% vs 4%), the frequency of bile leakage and other adverse

events did not significantly differ between the groups.17

Another fibrin sealant, Crosseal (American Red Cross, Washington, DC), (n=58) was compared with

other commercially available hemostatic agents (n=63) by Schwartz et al. Time to hemostasis was

shorter in the Crosseal group (282 vs 468 min, p=0,006) and significantly more patients achieved

hemostasis within ten minutes in the Crosseal group (p=0,003). There were significantly less

abdominal fluid collections and reoperations in the Crosseal group compared to the control group,

although this was a secondary endpoint.18

The largest prospective randomized controlled trial that compared the combination of Tissucol

(Baxter Immuno, Vienna, Austria) and an absorbable collagen sponge (Johnson & Johnson)

(n=150) with a control group (n=150) showed no differences between the two groups on need

for blood transfusion, postoperative complications (such as intra-abdominal abscesses and other

fluid collections or re-interventions) (19). Another randomized controlled trial compared Costasis

(Cohesion Technologies Inc, Palo Alto, Calif ) (n=28) with a collagen matrix (n=29). Costasis is a

composite of bovine microfibrillar collagen and bovine thrombin that is mixed with autologues

plasma at time of surgery. Although the sealant was more effective in controlling bleeding than the

collagen matrix, there were no differences in transfusion need or adverse events.20

Theoretically fibrin sealants might seal small bile ducts, which is the rationale for surgeons to use

fibrin sealants with the assumption to reduce biliary complications after partial liver resection. Only

a few clinical trials have focused on the effect of topical hemostatic agents on biliary leakage after

liver resection. Capusotti et al. performed a retrospective analysis in 610 patients to identify the risk

factors associated with bile leakage after liver resection. Bile leakage was defined as the drainage of

50 ml or more of bile from the surgical drain, or from drainage of an abdominal collection, beyond

the third postoperative day. After resection, fibrin sealant was applied to the raw resection surface

to improve hemostasis. At multivariate analysis, use of fibrin sealant appeared to be an independent

protective factor against bile leakage.14

Ten years earlier, a French group had similar results. In a randomized controlled trial they compared

the application of fibrin sealant on a dry resection surface after hepatic resection (n=38) with a

control group (n=44). The fibrin sealant group had significantly less drain production after three

days. The concentration of bilirubin in the drain fluid was also significantly lower in the fibrin sealant

group.21

In a retrospective study by Hayashibe et al, the combination of fibrin sealant and a matrix, in this case

a bioabsorbable polyglicolic acid felt (n=51), or fibrin sealant alone (n=37) were compared. Fibrin

sealant alone was used from 2001 until 2003, the combined agent was used from 2003 until 2005.

37


3

The combination of the two hemostatic agents was favourable for prevention of bile leakage after

hepatic resection. There was no bile leakage in the group treated with the combined agent versus

3 patients (8,1%) with bile leakage in the fibrin sealant group. Drawbacks of this study were the low

number of patients, the retrospective design and the difference in treatment by time period.22

Directions for future research

Despite the clear effect of topical hemostatic agents on intraoperative time to hemostasis, the

efficacy of these agents regarding clinically relevant postoperative outcome measures (such as bile

leakage or other resection surface related complications) remains to be demonstrated. More clinical

trials are needed focusing on resection surface related complications instead of time to hemostasis

or transfusion requirements. Apart from the study by Figueras et al, no previous trial was adequately

powered to show a significant difference in resection surface related complications. Since fibrin

sealants have proven to be more effective in hemostasis than matrix agents, further research should

focus on fibrin sealants or a combination of sealants with a matrix, the so-called carrier-bound fibrin

sealants. The concern of potential viral transmission when fibrin sealants based on human plasma-

derived coagulation proteins are used, has lead to the development of recombinant clotting factors.

It is likely that these recombinant products will replace products passed on plasma-derived human

thrombin and fibrinogen in the future.

CONCLUSION

There is a large variety of topical hemostatic agents available for use during surgery. The most

frequently used agents are fibrin sealants. Topical haemostatic agents are used on a large scale in

liver surgery. Despite a lack of clear evidence in the literature, most surgeons believe that topical

hemostatic agents reduce resection surface related complications after liver resection. Several

studies have been published about the use of hemostatic agents in liver resection. Most of these

studies lack clinically relevant primary endpoints. When scrutinizing the literature, it is important

to distinguish the studies that have time to hemostasis as primary outcome measure from those

studies that focus on more clinically relevant outcome measures, such as the need for postoperative

interventions to treat bleeding or resection surface related complications (e.g. biloma or other intra-

abdominal fluid collections). Fibrin sealants seem to be effective in reducing the time to hemostasis,

but their impact on reducing resection surface related complications remains contradictory. For this

reason more large, randomized controlled trials are needed to show efficacy of hemostatic agents

in reducing those postoperative complications.

38

Chapter 3

REFERENCES

1. Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, et al. Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Ann Surg 2004;240:698-708.

2. Jarnagin WR, Gonen M, Fong Y, Dematteo RP, Ben-Porat L, Little S, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397-406.

3. Imamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano K, et al. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 2003;138:1198-1206.

4. Kooby DA, Stockman J, Ben-Porat L, Gonen M, Jarnagin WR, Dematteo RP, et al. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 2003;237:860-869.

5. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg 1998;85:1058-1060.

6. Melendez JA, Arslan V, Fischer ME, Wuest D, Jarnagin WR, Fong Y, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 1998;187:620-625.

7. Smyrniotis V, Farantos C, Kostopanagiotou G, Arkadopoulos N. Vascular control during hepatectomy: review of methods and results. World J Surg 2005;29:1384-1396.

8. Lesurtel M, Selzner M, Petrowsky H, McCormack L, Clavien PA. How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies. Ann Surg 2005;242:814-822.

9. Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang 1997;72:133-143.

10. Haessler H, Stebbins MG. Effect of Bile on the clotting time of blood. J Exp Med 1919;29:445-449.

11. Chung SC, Kim YC, Hong SK, Lee PH. Effect of bile on the blood coagulation. Yonsei Med J 1964;5:24-28.

12. Nakajima Y, Shimamura T, Kamiyama T, Matsushita M, Sato N, Todo S. Control of intraoperative bleeding during liver resection: analysis of a questionnaire sent to 231 Japanese hospitals. Surg Today 2002;32:48-52.

13. Carless PA, Henry DA, Anthony DM. Fibrin sealant use for minimising peri-operative allogeneic blood transfusion. Cochrane Database Syst Rev 2003;:CD004171.

14. Capussotti L, Ferrero A, Vigano L, Sgotto E, Muratore A, Polastri R. Bile leakage and liver resection: Where is the risk? Arch Surg 2006;141:690-694.

15. Yamashita Y, Hamatsu T, Rikimaru T, Tanaka S, Shirabe K, Shimada M, et al. Bile leakage after hepatic resection. Ann Surg 2001;233:45-50.

16. Reed DN, Jr., Vitale GC, Wrightson WR, Edwards M, McMasters K. Decreasing mortality of bile leaks after elective hepatic surgery. Am J Surg 2003;185:316-318.

17. Frilling A, Stavrou GA, Mischinger HJ, de Hemptinne B, Rokkjaer M, Klempnauer J, et al. Effectiveness of a new carrier-bound fibrin sealant versus argon beamer as haemostatic agent during liver resection: a randomised prospective trial. Langenbecks Arch Surg 2005;390:114-120.

18. Schwartz M, Madariaga J, Hirose R, Shaver TR, Sher L, Chari R, et al. Comparison of a new fibrin sealant with standard topical hemostatic agents. Arch Surg 2004;139:1148-1154.

19. Figueras J, Llado L, Miro M, Ramos E, Torras J, Fabregat J, et al. Application of fibrin glue sealant

39


3

after hepatectomy does not seem justified: results of a randomized study in 300 patients. Ann Surg 2007;245:536-542.

20. Chapman WC, Clavien PA, Fung J, Khanna A, Bonham A. Effective control of hepatic bleeding with a novel collagen-based composite combined with autologous plasma: results of a randomized controlled trial. Arch Surg 2000;135:1200-1204.

21. Noun R, Elias D, Balladur P, Bismuth H, Parc R, Lasser P, et al. Fibrin glue effectiveness and tolerance after elective liver resection: a randomized trial. Hepatogastroenterology 1996;43:221-224.

22. Hayashibe A, Sakamoto K, Shinbo M, Makimoto S, Nakamoto T. New method for prevention of bile leakage after hepatic resection. J Surg Oncol 2006;94:57-60.

40

41

Role of fibrin sealants in liver surgery

Marieke T. de Boer

Elizabeth A. Boonstra

Ton Lisman

Robert J. Porte


4

42

Chapter 4

ABSTRACT

Background: Fibrin sealants are widely used in liver surgery. The aim of this article is to review the

literature on evidence of hemostatic and biliostatic capacities of different fibrin sealants in liver

surgery.

Methods: In PubMed, a literature search was done with the search terms ‘fibrin sealant’ or ‘fibrin glue’

combined with ‘liver resection’ or ‘bile leakage’. Thirteen comparative fibrin sealant studies were

selected.

Results: In general, these studies have shown a reduced time to hemostasis when fibrin sealants were

used. So far, only a few studies have been published that have focused on postoperative resection

surface-related complications. There is no strong evidence that fibrin sealants reduce the incidence

of bile leakage after liver resection. Important new evidence shows that bile contains profibrinolytic

activity that causes lysis of the clot formed by the fibrin sealant at least in vitro.

Conclusions: Fibrin sealants can be effective as an adjunct to achieve hemostasis during liver

resections. However, considering lack of evidence on the efficacy of fibrin sealants in reducing

postoperative resection surface-related complications, routine use of fibrin sealants in liver surgery

cannot be recommended.

43


4

INTRODUCTION

Advances in surgical techniques and patient care have led to improvement in outcome after liver

resections.1,2 Despite these improvements, intraoperative bleeding from the resection plane of

the liver and postoperative resection surface-related complications like bleeding, bile leakage

and abscess formation remain a major problem.2-4 Apparently, conventional surgical techniques

cannot completely eradicate these complications. Therefore, covering the liver resection surface

with a product that can seal both blood vessels and biliary radicals is an interesting concept. For

this reason, fibrin sealants are widely used in liver surgery5-7 despite scarce scientific evidence on

the clinical effectiveness of these products.8,9 The aim of this article is to review the literature on

evidence of hemostatic and biliostatic capacities of different fibrin sealants in liver surgery.

METHODS

In PubMed, a literature search was done with the search terms ‘fibrin sealant’ or ‘fibrin glue’ combined

with ‘liver resection’ or ‘bile leakage’. Clinical studies were selected that compared fibrin sealants

with control treatment. Controls were either no treatment or treatment with another type of topical

hemostatic agent or another type of fibrin sealant. Studies were selected that were published in

English and focused on hemostatic or biliostatic end points. In total, 163 titles were left for abstract

screening. Twelve clinical comparative studies were recognized; after checking cross-references,

one more comparative study was recognized.

Different types of sealants

Fibrin sealants are a group of topical hemostatic products that mimic the final stages of the blood

coagulation process (figure 1). Fibrin sealants are two-component products, containing thrombin

Figure 1 General working mechanism of fibrin sealants (components fibrinogen and thrombin) mimicking blood coagulation process. TAFI = Thrombin-activatable fibrinolysis inhibitor; dashed lines = inhibiting effect; continuous lines = stimulating effect.

44

Chapter 4

and fibrinogen. When mixed together during application of the sealants, thrombin cleaves the

fibrinogen to monomers, which polymerize to form a fibrin gel.9,10 Fibrin sealants can come in two-

component vials to form a glue (Tissucol®, Tisseel®, Quixil®, Evicel®, Crosseal®, Vivostat®, Beriplast®,

Biocol®, Bolheal®, Hemaseel®), but they can also be carried on a matrix, the so-called carrier-bound

fibrin sealants. Carrier-bound sealants are available in a solid form, consisting of a collagen fleece

coated with a dry form of fibrinogen and thrombin (Tachosil®, Tachocomb®), and in liquid form

containing thrombin and gelatin (Floseal®) or thrombin and collagen (Costasis®).

While the basic components of most fibrin sealants are similar, different formulations and

varying concentrations of the key components may cause differences between the products in

fibrin clot formation. Apart from the concentration of thrombin and fibrinogen, the presence of

antifibrinolytics, calcium concentration, the presence of other plasma proteins, ionic strength and

temperature all affect the speed of clot formation and stability and adhesive strength of the clot

that is formed.9,11-13

Clinical studies on fibrin sealants in liver surgery

Kohno et al.14 were the first to publish a randomized study on fibrin sealant in liver resection. The

aim of the study was to compare clinical efficacy of two hemostatic agents on hemostasis and

postoperative complications. They compared 31 patients receiving fibrin sealant glue (Beriplast)

with 31 patients receiving a microcrystalline collagen powder (Avitene®) in elective liver resection.

They showed equal hemostatic effects in both groups. A dry cut surface of the liver was obtained

during surgery in 27 (87%) patients in the fibrin glue group and in 25 (81%) in the collagen group.

Postoperative bleeding was 6% in both groups, and there were no differences in morbidity and

mortality. Considering the fact that there were fewer patients with bile leakage from the resection

surface of the liver in the fibrin sealant group (0 patients vs. 2 patients in the collagen group, n.s.),

they concluded that fibrin sealants were more reliable than microcrystalline collagen powder in the

postoperative course.14 Noun et al.15 randomized 82 patients comparing fibrin sealant glue (Biocol,

38 patients) on the liver resection plane with conventional hemostasis of the resection surface in

44 patients. The aim of the study was to evaluate the efficacy and safety of fibrin sealant after its

application to the liver resection surface. A dry cut surface of the liver was obtained in 97% in the

fibrin sealant group versus 81% in the conventional group (P value =0.016). There was no difference

between the groups in the time to reach complete hemostasis. There was also no difference in

the amount of perioperative blood transfusions. Postoperative morbidity and mortality in both

groups were equal, although the mean total fluid drainage during the first 3 days and the bilirubin

concentration in this fluid were significantly lower in the group with fibrin glue. They concluded

that fibrin glue application to the hepatic stump after hepatic resection provides effective sealing.15

A reduction in postoperative drain fluid production when fibrin sealants were applied on the

resection plane of the liver was confirmed in a pilot study by Eder et al.16 A fibrin sealant group

45


4

(Tissucol or Tachocomb, 13 patients) was compared with a group of patients who did not receive

fibrin sealant, only conventional hemostasis (12 patients). This was a small comparative non-

randomized study, although both groups appeared to be comparable considering age, sex and

extent of surgical resection. Drainage volumes were determined in 4-hour intervals through the

first 24 h after surgery, showing favorable results in the fibrin sealant group.16

Another randomized study showed a significant reduction in the amount of hemoglobin in

postoperative drain production when fibrin sealant was used.17 The use of fibrin sealant on the

resection surface (Beriplast, 20 patients) was compared with conventional hemostasis of the

resection surface in 20 patients in liver resection. The focus of the study was on the efficacy of fibrin

sealant in reducing postoperative bleeding complications. The conclusion of this study was that

fibrin sealant is useful in control of postoperative bleeding after liver resection.17

More recently, Chapman et al.18 compared the hemostatic performance of a composite of bovine

microfibrillar collagen and bovine thrombin mixed with autologous plasma (Costasis, 38 patients)

with the application of a collagen sponge (Instat®, 29 patients) on the hepatic resection margin,

in a randomized fashion. There were no differences regarding transfusion requirements. The

investigators did see a significant difference in the time to achieve hemostasis, favoring the fibrin

sealant group. In all 38 patients in the fibrin sealant group, complete hemostasis was achieved

within 10 min compared with only 69% of control subjects. The median time to controlled bleeding

was significantly longer for control subjects.18

A study with a similar primary end point was performed by Schwartz et al.19 comparing the use of a

fibrin sealant glue (Crosseal, 58 patients) with standard topical hemostatic agents (Actifoam®, Avitene,

Gelfoam®, Oxycel®, Surgicel®, Surgicel Nu-Knit®, and Thrombinar®, total 63 patients). Application of

fibrin sealant resulted in a statistically significant improvement in time to hemostasis compared to

application of standard topical hemostatic agents. Secondary end point of this study was focused

on postoperative resection surface-related complications. Postoperative complications (defined as

reoperation for any reason, a diagnosis of abdominal fluid collections or bilious drainage for at least

one day) were significantly lower in the fibrin sealant group (17.2%) compared to the control group

(36%). The percentage of patients with abdominal collections was significantly lower in the Crosseal

group than in the control group (3.4 vs. 14.3%). In this publication, there were no further details of

these results. The authors stated that there were no significant differences in intraoperative blood

loss, duration of postoperative bilious drainage, percentage of patients with bile loss, volume of

drainage fluid, and duration of drainage, though differences favored the fibrin sealant group.19

Frilling et al.20 reported on the hemostatic efficacy of a solid matrix fibrin sealant (Tachosil, 59

patients) versus argon beam coagulation of the resection surface (62 patients). This randomized

multicenter study showed that fibrin sealant was superior to argon beam regarding time to

hemostasis. Hemoglobin concentration at the 2nd day after surgery was significantly lower in the

fibrin sealant group. Bile leakage was reported in 4 (7%) patients in the fibrin sealant group versus

2 (4%) patients in the argon beam group, which did not reach statistical significance. Overall, the

46

Chapter 4

frequency of adverse events did not differ between groups.20

All the above studies mainly discussed the efficacy of fibrin sealants on hemostasis during hepatic

resection. Figueras et al.21 were the first to perform a study that primarily focused on postoperative

complications. In a large single-center randomized trial, they compared fibrin sealant (Tisseel plus

absorbable collagen sponge, 150 patients) with conventional hemostatic techniques in another

150 patients. Primary end points addressed bleeding complications and postoperative blood

transfusion. Secondary endpoints were other resection surface-related complications and overall

morbidity and mortality. There were no differences between groups in bleeding complications or

postoperative transfusion rates (18 vs. 12%, fibrin sealant vs. control), overall drainage volumes, days

of postoperative drainage, incidence of biliary fistula (10 vs. 11%) or postoperative morbidity (23 vs.

23%).21

Similarly, Berrevoet and de Hemptinne7 did not observe any differences in postoperative resection

surface-related complications in a retrospective comparative cohort study between two centers.

They compared the use of no sealant in their own center (Ghent, Belgium, 222 patients) with the

use of a solid matrix fibrin sealant (Tachocomb, Mulheim, Germany, 173 patients) in the other center

in hepatic resections performed over a period of 6 years. Patient and surgical characteristics were

comparable. There were no significant differences in postoperative blood transfusion, bile leakage

and reoperation for bleeding.7 Unfortunately, detailed information has not been published on this

study.

Recently, a prospective controlled quasi-experimental study was published by Briceno et al.22 that

focused on postoperative complications after the use of fibrin sealant in liver resection. A solid matrix

fibrin sealant (Tachosil, 57 patients) was compared with no sealant (58 patients). The use of fibrin

sealant appeared to be effective in decreasing drainage volume, postoperative blood transfusion

requirements, and moderate to severe postoperative complications. There was no difference

between groups in the incidence of bile leakage. Unfortunately, patients were not randomized in

this study. Instead, a ‘closure’ team decided whether to use fibrin sealant or to use conventional

hemostatic techniques.22

The most recent published randomized study on sealants in liver resection used a fibrin sealant

glue (Tissucol, 29 patients) as a control versus the use of Plasmajet® (29 patients) on the raw surface

of the liver after hepatic resection.23 The study was designed as a pilot study. Plasmajet is a device

that provides a high energy flow of ionized gas which seals small blood and lymph vessels. Instead

of a positive impact of fibrin sealants, this report described a higher incidence of fluid collections

requiring percutaneous drainage in the fibrin sealant group compared to the Plasmajet group. (20.6

vs. 3.4%, P value <0.001). Results of this study were not described in detail but pleural effusion was

also counted as a fluid collection. Abdominal fluid collections were drained in 10.3 vs. 3.4%; this

difference was not significant.23

Interestingly, two studies were published that compared two different types of fibrin sealants.

Hayashibe et al.24 published a retrospective historical cohort study comparing the use of fibrin

47


4

sealant alone (fibrin glue, not further specified, 37 patients, cohort 2001-2003) with the use of the

same fibrin sealant glue in combination with bio-absorbable polyglycolic acid (PGA) felt (51 patients,

cohort 2003-2005). They observed more bile leakage in the group of fibrin sealant alone than in the

fibrin sealant with PGA felt group (8.1 vs. 0%, P value =0.03). Their explanation for this phenomenon

was that PGA felt is thought to stimulate attachment and sealing of bile ducts by fibrin glue and

prevents early detachment of the fibrin glue from the cut surface of the liver.24 Similar results were

described in another retrospective historical cohort study, comparing two different fibrin sealants

in split liver transplantation.25 In the first cohort, fibrin glue was used (Tissucol, 16 patients, cohort

2003-2005); in the second, a solid matrix fibrin sealant was used (Tachosil, 16 patients, cohort 2005-

2006). Bile leakage was seen in 43.7 vs. 6.3% of patients, respectively (P value =0.03).25 Cohorts in this

last study were not completely comparable and sample sizes were low, but both studies suggest

that there might be a difference between fibrin glues and solid matrix fibrin sealants.

Fibrin sealants and prevention of bile leakage

Overall, the incidence of bile leakage has not decreased over the years, and has been described in

1-14% of patients after liver resection.2,4,26,27 Risk factors for bile leakage are high-risk procedures

with exposure of the major glissonian sheath, 3,4,26,28 resections combined with bilioenteric

anastomosis,29,30 size of resection plane,26 patient age,28 higher preoperative white blood cell count,28

and prolonged operation time.3,28 In a retrospective series of more than 600 patients, Capussotti et

al.4 showed an association between the application of fibrin sealant on the resection surface and

a lower incidence of bile leakage (RR =0.38, P value =0.046). As stated before, in clinical trials this

effect has not been confirmed. Only limited research has been done to investigate the efficacy of

fibrin sealants in reducing the incidence of bile leakage.(Table 1). So far, Figueras et al.21 are the only

group that performed a well-powered study on the use of fibrin sealants in liver resections, but this

study did not show a difference in the incidence of bile leakage in sealant use versus no sealant.

Studies that do show a reduction in bile leakage were either of poor methodological quality or were

underpowered.

Even though in clinical studies fibrin sealants do not seem to reduce bile leakage, there are some

studies that indicate that fibrin sealants may have the potential to seal bile ducts. Noun et al.15

showed that the concentration of bilirubin in the drains was significantly lower in fibrin sealant

versus no sealant, suggesting a sealing effect, but they did not report on the incidence of bile

leakage.(Table 1) In experimental studies, fibrin sealants have mainly been tested as an adjunct

to suture closure of the common bile duct. Results were contradictory; some studies showed a

protective effect of fibrin sealants on bile leakage from the anastomosis of the common bile duct

in a dog model,31,32 whereas another study in a pig model did not.33 Instead of using a fibrin sealant,

Wise et al.34 tested a synthetic sealant (polyethylene glycol/collagen biopolymer) in an experimental

liver resection model in pigs. In all pigs, they transected the common bile duct and performed an

incomplete end-to-end choledochocholedochostomy over a T-tube, leaving an anterior defect

48

Chapter 4

Tabl

e 1

1st.

auth

orIn

cl.

Des

ign

Tim

e to he

mo

stas

is

min

Com

pl.

hem

ost

asis

%

Tota

l dr

ain

day

s

Volu

me

dra

in m

lH

b g/

100

ml

Bili

rubi

nM

orbi

dity

%

Mor

talit

y %

Post

op.

bloo

d tr

ans

fusi

on %

Post

op. a

bd.

fluid

col

lec

tion

s %

Post

op.

blee

ding

%Re

ope

rati

on %

Bile

le

akag

e %

Liu

1720

FSG

vs.

620

NS

RCT

––

––

8.1

15.6

(g/d

ay)

––

––

––

––

Nou

n 15

38 F

SG v

s.44

NS

RCT

26a

2697 81

b

–24

250

5b (3 d

ays)

0.8

1.1

24 65b

––

18 25 (per

iop.

)

16 20–

––

Eder

1613

FSG

vs.

12 N

Sco

mp.

co

hort

––

–35

0c

950b (d

ay 1

)–

––

––

––

––

Kohn

o 14

31 F

SG v

s.31

col

lage

nRC

T–

87 817.

26.

316

415

6 (d

ay 1

)–

–39 45

10 13–

0 3 (abs

cess

)

6 6–

3 3

Schw

artz

1958

FSG

vs.

63 o

ther

d

RCT

4.7

7.8b

91 70b

no d

iff.

no d

iff.

––

17e

36b

2 10–

3 14b

––

no d

iff.

Gug

enhe

im 23

29 F

SG v

s.29

PJ

RCT

––

––

––

–10 7

3 310 3

(dra

ined

co

llect

ion)

–0 0

3 0

Figu

eras

2115

0 FS

G +

co

llage

n vs

.15

0 N

S

RCT

––

7.9

7.1

1,18

096

0 (o

vera

ll)–

–23 23

4 118 12

8 4 (a

bsce

ss)

1 16 3

10 11

Chap

man

1838

FSL

vs.

29 c

olla

gen

RCT

2.5

6.0b

100

69b

––

––

–0 7

no d

iff.

–no

diff

.–

–

Bric

eno

2257

FSS

vs.

58 N

Spr

osp.

qu

asi

exp.

––

3.8

6.1b

691

1,12

5b

(ove

rall)

––

18 430 0

19 77 4

(dra

ined

co

llect

ion)

5 05 0

10 7

Berre

voet

717

3 FS

S vs

.22

2 N

Sco

mp.

co

hort

––

––

––

––

no d

iff.

–3 0

no d

iff.

2 3

Frill

ing

2059

FSS

vs.

62 a

rgon

RCT

3.9

6.3b

97 906.

05.

752

549

6 (d

ay 1

)3.

33.

6 –

24 1110 3

–7 5

––

7 3

49


4

Hay

ashi

be 24

37 F

SG v

s.51

FSG

+

PGA

com

p.

coho

rt–

––

––

––

––

–3 0

–8 0b

Toti

(Spl

it LT

) 25

16 F

SS v

s.16

FSG

com

p.

coho

rt–

––

––

––

––

––

–6 43

b

FSG

= F

ibrin

seal

ant g

lue

(Tiss

ucol

, Tiss

eel, Q

uixi

l, Cro

ssea

l, Bio

col®

or B

erip

last

); FS

L =

fibrin

seal

ant +

liqu

id m

atrix

(Cos

tasis

); FS

S =

fibrin

seal

ant +

solid

mat

rix (T

acho

sil, T

acho

com

b); N

S =

no se

alan

t; RC

T =

rand

omiz

ed c

ontro

lled

tria

l; Com

p. c

ohor

t = c

ompa

rativ

e co

hort

stud

y; sp

lit LT

= sp

lit li

ver t

rans

plan

tatio

n; N

o di

ff. =

no

diffe

renc

e, a

s sta

ted

in p

ublic

atio

n, n

o nu

mbe

rs k

now

n; P

J = P

lasm

ajet

. a T

ime

to c

ompl

ete

hem

osta

sis a

nd b

ilios

tasis

. b S

tatis

tical

ly si

gnifi

cant

. c F

rom

num

bers

doc

umen

ted

in fi

gure

pub

licat

ion.

d O

ther

refe

rs to

oth

er to

pica

l hem

osta

tic a

gent

s. e C

ombi

ned

mor

bidi

ty e

ndpo

int:

% re

oper

atio

n fo

r any

reas

on, a

dia

gnos

is of

abd

omin

al fl

uid

colle

ctio

ns o

r bili

ous d

rain

age

for a

t lea

st 1

day

.

50

Chapter 4

of one sixth of the circumference. In 9 pigs, sealant was applied around the circumference of the

anastomosis. Nothing was applied in the control group. Bile leakage was seen in 5 out of 9 (56%) in

the control group versus 1 out of 9 (11%) in the sealant group (P value <0.05).34 In conclusion, use of

this synthetic sealant resulted in a reduction in the incidence of bile leakage, which could not clearly

be shown in other studies when fibrin sealants were used. Lack of evidence in the experimental

fibrin sealant studies might also be attributable to a poor design of these studies.

Erdogan and van Gulik35 suggested adhesive strength of the fibrin sealant to be an important factor

in the prevention of bile leakage. They performed an experimental study in a partial liver resection

model in pigs. They compared the use of a solid matrix fibrin sealant (Tachosil, 4 pigs) with the use

of a fibrin sealant glue (Tissucol, 4 pigs) on the liver resection surface.35 A catheter was introduced

in the common bile duct. Two hours after application of the sealant, pressure in the common bile

duct was increased with the use of saline. The pressure that could be resisted with the liquid fibrin

sealant was significantly lower compared to solid matrix fibrin sealant. This study showed that

the adhesive strength of this solid matrix sealant was better than the fibrin glue.35,36 Whether the

adhesive strength of these solid matrix sealants is intrinsic to the product or caused by the fact that

the sealant is applied to the surface by pressure has not been investigated. It has been postulated

that the adhesive strength of products that can be applied with pressure are theoretically better

than products that are applied without pressure, like the liquid fibrin sealants.9 This could also be

concluded from the two clinical studies by Hayashibe et al.24 and Toti et al.25 Both studies compared

different sealants or different combination and application of products. Again, from these studies it

is not clear whether the possible differences in effect on bile leakage between fibrin sealant glues

and solid matrix fibrin sealants are caused by the products themselves or by the differences in

application (pressure vs. no pressure).

The stability of fibrin sealants on dissected bile ducts has not been studied in detail. The study

previously discussed by Erdogan and van Gulik35 used saline to increase pressure in the common

bile duct instead of bile. Interestingly, there are indications from the literature that bile interferes

with the hemostatic process, a process which is mimicked by the fibrin sealant when applied to

the resection surface of the liver. In 1919, Haessler and Stebbins were the first to report on the

anticoagulant effect of bile.37 More than 50 years later, bile was found to contain fibrinolytic activity,

and a protein referred to as bilokinase was isolated.38-41 Several studies identified the presence of

different fibrinolytic proteins including plasminogen, plasminogen activator inhibitor type 1 (PAI-1)

and plasminogen activator (tPA) in human bile.42-44 Although these studies did not address whether

these proteins were functional, they do raise the question whether bile has a lytic effect on fibrin

sealants or not.

Recently, our group investigated the effect of human bile on the stability of different fibrin sealants

and plasma clots in vitro.45 Addition of bile to fibrin sealants accelerated lysis of in vitro clotted

fibrin sealants. The lysis-promoting activity of bile could be partially blocked by immunodepletion

of tissue-type plasminogen activator (tPA). Lytic activity was completely blocked when both tPA

51


4

and lysine-binding proteins were immunodepleted, which suggests that tPA and plasminogen are

responsible for the lysis-promoting effect of human bile. The lytic effect of bile could not be blocked

by the addition of high-dose PAI-1, and we showed that tPA in a biliary environment is unsusceptible

to PAI-1 inhibition. Results of this experimental study suggest that the presence of tPA and other

fibrinolytic proteins in human bile cause lysis of plasma and fibrin glues.45 Whether these effects

account for all fibrin sealants or only for the fibrin sealants tested in this study, remains to be seen.

These lytic effects of bile on fibrin sealants have not been proven in vivo, but might be an

explanation why there is no evidence so far for the efficacy of fibrin sealants in reducing bile leakage

after liver resection. Future studies are needed that focus on the effect of fibrin sealants on the

incidence of bile leakage. We are currently awaiting the results of a Dutch multicenter randomized

study on the effect of fibrin sealants in reducing resection surface-related complications (FRESCO

study; controlledtrials.com: ISRCTN85205641). Future focus of bile leakage reduction may lie in the

development of synthetic sealants.

In conclusion, fibrin sealants are widely used in liver surgery. Several fibrin sealant studies were

performed in the field of liver surgery to analyze their efficacy on hemostasis, postoperative drain

fluid production and resection surface-related complications like bile leakage, bleeding and

abscess formation. In general, these studies have shown a reduced time to hemostasis when fibrin

sealants were used. However, few studies have been published so far that focused on postoperative

resection surface-related complications, like bile leakage, bleeding or abscess formation. Although

different types of fibrin sealants showed different results, there is no strong evidence that fibrin

sealants reduce the incidence of bile leakage after liver resections. Studies that did show a reduction

in resection surface related complications were either of poor methodological quality or were

underpowered. Important new evidence shows that bile contains profibrinolytic activity that

causes lysis of the clot formed by the fibrin sealant at least in vitro. Future studies are needed to

further analyze the lysis of different fibrin sealants (fibrin glues vs. solid matrix fibrin sealants) in

vitro and in vivo by human bile. Apart from improvement of surgical techniques, a possible solution

to the problem of bile leakage after liver resection may lie in the development of safe and ready to

use synthetic sealants instead of fibrin sealants. Since there is no evidence on the efficacy of fibrin

sealants in reducing postoperative resection surface-related complications, routine use of fibrin

sealants in liver surgery cannot be recommended.

52

Chapter 4

REFERENCES

1 Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben Porat L, Little S, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397-406.

2 Reed DN Jr, Vitale GC, Wrightson WR, Edwards M, McMasters K. Decreasing mortality of bile leaks after elective hepatic surgery. Am J Surg 2003;185:316-318.

3 Yamashita Y, Hamatsu T, Rikimaru T, Tanaka S, Shirabe K, Shimada M, et al. Bile leakage after hepatic resection. Ann Surg 2001;233:45-50.

4 Capussotti L, Ferrero A, Vigano L, Sgotto E, Muratore A, Polastri R. Bile leakage and liver resection: where is the risk? Arch Surg 2006;141:690-694.

5 Boonstra EA, Molenaar IQ, Porte RJ, de Boer MT. Topical haemostatic agents in liver surgery: do we need them? HPB 2009;11:306-310.

6 Nakajima Y, Shimamura T, Kamiyama T, Matsushita M, Sato N, Todo S. Control of intraoperative bleeding during liver resection: analysis of a questionnaire sent to 231 Japanese hospitals. Surg Today 2002;32:48-52.

7 Berrevoet F, de Hemptinne B. Clinical application of topical sealants in liver surgery: does it work? Acta Chir Belg 2007;107:504-507.

8 Kraus TW, Mehrabi A, Schemmer P, Kashfi A, Berberat P, Buchler MW. Scientific evidence for application of topical hemostats, tissue glues, and sealants in hepatobiliary surgery. J Am Coll Surg 2005;200:418-427.

9 Berrevoet F, de Hemptinne B. Use of topical hemostatic agents during liver resection. Dig Surg 2007;24:288-293.

10 Mosesson MW. Fibrin polymerization and its regulatory role in hemostasis. J Lab Clin Med 1990;116:8-17.

11 Dickneite G, Metzner H, Pfeifer T, Kroez M, Witzke G. A comparison of fibrin sealants in relation to their in vitro and in vivo properties. Thromb Res 2003;112:73-82.

12 Busuttil RW. A comparison of antifibrinolytic agents used in hemostatic fibrin sealants. J Am Coll Surg 2003;197:1021-1028.

13 Okada M, Blomback B. Factors influencing fibrin gel structure studied by flow measurement. Ann N Y Acad Sci 1983;408:233-253.

14 Kohno H, Nagasue N, Chang YC, Taniura H, Yamanoi A, Nakamura T. Comparison of topical hemostatic agents in elective hepatic resection: a clinical prospective randomized trial. World J Surg 1992;16:966-969.

15 Noun R, Elias D, Balladur P, Bismuth H, Parc R, Lasser P, et al. Fibrin glue effectiveness and tolerance after elective liver resection: a randomized trial. Hepatogastroenterology 1996;43:221-224.

16 Eder F, Meyer F, Nestler G, Halloul Z, Lippert H. Sealing of the hepatic resection area using fibrin glue reduces significant amount of postoperative drain fluid. World J Gastroenterol 2005;11:5984-5987.

17 Liu M, Lui WY. The use of fibrin adhesive for hemostasis after liver resection. Zhonghua Yi Xue Za Zhi 1993;51:19-22.

18 Chapman WC, Clavien PA, Fung J, Khanna A, Bonham A. Effective control of hepatic bleeding with a novel collagen-based composite combined with autologous plasma: results of a randomized controlled trial. Arch Surg 2000;135:1200-1204.

19 Schwartz M, Madariaga J, Hirose R, Shaver TR, Sher L, Chari R, et al. Comparison of a new fibrin sealant with standard topical hemostatic agents. Arch Surg 2004;139:1148-1154.

20 Frilling A, Stavrou GA, Mischinger HJ, de Hemptinne B, Rokkjaer M, Klempnauer J, et al. Effectiveness of

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4

a new carrier-bound fibrin sealant versus argon beamer as haemostatic agent during liver resection: a randomised prospective trial. Langenbecks Arch Surg 2005;390:114-120.

21 Figueras J, Llado L, Miro M, Ramos E, Torras J, Fabregat J, et al. Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients. Ann Surg 2007;245:536-542.

22 Briceno J, Naranjo A, Ciria R, Diaz-Nieto R, Sanchez-Hidalgo JM, Luque A, et al. A prospective study of the efficacy of clinical application of a new carrier-bound fibrin sealant after liver resection. Arch Surg 2010;145:482-488.

23 Gugenheim J, Bredt LC, Iannelli A. A randomized controlled trial comparing fibrin glue and PlasmaJet on the raw surface of the liver after hepatic resection. Hepatogastroenterology 2011;58:922-925.

24 Hayashibe A, Sakamoto K, Shinbo M, Makimoto S, Nakamoto T. New method for prevention of bile leakage after hepatic resection. J Surg Oncol 2006;944:57-60.

25 Toti L, Attia M, Manzia TM, Lenci I, Gunson B, Buckels JA, et al. Reduction in bile leaks following adult split liver transplant using a fibrin-collagen sponge: a pilot study. Dig Liver Dis 2010;42:205-209.

26 Nagano Y, Togo S, Tanaka K, Masui H, Endo I, Sekido H, et al. Risk factors and management of bile leakage after hepatic resection. World J Surg 2003;27:695-698.

27 van den Broek MA, van Dam RM, Malago M, Dejong CH, van Breukelen GJ, Olde Damink SW. Feasibility of randomized controlled trials in liver surgery using surgery-related mortality or morbidity as endpoint. Br J Surg 2009;962:1005-1014.

28 Lo CM, Fan ST, Liu CL, Lai EC, Wong J. Biliary complications after hepatic resection: Risk factors, management, and outcome. Arch Surg 1998;133:156-161.

29 IJtsma AJ, Appeltans BM, de Jong KP, Porte RJ, Peeters PM, Slooff MJ. Extrahepatic bile duct resection in combination with liver resection for hilar cholangiocarcinoma: a report of 42 cases. J Gastrointest Surg 2004;8:686-694.

30 Erdogan D, Busch OR, Gouma DJ, van Gulik TM. Prevention of biliary leakage after partial liver resection using topical hemostatic agents. Dig Surg 2007;24:294-299.

31 Couto J, Kroczek B, Requena R, Lerner R. Autologous fibrin glue as a sealant of the common bile duct. Surgery 1987;101:354-356.

32 Kram HB, Garces MA, Klein SR, Shoemaker WC. Common bile duct anastomosis using fibrin glue. Arch Surg 1985;120:1250-1256.

33 Jones DB, Brewer JD, Meininger TA, Soper NJ. Sutured or fibrin-glued laparoscopic choledochojejunostomy. Surg Endosc 1995;9:1020-1027.

34 Wise PE, Wudel LJ Jr, Belous AE, Allos TM, Kuhn SJ, Feurer ID, et al. Biliary reconstruction is enhanced with a collagen-polyethylene glycol sealant. Am Surg 2002;68:553-561.

35 Erdogan D, de Graaf W, van Gulik TM. Adhesive strength of fibrinogen-coated collagen patch or liquid fibrin sealant in an experimental liver resection model in pigs. Eur Surg Res 2008;41:298-302.

36 Erdogan D, van Gulik TM. Evolution of fibrinogen-coated collagen patch for use as a topical hemostatic agent. J Biomed Mater Res B Appl Biomater 2008;85:272-278.

37 Haessler H, Stebbins MG. Effect of bile on the clotting time of blood. J Exp Med 1919;29:445-449.

38 Chung SC, Kim YC, Hong SK, Lee PH: Effect of bile on the blood coagulation. Yonsei Med J 1964;5:24-28.

39 King JB. Fibrinolysis by bile. Thromb Diath Haemorrh 1972;28:299-305.

40 Oshiba S, Ariga T. Purification and characterization of the biliary plasminogen activator bilokinase. J Biol Chem 1983;258:622-628.

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41 Oshiba S, Ariga T. Proceedings: purification and characterization of bilokinase, a biliary plasminogen activator. Thromb Diath Haemorrh 1975;34:319.

42 Scott-Coombes DM, Whawell SA, Havranek EG, Thompson JN. Fibrinolysis and the biliary tree. Gut 1997;40:92--94.

43 Gil D, Michalski A, Kondera-Anasz Z, Gil B, Starzewski J, Gonciarz Z. Do fibrinolytic proteins of human bile derive exclusively from gall bladder? Med Sci Monit 2001;7(suppl 1):262-263.

44 Kondera-Anasz Z, Michalski A, Gil D, Gil B, Starzewski J, Gonciarz Z. Accuracy of t-PA, u-PA, PAI-1 and PAI-2 estimation in human bile by ELISA kits. Med Sci Monit 2000;6:616-617.

45 Boonstra EA, Adelmeijer J, Verkade HJ, de Boer MT, Porte RJ, Lisman T. Fibrinolytic proteins in human bile accelerate lysis of plasma clots and induce breakdown of fibrin sealants. Ann Surg 2012;256:306-312.

55

Fibrin sealant for prevention of resection surface-related complications after liver resection. A randomized controlled trial

Marieke T. de Boer

Joost M. Klaase

Cornelis Verhoef

Ronald M. van Dam

Thomas M. van Gulik

I. Quintus Molenaar

Koop Bosscha

Cornelis H.C. Dejong

Eric J. van der Jagt

Robert J. Porte; for the

FRESCO Trial Group

Annals of Surgery 2012;256:229-234

5

56

Chapter 5

ABSTRACT

Objective: To evaluate efficacy of fibrin sealant in reducing resection surface-related complications

in liver surgery.

Background: Bile leakage, bleeding and abscess formation are major resection surface-related

complications after liver resection. It is unclear whether application of fibrin sealant to the resection

surface is effective in reducing these complications.

Methods: In a multicenter, randomized trial in 310 non-cirrhotic patients undergoing liver resection,

we compared prophylactic application of fibrin sealant to the resection surface (156 patients)

with no application of fibrin sealant (154 patients). In addition to clinical assessments, patients

underwent protocolized CT-scan one week postoperatively. Primary endpoint was a composite

of postoperative resection surface-related complications (bile leakage, bleeding or abscess), as

adjudicated by a clinical-events committee that was unaware of the study-groups assignments.

Results: Overall rate of resection surface-related complications was not different between the two

groups: 24% (38/156 patients) in the fibrin sealant group and 24% (37/154 patients) in the control

group. Bile leakage was detected in 14% of patients in the fibrin sealant group and in 14% of

controls. CT-scans showed a fluid collection at the resection surface ≥100mL in 28% of patients

in the fibrin sealant group and in 26% of controls (P value =0.800). The rate of reinterventions for

resection surface-related complications (12% vs. 10%; P value =0.492) and severity of complications

did also not differ between the two groups.

Conclusion: This randomized multicenter trial shows that prophylactic application of fibrin sealant at

the resection surface after liver resections does not lead to a reduction in the incidence or severity

of postoperative bile leakage or other resection surface-related complications. (Controlled trial

number, ISRCTN85205641)

57

Fibrin sealant for prevention of resection surface-related complications after liver resection

5

INTRODUCTION

Mortality and morbidity of liver surgery have decreased due to better patient selection, improvement

in surgical techniques and perioperative management.1 Postoperative bleeding and bile leakage

from the remnant liver resection surface, however, remain major complications. Bile leakage from the

liver resection surface has been described in 1-14% of patients, leading to additional interventions,

prolonged hospital stay, mortality, and higher costs.2-7

Fibrin sealants are commercial or homemade preparations of human fibrinogen and human or

bovine thrombin that are mixed together on a wound surface to form a fibrin gel. Several studies

have shown the safety and efficacy of these products in promoting local hemostasis during

surgery.8-17 The worldwide market for these products is rapidly expanding and annual global

sales are estimated around 1.5 billion US dollars.18 In many countries fibrin sealants are registered

as adjuncts to achieve hemostasis at the liver resection surface in liver surgery. Apart from the

hemostatic capacities, surgeons are also using these agents prophylactically with the assumption

that this will reduce postoperative leakage of blood or bile from the resection surface.17,19,20 National

surveys performed in the Netherlands and Japan have indicated that 80% of liver surgeons use

fibrin sealants.19,21 However, half of them had doubts about their efficacy in reducing resection

surface-related complications.19 Indeed, formal scientific evidence for this is lacking.

To test the hypothesis that the application of fibrin sealant to the raw surface of the liver remnant

after resections decreases the incidence of resection surface-related complications, we conducted

a multicenter, randomized trial comparing prophylactic application of fibrin sealant with no

application of fibrin sealant.

METHODS

Patients

Patients were enrolled at 7 sites in the Netherlands. All patients provided written informed consent.

Adult patients of 18 years and older who underwent resection of at least one liver segment or a

non-anatomical resection were eligible for inclusion in the study. Exclusion criteria were: wedge

resections, concomitant extrahepatic bile duct resection or bowel resection, cirrhosis, hemostatic

disorders, polycystic liver disease, pregnancy, and history of hypersensitivity or allergic reaction to

any plasma derived product.

Study design

This was a randomized, controlled study that was initiated by the investigators. Fibrin sealants were

kindly provided by the distributor Johnson & Johnson, but this company was not involved in data

collection and analysis. The study was coordinated and the data was analyzed by the coordinating

study group of the University Medical Center Groningen. Medical ethical review committees at

participating institutions approved the study protocol, and the study was performed in accordance

with it.

Our objective was to study the efficacy of fibrin sealant in reducing resection surface-related

58

Chapter 5

complications, including bile leakage, bleeding, or abscess formation at the resection surface, in

patients undergoing liver resection. The hypothesis was that prophylactic application of fibrin

sealant to the dry resection surface of the liver after a resection reduces the rate of resection surface-

related complications.

Study treatment and randomization

The fibrin sealant used in this study was Quixil® (Johnson & Johnson Medical, New Brunswick, NJ).

In the U.S. this fibrin sealant is approved and marketed under the name Crosseal®. It consists of a

package containing two separate vials of 5 ml and a double-syringe spray-device. Vial I contains a

concentrate of human fibrinogen (40-60 mg/mL) and tranexamic acid, a synthetic antifibrinolytic

agent (85-105 mg/mL). Vial II consists of a high concentration of human thrombin (800-1200 IU/mL).

After obtaining hemostasis and biliostasis at the liver resection surface by conventional techniques

such as suture or clip application, or coagulation, patients were randomized. In the treatment group,

10 mL fibrin sealant was sprayed on the resection surface and on the bare surface of the diaphragm.

In the control group nothing was applied. All local investigators were instructed by the company

prior to trial commencement in the use of fibrin sealant.

A statistician who was not otherwise involved in the conduct of the study prepared the

randomization list, using computer random number generation. Treatment allocation employed a

sequentially numbered, opaque and sealed envelope system. Patients were stratified by center and

by benign versus malignant diagnosis. Patients, who appeared to be irresectable, in whom only a

wedge resection was performed, or in whom we could not achieve hemostasis without the use of a

fibrin sealant, were not randomized.

Surgeons could not be kept unaware of treatment allocation, but patients, local investigators

responsible for data gathering, data analysts, and radiologists did remain unaware of the study

group assignment.

Data collection

Standard preoperative demographic and intraoperative characteristics were recorded. Postoperative

data collection, including drain fluid analysis, was focused on detection of resection surface-related

complications and general complications of liver surgery. At one week after surgery, a protocolized

contrast enhanced CT-scan of the upper abdomen and chest was performed to objectively detect

and quantify fluid collections in proximity of the resection surface of the liver or pleural effusion. CT

images were collected in the coordinating center and were judged by two radiologists who were

blinded for the study group assignment. Patients were followed at least until 30 days after discharge.

Primary and secondary endpoints

Primary endpoint was the occurrence of a resection surface-related complication, including bile

leakage, bleeding or abscess, as detected by clinical symptoms, reinterventions, or protocol CT

59


5

scan (fluid collections ≥100 mL). These endpoints were analyzed individually as well as a composite

endpoint. Bile leakage was defined as drainage of bile or bile containing fluid (bilirubin concentration

≥100 µmol/L) from the abdominal wound or drain, or intra-abdominal collection of bile confirmed at

the time of reoperation or by percutaneous drainage, or cholangiographic evidence of bile leakage.

Bleeding was defined as leakage of blood from an abdominal drain with hemodynamic instability,

or the need for blood transfusion within 24hrs postoperatively, or evidence of a hematoma in

proximity to the resection surface of the liver. Abscess was defined as a localized fluid collection

near the resection surface, requiring radiological or surgical drainage based on clinical, radiological,

or microbiological evidence of infection.

Secondary endpoints were: amount of drain fluid production (mL/day), hemoglobin (mmol/L)

and bilirubin concentration (μmol/L) in drain fluid during the first three days postoperatively;

postoperative morbidity and mortality. Complications were graded according to the Clavien-Dindo

classification.22,23

Statistical analysis

For calculation of the required study-population size, resection surface-related complications such

as bile leakage, bleeding, and/or abscess formation, and fluid collections (≥100 mL) in proximity to

the resection surface detected on CT-scan, were considered the most important target variables.

Based on experience and previous publications, overall proportion of these complications was

estimated to be 15-20% when no fibrin sealant was used. A difference of about 50% was considered

clinically significant. Based on this, we calculated that 220 patients were needed in each group to

achieve 80% power at the 5% significance level. Because the exact incidence of CT-scan detected

fluid collections was not known, we planned an interim analysis after 180 patients to determine

the incidence of the composite primary endpoint in the control group only. This interim analysis,

performed by an independent statistician, revealed a composite primary endpoint rate in the

control group of 30.4%. This resulted in a recalculated study size of 131 patients in each group.

To compensate for potential dropout it was decided to continue the study with enrollment of 150

patients in each group.

All analyses were based on intention-to-treat methods. Missing data were treated as missing

according to a list wise deletion approach. Continuous variables were expressed as median and

interquartile range (IQR). Categorical variables were expressed as number and percentage.

Comparisons of categorical variables between the two study groups were performed with the

use of Fisher’s exact test or chi-square tests. For comparison of continuous variables we used the

Mann-Whitney U test. A two-sided P value of less than 0.05 was considered to indicate statistical

significance. All statistical analyses were performed with the use of PASW Statistics Software, version

18.0 (SPSS, Chicago, IL).

60

Chapter 5

RESULTS

Patients and surgical characteristics

Overall, 310 patients were randomized in 7 centers in the Netherlands between June 2006 and June

2010.(Figure 1) No patients were lost to follow-up. The median follow-up was 39 days, ranging from

33 to 149 days. In total, 156 patients were assigned to the sealant group and 154 patients to the

control group. The groups were balanced with regard to baseline characteristics, indications for liver

resection, and surgical characteristics.(Table1) The majority of patients underwent liver resection

because of colorectal metastases (74% in both groups) and 52% of the resections were major liver

resections, defined as resection of 3 or more segments. The size of the resection surface did not

differ between groups. Overall, a drain was placed at the resection surface in 68% of the patients

and a postoperative CT scan was performed in 95% of the patients (no significant differences

between the groups).

154 Were assigned not to receive �brin sealant (Control group) 154 patients received assigned treatment

132 Patients were excluded: 70 No resection 19 Wedge resections 17 No hemostasis 8 Combined procedure 10 Sealant unavailable 6 Unclear reason 1 Laparoscopic procedure 1 Withdrawn consent

442 Patients were enrolled

310 Patients were randomized

156 Were assigned to receive �brinsealant (Fibrin sealand group) 155 received assigned �brin sealant 1 received other type of sealant

156 Were included in the intention-to-treat analysis 149 patients could be fully judged on primary endpoint 7 patients did not receive a CT scan and did not meet primary endpoint

154 Were included in the intention-to-treat analysis 146 patients could be fully judged on primary endpoint 9 patients did not receive a CT scan but 1did meet primary endpoint (relaparotomy)

Figure 1. Enrollment and Randomization

61


5

Table 1. Baseline and Surgical Characteristics of the Patients, According to the Study Group

Characteristic Fibrin Sealant (n=156)

Control (n=154) P Value

Age - yrMedian (IQR) 62 (53-68) 61 (51-69) 0.50

Male sex - no. (%) 83 (53) 76 (49) 0.57Tumor type - no. (%) 0.10

Colorectal metastases 116 (74) 114 (74)Hepatocellular carcinoma 8 (5) 8 (5)Other malignant tumor 7 (5) 10 (7)Benign tumor 25 (16) 22 (14)

Chemotherapy < 3 months before surgery - no. (%)

30 (20) 17 (12) 0.06

Previous abdominal surgery - no. (%) 121 (78) 120 (78) 1.00Previous liver surgery - no. (%) 19 (12) 15 (10) 0.59Preoperative laboratory values

Hemoglobin - mmol/lMedian (IQR) 8.5 (7.8-9.0) 8.5 (7.9-9.1) 0.40

Serum bilirubin - μmol/l Median (IQR) 10 (7-14) 9 (7-14) 0.42

Serum creatinin - µmol/l Median (IQR) 74 (64-86) 76 (66-86) 0.46

Platelet count - 10E9/lMedian (IQR) 243 (199-295) 244 (201-307) 0.95

Serum alanine aminotransferase - U/lMedian (IQR) 27 (17-37) 24 (18-32) 0.52

Prothrombin time - secMedian (IQR) 10.7 (10.4-11.2) 10.7 (10.4-11.6) 0.89

Surgical characteristicsType of liver resection

Major resection - no. (%)† 84 (54) 76 (49) 0.50Inflow occlusion - no. (%)‡ 38 (24) 37 (24) 1.00Resection combined with RFA- no. %) 14 (9) 17 (11) 0.58

Parenchymal transection technique - no. (%)§ 0.35Ultrasonic 57 (37) 55 (36)Electric coagulation based 43 (28) 31 (20)Combined 55 (35) 66 (43)Clamp crush 1 (0) 2 (1)

Size resection surface - cm2¶Median (IQR) 75 (43-101) 72 (38-100) 0.73

Drain placed at resection surface - no. (%) 106 (68) 106 (69) 0.90CVP during transection - mmHg

Median (IQR) 4 (2-6) 4 (3-6) 0.80Estimated intra-operative blood loss - ml

Median (IQR) 675 (300-1140) 550 (300-1000) 0.30Intraoperative RBC transfusion - no. units (%) 24 (15) 14 (9) 0.12CT scan 1 week after resection - no. (%)# 149 (96) 145 (94) 0.61

* To convert values for hemoglobin to g/dl, multiply by 1.650. To convert values for bilirubin to mg/dl, divide by 88.4. RFA denotes radiofrequency ablation of tumor nodules in the remnant liver, IQR interquartile range, and RBC red blood cells.

† Major liver resection was defined as resection of at least 3 liver segments‡ Inflow occlusion (Pringle maneuver) during liver parenchyma transsection § Ultrasonic based parenchymal transection means use of CUSA; electric coagulation based means use of argon or

diathermia transection, radiofrequency transection devices (Habib sealer or tissue link) or sealing devices (Ligasure); Combined means a combination ultrasonic and electric coagulation.

¶ The size of the resection surface was approximated with the surface area equation of an ellipse: A=πab (a and b were measured after resection, and represent the two perpendicular diameters of the resection surface, both divided by 2)

# Contrast enhanced CT scan of the abdomen and chest was made according to study protocol at one week after surgery: volumetry of fluid collections at the resection surface or pleural effusions were calculated by a radiologist who was unaware of the study group assignment.

62

Chapter 5

Primary endpoint

Resection surface-related complications, defined as a composite endpoint of bile leakage, bleeding

or abscess, were observed in 24% of patients in both study groups.(Table 2) Bile leakage was

diagnosed in 14% of the patients in both groups. Incidence of postoperative bleeding was 10%

in the sealant group, versus 7% in the control group, and the incidence of abscess formation at

the resection surface was 6% in the sealant group versus 8% in the control group. None of these

differences was statistically significant.

The overall incidence of bile leakage requiring a reintervention was 7%, with no significant difference

between the groups. The overall rate of reinterventions for resection surface-related complications

was also not different between the two groups (12% in sealant group, compared to 10% in controls).

Table 2. Characteristics of Postoperative Resection Surface Related Complications, According to the Study Group

Variable Fibrin Sealant (n=156) Control (n=154) P Value

Composite endpoint bile leakage, abscess or bleeding at resection surface - no. (%) 38 (24) 37 (24) 1.00

Bile leakage* 22 (14) 21 (14) 1.00

Grade 1 § 8 15

Grade 3 12 6

Grade 4 1 0

Grade 5 1 0

Abscess† 10 (6) 12 (8) 0.67

Grade 3 9 10

Grade 4 0 1

Grade 5 1 1

Bleeding‡ 18 (11) 11 (7) 0.24

Grade 2 15 10

Grade 3 3 1

Any reintervention for resection surface related complications - no. (%) 19 (12) 15 (10) 0.59

Surgical reintervention 4 (3) 1 (1) 0.37

Radiological reintervention 13 (8) 13 (8) 1.00

Endoscopic reintervention 9 (6) 4 (3) 0.26

Protocol postoperative CT scan - no. (%)

Fluid collection at resection surface >100 ml 41 (28) 38 (26) 0.90

Composite endpoint bile leakage, abscess, bleeding or reintervention or fluid collection at resection surface >100 ml on CT scan - no. (%) 66 (44) 58 (40) 0.56

* Bile leakage was defined as drainage of bile from the abdominal wound or drain (bilirubin concentration >100 µmol/l or > 1.13 mg/dl), or intra-abdominal collection of bile (biloma) confirmed at the time of reoperation or percutaneous drainage, or cholangiographic evidence of biliary leakage.

† Abscess was defined as a localized fluid collection near the resection surface, requiring radiological or surgical drainage based on clinical, radiological, or microbiological evidence of infection

‡ Bleeding was defined as leakage of blood via the drain with hemodynamic instability or the need for blood transfusion within 24 hours postoperatively, or evidence of a hematoma in proximity to the resection surface of the liver.

§ Grading complications according to Clavien-Dindo classification.22,23

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5

Secondary endpoints and safety

Median bilirubin concentration in drain fluid at day 1 was slightly lower in the sealant group,

compared to the control group.(Table 3) Although this difference was statistically significant, clinical

significance was minimal as there was no difference in the overall incidence of postoperative bile

leakage. Total amount of drain production during the first three postoperative days and the duration

of drainage did also not differ between the two groups.

There were no differences in microbiology-confirmed intra-abdominal infections in the fibrin sealant

group and control group (11.5% vs. 10.4%, P value =0.76). There were no side effects reported of the

application of fibrin sealant, such as air-embolism or allergic reactions.

The incidence and severity of general postoperative complications, graded according to the Clavien-

Dindo classification, was not different in both groups.(Table 4) Mortality was slightly higher in the

sealant group, but this was not statistically significant. In none of the patients who died, the cause

of death could be related to the use of fibrin sealant.

Table 3. Drain Fluid Analysis, According to the Study Group

Variable Fibrin Sealant (n=106) Control(n=106) P Value

Mean drain volume at day 1 to 3 - ml/day median (IQR) 105 (50-275) 138 (38-274) 0.96

Hemoglobin at day 1 - mmol/l* median (IQR) 0.4 (0.2-0.5) 0.4 (0.2-1.1) 0.10

Bilirubin at day 1 - µmol/l median (IQR) 15 (12-22)) 24 (14-53) 0.01

Duration drainage - days median (IQR) 5 (3-9) 6 (3-8) 0.58

* To convert values for hemoglobin to g/dl, multiply by 1.650. To convert values for bilirubin to mg/dl, divide by 88.4. IQR

denotes interquartile range.

64

Chapter 5

DISCUSSION

Contrary to the initial expectations, we found that prophylactic application of fibrin sealant at the

dry resection surface of the remnant liver does not lead to a reduction in the incidence or severity of

resection surface-related complications after liver resection. We found no significant differences in

the incidence of postoperative bile leakage, bleeding, or abscess formation in patients treated with

or without fibrin sealant. In addition, there were no significant differences in overall postoperative

morbidity or mortality. In general, the rate of resection surface-related complications, as well as

overall morbidity and mortality were comparable to what has been reported in recent literature.4,5,6,12

In liver surgery, fibrin sealants have been registered as adjuncts to stimulate hemostasis.10,13,15-17

Some studies have suggested that fibrin sealant may also reduce the incidence of postoperative bile

leakage,11,14 although this could not be confirmed by others.12,13 All previous studies, however, were

Table 4. Characteristics of Postoperative General Complications, According to the Study Group

Variable Fibrin Sealant

(n=156)Control (n=154) P Value

Overall postoperative complications according to Clavien-Dindo – highest grade per patient - no. (%)* 0.14

No complications 74 (47) 65 (42)

Grade 1 8 (5) 16 (10)

Grade 2 40 (26) 49 (32)

Grade 3 22 (14) 17 (11)

Grade 4 6 (4) 6 (4)

Grade 5 6 (4) 1 (1)

Specific general complications - no. (%)

Postoperative transfusion 26 (17) 22 (14) 0.64

Pleural effusion (>250ml on CT volumetry) 30 (20) 22 (14) 0.17

Pneumonia 12 (8) 8 (5) 0.49

Urinary tract infection 10 (6) 12 (8) 0.67

Wound infection 13 (8) 10 (7) 0.67

Ascites infection 3 (2) 5 (3) 0.50

Liver insufficiency 9 (6) 4 (3) 0.26

Renal insufficiency 4 (3) 5 (3) 0.75

Pulmonary embolism 0 (0) 5 (3) 0.03

Deep venous thrombosis 0 (0) 1 (1) 0.50

Portal vein thrombosis 1 (1) 1 (1) 1.00

Cerebrovascular accident 1 (1) 1 (1) 1.00

Myocardial infarction 0 (0) 1 (1) 0.50

Mortality - no. (%)

In-hospital mortality 5 (3.2) 1 (0.6) 0.21

30-day mortality 6 (3.8) 1 (0.6) 0.12

Intra-operative mortality 0 0

* Grading complications according to Clavien-Dindo classification.22,23

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5

primarily designed to study the intraoperative hemostatic efficacy and the effect on postoperative

bile leakage was never studied as primary endpoint. In addition, most previous studies were of poor

methodological quality or underpowered. In one well-designed, single center study, including 300

patients, postoperative complications were the main outcome parameter.12 Primary objective in this

study was to determine whether fibrin sealant could decrease postoperative bleeding and blood

transfusion. The secondary objective addressed other complications, such as bile leakage and intra-

abdominal abscesses. Although another type of fibrin sealant was used in this study, it also did not

show any reduction in resection surface-related complications.12

Because it was not our aim to study the efficacy of fibrin sealant in obtaining intraoperative

hemostasis, we only randomized patients after complete hemo- and biliostasis was obtained by

traditional surgical methods such as suturing and coagulation. This allowed us to specifically study

the efficacy of the prophylactic use of fibrin sealant in reducing postoperative complications. Only

17 patients (5.2%) would not be included because hemostasis could not be obtained without a

fibrin sealant. This indicates that local hemostatic agents are needed in only a minority of patients

and our data do not contradict their efficacy in obtaining hemostasis. Today, however, many

surgeons are using fibrin sealants prophylactically, assuming that they may reduce postoperative

complications.11,19,20 The results of our study indicate that the prophylactic use of fibrin sealants is

not justified and only leads to increased costs.

One may argue the expected 50% reduction in complications required in this sample size calculation.

While a smaller difference of 30% might not be detected by this sample size, we deliberately chose

a higher percentage for two reasons. A reduction of 50% (from 15% to 7,5 %) complications was

considered clinically relevant, as opposed to, for example, a 30% reduction (from 15% to 10%)

that would be less relevant considering the high costs of fibrin sealants and the higher number of

patients needed to treat to obtain a benefit (from 13 to 20). Another argument was the high number

of patients required to detect a smaller difference.5 Randomization of around 3 times more patients

would have been impractical. While we did not show any difference at all between groups we do

not think that the results would have been any different when a larger sample size was selected.

An important aspect of this study was the objective assessment of fluid collections at the resection

surface using a CT-scan. While one may argue that fluid collections detected by CT-scan are not

always clinically relevant, this did provide us the most objective tool to assess the main endpoint.

Importantly, the results of this study did not change when only symptomatic outcome parameters,

including reinterventions or medication for resection surface-related complications, were compared.

Despite the lack of any clinically relevant difference in complications, we did find a statistically

significant lower bilirubin concentration in drain fluid at postoperative day 1 in the fibrin sealant

group, compared to controls. This suggests that there may be a minor effect of fibrin sealant that

is short lasting and does not result in an overall clinically relevant reduction of resection surface-

related complications.

We intentionally did not standardize the surgical technique for parenchymal transection. Today,

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Chapter 5

various surgical techniques are used in liver surgery and even within one patient surgeons may

switch between techniques. The current study, therefore, reflects everyday surgical practice,

allowing extrapolation and generalization of the results. The multicenter setting of this study adds

to the generalisability of the results.

The results of this study are unambiguous, but they are opposite from what we initially expected.

Application of a layer of fibrin gel to the liver resection surface seemed a logical method to reduce

resection surface-related complications and the question remains why fibrin sealants are not

effective in reducing bile leakage from the liver surface? An answer to this question may be derived

from a recent in vitro study in which the effect of bile on stability of fibrin clots was examined.24

Human bile was shown to contain a significant amount of tissue-type plasminogen activator,

which contributes to the premature lysis of fibrin clots. Addition of a high dose of plasminogen

activator inhibitor-1 did not attenuate the fibrinolytic activity, raising the possibility that tissue-type

plasminogen activator in bile is resistant to plasminogen activator inhibitor-1 inhibition. This was

not different for fibrin sealants with or without an antifibrinolytic agent.24

The results of this study have clinical and financial implications. Fibrin sealants are increasingly used

in surgical practice and global sales are rising annually.18 Surveys in the Netherlands and Japan have

shown that fibrin sealants are used in the vast majority of patients undergoing liver resection.19,21 In

the U.S. more than 14,000 liver resections for colorectal liver metastases are performed annualy.25-27

Based on the average costs per application of fibrin sealant of 400 US dollars and the assumption

that, similar to Japan and the Netherlands, fibrin sealants are used in 80% of the cases, the estimated

annual costs for fibrin sealants in liver surgery in the U.S are 4.5 million dollars. Abrogation of the

routine use of fibrin sealants in liver surgery, therefore, would lead to a significant reduction of

procedure-related costs.

A limitation of this study is that we examined the efficacy of only one fibrin sealant. Based on the

minor differences in composition of the commercially available fibrin sealants, however, it is not

likely that outcome would have been different with another fibrin sealant. Nevertheless, we did not

compare the efficacy of this fibrin sealant with the newer, so called carrier-bound fibrin sealants,

consisting of a solid matrix (e.g. collagen fleece) with an active component consisting of thrombin

and fibrinogen.9,13,28 Other well-powered studies will be needed to determine whether these carrier-

bound fibrin sealants are more effective.

In conclusion, our multicenter trial shows that the prophylactic application of fibrin sealant at

the resection surface of the remnant liver after liver resection does not lead to a reduction in the

incidence or severity of postoperative bile leakage or other resection surface related complications.

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5

ACKNOWLEDGEMENT

This study was supported by the Fund for Medical Technology Assessment of the University Medical

Center Groningen and by Johnson & Johnson Medical.

The study protocol was approved by and the study was conducted under auspices of the Dutch

Study Group for Liver Surgery (Nederlandse Werkgroep Leverchirurgie)

APPENDIX

In addition to the authors, the following investigators participated in this study (all institutions are

in the Netherlands): University Medical Center Groningen, Groningen – P.M.J.G. Peeters, K.P. de Jong,

E. Sieders, M.J.H. Slooff, P. Kele; Medisch Spectrum Twente, Enschede – J.J.G.M. Gerritsen, J. Mulder,

A. Stam; Erasmus Medical Center, Daniel den Hoed Hospital, Rotterdam – N. Ayez, A. van der Pool;

Maastricht University Medical Center, Maastricht – M.H.A. Bemelmans, S.W.A.G. Dello; Academic

Medical Center, Amsterdam – O.R.C. Busch; N. van de Esschert, M. Bieze; University Medical Center

Utrecht, Utrecht – R. van Hillegersberg.

Protocol Writing Committee – M.T. de Boer, R.J. Porte, E.J. van der Jagt; Adjudication Committee – M.T.

de Boer, R.J. Porte, P. Kele, E.J. van der Jagt; Statistical Analysis – Y. van Leeuwen, M.T. de Boer, R.J.

Porte; Central Data Collection – M.T. de Boer, J.T. Bottema, I.T.A. Pereboom, E. Boonstra.

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Chapter 5

REFERENCES

1. Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397-406.

2. Nagano Y, Togo S, Tanaka K, et al. Risk factors and management of bile leakage after hepatic resection. World J Surg 2003;27:695-698.


4. Reed DN,Jr, Vitale GC, Wrightson WR, Edwards M, McMasters K. Decreasing mortality of bile leaks after elective hepatic surgery. Am J Surg 2003;185:316-318.

5. van den Broek MA, van Dam RM, Malago M, Dejong CH, van Breukelen GJ, Olde Damink SW. Feasibility of randomized controlled trials in liver surgery using surgery-related mortality or morbidity as endpoint. Br J Surg 2009;96:1005-1014.

6. Lo CM, Fan ST, Liu CL, Lai EC, Wong J. Biliary complications after hepatic resection: risk factors, management, and outcome. Arch Surg 1998;133:156-161.

7. Tsao JI, Loftus JP, Nagorney DM, Adson MA, Ilstrup DM. Trends in morbidity and mortality of hepatic resection for malignancy. A matched comparative analysis. Ann Surg 1994;220:199-205.

8. Albala DM. Fibrin sealants in clinical practice. Cardiovasc Surg 2003;11(Suppl1):5-11.

9. Briceno J, Naranjo A, Ciria R, et al. A prospective study of the efficacy of clinical application of a new carrier-bound fibrin sealant after liver resection. Arch Surg 2010;145:482-488.

10. Chapman WC, Clavien PA, Fung J, Khanna A, Bonham A. Effective control of hepatic bleeding with a novel collagen-based composite combined with autologous plasma: results of a randomized controlled trial. Arch Surg 2000;135:1200-1204.

11. Eder F, Meyer F, Nestler G, Halloul Z, Lippert H. Sealing of the hepatic resection area using fibrin glue reduces significant amount of postoperative drain fluid. World J Gastroenterol 2005;11:5984-5987.

12. Figueras J, Llado L, Miro M, et al. Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients. Ann Surg 2007;245:536-542.

13. Frilling A, Stavrou GA, Mischinger HJ, et al. Effectiveness of a new carrier-bound fibrin sealant versus argon beamer as haemostatic agent during liver resection: a randomised prospective trial. Langenbecks Arch Surg 2005;390:114-120.


15. Kohno H, Nagasue N, Chang YC, Taniura H, Yamanoi A, Nakamura T. Comparison of topical hemostatic agents in elective hepatic resection: a clinical prospective randomized trial. World J Surg 1992;16:966-969.

16. Noun R, Elias D, Balladur P, et al. Fibrin glue effectiveness and tolerance after elective liver resection: a randomized trial. Hepatogastroenterology 1996;43:221-224.

17. Schwartz M, Madariaga J, Hirose R, et al. Comparison of a new fibrin sealant with standard topical hemostatic agents. Arch Surg 2004;139:1148-1154.

18. Worldwide surgical sealants, glues & wound closure,from MedMarkets Report #S145. Available at: http://mediligence.com/blog/2008/02/11/wound-sealant. Accessed August 29, 2011.

19. Boonstra EA, Molenaar IQ, Porte RJ, de Boer MT. Topical haemostatic agents in liver surgery: do we need them? HPB 2009;11:306-310.

20. Ijichi M, Takayama T, Toyoda H, Sano K, Kubota K, Makuuchi M. Randomized trial of the usefulness of a bile

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leakage test during hepatic resection. Arch Surg 2000;135:1395-1400.

21. Nakajima Y, Shimamura T, Kamiyama T, Matsushita M, Sato N, Todo S. Control of intraoperative bleeding during liver resection: analysis of a questionnaire sent to 231 Japanese hospitals. Surg Today 2002;32:48-52.

22. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213.

23. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187-196.

24. Boonstra EA, Adelmeijer J, Verkade HJ, de Boer MT, Porte RJ, Lisman T. Fibrinolytic proteins in human bile accelerate lysis of plasma clots and induce breakdown of fibrin sealants. Ann Surg 2012;29:54-61.

25. Fong Y, Cohen AM, Fortner JG, et al. Liver resection for colorectal metastases. J Clin Oncol 1997;15:938-946.

26. Kemeny N, Jarnagin W, Gonen M, et al. Phase I/II study of hepatic arterial therapy with floxuridine and dexamethasone in combination with intravenous irinotecan as adjuvant treatment after resection of hepatic metastases from colorectal cancer. J Clin Oncol 2003;21:3303-3309.

27. Bentrem DJ, Dematteo RP, Blumgart LH. Surgical therapy for metastatic disease to the liver. Annu Rev Med 2005;56:139-156.

28. Toti L, Attia M, Manzia TM, et al. Reduction in bile leaks following adult split liver transplant using a fibrin-collagen sponge: A pilot study. Dig Liver Dis 2010;42:205-209.

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Part II. Studies in Liver Transplantation

71

Part II. Studies in Liver Transplantation

72

73

Minimizing blood loss in liver transplantation: progress through research and evolution of

techniquesMarieke T. de Boer

I. Quintus Molenaar

Herman G.D. Hendriks

Maarten J.H. Slooff

Robert J. Porte


6

74

Chapter 6

ABSTRACT

Blood loss during liver transplantation has long been recognized as an important cause of

morbidity and, especially in the early days, also mortality. It is well known that blood transfusions

are associated with an increased risk of postoperative complications, such as infections, pulmonary

complications, protracted recovery, and a higher rate of reoperations. Many studies have been

performed during the past decades to elucidate the mechanisms of increased blood loss in

liver transplantation. In the late 1980s, primary hyperfibrinolysis was identified as an important

mechanism of bleeding during liver transplantation. This has provided the scientific basis for the

use of antifibrinolytic drugs in liver transplant recipients. Several randomized, controlled studies

have shown the efficacy of these compounds in reducing blood loss and transfusion requirements

during liver transplantation. In addition, increasing experience and improvements in surgical

technique, anesthesiological care and better graft preservation methods have contributed to

a steady decrease in blood transfusion requirements in most liver transplant programs. Several

centers are now reporting liver transplantation without any need for blood transfusion in up to

30% of their patients. Despite these improvements, most patients undergoing liver transplantation

still require blood transfusions that have a negative impact on outcome, emphasizing the need

for further attempts to control blood loss by surgeons and anesthesiologists. This paper provides

an overview of the clinical and research developments, which have contributed to a reduction

in blood loss and transfusion requirements, resulting in an important reduction in morbidity and

mortality after liver transplantation during the last two decades.

75

Minimizing blood loss in liver transplantation

6

INTRODUCTION

Liver transplantation is an accepted treatment for end-stage chronic liver disease, fulminant hepatic

failure, irresectable primary liver tumors and various metabolic disorders. One-year patient survival

after liver transplantation is about 80-90% and long-term survival is around 70%.1 Currently, more

than 10,000 liver transplantations are performed each year in Europe and North America. The first

human liver transplantation was reported by Starzl et al.2 in 1963. Unfortunately, this first patient

died of exsanguination during the procedure, exemplifying what would become one of the most

important barriers in liver transplantation in the following years. Many hurdles towards successful

liver transplantation have been overcome since then and the number of liver transplantations has

increased progressively during the last four decades. The introduction of cyclosporine in the early

1980s was a major step forward in the reduction of acute rejection as a cause of graft loss. The

development of the University of Wisconsin preservation solution in the late 1980s reduced graft

preservation injury and allowed longer cold ischemia times.3 In parallel with these innovations,

surgical techniques have evolved, resulting in a more standardized and less blood consuming

procedure. Liver transplantation has changed from an emergency procedure with an unpredictable

outcome, to a semi-elective, better controlled procedure, with a high likelihood of success.

Until the mid 1980s, liver transplantation was accompanied by high morbidity and mortality rates,

frequently related to high intraoperative blood loss and transfusion requirements.4,5 During the

past 15 years, a steady decrease in blood loss and transfusion requirements has been observed

in most experienced centers.(Figure 1) The explanation for this is multifactorial. Extensive research

Figure 1. Red blood cell transfusion requirement in adult patients undergoing a first orthotopic liver transplantation at the University Medical Center Groningen between 1989 and 2003. Data presented as box plots, representing median, interquartile range, and 5–95% range (updated from Porte et al.11)

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Chapter 6

on perioperative changes in coagulation and fibrinolysis has improved the understanding of

the hemostatic disorders that are associated with liver transplantation.6-8 Based on this, new

pharmacological strategies have been developed to correct hemostatic abnormalities and reduce

blood loss.6-8 In addition, improvements in surgical technique, anesthesiological care, as well as organ

preservation have contributed to a steady reduction of transfusion requirements.9 The number of

patients without any need for blood transfusion has increased in recent years.10,11 (Figure 2)

This paper provides an overview of the clinical and research developments in the field of hemostasis,

as well as surgical technique and anesthesiological care, which have contributed to the impressive

reduction in blood loss and transfusion requirements, contributing to an important reduction in

morbidity and mortality after liver transplantation during the last two decades

Figure 2. Percentage of adult patients, undergoing a first orthotopic liver transplantation at the University Medical Center Groningen in the period 1992--2003, who did not require intraoperative, allogenic red blood cell transfusion (updated from Porte et al.11).

Impact of blood loss and transfusion requirements on outcome

It is well known that blood transfusions have an immunosuppressive effect and are associated

with the induction of several complications, such as pulmonary edema.12 This may account for the

negative correlation between the amount of intraoperative blood transfusion and postoperative

outcome, as has been described by several groups.9,13,14 Even today, in centers with median red

blood cell transfusion requirements of 2-3 units in adult patients, a significant correlation between

intraoperative blood transfusion requirement and postoperative infection rate and morbidity

can still be found.9,14 In parallel with this, we have observed an association between long-term

patient survival rates and the number of intraoperative red blood cell transfusions during adult

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6

liver transplantation. Also in pediatric patients, increased blood loss is a significant independent

negative predictor of long-term actual patient survival,15 probably caused by a higher incidence

of reinterventions and septic complications in this group of patients.13,16 In a recent analysis of 231

consecutive adult liver transplantations transplanted in Groningen, intraoperative blood loss was

found to be the main determinant of early surgical reinterventions after liver transplantation.17

Independent risk factors for blood transfusion, identified by multivariate analyses, are kidney

function, preoperative hematocrit, preoperative medical condition (Child-Pugh classification,

United Network of Organ Sharing Classification), year of transplantation, cold ischemia time of

the donor liver, and variables related to the surgical technique.9,10,18 In addition to these factors,

specific pre- and intraoperative disturbances in the hemostatic system may occur in liver transplant

recipients, contributing to a high bleeding tendency in these patients.6,7

Hemostatic disorders in liver transplantation

Extensive research in the field of hemostasis has led to a marked development of this part of

medicine during the last 20 years. Specific hemostatic disorders responsible for non-surgical blood

loss during liver transplantation, like primary hyperfibrinolysis, have been identified.6,7,19 Hemostatic

disorders in liver transplant patients are primarily caused by the underlying liver disease. During the

transplant procedure, depending on the stage of operation, these preexisting disorders may worsen

and new hemostatic disorders are superimposed.

Preoperative hemostatic dysfunction

The liver plays a central role in the hemostatic system and liver failure may lead to dysfunction of

several components of normal hemostasis.(Table 1) The liver produces and regulates several proteins

of the coagulation and fibrinolysis cascades.20 In the normal situation these two proteolytic cascades

are in a delicate balance. Activation of the coagulation system is evoked by vessel injury, which leads

to aggregation and activation of platelets by components of the exposed subendothelium and

subsequent formation of a primary hemostatic platelet plug. This plug is subsequently stabilized by

fibrin formation. Fibrinolysis, a more slow-acting process, is responsible for removal of fibrin clots

once the integrity of the vessel wall has been restored.(Figure 3) The reticuloendothelial system

Table 1. Processes contributing to hemostatic disorders in liver disease

- Reduced synthesis of coagulation and fibrinolysis factors and their inhibitors

- Presence of qualitative abnormal coagulation factors

- Thrombocytopenia and platelet dysfunction

- Increased fibrinolytic activity

- Influence of red cells and hemolysis

- Loss of hemostatic factors in enlarged extravascular space

- Portal hypertension with reduced hepatic perfusion, shunt circulation, and sequestration of platelets in the enlarged spleen

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of the liver contributes to the clearance of hemostasis factors and their degradation products. In

chronic liver disease, dysfunctioning synthesis and clearance of hemostatic factors can lead to

poor hemostasis.6,20 Consequently, intraoperative changes in hemostasis and blood loss during

liver transplantation are strongly related to the severity of the liver disease.6,19 In addition to this,

hypersplenism secondary to portal hypertension is responsible for the decreased number of

circulating platelets, contributing to the hemostatic dysfunction.

Intraoperative hemostatic dysfunction

Figure 3. Schematic presentation of the balance between coagulation and fibrinolysis, and the levels at which antifibrinolytic drugs interfere with the fibrinolytic system (––– = activation, - - - = inhibition). EACA = ε-Aminocaproic acid; TAC = tranexamic acid; KIU = kallikrein inhibiting units; HMWK = high-molecular-weight kininogen; t-PA = tissue plasminogen activator; FDPs = fibrin degradation products.

Hyperfibrinolysis. When discussing changes in hemostasis during liver transplantation, it is important

to keep the three stages of the surgical procedure in mind. The first stage is the preanhepatic stage,

during which the host liver is removed, ending with the occlusion of the native liver blood flow.

Blood loss during this stage merely reflects the preoperative condition depending on the etiology

and severity of liver disease and the experience of the surgeon.19,21 Serious changes in coagulation

and fibrinolytic activity are usually not found in this stage of the operation.19,21 The second stage is

the anhepatic stage, which begins with the vascular exclusion of the native liver and continues until

the donor liver is reperfused. In this stage, hepatic synthesis and clearance is absent. In this stage

there are not many surgical dissections and the major abdominal vessels are clamped off. Therefore,

blood loss during this stage of the operation originates mainly from hemostatic defects. Diffuse

blood loss may occur in previously dry surgical fields. Hyperfibrinolysis, the most striking hemostatic

disorder in liver transplantation, may develop during this stage.19,22 Hyperfibrinolysis is caused by

a rise in plasma levels of tissue-plasminogen activator (t-PA), the most important endogenous

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6

activator of plasminogen.22 Plasminogen activators stimulate the conversion of plasminogen into

plasmin, which is the active enzyme that degrades fibrin into fibrin degradation products. Plasma

t-PA activity increases rapidly during the anhepatic and early post-reperfusion stage, the third stage

of the operation.(Figure 4) The increase in t-PA is believed to be caused by a lack of hepatic clearance

during the anhepatic period and the release of t-PA from the ischemically injured endothelium

of the donor liver at the time of reperfusion.22,23 Elevation of t-PA results in the consumption of

Figure 4. Intraoperative levels of t-PA activity (mean ± SEM) in 20 patients undergoing liver transplantation. Timepoints represent: (1) induction of anesthesia, (2) 30 min before anhepatic stage, (3) 10 min after start anhepatic stage, (4) 5 min before reperfusion, (5--9) 5, 30, 60, 150 and 270 min after reperfusion, respectively (redrawn from Porte et al.22).

the naturally occurring inhibitor, plasminogen activator inhibitor-1, causing imbalance in the

fibrinolysis cascade and premature breakdown of hemostatic clots. Usually, t-PA activity normalizes

during the late post-reperfusion stage, which has been explained by the restoration of the normal

hepatic clearance of t-PA after the implantation of a viable donor liver.22,23 Increase of the inhibitor,

plasminogen activator inhibitor-1, towards the end of the operation also contributes to a decline

in t-PA activity.(Figure 4) Although it is not fully understood why some patients develop high t-PA

plasma levels, whereas others do not, hyperfibrinolysis in liver transplant recipients is considered to

be of primary origin and not secondary to intravascular thrombosis.6,24 This knowledge has provided

the basis for interventional studies using antifibrinolytic drugs (see below).

Thrombocytopenia and platelet dysfunction

Platelet count often decreases during liver transplantation, especially after graft recirculation,

contributing to an increased bleeding tendency.25 Postoperatively, platelet count may continue to

decline further, usually reaching a nadir on postoperative day 2 or 3, after which it slowly recovers

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Chapter 6

towards normal values.26 In addition, changes in platelet function, as reflected by a transient

prolongation of bleeding time and abnormal platelet function studies, have been found in both

clinical and experimental studies.27,28

Experimental studies have suggested a role for the transplanted liver in the origin of

thrombocytopenia.25,26 Platelets sequestrate in the sinusoids of the donor liver upon reperfusion.26,29

Simultaneous measurements of platelet count in the arterial inflow and venous outflow showed a

reduction of 55% in the platelet count in reperfused grafts.26 The degree of platelet loss has been

shown to be related to the severity of ischemia/reperfusion injury of the liver.28-30 Intrahepatic platelet

sequestration in the sinusoids, local thrombin formation on the damaged graft endothelium, platelet

extravasation in the spaces of Disse, and increased platelet phagocytosis by Kupffer cells have all

been hypothesized as an explanation for thrombocytopenia.25,26 Electron microscopic studies,

however, have showed most platelets lying free in the sinusoids, although many of them having

lost their granules.26,29 Platelet aggregates, as a result of coagulation, are rarely seen. Therefore, the

sequestration of platelets inside the reperfused liver is most likely independent from the activation

of coagulation. Experimental studies using isolated perfused rat livers have demonstrated that

platelets stick to the sinusoidal endothelial cells and contribute to ischemia/reperfusion injury of

the liver by the induction of apoptotic cell death of endothelial cells. 29,30 Adhesion molecules of the

selectin family play a critical role in this interaction between platelets and endothelial cells inside

the liver. Based on these observations, it is currently advised to avoid platelet transfusions in liver

transplant recipients, especially after reperfusion of the graft.29,30

Heparin(-like) activity

A heparin-like effect can be seen after graft reperfusion and may contribute to coagulopathy. This

effect has been explained by the release of heparin from the donor liver after heparinization of

the donor,24 or by release of endogenous heparin-like substances from the damaged ischemic graft

endothelium.31 This effect is generally short-lasting. However, some patients may have a greater

sensitivity to heparin and may not clear these substances adequately,32 supporting the use of

protamine sulfate when heparin activity is documented in the setting of increased blood loss.24

Humoral and metabolic factors

In general, metabolic acidosis, reduced cardiovascular performance, low ionized plasma calcium

and hypothermia can adversely affect the hemostatic system. All these changes can be observed

during liver transplantation and may play a role in the appearance of hemostatic disorders after graft

recirculation.6,7 Coinciding with the recovery of the above metabolic abnormalities about 30 min

after graft recirculation, improved blood coagulability has been observed by thromboelastography,

despite the lack of significant changes in coagulation factors.19

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Evolution of surgical techniques to minimize blood loss

Liver transplantation is a major surgical procedure and it is beyond doubt that surgical skills and

experience have an important impact on intraoperative blood loss during this procedure. Changes

in surgical technique have contributed to a reduction in blood loss during liver transplantation.

Venovenous bypass, introduced in the 1980s, allows decompression of the splanchnic and

retroperitoneal circulations, avoiding major hemodynamic changes during the anhepatic phase

of a ‘classical’ liver transplantation.33 Although never formally proven by a randomized controlled

trial, it has been suggested that venovenous bypass also results in a reduction of intraoperative

blood loss.33 Another important step forward has been the introduction of the so-called ‘piggyback’

technique.34,35 In contrast with the ‘classical’ technique of liver transplantation, in the piggyback

technique the retrohepatic inferior vena cava (IVC) is not removed together with the native liver.

The retrohepatic IVC of the donor liver is subsequently anastomosed in an end-to-end fashion to the

cuffs of the native hepatic veins or directly to the recipient IVC using a side-to-side or end-to-side

technique.(Figure 5) A major advantage of the piggyback technique is the avoidance of dissection

of the retroperitoneum in patients with portal hypertension and multiple venous collaterals

in this area. Moreover, the warm ischemia time during implantation of the graft is shorter in the

‘piggyback’ technique since only one cavo-caval anastomosis has to be made, compared to the

two end-to-end anastomoses of the IVC in the ‘classical’ technique.36 In a recent comparison of the

two techniques, we demonstrated significantly lower blood transfusion requirements in patients in

Figure 5. Cavo-cavostomy viewed from the left side of the patient in the ‘piggyback’ technique. The retrohepatic inferior vena cava of the donor liver is anastomosed to the recipient inferior vena cava using a side-to-side or end-to-side technique (drawing kindly provided by Balázs Nemes).

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whom the ‘piggyback’ technique was used, compared with patients transplanted using the ‘classical’

technique.36 Similar observations have been made by other groups.35

Evolution of anesthesiological management to improve hemostasis

Anesthesiological measures to reduce intraoperative blood loss focus on the monitoring and

correction of coagulation abnormalities. Massive bleeding is associated with severe problems,

such as citrate intoxication, low levels of ionized calcium, hyperkalemia, metabolic acidosis, and

hypothermia.37 Mostly, coagulation abnormalities are corrected by the administration of blood

components, such as fresh-frozen plasma, or fibrinogen concentrate and platelet concentrates. In

addition, pharmacological prohemostatic agents are used successfully in patients undergoing liver

transplantation, as will be discussed below. Coagulation abnormalities may become aggravated

by hypothermia or metabolic acidosis. Hypothermia occurs during long operations, especially

when large volumes are transfused without precautions. Decreased body core temperature is

linearly correlated with prolonged clotting times.38 Administering fluids at a temperature of 39°C

and active warming of the patient by heating blankets have shown to be effective measures to

avoid hypothermia.36 The mechanisms by which metabolic acidosis affects hemostasis are not fully

understood, but probably include inhibition of platelet function.39

Adequate monitoring of hemostasis is essential to detect coagulation abnormalities in time and to

evaluate the effects of therapy. Standard coagulation tests, such as activated partial thromboplastin

time, prothrombin time, and measurement of plasma fibrinogen levels only enable to screen for

deficiencies of one or more coagulation factors. These tests are performed in plasma samples at

37°C, neglecting the in vivo role of temperature and interactions with platelets and red blood cells

in clot formation. Results of these screening tests before and during operation have not shown a

very good correlation with the amount of blood loss during liver transplantation.13,40,41 In addition,

simple and reliable laboratory tests to quantify changes in fibrinolysis are not available. Therefore,

the use of thrombelastography has been advocated as a tool to monitor hemostasis during liver

transplantation. In thrombelastography whole blood is used. It provides a dynamic representation of

various aspects of clot formation as well as fibrinolysis. Thrombelastography can be used as a point-

of-care diagnostic test and results can usually be obtained within 30 min. Kang et al.19 were amongst

the first to use thrombelastography as a guide to blood product replacement and prohemostatic

drug therapy during liver transplantation.

With the wider application of the ‘piggyback’ technique, measures to maintain a low central venous

pressure (CVP) have become possible. The CVP is directly related to the hepatic vein pressure.

During liver resections there is an almost linear correlation between intraoperative blood loss and

the height of the CVP.42 Maintaining the CVP below 5 cm H2O, by reducing intravenous fluids, may

therefore help to minimize blood loss during explantation of the liver. When the ‘classical’ technique

is used, patients usually do not tolerate a low CVP when the IVC is clamped during the anhepatic

phase. However, with preservation of the retrohepatic IVC in the, nowadays more frequently used,

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‘piggyback’ technique the retrohepatic IVC can be clamped only partially with a side-biting clamp.

(Figure 5)

Blood loss during OLT can be corrected by allogeneic or autologous (cell saver) transfusion.

Although autotransfusion of blood is an attractive alternative to allogeneic blood transfusions,

we do not routinely use the cell saver in our liver transplant patients. The low amounts of blood

loss encountered in recent years did no longer allow a cost-effective use of the cell saver. Also, in

a retrospective study, we unexpectedly observed higher blood loss in patients when using the cell

saver.18 A possible explanation for this is that released fibrinolytic compounds from blood cells in the

collected blood are not washed out adequately by the cell saver. However, the exact mechanisms

remain unclear and further research in this area is warranted.

Pharmacological strategies to reduce blood loss

Although the cause of increased blood loss during liver transplantation is multifactorial, primary

hyperfibrinolysis has been identified as an important component of the hemostatic dysfunction

during this procedure.22,23 This has provided a scientific basis for the use of antifibrinolytic drugs, in

an attempt to restore the balance between coagulation and fibrinolysis and to reduce blood loss.

Aprotinin

Aprotinin is a low-molecular-weight serine-protease inhibitor with potent antifibrinolytic activity.43

It is known as an inhibitor of several naturally occurring serine-proteases such as plasmin and

kallikrein.43 The estimated plasma concentrations of aprotinin required to inhibit the different

serine-proteases differ from 50 kallikrein inhibiting units (KIU)/mL for plasmin to approximately 200

KIU/mL for kallikrein.43 Aprotinin may therefore reduce fibrinolytic activity and thus blood loss, not

only by direct inhibition of plasmin but, at higher concentration, also by inhibition of the kallikrein

pathway, hereby reducing the formation of t-PA.(Figure 3) The use of aprotinin in liver transplant

recipients was first described by Neuhaus et al.44 in 1989. These investigators observed a reduction

of blood loss and transfusion requirements of 35 and 50%, respectively, in 10 patients undergoing

liver transplantation, compared to historical controls. Several studies on the use of aprotinin in liver

transplantation have been performed since then.45-48 However, in most of these studies retrospective

control groups were used or the studies were too small to draw definite conclusions. A beneficial

effect of increased surgical experience or a statistical type II error could therefore not be excluded

and the efficacy of aprotinin in liver transplantation initially remained debated.49,50 More recently,

the efficacy of aprotinin in reducing blood transfusion requirements during liver transplantation

has been proven by well-designed, placebo-controlled, randomized, controlled trials.51-53 These

prospective studies have shown that the prophylactic use of aprotinin reduces blood transfusion

requirements in liver transplant recipients by about 30%.51,52,54 In addition to this, aprotinin has

potent anti-inflammatory properties which may explain the improved hemodynamic stability,

lower plasma levels of interleukin-6, and better outcome in patients who have received aprotinin,

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compared to placebo.11,55-58 No increased risk of thromboembolic complications has been shown in

any of the randomized controlled trials. We even found a small antithrombotic effect in an analysis

of the effect of aprotinin on coagulation and fibrinolysis in liver transplantation.59,60

ε-Aminocaproic acid and tranexamic acid

The synthetic antifibrinolytics ε-aminocaproic acid (EACA) and tranexamic acid were developed in

the early 1960s. The antifibrinolytic activity of these lysine analogues is caused by a competitive

inhibition of the binding of plasminogen to fibrin. By blocking access to fibrin, these drugs

substantially decrease the degradation of these fibrin clots. Tranexamic acid is seven times more

potent and has a longer half-life than EACA. In one double-blind, randomized, placebo-controlled

study, high-dose tranexamic acid was shown to be effective in reducing blood loss and transfusion

requirements during liver transplantation by 46 and 31%, respectively, when compared with

placebo.61 In another study, a small dose of tranexamic acid was shown to adequately inhibit

fibrinolysis, but no effect on transfusion requirements could be found.62 The number of patients in

this study however was very small (16 patients in each group) and, therefore, definitive conclusions

could not be drawn.

The use of EACA in liver transplant patients has been studied in only one randomized, controlled

study.63 In this study, where patients were randomized to receive EACA, tranexamic acid or placebo,

no differences in blood transfusion requirement were found between the EACA and placebo group.

However, in accordance with the other study described above, mean intraoperative red blood cell

requirement was 36% lower in the tranexamic acid group, compared with placebo.

A head-to-head comparison between aprotinin and tranexamic acid has been performed in only

one randomized, controlled trial.53 Interestingly, this study did not reveal any difference in blood

transfusion requirements between aprotinin and tranexamic acid-treated patients, suggesting

equal effectiveness of these two drugs. It remains to be established whether the potent anti-

inflammatory activities of aprotinin in addition to its antifibrinolytic activity make this drug more

preferable to tranexamic acid.

Recombinant factor VIIa

In recent years, the efficacy and safety of recombinant factor VIIa (rFVIIa) has been investigated

during liver transplantation. rFVIIa has been shown to be effective in a variety of hemostatic

disorders.8 FVIIa binds to tissue factor at the site of vascular injury and plays a central role in the

activation of coagulation. In a pilot study of 6 patients treated with a single dose of rFVIIa at the

beginning of liver transplantation, we have observed a significant reduction in blood transfusion

requirements, compared to a matched historical control group.64,65 Two large, placebo-controlled,

multicenter trials to study the efficacy and safety of rFVIIa in liver transplant recipients have

recently been completed. In the first multicenter trial, reported by Planinsic et al.66, 82 patients

were randomized to receive placebo, 20, 40, or 80 μg/kg rFVIIa as a single dose at the start of the

procedure. Although the use of a single dose regimen was in line with our initial pilot study,63 the

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6

positive effect on perioperative RBC transfusion requirements observed in the pilot study could

not be reproduced in the multicenter trial. As regards safety, there were no significant differences

in thromboembolic complications among the four groups in the multicenter study. In the second

multicenter trial reported by Lodge et al.67, 183 patients were randomized to receive placebo, 80 or

120 μg/kg of rFVIIa and the doses were repeated every 2 h during the operation until 30 min before

graft reperfusion. In addition, an extra dose of rFVIIa was given at the end of surgery. Despite a more

sustained shortening of the prothrombin time and longer duration of detectable plasma levels of

FVIIa during the operation, this trial again did not result in a significant reduction of RBC transfusion

requirements in rFVIIa-treated patients compared to placebo. However, a small, but significant,

increase in the percentage of patients who did not require any RBC transfusions was found in favor

of the rFVIIa-treated patients. Although encouraging, the latter was not the primary endpoint of the

study.

At this moment it is questionable whether rFVIIa should be used as a prophylaxis in patients

undergoing liver transplantation outside the setting of prospective clinical trials.68 More work is

needed to define the possible role of this new drug with attention focused on its use as a therapeutic

(‘rescue’) agent rather than as a prophylactic agent.

CONCLUSIONS

In recent decades, blood loss and transfusion requirements in patients undergoing liver

transplantation have decreased significantly. Median red blood cell transfusion requirement in

adult patients undergoing a first liver transplant in our center has declined from around 20 units in

the late 1980s to 2 units in the year 2003. Nowadays, approximately one-third of all adult patients

undergoing a first liver transplant do not require any intraoperative transfusion of red blood cells.

Extensive clinical and experimental research has led to the identification of independent risk factors

for and mechanisms of increased blood loss in patients undergoing liver transplantation. Blood

loss in these patients has shown to be influenced by multiple factors, such as the preoperative

condition of the patient, surgical technique, organ preservation, hemostatic disorders occurring

during the operation, as well as anesthesiological care. Considerable progress has been made in

all of these fields, leading to this remarkable reduction in intraoperative blood loss and transfusion

requirements, contributing to improved outcome after liver transplantation.

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10 Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S, Concepcion W, So SK, Esquivel CO: Primary liver transplantation without transfusion of red blood cells. Surgery 1996;120:698-704.

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13 Mor E, Jennings L, Gonwa TA, Holman MJ, Gibbs J, Solomon H: The impact of operative bleeding on outcome in transplantation of the liver. Surg Gynecol Obstet 1993;176:219-227.

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15 Sieders E, Peeters PM, TenVergert EM, de Jong KP, Porte RJ, Zwaveling JH, Bijleveld CM, Slooff MJ: Prognostic factors for long-term actual patient survival after orthotopic liver transplantation in children. Transplantation 2000;70:1448-1453.

16 Peeters PM, ten Vergert EM, Bijleveld CM, Pisarski P, Verwer R, Slooff MJ: The influence of intraoperative blood loss on graft survival and morbidity after orthotopic liver transplantation in children. Pediatr Surg Int 1995;10:120-125.

17 Hendriks HG, van der Meer J, de Wolf JTM, Peeters PMJG, de Jong KP, Lip H, Post WJ, Slooff MJH: Intraoperative blood transfusion requirement is the main determinant of early surgical reintervention after orthotopic liver transplantation. Transpl Int 2005;17:673-679.

18 Hendriks HG, van der Meer J, Klompmaker IJ, Choudhury N, Hagenaars JA, Porte RJ, de Kam PJ, Slooff MJ, de Wolf JT: Blood loss in orthotopic liver transplantation: a retrospective analysis of transfusion requirements and the effects of autotransfusion of cell saver blood in 164 consecutive patients. Blood Coagul Fibrinolysis 2000;11:S87-S93.

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19 Kang YG, Martin DJ, Marquez J, Lewis JH, Bontempo FA, Shaw BW Jr, Starzl TE, Winter PM: Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985;64:888-896.

20 Brozovic M: Acquired disorders of coagulation; in Bloom AL, Thomas DP (eds): Haemostasis and Thrombosis. Edinburgh, Churchill Livingstone, 1987, pp 542-553.

21 Lewis JH, Bontempo FA, Awad SA, Kang YG, Kiss JE, Ragni MV, Spero JA, Starzl TE: Liver transplantation: intraoperative changes in coagulation factors in 100 first transplants. Hepatology 1989;9:710-714.

22 Porte RJ, Bontempo FA, Knot EA, Lewis JH, Kang YG, Starzl TE: Systemic effects of tissue plasminogen activator-associated fibrinolysis and its relation to thrombin generation in orthotopic liver transplantation. Transplantation 1989;47:978-984.

23 Dzik WH, Arkin CF, Jenkins RL, Stump DC: Fibrinolysis during liver transplantation in humans: role of tissue- type plasminogen activator. Blood 1988;71:1090-1095.

24 Bakker CM, Metselaar HJ, Gomes MJ, Porte RJ, Groenland TN, Schalm SW, Terpstra OT, Stibbe J: Intravascular coagulation in liver transplantation – Is it present or not? A comparison between orthotopic and heterotopic liver transplantation. Thromb Haemost 1993;69:25-28.

25 Hutchison DE, Genton E, Porter KA, Daloze PM, Huguet C, Brettschneider L, Groth CG, Starzl TE: Platelet changes following clinical and experimental hepatic homotransplantation. Arch Surg 1968;97:27-33.

26 Porte RJ, Blauw E, Knot EA, de Maat MP, de Ruiter C, Minke BC, Terpstra OT: Role of the donor liver in the origin of platelet disorders and hyperfibrinolysis in liver transplantation. J Hepatol 1994;21:592-600.

27 Schalm SW, Terpstra JL, Achterberg JR, Noordhoek Hegt V, Haverkate F, Popescu DT, Krom RA, Veltkamp JJ: Orthotopic liver transplantation: an experimental study on mechanisms of hemorrhagic diathesis and thrombosis. Surgery 1975;78:499-507.

28 Himmelreich G, Muser M, Neuhaus P, Bechstein WO, Slama KJ, Jochum M, Riess H: Different aprotinin applications influencing hemostatic changes in orthotopic liver transplantation. Transplantation 1992;53:132-136.

29 Sindram D, Porte RJ, Hoffman MR, Bentley RC, Clavien PA: Platelets induce sinusoidal endothelial cell apoptosis upon reperfusion of the cold ischemic rat liver. Gastroenterology 2000;118:183-191.

30 Sindram D, Porte RJ, Hoffman MR, Bentley RC, Clavien PA: Synergism between platelets and leukocytes in inducing endothelial cell apoptosis in the cold ischemic rat liver: a Kupffer cell-mediated injury. Faseb J 2001;15:1230-1232.

31 Kettner SC, Gonano C, Seebach F, Sitzwohl C, Acimovic S, Stark J, Schellongowski A, Blaicher A, Felfernig M, Zimpfer M: Endogenous heparin-like substances significantly impair coagulation in patients undergoing orthotopic liver transplantation. Anesth Analg 1998;86:691-695.

32 Harding SA, Mallett SV, Peachey TD, Cox DJ: Use of heparinase modified thrombelastography in liver transplantation. Br J Anaesth 1997;78:175-179.

33 Shaw BW Jr, Martin DJ, Marquez JM, Kang YG, Bugbee AC Jr, Iwatsuki S, Griffith BP, Hardesty RL, Bahnson HT, Starzl TE: Venous bypass in clinical liver transplantation. Ann Surg 1984;200:524-34.

34 Tzakis A, Todo S, Starzl TE: Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 1989;210:649-652.

35 Jovine E, Mazziotti A, Grazi GL, Ercolani G, Masetti M, Morganti M, Pierangeli F, Begliomini B, Mazzetti PG, Rossi R, Paladini R, Cavallari A: Piggy-back versus conventional technique in liver transplantation: report of a randomized trial. Transpl Int 1997;10:109-112.

36 Miyamoto S, Polak WG, Geuken E, Peeters PM, Jong KP, Porte RJ, Berg AP, Hendriks HG, Slooff MJ: Liver

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transplantation with preservation of the inferior vena cava. A comparison of conventional and piggyback techniques in adults. Clin Transplant 2004;18:686-693.

37 Hendriks HG: Transfusion requirements in orthotopic liver transplantation; Thesis, Groningen. ISBN 90–367–2015–X.

38 Reed RL 2nd, Bracey AW Jr, Hudson JD, Miller TA, Fischer RP: Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels. Circ Shock 1990;32:141-152.

39 Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA: Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg 1990;160:515-518.

40 Ritter D, Retke SR, Lunn RJ, Bowie EJ, Ilstrup D: Preoperative coagulation screen does not predict intraoperative blood product requirements in orthotopic liver transplantation. Transpl Proc 1989;21:3533-3534.

41 Reyle-Hahn M, Rossaint R: Coagulation techniques are not important in directing blood product transfusion during liver transplantation. Liver Transpl Surg 1997;3:659-663.

42 Jones RM, Moulton CE, Hardy KJ: Central venous pressure and its effect on blood loss during liver resection. Br J Surg 1998;85:1058-1060.

43 Royston D: High-dose aprotinin therapy: a review of the first five years’ experience. J Cardiothorac Vasc Anesth 1992;6:76-100.

44 Neuhaus P, Bechstein WO, Lefebre B, Blumhardt G, Slama K: Effect of aprotinin on intraoperative bleeding and fibrinolysis in liver transplantation. Lancet 1989;2:924-925.

45 Marcel RJ, Stegall WC, Suit CT, Arnold JC, Vera RL, Ramsay MA, O’Donnell MB, Swygert TH, Hein HA, Whitten CW: Continuous small-dose aprotinin controls fibrinolysis during orthotopic liver transplantation. Anesth Analg 1996;82:1122-1125.

46 Patrassi GM, Viero M, Sartori MT, De Silvestro G, Rossaro L, Burra P, Nolli ML, Piccinni P, Bassi N: Aprotinin efficacy on intraoperative bleeding and transfusion requirements in orthotopic liver transplantation. Transfusion 1994;34:507-511.

47 Groh J, Welte M, Azad SC, Anthuber M, Haller M, Kratzer MA: Does aprotinin really reduce blood loss in orthotopic liver transplantation? Semin Thromb Hemost 1993;19:306-308.

48 Mallett SV, Cox D, Burroughs AK, Rolles K: The intra-operative use of trasylol (aprotinin) in liver transplantation. Transpl Int 1991;4:227-230.

49 Garcia-Huete L, Domenech P, Sabate A, Martinez-Brotons F, Jaurrieta E, Figueras J: The prophylactic effect of aprotinin on intraoperative bleeding in liver transplantation: a randomized clinical study. Hepatology 1997;26:1143-1148.

50 Porte RJ, Molenaar IQ: Aprotinin in liver transplantation. Hepatology 1998;27:1169-1171.

51 Porte RJ, Molenaar IQ, Begliomini B, Groenland TH, Januszkiewicz A, Lindgren L, Palareti G, Hermans J, Terpstra OT: Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. Lancet 2000;355:1303-1309.

52 Findlay JY, Rettke SR, Ereth MH, Plevak DJ, Krom RA, Kufner RP: Aprotinin reduces red blood cell transfusion in orthotopic liver transplantation: a prospective, randomized, double-blind study. Liver Transpl 2001;7:802-807.

53 Dalmau A, Sabate A, Koo M, Bartolome C, Rafecas A, Figueras J, Jaurrieta E: The prophylactic use of tranexamic acid and aprotinin in orthotopic liver transplantation: a comparative study. Liver Transpl 2004;10:279-284.

54 Porte RJ, Slooff MJ: Aprotinin: safe and effective in all patients undergoing orthotopic liver transplantation?

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Liver Transpl 2001;7:808-810.

55 Molenaar IQ, Veldman M, Begliomini B, Groenland HN, Januszkiewicz A, Lindgren L, Metselaar HJ, Terpstra OT, Porte RJ: Improved early graft survival in patients receiving aprotinin during orthotopic liver transplantation. Transplant Proc 2001;33:1345-1346.

56 Molenaar IQ, Begliomini B, Martinelli G, Putter H, Terpstra OT, Porte RJ: Reduced need for vasopressors in patients receiving aprotinin during orthotopic liver transplantation. Anesthesiology 2001;94:433-438.

57 Molenaar IQ, Begliomini B, Grazi GL, Ringers J, Terpstra OT, Porte RJ: The effect of aprotinin on renal function in orthotopic liver transplantation. Transplantation 2001;71:247-252.

58 Kuyvenhoven JP, Molenaar IQ, Verspaget HW, Veldman MG, Palareti G, Legnani C, Moolenburgh SE, Terpstra OT, Lamers CB, van Hoek B, Porte RJ: Plasma MMP-2 and MMP-9 and their inhibitors TIMP-1 and TIMP-2 during human orthotopic liver transplantation. The effect of aprotinin and the relation to ischemia/reperfusion injury. Thromb Haemost 2004;91:506-513.

59 Molenaar IQ, Porte RJ: Aprotinin and thromboembolism in liver transplantation: is there really a causal effect? Anesth Analg 2002;94:1367-1368.

60 Molenaar IQ, Legnani C, Groenland TH, Palareti G, Begliomini B, Terpstra OT, Porte RJ: Aprotinin in orthotopic liver transplantation: evidence for a prohemostatic, but not a prothrombotic, effect. Liver Transpl 2001;7:896-903.

61 Boylan JF, Klinck JR, Sandler AN, Arellano R, Greig PD, Nierenberg H, Roger SL, Glynn MF: Tranexamic acid reduces blood loss, transfusion requirements, and coagulation factor use in primary orthotopic liver transplantation. Anesthesiology 1996;85:1043-1048.

62 Kaspar M, Ramsay MA, Nguyen AT, Cogswell M, Hurst G, Ramsay KJ: Continuous small-dose tranexamic acid reduces fibrinolysis but not transfusion requirements during orthotopic liver transplantation. Anesth Analg 1997;85:281-285.

63 Dalmau A, Sabate A, Acosta F, Garcia-Huete L, Koo M, Sansano T, Rafecas A, Figueras J, Jaurrieta E, Parrilla P: Tranexamic acid reduces red cell transfusion better than ε-aminocaproic acid or placebo in liver transplantation. Anesth Analg 2000;91:29-34.

64 Hendriks HG, Meijer K, de Wolf JT, Klompmaker IJ, Porte RJ, de Kam PJ, Hagenaars AJ, Melsen T, Slooff MJ, van der Meer J: Reduced transfusion requirements by recombinant factor VIIa in orthotopic liver transplantation: a pilot study. Transplantation 2001;71:402-405.

65 Hendriks HG, Meijer K, de Wolf JT, Porte RJ, Klompmaker IJ, Lip H, Slooff MJ, van der Meer J: Effects of recombinant activated factor VII on coagulation measured by thromboelastography in liver transplantation. Blood Coagul Fibrinolysis 2002;13:309-313.

66 Planinsic RM, van der Meer J, Testa G, Grande L, Candela A, Porte RJ, Ghobrial RM, Isoniemi H, Schelde PB, Erhardtsen E, Klintmalm G, Emre S: Safety and efficacy of a single bolus administration of recombinant factor VIIa in liver transplantation. Liver Transpl 2005;11:895-900.

67 Lodge JP, Jonas S, Jones RM, Olausson M, Mir JP, Soefelt S, Garcia-Valdecasas JC, McAlister V, Mirza D: Efficacy and safety of repeated periopeartive doses of recombinant factor VIIa in liver transplantation. Liver Transpl 2005;11:973-979.

68 Porte RJ, Caldwell SH: The role of recombinant factor VIIa in liver transplantation. Liver Transpl 2005;11:872-874.

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The impact of intraoperative transfusion of platelets and red blood cells on survival after

liver transplantationMarieke T. de Boer

Michael C. Christensen

Mikael Asmussen

Christian S. van der Hilst


Maarten J.H. Slooff

Robert J. Porte

Anesthesia & Analgesia

2008;106:32-44

7

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ABSTRACT

Background: Intraoperative transfusion of red blood cells (RBC) is associated with adverse outcome

after orthotopic liver transplantation (OLT). Although experimental studies have shown that

platelets contribute to reperfusion injury of the liver, the influence of allogeneic platelet transfusion

on outcome has not been studied in detail. The aim of this study was to evaluate the impact of

various blood products on outcome after OLT.

Methods: Twenty-nine variables, including blood product transfusions, were studied in relation

to outcome in 433 adult patients undergoing a first OLT between 1989 and 2004. Data were

analyzed using univariate and multivariate stepwise Cox s proportional hazards analyses, as well as

propensity score-adjusted analyses for platelet transfusion to control for selection bias in the use of

blood products.

Results: The proportion of patients receiving transfusion of any blood component decreased from

100% in the period 1989-1996 to 74% in the period 1997-2004. In uni- and multivariate analyses the

indication for transplantation, transfusion of platelets and RBC were highly dominant in predicting

one-year patient survival. These risk factors were independent from well-accepted indices of

disease, such as the MELD score and Karnofsky score. The effect on one-year survival was dose-

related with a hazard ratio of 1.377 per unit of platelets (P value =0.01) and 1.057 per unit of RBC (P

value =0.001). The negative impact of platelet transfusion on survival was confirmed by propensity-

adjusted analysis.

Conclusion: This retrospective study indicates that, in addition to RBC, platelet transfusions are

an independent risk factor for survival after OLT. These findings have important implications for

transfusion practice in liver transplant recipients.

Implications statement:

Platelet transfusions are a risk factor for patient survival after liver transplantation, which appears to

be independent from other well-known risk factors. These findings call for a cautious use of platelet

transfusions in patients undergoing liver transplantation.

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The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation

7

INTRODUCTION

Over the past decade a variety of donor and recipient characteristics has been identified as risk factors

influencing graft and patient survival after orthotopic liver transplantation (OLT). With knowledge

and anticipation of these factors, graft and patient survival have improved substantially.1 Important

factors affecting patient and graft survival rates following OLT include primarily the indication for

transplantation, pretransplant morbidity, renal function, the Model for End-Stage Liver Disease

(MELD) score, Child-Turcotte-Pugh score (CTP), donor and recipient age, year of transplantation,

primary dysfunction following transplantation, the warm and cold ischemia times, and type of

immunosuppression.2-13

In addition to these recipient and donor-related factors, several studies have shown that

intraoperative blood loss and red blood cell (RBC) transfusion requirements have a negative

impact on outcome after OLT.14,15 The risk of allogeneic blood transfusion extends beyond viral

transmission and includes allergic reactions, alloimmunization, bacterial sepsis, transfusion-related

acute lung injury, renal failure, volume overload, and immunosuppressive effects.16 Most previous

studies in liver transplantation have focused on the impact of RBC transfusions only, ignoring

the possible additional effect of other blood components, such as fresh frozen plasma (FFP) and

platelet concentrates. In cardiac surgery patients, platelet transfusions have been identified as an

independent risk factor for adverse postoperative outcome.17 In addition, animal models of liver

transplantation have shown that platelets are critically involved in the pathogenesis of reperfusion

injury of the liver.18,19 Based on these experimental studies, it has been suggested that platelet

transfusions should best be avoided in patients undergoing OLT. The influence of various blood

components on outcome after clinical liver transplantation, however, has not been studied in

detail. Moreover, blood transfusions may simply be a surrogate marker for sicker patients and more

complex surgery and have no direct causal role in outcome.

The purpose of this study was to evaluate the impact of transfusion of individual blood products on

outcome after OLT, as reflected by patient and graft survival rates. By including variables reflecting

severity of disease and surgical risk factors for excessive blood loss (e.g. previous abdominal surgery),

and by using propensity score-adjusted statistical analysis, we have attempted to limit the influence

of possible confounding factors related to both blood transfusion and outcome.

METHODS

Patients

A total of 749 consecutive liver transplantations were performed in our center between January

1, 1989 and December 31, 2004. After excluding pediatric transplants (age < 18 years; n=236),

retransplantations (n=69) and combined organ transplantations (n=11), 433 adult patients

undergoing a first OLT formed the basis of the current study. End of follow-up was September 1,

2005. Characteristics of the patients, including donor and recipient variables, as well as surgical

factors were obtained from a prospectively maintained computer database. When necessary the

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original patient notes were reviewed for missing information. The maximum percentage of missing

data per variable was 4%. National legislation and the ethical committee of our institution approved

this retrospective study.

Surgical technique

ABO blood group identical or compatible grafts from deceased brain-death (DBD) donors and DCD

(donation after cardiac death) donors were used for all patients. Organ procurement was performed

according to standard techniques.20 Both the conventional technique for OLT and the cava-sparing

piggyback technique were used for implantation.21 The piggyback technique was first performed in

our center in 1994 and it has become the preferred surgical technique in most patients since 1997.22

Before 1997, veno-venous bypass was used in most cases of conventional OLT, yet in recent years it

is rarely used.

Anesthetic management and blood transfusion policy

Anesthesia was maintained with a total intravenous technique using sufentanil, midazolam,

and vecuronium, and volume-controlled ventilation. Aprotinin was administered in all patients,

except patients with known thrombophilia or preexisting thrombotic conditions, or signs of

hypercoagulability on thrombelastography at time of induction of anesthesia. Based on evolving

scientific evidence concerning the efficacy of aprotinin, guidelines have been slightly adapted

during the study period.23

The transfusion policy in our center is characterized by a restrictive use of blood products. Blood

loss was counteracted by transfusion of allogeneic RBC, with the aim to maintain hematocrit

between 0.25 and 0.30. In addition, the cell saver device (Haemonetics, Braintree, MA, USA) was

used in selected patients when excessive blood loss was anticipated. Administration of other blood

products such as FFP and platelets was never solely dictated by laboratory values. These products

were only given in the presence of excessive blood loss, which could not be controlled by standard

surgical measures. FFP was then administered to correct prolonged prothrombin time (PT), or

prolonged r-value on TEG. Fibrinogen concentrate or cryoprecipitate was given when fibrinogen

levels fell below 70 mg/dL despite administration of FFP. Platelet concentrates were given in the

above mentioned situation if platelet count dropped below 50 x 109/L. Until 1999, all patients

received a lower body convective warming blanket (Warm Touch, Nellcor, Pleasanton, CA) and an

esophagus heating device (Thermal Tube, TTA-2250, Maquet, Rastatt, Germany) after that a lower

body and upper body convective warming blanket was used.

Postoperative management

Two types of immunosuppressive schemes were used. A triple immunosuppressive scheme,

consisting of cyclosporine A, azathioprine, and low dose prednisolone, was used for patients

with autoimmune diseases such as autoimmune hepatitis, primary biliary cirrhosis, and primary

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sclerosing cholangitis. All other patients received tacrolimus and low dose prednisolone. In patients

with compromised kidney function, calcineurin inhibitors were withheld until creatinine clearance

was over 50 mL/minute and induction therapy with 2 doses of 20 mg/day basiliximab, with an

interval of 4 days, was started.

Only biopsy-proven rejections were treated with a bolus of methylprednisolone on 3 consecutive

days. Steroid-resistant rejections were treated either by conversion to tacrolimus in patients on

cyclosporine A or by giving 5 doses of antithymocyte globulin 4 mg/kg intravenously on alternative

days.

Risk factors and outcome variables

Risk factors determined to be meaningful predictors of patient and graft survival were selected

based on a review of the literature. The following recipient-related variables were included: age,

sex, year of transplantation, body mass index (BMI), previous abdominal surgery, indication for

transplantation, preoperative Karnofsky score, preoperative CTP score and MELD score, preoperative

hemoglobin, hematocrit, platelet count, prothrombin time, serum total bilirubin level, serum

creatinine level, postoperative immunosuppressive drug scheme (cyclosporine versus tacrolimus-

based), acute rejection, and length of stay in the intensive care unit (ICU). Donor-related variables

included age, sex, type of donor (DBD versus DCD), and graft type (full size versus partial grafts).

In addition, the following surgical variables were studied: surgical technique (conventional versus

piggyback), operating time, and cold and warm ischemia time. With respect to intraoperative blood

component transfusion requirement the following variables were analyzed: the number of units of

allogeneic and autologous RBC (one unit contained 300 mL), units of FFP (one unit contained 250

mL), and units of platelets concentrates (1 unit contained approximately 150 mL and was obtained

from 5 donors).

Initial data analysis, as well as results obtained from the literature, allowed us to categorize continuous

variables, such as age, MELD score, ischemia times and units of blood products, into dichotomous

or ordinal variables with discrete clinically meaningful cut off points. For RBC transfusion, previous

studies have shown that the requirement of > 6 units is a clinically relevant cut-off value.14

Patient survival was defined as the time period between transplantation and the end of follow-up or

patient death. Graft survival was defined as the time period between transplantation and the end of

follow-up or graft loss by patient death or by graft failure requiring retransplantation.


Continuous variables are presented as medians with ranges and categorical variables as numbers

with percentages. Patient and graft survival rates were calculated according to the Kaplan-Meier

method, and differences between groups were investigated using the log-rank test. Categorical

variables were compared using the Pearson’s chi-square test or Fisher’s exact test. Comparison of

continuous variables was performed using the Mann-Whitney U test. All variables tested in the

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univariate analysis with a P value <0.10 were included in a multivariate survival analysis, using

stepwise Cox proportional hazard models with forward elimination. To determine the additional risk

of each unit transfused, blood products were entered as continuous variables into the multivariate

analysis. In addition, propensity score-based stratification in quintiles was used to study the impact of

platelet transfusion on outcome (platelet transfusion versus no platelet transfusion). The propensity

score is a single probability function in which confounding covariates are summarized and which

can be used to control for all confounding covariates that could potentially affect treatment

decision.24 Propensity scores were calculated for each patient, based on a stepwise multiple logistic

regression model consisting of the following covariates: preoperative platelet count, hematocrit,

serum creatinine, MELD score, indication, era of transplantation, donor age and gender, operating

time, type of graft and venous anastomosis, cold and warm ischemia time, and transfusion of RBC,

FFP and cell saver blood. The area under the receiver operating characteristic curve (C-index), for this

model was 0.88, indicating good discrimination between patients receiving platelets transfusion or

not. Statistical tests were assumed to have reached significance at the conventional level of 0.05.

Statistical analysis was performed using the SPSS/PC Advanced Statistics Package, Version 12.0

(SPSS, Chicago, IL).

RESULTS

Patient characteristics

Patient and donor characteristics as well as surgical variables for the entire group of 433 patients

are summarized in Table 1. Median postoperative follow up was 98 months (range 8-200 months).

One- and 5-year patient survival rates were 84% and 76%, respectively. Graft survival rates at 1- and

5-year were 78% and 67%, respectively.

Intraoperative transfusion of blood products

The median (range) requirement of blood products for the entire study period was 7 units of RBC (0-

105 units), 9 units of FFP (0-51 units) and 0 units of platelet concentrate (0-4 units).(Table 1) The use

of blood products decreased during the study period.(Table 2) The proportion of patients receiving

transfusion of any blood component decreased from 100% in the period 1989-1996 to 74% in the

most recent years (1997-2004).(Table 3)

The impact of platelet and allogeneic RBC transfusion on survival

Patient survival after transplantation was significantly associated with the number of allogeneic RBC

or platelet concentrates transfused during surgery.(Figure 1 & 2) Although the observed step-wise

relationship between the number of units transfused and survival is suggestive of a causal role,

these observations could also mean that blood product transfusion is simply a surrogate marker

for sicker patients. We, therefore, performed multivariate regression analysis including possible

confounding factors, such as severity of disease, co-morbidity and previous abdominal surgery.

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Table 1. Characteristics of the study population (1989-2004)

Variable Study population (n = 433)

Recipient variables Range or %

Age (years) 45 (18-68)

Gender: Male 224 (52%)

Female 209 (48%)

Era of transplantation

1989 – 1996 195 (45%)

1997 – 2004 238 (55%)

BMI 24 (15-42)

Indication for transplantation

Biliary Cirrhosis 131 (30%)

Postnecrotic Cirrhosis 222 (51%)

Acute Liver Failure 37 (9%)

Metabolic Disease 16 (4%)

Miscellaneous 26 (6%)

Karnofsky score 60 (10 – 100)

CTP score

CTP A 66 (16%)

CTP B 165 (38%)

CTP C 199 (46%)

MELD score 16 (6-40)

Serum Creatinine before OLT (µmol/l; normal <110 µmol/l)* 84 (34-735)

Serum total Bilirubin before OLT (µmol/l; normal 0-17 µmol/l)* 67 (5-1343)

INR before OLT 1.5 (0.9-15.6)

Platelet count before OLT (x109/l; normal 150-350) 89 (2-651)

Hemoglobin before OLT (mmol/l; normal 8.7-10.2)* 6.8 (3.1-9.9)

Hematocrit before OLT (normal 0.33-0.40) 0.32 (0.14-0.50)

Previous abdominal surgery

No previous surgery 316 (74%)

Previous surgery right upper abdomen 111 (26%)

Rejection

No rejection 223 (52%)

Mild rejection, untreated 90 (21%)

Rejection treated 115 (27%)

Immunosuppression (initial postoperative period)

Tacrolimus based 90 (21%)

Cyclosporin based 336 (79%)

Length of intensive care stay (days) 4 (0-155)

Length of total hospital stay (days) 39 (0-235)

Donor variables

Age (years) 42 (11-72)

Gender: Male 219 (53%)

Female 202 (47%)

Donor-Recipient gender match

Male-male 124 (29%)

Female – female 107 (25%)

Male – female 95 (23%)

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Chapter 7

Female – male 95 (23%)

Type of donor liver

Deceased donor (brain death) 429 (99%)

Donation after cardiac death (DCD) 4 (1%)

Graft size

Full size 421 (97%)

Reduced size or split 12 (3%)

Transplantation variables

Operating time (min) 540 (280-1080)

Venous anastomosis

Classic 252 (58%)

Piggyback 181 (42%)

CIT** (min) 600 (203-1440)

WIT† (min) 55 (20-129)

RBC (units) (allogeneic) 7 (0-105)

FFP (units) 9 (0-51)

Platelets (units) 0 (0-4)

Cell saver RBC (units) 0 (0-81)

Antifibrinolytic drugs used

No 243 (58%)

Aprotinin 160 (38%)

Tranexamic acid 16 (4%)

Data represent numbers (percentages) for categorical variables or median (range) for continuous variables.* To convert the value for creatinine to mg/dL, divide by 88.4. To convert the value for bilirubin to mg/dL, divide by 17.1. To convert the value for hemoglobin to g/dL, divide by 0.62.** Time from in situ flushing of the donor organ until the liver is removed from ice for implantation.† Time from removal of liver from ice until reperfusion via portal vein, hepatic artery or both.BMI= body mass index; CTP= Child Turcotte Pugh score; MELD= model of end-stage liver disease; CIT= cold ischemia time; WIT= warm ischemia time; RBC= red blood cell transfusion; FFP= fresh frozen plasma transfusion; DCD= donation after cardiac death.For some variables the total number of cases may be less than 433, reflecting missing data (overall <4%).

Table 2. Median number (interquartile range) of units transfused per era

Era Allogeneic RBCtransfusion

Cell saver RBCtransfusion Platelet transfusion FFP transfusion

1989–1996 12 (8-18) 2 (0-6) 1 (0-1) 17 (11-22)

1997–2004 2.5 (0-6) 0 (0-1) 0 (0-1) 2 (0-7)

Total 7 (2-12) 0 (0-3) 0 (0-1) 9 (2-18)

RBC= red blood cell; FFP= fresh frozen plasma.

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Table 3. Percentage of patients receiving blood transfusion per era

Era Allogeneic RBCtransfusion

Cell saver RBCtransfusion

Platelet transfusion

FFP transfusion

Any transfusion

1989-1996 100% (192/194) 58% (112/194) 56% (109/194) 100% (192/194) 100% (193/194)

1997-2004 69% (163/236) 25% (60/237) 30% (71/236) 59% (140/236) 74% (175/236)

Total 82% (355/430) 40% (172/431) 42% (180/430) 77% (332/430) 86% (368/430)

RBC= red blood cell; FFP= fresh frozen plasma.

Total of cases may be less than 433, representing missing data (<1%).

Figure 1. Kaplan Meyer curves representing cumulative patient survival in relation to the number of intraoperative red blood cell (RBC) transfusion requirements.

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Uni- and multivariate analysis of patient survival

The results of univariate analysis of all potential risk factors for 1- and 5-year patient survival are

summarized in Table 4. Of the 26 variables studied, 11 were associated with 1- and 5-year patient

survival. Apart from the well-known variables associated with patient survival, such as the era of

transplantation, significant factors affecting survival were indication for transplantation, severity of

disease (e.g. Karnofsky score, Child-Turcotte-Pugh score and MELD score), graft type, and ischemia

times, and all types of blood product transfusion (autologous and allogeneic RBC, FFP and platelets).

When entering all variables with a P value <0.10 into a multivariate Cox regression model, only three

variables remained as independent predictors of 1-year patient survival, while four variables were

independent risk factors for 5-year survival. (Table 5) Platelet transfusions and RBC transfusions

were highly dominant in predicting patient survival. Although indices of disease severity such as the

Figure 2. Kaplan Meyer curves representing cumulative patient survival in relation to the number of intraoperative platelet transfusions.

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Table 4. Univariate analysis of patient survival

Variable One-year Five-year

Recipient variables n % P value % P value

Age <55 years 333 85 0.547 77 0.468

>55 years 100 82 74

Gender: Male 224 84 0.709 74 0.265

Female 209 85 78

BMI <20 56 86 0.285 84 0.031*

20-30 336 85 77

30+ 32 75 59

Indication for transplantation <0.001* 0.006*

Biliary Cirrhosis 131 92 85

Postnecrotic Cirrhosis 222 84 73

Acute Liver Failure 37 60 60

Metabolic Disease 16 88 75

Miscellaneous 26 81 81

Karnofsky score 0-40 145 72 <0.001* 68 0.009*

50-70 189 92 81

80-100 99 87 79

CTP score A 66 88 0.015* 80 0.009*

B 165 89 82

C 199 78 69

Serum Creatinine

normal (♀ <110 µmol/l, ♂<120 µmol/l) 333 86 0.053* 78 0.095*

abnormal (♀>110 µmol/l, ♂ >120 µmol/l) 100 78 70

MELD-score cont cont 0.009* cont 0.023*

MELD category: <11 81 89 0.018† 80 0.202

11-18 170 86 79

19-24 73 89 77

>25 91 74 69

Platelet count before OLT (x109/l) cont cont 0.158 cont 0.143

Hemoglobin before OLT (mmol/l) cont cont 0.214 cont 0.314

Hematocrit before OLT cont cont 0.243 cont 0.282

Previous abdominal operations: Yes 111 88 0.689 78 0.712

No 316 85 77

Rejection No 223 83 0.201 75 0.520

Mild, untreated 90 90 80

Yes, treated 115 86 77

Immunosuppression Tacrolimus 90 90 0.150 83 0.126

Cyclosporin 336 84 76

Donor variables

Age <40 years 186 86 0.330 78 0.277

>40 years 247 83 75

Gender Male 219 83 0.459 76 0.823

Female 202 86 77

Donor-recipient gender match 0.875 0.681

Male - male 124 84 76

Female - female 107 86 80

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Male - female 95 82 76

Female – male 95 85 73

Type donor liver Deceased (brain death) 429 84 0.404 76 0.402

DCD 4 100 100

Graft size: Full size 421 85 0.009* 77 0.078*

Split/reduced size 12 58 58


Year of transplantation: 1989-1996 195 81 0.120 71 0.067*

1996-2004 238 87 80

Operating time (cont) cont cont 0.781 cont 0.862

Venous anastomosis: Classic 252 82 0.298 73 0.192

Piggy back 181 86 80

CIT: <12 hr 286 87 0.022* 82 0.001*

>12 hr 143 78 64

WIT: <60 min 266 86 0.095* 80 0.016*

>60 min 163 80 69

RBC units (allogeneic) cont cont <0.001* cont <0.001*

RBC units: 0 75 92 0.007† 87 0.004†

0-6 136 88 82

>6 219 79 69

FFP units cont cont <0.001* cont <0.001*

FFP units: 0 98 94 <0.001† 89 0.001†

0-4 50 94 86

>4 281 79 70

Platelets units cont cont <0.001* cont <0.001*

Platelets units: 0 250 92 <0.001† 84 <0.001†

>0-2 160 76 68

>2 20 55 40

Cell saver RBC units cont cont 0.075* cont 0.013*

Cell saver RBC: 0 258 86 0.092† 80 0.082†

0-6 106 86 75

>6 66 76 65

Antifibrinolytic use: No 243 86 0.235 79 0.033*

Yes 176 81 71

† Continuous variables were used for multivariate analysis.* Included in multivariate analysescont= continuous variables; BMI= body mass index; CTP= Child Turcotte Pugh score; MELD= model of end-stage liver disease; RBC= red blood cell transfusion; FFP= fresh frozen plasma transfusion; CIT= cold ischemia time; WIT= warm ischemia time; DCD= donation after cardiac death.For some variables the total number of cases may be less than 433, representing missing data (overall <4%).

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Karnofsky score and MELD score were not associated with post transplant survival in multivariate

analysis, patients receiving RBC or platelets may still be sicker, than patients who do not need

transfusion.

To exclude the effect of a possible interaction between transfusions and disease severity we

performed a second multivariate analysis including the interactions of RBC and platelets with the

Karnofsky score and MELD score. The results of this second model were similar to the results of the

first model with a hazard ratio (HR) of 1.359 per unit of platelets (P value =0.014) and 1.055 per unit

of RBC (P value <0.001) for 1-year survival and an HR of 1.429 per unit of platelets (P value =0.001)

and 1.047 per unit of RBC (P value =0.001) for 5-year survival.

To further eliminate the effect of selection bias for platelet transfusion we performed a propensity

score-adjusted analysis as described above. The propensity-adjusted HR for one-year survival in

patients who received platelet transfusion was 2.613 (95% confidence interval 1.315 to 5.192; P

value =0.012).

Uni- and multivariate analysis of graft survival

The results of univariate analysis of all potential risk factors for 1- and 5-year graft survival are

summarized in Table 6. Of the 26 variables studied, 9 were identified to be associated with 1- and

5-year graft survival. As for patient survival, all types of blood product transfusion (RBC, FFP and

platelets) were negatively associated with graft survival. Other significant factors were indication

for transplantation, acute rejection, graft type, era of transplantation and ischemia times. After

Table 5. Multivariate Cox regression analysis of patient survival

One-year Patient Survival Five-year Patient Survival

Variable P value Hazard Ratio (95% confidence interval) P value Hazard Ratio

(95% confidence interval)

Indication 0.020 * *

Biliary Cirrhosis **

Acute Liver Failure 4.206 (1.653-10.070)

Postnecrotic Cirrhosis 1.500 (0.729-3.086)

Metabolic Disease 3.548 (0.764-16.475) Miscellaneous 1.232 (0.385-3.946)RBC units (allogeneic) <0.001 1.055 (1.036-1.076) 0.001 1.047(1.028-1.067)

Platelets units 0.014 1.359 (1.064-1.736) 0.001 1.429(1.166-1.751)

CIT * * 0.002 0.494(0.315-0.776)

Era of Transplantation * * 0.008 0.515(0.315-0.843)

* Not statistically significant after multivariate analysis ** Biliary cirrhosis was used as the reference category for indication CIT= cold ischemia time; RBC= red blood cell transfusion

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Table 6. Univariate analysis of graft survival

Variable 1-yr 5-yr

Recipient variables n % P value % P value

Age: <55 years 333 78 0.896 67 0.929

>55 years 100 78 69

Gender: Male 224 80 0.224 68 0.590

Female 209 75 67

BMI: <20 56 77 0.695 75 0.137

20-30 336 79 68

30+ 32 72 53

Indication for transplantation

Biliary Cirrhosis 131 83 <0.001* 76 0.013*

Postnecrotic Cirrhosis 222 80 66

Acute Liver Failure 37 54 51

Metabolic Disease 16 75 63

Miscellaneous 26 65 62

Karnofsky score: 0-40 145 68 0.003* 63 0.265

50-70 189 84 70

80-100 99 79 69

CTP score: A 66 79 0.356 70 0.244

B 165 81 72

C 199 74 63

Serum Creatinine

normal (♀ <110 µmol/l, ♂ <120 µmol/l) 333 79 0.308 68 0.667

abnormal (♀ >110 µmol/l, ♂ >120 µmol/l) 100 74 66

MELD-score cont cont 0.189 cont 0.487

MELD category: <11 81 80 0.085† 68 0.586

11-18 170 79 71

19-24 73 85 70

>25 91 69 64

Platelet count before OLT (x109/l) cont cont 0.411 cont 0.158

Hemoglobin before OLT (mmol/l) cont cont 0.735 cont 0.397

Hematocrit before OLT cont cont 0.803 cont 0.429

Previous abdominal operations: Yes 111 81 0.520 71 0.484

No 316 78 67

Rejection: No 223 74 0.018* 63 0.018*

Mild, untreated 90 88 78

Yes, treated 115 80 70

Immunosuppression: Tacrolimus based 90 86 0.065* 76 0.105

Cyclosporin based 336 77 67

Donor variables

Age: <40 years 186 80 0.361 70 0.208

>40 years 247 76 66

Gender: Male 219 77 0.703 68 0.987

Female 202 79 68

Donor-recipient gender match 0.456 0.870

Male - male 124 80 68

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Female - female 107 76 65

Male - female 95 74 67

Female - male 95 82 71

Type donor liver: Deceased (brain death) 429 77 0.332 67 0.332

DCD 4 100 100

Graft size: Full size 421 79 <0.001* 69 <0.001*

Split/reduced size 12 25 25


Year of transplantation: 1989-1996 195 74 0.167 62 0.094*

1996-2004 238 80 72

Operating time cont cont 0.736 cont 0.866

Venous anastomosis: Classic 252 77 0.600 64 0.242

Piggyback 181 79 72

CIT: <12 hr 286 81 0.018* 74 <0.001*

>12 hr 143 71 54

WIT: <60 min 266 80 0.153 73 0.020*

>60 min 163 74 60

RBC units (allogeneic) cont cont <0.001* cont <0.001*

RBC units: 0 75 91 0.002† 85 0.002†

0-6 136 80 69

>6 219 72 60

FFP units cont cont <0.001* cont <0.001*

FFP units: 0 98 88 0.001† 83 0.003†

0-4 50 90 74

>4 281 72 61

Platelets units cont cont <0.001* cont <0.001*

Platelets: 0 250 84 <0.001† 74 <0.001†

>0-2 160 71 61

>2 20 55 35

Cell saver blood units cont cont 0.081* cont 0.025*

Cell saver blood units: 0 258 80 0.102† 72 0.236

0-6 106 79 64

>6 66 68 59

Antifibrinolytic use: No 243 77 0.933 69 0.283

Yes 176 77 66

† Continuous variables were used for multivariate analysis.* Included in multivariate analysiscont= continuous variables; BMI= body mass index; CTP= Child Turcotte Pugh score; MELD= model of end-stage liver disease; RBC= red blood cell transfusion; FFP= fresh frozen plasma transfusion; CIT= cold ischemia time; WIT= warm ischemia time; DCD= donation after cardiac death.For some variables the total of cases may be less than 433, representing missing data (overall <4%).

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multivariate analysis only three variables were identified as independent risk factors for 1-year graft

survival: RBC transfusions, indication for transplantation and graft type.(Table 7) Four variables were

independent risk factors for 5-year graft survival: RBC transfusion, indication for transplantation,

graft size and cold ischemia time.

DISCUSSION

Developing OLT as a therapy for patients with end-stage liver disease would not have been possible

without therapeutic approaches for bleeding including blood products. Advances in the surgical and

anesthetic management of patients undergoing OLT, as well as better understanding of risk factors

for massive blood loss, have resulted in a steady decrease in intraoperative blood loss and transfusion

requirements.14,25-27 Currently, several centers report the complete avoidance of RBC transfusions in

up to 40% of their liver transplant recipients.14,25,26,28 Despite these major achievements, most liver

transplant recipients require blood product transfusions. However, there is increasing evidence

that transfusion of blood products is associated with side effects.16,29 Our study confirms previous

reports suggesting that intraoperative RBC transfusions are an independent risk factor for patient

survival after OLT.14,15 More importantly, this study identified the transfusion of platelet concentrates

as an important prognostic factor for survival after OLT in addition to RBC transfusions. This negative

effect of platelets is in agreement with a study by Spiess reported in cardiac surgical patients.17

The risk of allogeneic blood transfusion extends beyond viral transmission and includes allergic

reactions, alloimmunization, bacterial sepsis, transfusion-related acute lung injury, graft-versus-host-

disease, renal failure, and immunosuppressive effects.16,29 Of all blood components, most previous

Table 7. Multivariate Cox regression analysis of graft survival

One-year Graft Survival Five-year Graft Survival

Variable P value Hazard Ratio (95% confidence interval) P value Hazard Ratio

(95% confidence interval)

Indication 0.006 0.005

Biliary Cirrhosis ** **

Acute Liver Failure 3.215 (1.607-6.432) 2.982 (1.615-5.506)

Postnecrotic Cirrhosis 1.051 (0.627-1.760) 1.334 (0.873-2.039)

Metabolic Disease 2.238 (0.844-7.584) 2.682 (1.098-6.549) Miscellaneous 1.370 (0.549-3.420) 1.365 (0.622-2.993)

Graft size (full/split) 0.001 0.181(0.086-0.382) <0.001 0.269(0.130-0.558)

RBC unit 0.001 1.050(1.029-1.071) 0.001 1.032(1.013-1.051)

CIT * * 0.001 0.592(0.414-0.846)

* Not statistically significant after multivariate analysis ** Biliary cirrhosis was used as the reference category for indication

CIT= cold ischemia time; RBC= red blood cell transfusion

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studies have focused on the adverse effects of RBC transfusions. In liver transplant recipients, clinical

studies have shown that even a moderate number of RBC transfusions is associated with longer

hospital stay, and transfusion of more than six RBC transfusions has been associated with diminished

survival.14,15,28 Even today, centers with median RBC transfusion requirements of 2-3 units in adult

patients still report a significant correlation between intraoperative blood transfusion requirement

and postoperative infection rate and morbidity.14,15,28-32 The impact of RBC transfusion has been

shown to be independent of other well-known predictors of surgical blood loss and post-transplant

survival, such as previous abdominal surgery, renal failure, other co-morbidities and the severity of

liver disease. Although the exact mechanisms underlying the adverse effects of RBC transfusions

are not fully elucidated, residual amounts of donor leukocytes present in RBC transfusions as

well as preservation related changes in erythrocytes are assumed to be involved.33-36 Currently,

leukoreduction technologies are increasingly used according to local and national regulations.37

Whether these technologies will lead to a decrease of transfusion-related complications will need

to be validated.37 Other studies have suggested that duration of storage of transfused RBC is an

important factor for transfusion-associated complications.38 Unfortunately we did not have access

to the storage time of RBC or other blood products used in our patients.

Few data exist on the negative effect of platelet transfusion on patient survival after OLT, as

suggested in the current study. A negative effect of platelet transfusion on graft survival has been

described previously.39 In this study, patients were arbitrarily divided in two groups based on the

transfusion of more than 20 units of platelets. This study of platelet transfusions is less relevant to

current practice, because fewer platelet transfusions are administered.

Many cirrhotic patients undergoing OLT have a low platelet count due to hypersplenism, increased

platelet consumption, bone marrow depression, and reduced thrombopoietin levels.40-42 Platelet

concentrates are frequently administered during OLT for the prevention or treatment of bleeding.

Although the “Practice Guidelines for Perioperative Blood Transfusion“ of the American Society of

Anesthesiologists do not recommend prophylactic administration of platelets in surgical patients,43

a recent survey indicated that most centers would use prophylactic platelet administration in

cirrhotic patients undergoing invasive procedures.44 However, no consensus exists regarding the

appropriate threshold for platelet transfusion. Platelet transfusion-related complications are among

the leading causes of fatalities associated with blood product transfusions in the United States.17 In a

study of 1,720 patients undergoing coronary artery bypass graft surgery, Spiess17 identified platelet

transfusion as an important risk factor for serious adverse events such as infection, vasopressor

use, respiratory medication use, stroke, multiorgan failure and death. Using multivariate logistic

regression analysis with propensity score adjustments for confounding variables, a five times higher

death rate was identified in patients who received platelet transfusion.17

In experimental liver transplantation, several studies have demonstrated that platelets are involved

in the pathogenesis of reperfusion injury of the liver graft by inducing endothelial cell apoptosis.18,19

This effect is independent of ischemia-related endothelial cell injury and cannot simply be explained

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by activation of the coagulation system and aggregation of platelets at the site of endothelial cell

injury.18,19,45,46 There is compelling evidence the role of platelets is not limited to their well-known

involvement in hemostasis. Platelets contain many cytokines and vasoactive and inflammatory

mediators, which are rapidly released on activation by various stimuli following reperfusion. In

addition, during procurement and preparation of platelet concentrates for transfusion, additional

changes may occur. Platelets become conjugated with leukocytes and undergo activation and

expression of various cellular ligands.17 Cytokine levels can rise as high as 1000-fold with processing,

making platelet transfusions proinflammatory.45 These substances may potentially be involved in

post-transplantation inflammatory reactions, but have not been specifically studied. Despite this

experimental evidence, we have not been able to identify platelet transfusion as an independent

risk factor for graft survival. Platelet transfusion was significantly associated with lower graft survival

in the univariate analysis, but not in the multivariate analysis. This topic is subject of further research

in our group. Preliminary results suggest that timing of platelet transfusion in relation to graft

reperfusion is critical. Platelet transfusions given shortly before or after reperfusion seem to have

a greater impact on the liver graft than transfusions given in the early phases of the operation.

Based on the experimental data and these clinical observations we currently try to avoid platelet

transfusions short before or early after reperfusion of the donor liver.

Two types of platelet products are currently used worldwide: pooled random donor platelets,

manufactured from whole blood donations and single donor platelets, collected by pheresis.46,47

Whereas pheresis from single donors is most often used in the US, many European blood banks use

the less expensive method of buffy coat whole blood-derived platelet concentrates. In the current

study, patients received platelet concentrates derived from 5 pooled random donors, resulting in

a total volume of approximately 150 mL. The results of our study may not be directly extrapolated

to patients who received pheresis-derived platelets from single donors, because these products

may not be the same. Although whole blood-derived platelets are less expensive and a more

efficient use of limited donor resources, pheresis-derived platelets have been associated with a

lower risk of alloimmunization and infectious complications.46 In addition, some data suggest that

different manufacturing methods of whole blood-derived platelets (platelet-rich plasma or buffy

coat intermediate steps) result in differing degrees of platelet activation, which may impact on the

quality of stored concentrates.47 The impact of these differences on outcome after OLT requires

further investigation.

Although the current multivariate analysis provides strong support for a detrimental impact

of RBC and platelet transfusions on outcome after OLT, it remains difficult to prove causality in a

retrospective analysis. RBC and platelet transfusions may be a surrogate marker for sicker patients

and more complex surgery and have no causal role in the outcome observed. However, we have

attempted to minimize the influence of these potential confounders by studying the interaction

of RBC and platelets with Karnofsky and MELD scores in the second multivariate model. This did

not change the results of our first multivariate analysis, indicating the negative impact of RBC and

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platelet transfusion is not simply related to a higher transfusion need in sicker patients. Moreover,

we could confirm the negative impact of platelet transfusions on survival in a propensity score-

adjusted analysis, which is currently considered to be one of the most robust statistical methods to

control for selection bias for the use of specific treatment.24 Nevertheless, in this study we could not

completely distinguish if the worse outcome in platelet-transfused patients was because they were

thrombocytopenic and bleeding (the only condition under which platelets were administered) or

directly because they received platelets. This distinction could not even be fully addressed by using

propensity scores, because comparative patients who did not receive platelets (despite similar

propensity scores) were either not thrombocytopenic and/or not bleeding. Definite proof could only

come from prospective, randomized controlled studies, in which different transfusion thresholds

are compared. Although a prospective study comparing different triggers for RBC transfusion has

been performed in patients admitted to a critical care unit,48 to our knowledge such studies have

never been performed in the liver transplant recipients. Ethical considerations as well as the large

variations in thrombocytopenia and platelet function in patients undergoing OLT make it difficult

to perform such a trial. Despite the lack of randomized studies, our findings are in agreement with

previous clinical studies and are reinforced by the serious detrimental effects of platelets found

in experimental models of liver transplantation.14,15,18,19,49,50 These combined observations, both

within and outside the field of liver transplantation, provide substantial support for the hypothesis

of detrimental effects of RBC and platelet transfusions on outcome, independent from other risk

factors.

The current results should be considered when determining the risk–benefit ratio of blood product

transfusions in liver transplant patients. Apart from general measures to reduce blood loss, patients

undergoing OLT could possibly benefit from a more restrictive blood transfusion policy.51,52 Although

we currently have no alternatives for RBC and platelet transfusions in critical situations, there is wide

variability in using blood products among different centers51,54 as well among anesthesiologists

within centers.51 Therefore, improvements in the care for liver transplant patients should not

be limited to surgical and anesthetic measures to minimize intraoperative blood loss, but also

include a conservative and more targeted use of blood products, weighing the balance in each

individual patient of short-term benefits versus increased postoperative risk for adverse events. As

well as meticulous surgical technique, the use of prohemostatic pharmacological agents, such as

aprotinin, lysine analogues or recombinant factor VIIa, may contribute to a reduction or transfusion

requirements in selected cases.23,55,56

In conclusion, this retrospective study confirms the negative impact of RBC transfusion on outcome

after liver transplantation. In addition, we have shown that intraoperative platelet transfusions

are a strong independent risk factor for patient survival after OLT. The negative impact of platelet

transfusions is independent from other well-known risk factors and in accordance with the

biological adverse effects of platelets identified in patients undergoing cardiac surgery and in

experimental models of OLT. Our findings have clinical implications for the use of blood products in

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liver transplant recipients, and support previous reports regarding outcomes associated with both

RBC and platelet transfusions.

Acknowledgements:

The authors would like to acknowledge the support of Anette Woehl and Dr. Craig J. Currie of the

Cardiff Research Consortium.

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11. Ghobrial RM, Gornbein J, Steadman R, Danino N, Markmann JF, Holt C, Anselmo D, Amersi F, Chen P, Farmer DG, Han S, Derazo F, Saab S, Goldstein LI, McDiarmid SV, Busuttil RW. Pretransplant model to predict posttransplant survival in liver transplant patients. Ann Surg 2002; 236:315-322.

12. Seaberg EC, Belle SH, Beringer KC, Schivins JL, Detre KM. Long-term patient and retransplantation-free survival by selected recipient and donor characteristics: an update from the Pitt-UNOS Liver Transplant Registry. Clin Transpl 1997;1:15-28.

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13. Wiesner RH. A long-term comparison of tacrolimus (FK506) versus cyclosporine in liver transplantation: a report of the United States FK506 Study Group. Transplantation 1998;66:493-499.

14. Ramos E, Dalmau A, Sabate A, Lama C, Llado L, Figueras J, Jaurrieta E. Intraoperative red blood cell transfusion in liver transplantation: Influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl 2003;9:1320-1327.

15. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Busque S, Concepcion W, So SK, Esquivel CO. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg 1999;134:25-29.


17. Spiess BD, Royston D, Levy JH, Fitch J, Dietrich W, Body S, Murkin J, Nadel A. Platelet transfusions during coronary artery bypass graft surgery are associated with serious adverse outcomes. Transplantation 2004;44:1143-1148.

18. Sindram D, Porte RJ, Hoffman MR, Bentley RC, Clavien PA. Platelets induce sinusoidal endothelial cell apoptosis upon reperfusion of the cold ischemic rat liver. Gastroenterology 2000; 118:183-191.

19. Sindram D, Porte RJ, Hoffman MR, Bentley RC, Clavien PA. Synergism between platelets and leukocytes in inducing endothelial cell apoptosis in the cold ischemic rat liver: a Kupffer cell-mediated injury. FASEB J 2001;15:1230-1232.

20. Starzl TE, Marchioro TL, Von Kaulla KN, Herman G. Homotransplantation of the liver in humans. Surg Gynecol Obstet 1963;117:659-676.

21. Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 1989;210:649-652.

22. Miyamoto S, Polak WG, Geuken E, Peeters PM, de Jong KP, Porte RJ, van den Berg AP, Hendriks HG, Slooff MJ. Liver transplantation with preservation of the inferior vena cava. A comparison of conventional and piggyback techniques in adults. Clin Transpl 2004;18:686-693.

23. Porte RJ, Molenaar IQ, Begliomini B, Groenland TH, Januszkiewicz A, Lindgren L,Palareti G, Hermans J, Terpstra OT. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. Lancet 2000;355:1303-1309.

24. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika 1983;70:41-55.

25. de Boer MT, Molenaar IQ, Hendriks HGD, Slooff MJH, Porte RJ. Minimizing blood loss in liver transplantation: Progress through research and evolution in techniques. Dig Surg 2005;22:265-75.

26. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S, Concepcion W, So SK, Esquivel CO. Primary liver transplantation without transfusion of red blood cells. Surgery 1996; 120:698-704.

27. Steib A, Freys G, Lehmann C, Meyer C, Mahoudeau G. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth 2001;48:1075-1079.

28. Massicotte L, Sassine MP, Lenis S, Seal RF, Roy A. Survival rate changes with transfusion of blood products during liver transplantation. Can J Anaesth 2005;52:148-155.

29. Hensler T, Heinemann B, Sauerland S, Lefering R, Bouillon B, Andermahr J Neugebauer EA. Immunologic alterations associated with high blood transfusion volume after multiple injury: effects on plasmatic cytokine and cytokine receptor concentrations. Shock 2003;20:497-502.

30. Mor E, Jennings L, Gonwa TA, Holman MJ, Gibbs J, Solomon H. The impact of operative bleeding on outcome in transplantation of the liver. Surg Gynecol Obstet 1993;176:219-227.

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31. Bechstein WO, Neuhaus P. A surgeon’s perspective on the management of coagulation disorders before liver transplantation. Liver Transpl Surg 1997;3:653-655.

32. Hendriks HG, van der Meer J, de Wolf JThM, Peeters PMJG, Porte RJ, de Jong KP, Lip H, Post WJ, Slooff MJH. Intraoperative blood transfusion requirement is the main determinant of early surgical reinterventions after orthotopic liver transplantation. Transpl Int 2005;17:673-679.

33. McLellan SA, Walsh TS, McClelland DBL. Should we demand fresh red blood cells for perioperative and critically ill patients? Br J Anaesth 2002;89:537-540.

34. Beutler E. Liquid preservation of red blood cells. In: Simon TL, Dzik WH, Snyder EL, Stowell CP, Strauss RG, eds. Rossi’s principles of transfusion medicine, 3rd ed. Baltimore: Lippincott Williams & Wilkins 2002:50-61.

35. Beutler E, Muel A, Wood LA. Depletion and regeneration of 2,3 diphosphoglyceric acid in stored red blood cells. Transfusion 1969;9:109-114.

36. Messana I, Ferroni L, Misiti F, Girelli G, Pupella S, Castagnola M, Zappacosta B, Giarolina B. Blood bank conditions and RBCs: the progressive loss of metabolic modulation. Transfusion 2000; 40:353-360.

37. G.N. Tzimas, M. Deschenes, J.S. Barkun, P. Wong, J.I. Tchervenkov, H. Hayati, E. Alpert, and P. Metrakos. Leukoreduction and acute rejection in liver transplantation: an interim analysis. Transpl Proc 2004;36:1760-1762.

38. Basran S, Frumento RJ, Cohen A, Lee S, Du Y, Nishanian E, Kaplan HS, Stafford-Smith M, Bennett-Guerrero E. The association between duration of storage of transfused red blood cells and morbidity and mortality after reoperative cardiac surgery. Anesth Analg 2006;103:15-20.

39. Markmann JF, Markmann JW, Desai NM, Baquerizo A, Singer J, Yersiz H, Holt C, Ghobrial RM, Farmer DG, Busuttil RW. Operative parameters that predict the outcomes of hepatic transplantation. J Am Coll Surg 2003;196:566-572.

40. Hutchison DE, Genton E, Porter KA, Daloze PM, Huguet C, Brettschneider L, Groth CG, Starzl TE. Platelet changes following clinical and experimental hepatic homotransplantation. Arch Surg 1968; 97:27-33.

41. Porte RJ, Blauw E, Knot EA, de Maat MP, de Ruiter C, Bakker MC, Terpstra OT. Role of the donor liver in the origin of platelet disorders and hyperfibrinolysis in liver transplantation. J Hepatol 1994;21:592-600.

42. Schalm SW, Terpstra JL, Achterberg JR, Noordhoek Hegt V, Haverkate F, Popescu DT, Krom RA, Veltkamp JJ. Orthotopic liver transplantation: an experimental study on mechanisms of hemorrhagic diathesis and thrombosis. Surgery 1975;78:499-507.

43. The American Society for Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies. Available at: http://www.asahq.org/publicationsAndServices/ BCTGuidesFinal.pdf. Accessed on February 12, 2007.

44. Caldwell SH, Hoffman M, Lisman T, Masik BG, Northup PG, Reddy KR, Tripodi A, D, Sanyal AJ, Coagulation in Liver Disease Group. Coagulation disorders and hemostasis in liver disease: Pathophysiology and critical assessment of current management. Hepatology 2006;44:1039-1046.

45. Hartwig D, Hartel C, Hennig H, Muller-Steinhardt M, Schlenke P, Kluter H. Evidence for denovo synthesis of cytokines and chemokines in platelet concentrates. Vox Sang 2002;82:182-190.

46. Ness PM, Campbell-Lee SA. Single donor versus pooled random donor platelet concentrates. Curr Opin Hematol 2001;8:392-396.

47. Vassallo RR, Murphy S. A critical comparison of platelet preparation methods. Curr Opin Hematol 2006:13: 323-330.

48. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion

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Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-417.

49. Palomo Sanchez JC, Jimenez C, Moreno Gonzalez E, et al. Effects of intraoperative blood transfusion on postoperative complications and survival after orthotopic liver transplantation. Hepatogastroenterol 1998;45:1026-1033.

50. Bennett-Guerrero E, Feierman DE, Barclay GR, Parides MK, Sheiner PH, Mythen MG, Levine DM, Paker TS, Carroll SF, White ML, Winfree WJ. Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation. Arch Surg 2001;136:1177-1183.

51. Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl 2006;12:117-1123.

52. Pruvot F, Lebuffe G, Delhaye O, Dharancy S, Jude B, Gambiez L, Boleslawski E, Declerck N. Liver transplantation without the use of fresh frozen plasma, 227 cases. Liver Transpl 2006;12: C1-C142 (abstract 125).

53. Hendriks HG, van der Meer J, Klompmaker IJ, Choudbury N, Hagenaars JAM, Porte RJ, de Kam PJ, Slooff MJ, de Wolf JThM. Blood loss in orthotopic liver transplantation: a retrospective analysis of transfusion requirements and the effects of autotransfusion of cell saver blood in 164 consecutive patients. Blood Coag Fibrinol 2000:11:S87-S93.

54. Ozier Y, Pessione F, Samain E, Courtois F. Institutional variability in transfusion practice for liver transplantation. Anesth Analg 2003;97:671-679.

55. Dalmau A, Sabate A, Acosta F, Garcia-Huete L, Koo M, Sansano T, Rafecas A, Figueras J, Jaurrieta E, Parrilla P. Tranexamic acid reduces red cell transfusion better than epsilon-aminocaproic acid or placebo in liver transplantation. Anesth Analg 2000;91:29-34.

56. Porte RJ, Caldwell SH. The role of recombinant factor VIIa in liver transplantation. Liver Transpl 2005;11:872-874.

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Platelet transfusion during liver transplantation is associated with increased

postoperative mortality due to acute lung injury

Ilona T.A. Pereboom

Marieke T. de Boer

Elizabeth B. Haagsma


Ton Lisman

Robert J. Porte

Anesthesia & Analgesia

2009;108:1083-1091

8

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Chapter 8

ABSTRACT

Background: Platelet transfusions have been identified as an independent risk factor for survival

after orthotopic liver transplantation (OLT). Aim of this study was to analyze the specific causes of

mortality and graft loss in relation to platelet transfusions during OLT.

Methods: In a series of 449 consecutive adult patients undergoing a first OLT the causes of patient

death and graft failure were studied in patients who did or did not receive perioperative platelet

transfusions.

Results: Patient and graft survival were significantly reduced in patients who received platelet

transfusions, compared to those who did not (74% versus 92%, and 69% versus 85%, respectively

at 1 year; P value <0.001). Lower survival rates in patients who received platelets were attributed

to a significantly higher rate of early mortality due to acute lung injury (4.4% versus 0.4%; P value

=0.004). There were no significant differences in other causes of mortality between the two groups.

The main cause of graft loss in patients receiving platelets was patient death with a functioning

graft.

Conclusions: These findings suggest that platelet transfusions are an important risk factor for

mortality after OLT. The current study extends previous observations by identifying acute lung injury

as the main determinant of increased mortality. The higher rate of graft loss in patients receiving

platelets is related to the higher overall mortality rate and does not result from specific adverse

effects of transfused platelets on the grafted liver.

Implications statement:

Platelet transfusion during liver transplantation is associated with an increased postoperative

mortality due to acute lung injury. These findings call for a cautious use of platelet transfusions in

patients undergoing liver transplantation.

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Platelet transfusion during liver transplantation

8

INTRODUCTION

Evolution of surgical and perioperative care, as well as better understanding of risk factors for

excessive blood loss in patients undergoing orthotopic liver transplantation (OLT), have resulted

in a steady decrease in intra-operative blood loss and transfusion requirements.1 Presently, some

centers report a complete avoidance of blood product transfusions in up to 40% of liver transplant

recipients.1-3 This increasing number of patients, who do not receive any blood products during OLT,

makes it possible to study potential risks and benefits of transfused blood products.

Apart from the obvious life-saving benefits, there is accumulating evidence that transfusion of

blood products is associated with substantial side effects. Although, most previous studies in

liver transplantation have focused on the impact of red blood cell (RBC) transfusions,4,5 platelet

transfusions have also been identified as an independent risk factor for postoperative morbidity and

mortality.6,7 This negative impact is independent from well-accepted indices of severity of disease,

such as the model of end-stage liver disease (MELD) score and Karnofsky score, and similar to well-

described adverse effects of platelet transfusions in patients undergoing cardiac surgery.7 The

specific cause of increased mortality in liver transplant patients who receive platelet transfusion,

however, has not been examined.

The major complications of transfusion are infectious and immunologic.8-10 Although the risk of

viral transmissions (e.g. human immunodeficiency virus and cyomegalo virus) is well known, this

risk has decreased substantially during the last decade because of improved donor screening

and virus-inactivating procedures.11 Transfusion-related morbidity and mortality due to bacterial

contamination, however, remain a concern, especially for platelets which are stored at room

temperature.8 Transfusion-related immunological adverse effects include alloimmunization,

anaphylactic reactions, hemolysis, graft versus host disease, and nonspecific immunosuppressive

effects. In addition, blood product transfusions have been identified as a risk factor for transfusion

related acute lung injury (TRALI).8,12 Acute lung injury (ALI) and acute respiratory distress syndrome

(ARDS) are life threatening disorders characterized by severe inflammation of the lungs.13 The risk of

developing ALI / ARDS seems to be higher after transfusion of fresh frozen plasma (FFP) or platelets

than after RBC transfusion.14

Although platelet transfusions have been identified as a risk factor for reduced graft and patient

survival after OLT, no previous studies addressed mechanism. The aim of this study was to evaluate

the specific causes of graft loss and patient mortality in patients who received platelet transfusion

during OLT versus those who did not.

METHODS

Patients

Eight hundred three liver transplantations were performed in our center between January 1, 1989 and

December 31, 2005. After excluding pediatric transplants (age < 18 years; n =252), retransplantations

(n =90) and combined organ transplantations (n =12), 449 adult patients undergoing a first OLT

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formed the basis of the current study. Analysis of this same patient population6 previously showed

that intraoperative platelet transfusion is associated with increased mortality after OLT.

Characteristics of these patients, including donor and recipient variables, as well as surgical factors

were obtained from a prospectively maintained computer database. When necessary, the original

patient notes were reviewed for missing information. Individual patients were not identifiable

in the database. National legislation and the ethical committee of our institution approved this

retrospective study.

Surgical techniques and perioperative care

ABO group identical or compatible grafts from donation after brain death and cardiac death were

used for all patients. In the study period, both conventional technique for OLT and the cava-sparing

piggyback technique were used for implantation.15 The piggyback technique was first performed

in our center in 1994 and it has become the preferred surgical technique in the vast majority of

patients since 1997.16 Before 1997, veno-venous bypass was used in most cases of conventional OLT,

yet in recent years it has not been used in combination with the piggyback technique.

Anesthesia was initially maintained with a total intravenous technique using sufentanil, midazolam,

and vecuronium, and volume-controlled ventilation. (Midazolam has gradually been replaced

by isoflurane). Blood loss was compensated for by transfusion of allogeneic RBC to maintain the

hematocrit between 0.25 and 0.30. Haemonetics (Braintree, MA, USA) was used in selected patients,

when excessive blood loss was anticipated. Other blood products such as FFP and platelets were

only given in the presence of significant blood loss, and never solely dictated by laboratory values.

Platelet concentrates were given if platelet count dropped below 50 x 109/l, only in the presence

of diffuse bleeding. One unit of platelet concentrates contained approximately 150 mL and was

obtained from five random donors. Aprotinin was administered in all patients, except patients

with known thrombophilia or preexisting thrombotic conditions, or signs of hypercoagulability

on thrombelastography at time of induction of anesthesia. Based on evolving scientific evidence

concerning the efficacy of aprotinin, guidelines have been slightly adapted during the study

period.17

Patient and graft survival

Graft survival was assessed at 90-days and at 1-year after transplantation and was defined as the

time period between transplantation and patient death or retransplantation. Patient survival

was also assessed at 90-days and 1-year after transplantation and was defined as the time period

between transplantation and patient death.

Causes of graft loss were grouped into the following categories: primary non-function, hepatic

artery thrombosis, portal vein thrombosis, hepatic vein thrombosis, biliary complications (such as

nonanastomotic biliary strictures or recurrent cholangitis), acute or chronic rejection, and patient

death. In addition, the following causes of patient death were identified: graft failure, cardiovascular

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disease (including myocardial infarction and hypovolemic shock), pulmonary complications

(including ALI or ARDS and pulmonary embolism), central nervous system complications (including

ischemic and hemorrhagic stroke), sepsis or multiple organ failure, and malignancy.

ALI and ARDS were diagnosed using the American-European Consensus Conference.18


Continuous variables are reported as medians with ranges and categorical variables as numbers with

percentages. Categorical variables were compared using the Pearson’s chi-square test or Fischer’s

exact test. A comparison of continuous variables was performed using the Mann-Whitney U test.

Odds ratios and 95% confidence intervals were calculated using logistic regression analysis. Survival

curves were calculated according to the Kaplan-Meier method and compared using the log-rank

test. A two-tailed P value of <0.05 was considered statistically significant. Statistical analyses were

performed using SPSS version 14.0 (SPSS Inc., Chicago, IL).

RESULTS

Patient characteristics

Patient, donor and surgical characteristics as well as preoperative laboratory values for the entire

group of 449 patients are summarized in Table 1. The minimal postoperative follow-up was 12

months for each patient and median follow-up was 111 months (range 14-217 months). Overall

patient and graft survival rates at 1 year were 85% and 79%, respectively.

Impact of platelet transfusion during OLT on outcome

The median (range) requirement of platelet transfusion for the entire study group was 0 unit (range

0-1units).(Table1) In a univeriate analysis for platelet transfusions, patients who received platelet

transfusion during OLT had a higher MELD score, a lower Karnofsky score, higher blood loss, received

more RBC and FFP transfusions during OLT, and did have worse preoperative laboratory values.

Furthermore longer cold ischemia times were associated with patients who received platelets

during OLT.(Table1)

A statistically significant stepwise reduction in both patient and graft survival rates was observed

with increasing number of platelet transfusions. Patients who received platelets had reduced

survival early after transplantation (within 90 days) compared with those who did not receive

platelets, with no difference in survival after that period. Therefore, for further analysis, we focused

on determinants of early death or graft loss within 90 days after transplantation.

According to institutional guidelines, platelet transfusions were only given to patients who suffered

excessive blood loss and had low platelet counts (<50,000 x 109/L). We, therefore, examined

whether the lower survival rate in patients receiving platelets could be explained by the fact that

these patients had more blood loss or lower pre-operative platelet counts (and thus were sicker).

Patients who received platelet transfusions were indeed found to have significantly lower patient

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Table 1: Patient characteristics and demographics of the study groups.

Variables Total populationn=449

no PLTsn=267

PLTsn=182 P value

RecipientAge (years) cont 47 36-55 47 37-56 47 35-54 0.355Gender male 234 52% 138 52% 96 53% 0.825

female 215 48% 129 48% 86 47%Diagnosis biliary cirrhosis 139 31% 111 42% 28 15% <0.001

postnecrotic cirrhosis 22 50% 104 39% 121 67%metabolic disease 24 6% 24 9% 0 0%miscellaneous 23 5% 10 4% 13 7%acute liver failure 37 8% 17 6% 20 11%

MELD 16 11-23 14 10-20 18 13-27 <0.001Karnosfsky 60 30-70 70 50-70 50 20-70 <0.001Child Turcotte Pugh CTP-A 72 16% 56 22% 16 9% <0.001

CTP-B 170 39% 118 45% 52 29%CTP-C 200 45% 86 33% 114 63%

LOS ICU (days) 3 2-7 3 2-6 4 2-9 0.008Total LOS (days) 39 24-59 37 23-53 45 25-71 0.010DonorAge (years) 47 36-55 45 33-53 39 24-47 <0.001Gender male 228 52% 128 49% 100 57% 0.110

female 209 48% 133 51% 76 43%Type of donor deceased 437 97% 256 96% 181 99% 0.069

DCD 11 2% 10 3% 1 1%ABO identical 388 94% 239 95% 149 93% 0.469

compatible 24 6% 13 5% 11 7%TransplantationEra 1989-1996 194 43% 85 32% 109 60% <0.001

1997-2005 255 57% 182 68% 73 40%Operating time (min) 540 470-645 538 470-630 565 469-663 0.130

WIT (min) 54 46-63 52 45-62 57 49-65 <0.001CIT (min) 588 451-744 535 446-687 678 494-817 <0.001Venous anastomoses classical 252 56% 119 45% 133 73% <0.001

piggy back 197 44% 148 55% 49 27%Blood loss (L) 5,8 2.5-11 3.5 1.9-6.5 10 6.0-18 <0.001Any transfusion yes 374 84% 192 73% 182 100% <0.001

no 71 16% 71 27% 0 0%RBC units 6,3 1.7-13 3.3 0-8,3 11 5.8-18 <0.001FFP units 9 1.2-18 2.7 0-10 16 9.0-22 <0.001Platelet units 0 0-1 1 1.0-2.0Aprotinin yes 164 39% 102 41% 62 35% 0.191laboratory valuesPreop Hemoglobin (mmol/L) 5.9 5.3-6.7 6.2 5.4-7.1 5.7 5.1-6.2 <0.001Preop Platelet count (109/L) 79 51-122 103 67-157 53 39-77 <0.001Preop Prothrombin time (sec) 17.7 15.2-23.1 16.3 14.2-20.1 20.5 17.2-24.9 <0.001Initial postop Hemoglobin (mmol/L) 5.5 4.9-6.1 5.6 5.0-6.2 5.3 4.8-5.9 0.002Initial postop Platelet count (109/L) 57 38-100 80 52-139 40 34-54 <0.001Initial postop Prothrombin time (sec) 25.4 21.3-31.6 25.8 21.2-32.8 25.0 21.5-29.3 0.213

Data are reported as median (interquartile range) and number and proportion. PLTs= platelet transfusions; cont= continuous variables; MELD= model of end-stage liver disease; CTP= Child Turcotte Pugh score; LOS= length of stay; ICU= intensive care unit; WIT=warm ischemia time; CIT= cold ischemia time; RBC= red blood cell transfusion; FFP= fresh frozen plasma transfusion; DCD= donation after cardiac death.

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and graft survival rates than patients who suffered excessive blood loss (requiring >6 units of RBC)

without platelet transfusions.(Figure 1) In addition, patients who received platelets had significantly

lower patient and graft survival rates than patients who had a preoperative platelet count below

50 x 109/l, but who did not require platelet transfusions.(Figure 2) These findings indicate that the

Figure 1: Kaplan Meyer curve representing cumulative early patient survival in relation to the number of intraoperative RBC transfusions (< 6 units versus ≥ 6 units) in patients who did or did not receive platelet transfusions during liver transplantation. PLTs = platelet transfusions.

Table 2: Causes of early patient death (<90 days) after OLT in patients who received platelet transfusions versus those who did not.

Cause of Death No PLTsn=267

PLTsn=182 P value

n % n % OR (95% CI)

Liver related 1 0.4 2 1.1 3.96 (0.266-32.838) 0.569

Myocardial infarction 0 0.0 1 0.5 0.405

Hypovolemic shock 0 0.0 3 1.6 0.066

Acute lung injury/ARDS 1 0.4 8 4.4 12.23 (1.516-98.643) 0.004Pulmonary embolism 1 0.4 2 1.1 2.96 (0.266-32.838) 0.569

Hemorrhagic shock 2 0.7 5 2.7 3.74 (0.718-19.505) 0.125

Ischemic stroke 1 0.4 3 1.6 4.46 (0.460-43.199) 0.308

Sepsis or multiple organ failure 7 2.6 9 4.9 1.93 (0.706-5.286) 0.205

Malignancy 0 0.0 0 0.0 1.000

Unknown 2 0.7 6 3.3 4.52 (0.901-22.634) 0.052

Total 15 5.6 39 21.4 4.58 (2.441-8.602) <0.001

PLTs= platelet transfusions; OLT= orthotopic liver transplantation; ARDS= acute respiratory distress syndrome; CVA= cerebrovascular accident.

Figure 2: Kaplan Meyer curves representing cumulative early patient survival in relation to preoperative platelet count (PC) (≤ 50 x109/l versus > 50 x109/l) in patients who did or did not receive platelet transfusions during liver transplantation. PLTs = platelet transfusions.

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Table 3: Comparison of Patients with early mortality (<90 days) due to ARDS versus those who died from other causes.

Variables no ARDSn=45

ARDSn=9 P value

RecipientAge (years) 47 38-56 49 27-61 0.898Gender male 23 51% 6 67% 0.393

female 22 49% 3 33%Diagnosis biliary cirrhosis 6 14% 2 22% 0.632

postnecrotic cirrhosis 22 49% 6 67%metabolic disease 2 4% 0 0%miscellaneous 2 4% 0 0%acute liver failure 13 29% 1 11%

MELD 18 13-30 18 9-38 0.918Karnofsky 30 20-68 30 10-80 0.801Child Turcotte Pugh CTP-A 5 11% 1 11% 0.695

CTP-B 9 21% 3 33%CTP-C 30 68% 5 56%

LOS ICU (days) 9 3-17 5 1-20 0.409Total LOS (days) 19 9-37 13 3-30 0.390DonorAge (years) 43 24-50 47 16-62 0.609Gender male 26 62% 7 78% 0.366

female 16 38% 2 22%Type of donor deceased 44 98% 9 100% 0.652

DCD 1 2% 0 0%ABO identical 33 85% 5 63% 0.148

compatible 6 15% 3 37%TransplantationEra 1989-1996 26 58% 3 33% 0.179

1997-2005 19 42% 6 67%Operating time (min) 540 448-675 627 300-870 0.410

WIT (min) 55 49-62 60 44-78 0.314CIT (min) 651 471-841 664 480-900 0.776Venous anastomoses classical 15 33% 5 56% 0.208

piggy back 30 67% 4 44%Blood loss (l) 8.8 5.0-20.5 14.4 0.8-17.4 0.276RBC transfusion units 13.3 5.0-27.9 7.5 6.3-23.3 0.609FFP transfusion units 16.2 9.0-22.5 9 6.3-23.0 0.390Aprotinin yes 21 47% 4 44% 1.000Laboratory valuesPreop Hemoglobin (mmol/l) 5.7 4.9-6.3 5.9 4.7-6.9 0.944Preop Platelet count (109/l 67 43-98 51 37-74 0.313Preop Prothrombin time (sec) 20.8 17.3-27.9 18.5 16.6-20.7 0.278Initial postop Hemoglobin (mmol/L) 5.3 4.9-5.6 5.3 4.8-6.3 0.872Initial postop Platelet count (109/L) 40 34-67 48 35-60 0.882Initial postop Prothrombin time (sec) 28.1 21.8-44.0 26.6 24.3-35.7 0.494

Data are reported as median (interquartile range) and number and proportion. ARDS= acute respiratory distress syndrome; cont= continuous variables; MELD= model of end-stage liver disease; CTP= Child Turcotte Pugh score; LOS= length of stay; ICU= intensive care unit; WIT= warm ischemia time; CIT= cold ischemia time; DCD= donation after cardiac death.

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negative association between platelet transfusion and survival is not simply related to the fact the

patients receiving platelet transfusions had lower preoperative platelet counts or suffered greater

intraoperative blood loss.

Cause of increased patient death after platelet transfusion

To determine the cause of increased mortality in patients receiving platelets during OLT, the specific

causes of death in the two groups were compared. Death because of ALI / ARDS occurred more

frequently in patients who received platelets (OR 12.23; 95% CI, 1.51 to 98.64; P value =0.004).(Table

2). Eight patients who received intraoperative platelet transfusions died from ALI / ARDS. In three of

these patients, postmortem autopsy was performed, showing heavy lungs because of severe lung

edema in accordance with the clinical diagnosis of ARDS. All other causes of death were similarly

distributed. When comparing the characteristics of the patients with early mortality because of

ALI / ARDS with those who died from other causes, no other significant differences were found. In

particular preoperative platelet count and intraoperative blood loss were not different in patients

who died from ARDS, compared to those who died from other causes.(Table 3)

Causes of graft loss in relation to platelet transfusions

To determine the cause of graft loss in patients who received platelets, we compared the specific

causes of graft loss in patients who received platelets with those who did not.(Table 4) Patient death

with a functioning graft appeared to be the most frequent overall cause of graft loss. Early graft loss

because of patient death occurred significantly more frequently in patients who received platelets,

compared with those who did not. There were no significant differences in the distribution of the

other causes of early graft loss between the two groups.

Table 4. Causes of early graft failure (<90 days) after OLT in patients who received platelet transfusions versus those who did not.

Cause of Graft failure No PLTsn=267

PLTsn=182 OR (95% CI) P value

n % n %

Primary non function 4 1.5 0 0.0 0.128

Hepatic artery thrombosis 5 1.9 6 3.4 1.82 (0.55-6.06) 0.246

Portal vein thrombosis 0 0.0 1 0.6 0.401

Biliary complications 2 0.8 1 0.6 1.12 (0.24-5.08) 0.647

Rejection 2 0.8 0 0.0 0.358

Death with functioning graft 13 4.9 35 19.7 4.14 (2.32-7.39) <0.001

Unknown 1 0.4 3 1.6 4.46 (0.46-43.20) 0.308

Total 27 10.1 46 25.3 3.01 (2.32-7.39) <0.001

PLTs= platelet transfusions; OLT= orthotopic liver transplantation.

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DISCUSSION

Platelet transfusions have been identified as an independent risk factor for adverse postoperative

outcome after cardiac surgery and liver transplantation.6-7 Our group recently reported that

intraoperative platelet transfusions are an independent risk factor for one-year patient survival

after liver transplantation. Multivariate analysis revealed no significant negative impact of platelet

transfusion on graft survival.6 The present study extends this report, and shows that decreased

survival of patients as a function of platelet transfusion is due to ALI or ARDS. The increased rate of

graft loss after platelet transfusions was not related to graft-related thrombotic complications, such

as hepatic artery thrombosis, but caused by higher patient mortality with functioning graft.

The findings of our study indicate that the adverse effects of platelet transfusions are due to a

more systemic response. Transfusion of blood products can cause severe pulmonary reactions, also

known as TRALI or ARDS.19 TRALI / ARDS is the leading cause of transfusion related death because

in 5%-15% of these cases this reaction is fatal.19,20 Although massive RBC transfusion has long been

implicated as a risk factor for TRALI / ARDS, recent studies show that not RBC, but in fact plasma-

rich blood products, as FFP and platelet transfusions, are associated with the development of ALI /

ARDS.14 This is in line with two leading hypotheses for pathogenesis of TRALI / ARDS: passive transfer

of antileukocyte antibodies in plasma-rich blood products as platelets,8,21 and the accumulation of

inflammatory mediators in stored platelets.22

In our study the risk of developing TRALI / ARDS is higher in patients who received platelet

transfusions during liver transplantation in comparison to other blood products.

ALI and ARDS are clinical syndromes characterized by the acute onset of severe hypoxemia and

bilateral pulmonary infiltrates in the absence of clinical evidence for left atrial hypertension.13,23 Both

ALI and ARDS occur in association with a variety of clinical disorders, including sepsis, pneumonia,

aspiration, trauma including inhalational injury, and (massive) blood transfusions (TRALI). The

hallmark of ALI / ARDS is diffuse alveolar damage and increased pulmonary microvascular

permeability with increased protein content of the edema fluid.13,23 Two putative mechanisms

explaining the increased pulmonary microvascular permeability have been proposed: 1) binding of

cytotoxic leukocyte antibodies causing complement activation,21 and 2) neutrophil priming activity

of biologically active substances such as lipids or cytokines.22 Both effects cause endothelial damage

and capillary leakage resulting in ALI. Next to leukocytes and erythrocytes, platelets do play a role in

enhancing lung endothelial injury in concert with cytokines-releasing leukocytes.13,21,22-24

Pulmonary platelet sequestration has also been implicated in the pathophysiology of ALI /

ARDS.23,25 The cause of platelet aggregation, however, is unclear and different hypotheses are

known in liver transplant recipients, including pulmonary aggregation of platelets because of cell

debris released from the ischemic donor liver,26,27 or by the release of endotoxins from the donor

liver after reperfusion.28 Transfused platelets have been suggested as a possible cause of multiple

platelet emboli in the lung.29,30 Platelet microaggregates formed in stored platelet concentrates may

obstruct small pulmonary vessels and therefore lead to ALI / ARDS.

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Platelet concentrates can be stored for up to five days at room temperature. Storage for several days

results in platelet activation accompanied by release of growth factors and cytokines from platelet

granules, as well as conjugation with white blood cells. Cytokine levels in the medium of platelet

concentrates can increase as high as 1000-fold compared with the plasma levels seen in normal

healthy individuals. In that way a platelet transfusion itself is proinflammatory and a risk factor for

the development of TRALI / ARDS.31 Storage at room temperature makes platelet concentrates prone

to bacterial contamination. Bacterial infection or sepsis may lead to activation of leukocytes and

subsequent priming and sequestration of leukocytes into the lungs, which is a serious risk factor

for TRALI / ARDS.19 Unfortunately, we had no information on the storage times of blood platelet

concentrates given to the individual patients in our study.

Platelet concentrates are prepared by using either one of the two whole-blood procedures (platelet-

rich plasma or buffy coat based) or by using plateletapheresis.9 Both the platelet-rich plasma

and buffy coat procedures use a two-step differential centrifugation process. Plateletpheresis is

done by blood-cell separators that allow the selective collection of large numbers of platelets in

predefined volumes of donor plasma. Only one donor is used for platelet concentrates prepared

by plateletpheresis, whereas platelet concentrates prepared from whole blood use pooled material

from four to eight donors. Although plateletpheresis is more expensive, the fewer donors to which

recipients are exposed decreases the risk of transfusion-related complications.32 In the current study,

all platelet concentrates were prepared by the buffy coat-based procedure, in which platelets from

five donors were pooled for one unit of platelets. The increased rate of early postoperative death

because of ALI / ARDS may have been related to the preparation procedure used, but based on our

data we cannot make conclusions on the impact of the preparation method.

Although platelet transfusions in liver transplantation appear to be a risk factor for decreased

patient survival after liver transplantation because of ALI / ARDS, it is difficult to prove causality

in a retrospective analysis. Platelet transfusions might be a surrogate marker for sicker patients.

When comparing recipient, donor, and transplantation characteristics for patients who did and

patients who did not receive platelet transfusions during liver transplantation, patients receiving

platelet transfusion had a higher MELD score, a lower Karnofsky score, higher blood loss, received

more FFP and RBC transfusions during liver transplantation, were associated with longer cold and

warm ischemia times, and had worse preoperative laboratory values. All these variables indicate

that patients who receive platelets during liver transplantation were sicker. However, in our

previous study on the same cohort used here, we already showed that patient survival rates were

independently associated with platelet transfusions during liver transplantation.6 Furthermore,

the suggestion can be made that patients who received platelets during liver transplantation

suffered from lower preoperative platelet counts or greater intraoperative blood loss and thus were

sicker. When calculating survival rates in patients with greater intraoperative blood loss and lower

preoperative platelet counts who did and did not receive platelets, survival was significantly lower

in those patients who received platelets in comparison to those who did not. Actually, survival

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rates in patients who had low preoperative platelet counts and high intraoperative blood loss,

but who did not receive any platelet concentrates, were similar to survival rates in the reference

population (patients with normal preoperative platelet counts and and no major blood loss).

These findings indicate that the negative association between platelet transfusion and survival is

not simply related to the fact that patients receiving platelet transfusions were sicker, or had lower

preoperative platelet counts and/or high intraoperative blood loss. Definite proof, however, could

only come from prospective randomized controlled studies in which different thresholds for platelet

transfusions will be compared. Although prospective trials comparing different platelet thresholds

as a trigger for platelet transfusions have been performed in patient suffering from leukemia,35

to our knowledge, such studies have never been performed in liver transplant recipients. Ethical

consideration, and the large variation in platelet function and thrombocytopenia in these patients,

will make this kind of study very difficult to perform. Despite the lack of randomized studies, our

findings are in agreement with previous studies in and outside the field of liver transplantation, and

provide substantial support for the hypothesis that platelet transfusions are a risk factor for ALI /

ARDS influencing outcome after liver transplantation.

Based on this hypothesis, more rational platelet transfusion regimens are urgently needed. Triggers

for platelet transfusion in liver transplant recipients should not just be based on platelet counts

alone. Although a minimum number of platelets are probably required for normal hemostasis,

it remains to be established at which threshold platelets should be transfused. Recent studies

focusing on primary hemostasis in patients with cirrhosis have suggested that the highly elevated

levels of von Willebrand Factor in these patients compensate for the reduced platelet number

and primary hemostasis may not be as abnormal as would be expected based on platelet count

alone.36,37 Laboratory tests that measure overall coagulation function in whole blood samples, such

as thrombelastography, seem more appropriate to distinguish patients who may require platelet

transfusion than measurement of platelet count alone.36-38 In addition, it seems relevant to distinguish

between prophylactic platelet transfusion (i.e., platelet count under a certain threshold, without

bleeding complications) and transfusions intended to control bleeding. Given the detrimental

effects of platelet transfusions, it seems reasonable not to transfuse patients based on a low platelet

count alone (as long as perioperative hemostasis is secured), and only to transfuse if bleeding

complications do occur. It may, however, be difficult to assess whether a bleeding complication

during liver transplantation is a result of the lack of (functional) platelets, is due to defects in other

hemostatic systems, or has a surgical origin. An emerging new strategy to avoid platelet transfusion

may be the preprocedural stimulation of platelet synthesis by a thrombopoietin-receptor agonist.39

A possible concern, however, may be the induction of thrombo-embolic complications when

platelet counts are normalized in patients with cirrhosis who usually have very high levels of von

Willebrand Factor.34,35

In conclusion, this study confirms and extends previous hypotheses regarding the negative

effects of platelet transfusions on outcome after OLT. Increased postoperative mortality in patients

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receiving platelets is ascribed to an increased mortality due to ALI / ARDS. Platelet transfusions were

not associated with an increased occurrence of graft-related thrombotic complications. Although

there is no good alternative therapy for platelet transfusions in the situation of excessive bleeding,

it seems advisable to avoid unnecessary prophylactic transfusion of platelets in liver transplant

recipients.

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REFERENCES

1. de Boer MT, Molenaar IQ, Hendriks HG, Slooff MJ, Porte RJ. Minimizing blood loss in liver transplantation: progress through research and evolution of techniques. Dig Surg 2005;22:265-275.

2. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S, et al. Primary liver transplantation without transfusion of red blood cells. Surgery 1996;120:698-704.

3. Massicotte L, Sassine MP, Lenis S, Seal RF, Roy A. Survival rate changes with transfusion of blood products during liver transplantation. Can J Anaesth 2005;52:148-155.

4. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Busque S, Concepcion W, et al. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg 1999;134:25-29.


6. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HGD, Slooff MJH, et al. Impact of intraoperative transfusion of platelets and red blood cell on survival after liver transplantation. Anesth Analg 2008;106:32-44.

7. Spiess BD, Royston D, Levy JH, Fitch J, Dietrich W, Body S, et al. Platelet transfusions during coronary artery bypass graft surgery are associated with serious adverse outcomes. Transfusion 2004;44:1143-1148.

8. Kopko PM, Holland PV. Mechanisms of severe transfusion reactions. Transfus Clin Biol 2001;8:278-281.


10. Stroncek DF, Rebulla P. Platelet transfusions. Lancet 2007;370:427-438.

11. Goodnough LT, Shander A, Brecher ME. Transfusion medicine: looking to the future. Lancet 2003:11;361:161-169.

12. Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care Med 1995;151:293-301.

13. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 2000;342:1334-1349.

14. Khan H, Belsher J, Yilmaz M, Afessa B, Winters JL, Moore SB, et al. Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients. Chest 2007;131:1308-1314.

15. Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 1989;210:649-652.

16. Miyamoto S, Polak WG, Geuken E, Peeters PM, de Jong KP, Porte RJ, et al. Liver transplantation with preservation of the inferior vena cava. A comparison of conventional and piggyback techniques in adults. Clin Transplant 2004;18:686-693.

17. Porte RJ, Molenaar IQ, Begliomini B, Groenland TH, Januszkiewicz A, Lindgren L,Palareti G, Hermans J, Terpstra OT. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. Lancet 2000; 355: 1303-1309.

18. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R: The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994, 149:818-824.

19. Toy P, Popovsky MA, Abraham E, Ambruso DR, Holness LG, Kopko PM, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med 2005;33:721-726.

20. Goldman M, Webert KE, Arnold DM, Freedman J, Hannon J, Blajchman MA. Proceedings of a consensus

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conference: towards an understanding of TRALI. Transfus Med Rev 2005;19:2-31.

21. Popovsky MA, Moore SB. Diagnostic and pathogenetic considerations in transfusion-related acute lung injury. Transfusion 1985;25:573-577.

22. Silliman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med 2006;34:S124-S131.

23. Gosseye S, van Obbergh L, Weynand B, Scheiff JM, Moulin D, de Ville de Goyet J et al. Platelet aggregates in small lung vessels and death during liver transplantation. Lancet 1991;338:532-534.

24. Ware LB. Pathophysiology of acute lung injury and the acute respiratory distress syndrome. Semin Respir Crit Care Med 2006;27:337-349.

25.. Sankey EA, Crow J, Mallett SV, Alcock RJ, More L, Burroughs AK et al. Pulmonary platelet aggregates: possible cause of sudden preoperative death in adults undergoing liver transplantation. J Clin Pathol 1993;46:222-227.

26. Jansson IG, Hetland O, Rammer LM, Prydz HE, Lennquist SE. Effects of phospholipase C, a tissue thromboplastin inhibitor, on pulmonary microembolism after missile injury of the limb. J Trauma 1988;28:S222-S225.

27. McCandless BK, Kaplan JE, Cooper JA, Malik AB. Determinants of platelet kinetics: effects of pulmonary microembolism. J Appl Physiol 1988;65:1716-1722.

28. Rabinovici R, Esser KM, Lysko PG. Priming by platelet-activating factor of endotoxin-induced lung injury and cardiovascular shock. Circ Res 1991;69:12-25.

29. McNamara JJ, Anderson BS, Hayashi T. Stored blood platelets and microaggregate formation. Surg Gynecol Obstet 1978;147:507-512.

30. Mosely RV, Doty DB. Changes in the filtration characteristics of stored blood. Am Surg 1970;171:329-335.

31. Spiess BD. Risks of transfusion: outcome focus. Transfusion 2004;44:4S-14S.


33. Rebulla P, Finazzi G, Marangoni F, Avvisati G, Gugliotta L, Tognoni G, et al. The threshold for prophylactic platelet transfusions in adults with acute myeloid leukaemia. Gruppo Italiano Malattie Ematologiche Maligne dell’Adulto. N Eng J Med 1997;337:1870-1875.

34. Lisman T, Bongers TN, Adelmeijer J, Janssen HLA, de Maat MPM, de Groot PG, et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006;44:53-61.

35. Lisman T, Caldwell SH, Leebeek FWG, Porte RJ. Hemostasis in chronic liver disease. J Thromb Haemost 2006 ;4:2059-2060.

36. Kang YG, Martin DJ, Marquez J, Lewis JH, Bontempo FA, Shaw BW, et al. Intraoperative changes in blood coagulation and thromboelastographic monitoring in liver transplantation. Anesth Analg 1985;64:888-896.

37. Pivalizza EG, Abramson DC. Thromboelastography as a guide to platelet transfusion. Anesthesiology 1995;82:1086.

38. Salooja N, Perry DJ. Thromboelastography. Blood Coagul Fibrinolysis 2001;12:327-337.

39. McHutchison JG, Dusheiko G, Shiffman ML, Rodriguez-Torres M, Sigal S, Bourliere M, et al. Eltrombopag for thrombocytopenia in patients with cirrhosis associated with hepatitis C. N Engl J Med 2007;357:2227-2236.

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The impact of blood transfusion on the incidence of acute rejection in orthotopic liver

transplantationMarieke T. de Boer

Fraukje A.M. PondsAad P. van den Berg

Ton LismanHerman G.D. Hendriks

Annette S.H. GouwRobert J. Porte

Submitted for publication

9

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Chapter 9

ABSTRACT

Introduction: Improvements in anesthesiological and surgical techniques have lead to a decrease in

the use of blood products during orthotopic liver transplantation (OLT). Nowadays several centers

describe series of patients who were transplanted without intraoperative blood transfusion. Blood

transfusion is generally considered to be harmful, although in kidney transplantation early reports

have suggested a protective effect of RBC transfusion on the incidence of rejection after kidney

transplantation. Aim of our study was to determine whether RBC transfusion has a protective effect

against rejection in OLT.

Patients and Methods: Between 1995 and 2004, 292 primary liver transplantations in adults were

performed. Specific reason to select this decade is that at that time it was our policy to perform a

routine liver biopsy within 2 weeks after OLT, if the clinical condition would allow this. This policy

was abandoned after 2004. All patients who underwent a biopsy within 2 weeks were included.

Patients who died or were retransplanted <7 days after OLT were excluded. Recipient and donor

parameters and intraoperative transfusion requirements were available in a prospectively collected

database. Uni- and multivariate analysis was performed to determine the risk factors for histological

graft rejection.

Results: In total, 197 patients had a biopsy within 2 weeks after OLT. Median age was 49 years, 57%

of recipients was male, median MELD score was 16. Fifty-nine (30%) patients did not receive any

RBC transfusion during OLT. Sixty (31%) patients had no signs of acute rejection in the biopsy. After

uni-and multivariate analysis the following variables were found to be independently associated

with reduced risk of acute rejection (any Banff grade): RBC transfusion intraoperative (OR 2.811, 95%

CI 1.258-6.280, P value =0.012), and induction immunosuppression (OR 2.061, 95% CI 1.085-3.915,

P value =0.027)

Conclusion: This study shows that there is an increased risk of developing acute rejection after OLT

when patients do not receive any RBC transfusion during OLT.

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The impact of blood transfusion on the incidence of acute rejection in orthotopic liver transplantation

9

INTRODUCTION

Until the mid 1980s liver transplantation was a procedure with high morbidity and mortality,

frequently related to high blood loss and transfusion requirements.1,2 Over the years anesthesiological

and surgical techniques in liver transplantation have improved, and it became possible to perform

liver transplantation without transfusion of blood products.3 Nowadays several centers describe

series of patients who were transplanted without intraoperative blood transfusion.3-6 Transfusion

of blood products in liver transplantation is generally considered to be harmful,7-10 which is

thought to be related to the immunosuppressive effect of blood transfusions.11 Early reports in

kidney transplantation have suggested a protective effect of RBC transfusion on the incidence of

rejection.12-15 Aim of our study was to determine whether RBC transfusion in liver transplantation

has a protective effect against rejection in liver transplantation.

PATIENTS AND METHODS

Study population

Between the first of January 1995 and the 31st of December 2004, 574 patients underwent a OLT

at our center. After exclusion of retransplantations (n=151), pediatric OLTs (n=116), and combined

organ transplantations (n=15), 292 adult patients undergoing a primary transplant were identified

as the cohort of our current study. Specific reason to select this era was that during this decade it

was our policy to perform a routine liver biopsy within 2 weeks after transplantation. After 2004 this

policy was abandoned, because of risk of complications combined with the reduced clinical impact

of the results of these biopsies. Biopsy is from then onward only performed “on indication”. Patients

who died within one week after transplant or who underwent a retransplantation within one week

were excluded. Patients who had a biopsy within 2 weeks after OLT were included and patients

without a routine biopsy were separately analyzed.(Figure 1) To rule out selection bias, baseline

characteristics between the routine biopsy group were compared to the whole group of patients.

Follow-up was complete until the 31st of December 2012. Patient characteristics, including donor

and recipient variables, as well as intraoperative transfusion requirements and biopsy results

were obtained from a prospectively maintained computer database. Preoperative transfusion

requirements (<3 months before transplantation) and postoperative transfusion requirements (<1

week after transplantation) were collected retrospectively. The original patient notes were reviewed

in case of missing information. According to the national legislation in the Netherlands, this type of

retrospective analysis is allowed without individual consent of patients.

Blood transfusion policy

As has been described previously, the transfusion policy in our center is characterized by a restrictive

use of blood products.3,9 RBC transfusion were leucocyte-reduced from the first of January 2002

onward. Surgical techniques, anesthetic management and general blood transfusion policy in our

center were extensively described previously.9

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Immunosuppressive management

After transplantation two types of immunosuppressive schemes were used. The standard scheme

was tacrolimus with small-dose prednisolone. Patients with autoimmune diseases (autoimmune

hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis) were treated with triple

therapy, consisting of cyclosporine A, azathioprine and small-dose prednisolone. Mycophenolate

mofetil was added and calcineurin inhibitors were withheld in patients with a compromised kidney

function, until creatinine clearance was more than 50mL/min, and induction therapy was started.

Until 1997 induction therapy consisted of one-week cyclophosphamide, after 1997 of basiliximab

in two doses of 20 mg/day, with an interval of 4 days. Our current immunosuppressive scheme has

not changed apart from the fact that induction therapy with basiliximab is now given to all patients.

Biopsy-proven rejection was treated with methylprednisolone on three consecutive days. Treatment

was converted to tacrolimus in patients with cyclosporine A or by five doses of antithymocyte

globuline (ATG) on alternative days when rejection was steroid-resistant.

Rejection analysis

One dedicated liver pathologist reviewed all biopsies and grading was done according to the Banff

grading system.16 Acute graft rejection was divided in 4 grades (indeterminate, mild, moderate,

severe) versus no rejection.(Table 1)

Figure 1 Consort table patient inclusion.

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Risk factors and outcome variables

Primary endpoint of this study was to analyze the effect of RBC transfusion on the incidence of

acute rejection after liver transplantation. General risk factors for rejection were selected based on

a review of the literature. The following recipient-related variables were included: age, sex, era of

transplantation, body mass index, indication for transplantation, preoperative CTP score and MELD

score, postoperative immunosuppressive drug scheme (cyclosporine versus tacrolimus-based,

and induction therapy versus no induction therapy). Donor-related variables included age, sex,

type of donor (deceased brain-death versus donation after cardiac death), and graft type (full size

versus partial grafts). In addition, the following surgical variables were studied: blood loss, surgical

technique (conventional versus piggyback), operating time, and cold and warm ischemia time. With

respect to intraoperative blood component transfusion requirement, the following variables were

analyzed: the number of units of allogeneic and RBC, units of FFP, and units of platelets concentrates

(one unit was obtained from five donors). With respect to a possible immunosuppressive effect of

transfusions, blood products were also categorized in zero transfusion versus any transfusion.

Graft survival was defined as the timeframe between transplantation and the end of follow-up

or graft loss by patient death or by graft failure requiring retransplantation. Patient survival was

defined as the timeframe between transplantation and the end of follow-up.


Uni- and multivariate analysis was performed to determine the risk factors for histological graft

rejection. Missing data were treated according to a listwise deletion approach. Categorical variables

were expressed as number and percentage. Continuous variables were expressed as median and

interquartile range (IQR). Comparisons of categorical variables were performed with the use of

Fisher’s exact test or Pearson chi-square test. For comparison of continuous variables we used the

Mann-Whitney U test. All statistical tests were performed two-tailed.

Univariate tested variables with a P value <0.10 were included in a multivariate logistic regression

analysis. A P value =<0.05 was considered to indicate statistical significance. One-, 5-, and 10-year

patient and graft survival rates were analyzed according to the Kaplan-Meier method and differences

Table 1: Grading acute cellular rejection in liver transplantation

Grade

No rejection 0

Indeterminate 0-IPortal inflammatory infiltrate that fails to meet the criteria for the diagnosis of acute rejection

Mild rejection IRejection infiltrate in a minority of the triads, that is generally mild, and confined with portal spaces

Moderate rejection II Rejection infiltrate, expanding most or all of the triads

Severe rejection IIIAs above for moderate, with spillover into periportal areas and moderate to severe perivenular inflammation that extends into the hepatic parenchym and is associated with perivenular hepatocyte necrosis

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between groups were investigated using the log-rank test. Statistical analyses were performed with

the use of PASW Statistics Software, version 20.0 (SPSS, Chicago, IL).

RESULTS

Study population

To analyze the risk factors for rejection, 16 patients from the cohort of 292 OLT recipients were

excluded.(Figure 1) Eleven patients died within 7 days after transplantation, and 5 underwent a

retransplantation within 7 days after OLT. Of the 276 evaluable patients 79 patients did not get

a routine biopsy for several clinical reasons (32 patients because of disturbed coagulation tests

or thrombocytopenia, in 27 patients biopsy was contraindicated because of their poor clinical

condition, and in 20 patient the reason not to biopsy was unknown). In total, 197 patients had a

biopsy within 2 weeks after OLT.

Recipient characteristics

The median age of this group of recipients was 49 years old, and 57% (n=113) of recipients were

male. In total, 60 patients (31%) had no signs of rejection in the biopsy. (Table 2) When compared

to the group of 79 patients without a routine biopsy, baseline characteristics did differ between

the two groups. Patients who did not get a routine biopsy were more often operated in the era

1994-1999, had more classical implantations, had longer cold ischemia times, and had a higher

RBC and FFP transfusion rate. This probably represents a clinically sicker group of patients with

contraindications for routine biopsy.

Patient and graft survival rates were calculated for the cohort of 276 patients. Patient survival at 1-,

5- and 10-year was 88%, 79% and 71%, respectively. One-, 5-, and 10-year graft survival was 83%,

70%, and 59% respectively.

Transfusion of blood products

There was no need for intraoperative RBC transfusion in 59 (30%) patients, and FFP transfusion

in 73 (37%) patients in the routine biopsy group.(Table 3) Preoperatively (within 3 months before

transplantation) only 21 (11%) patients received RBC transfusion and 21 (11%) received FFP

transfusion. Postoperatively (within 1 week after transplantation) 109 (55%) patients received RBC

transfusion and 56 (29%) received FFP transfusion.

Uni- and multivariate analysis of variables associated with acute cellular rejection

Continuous variables associated with an increased incidence of any grade of acute cellular rejection

after liver transplantation in the univariate analysis were: Intraoperative RBC transfusion, total RBC

transfusion, intraoperative FFP transfusion, total FFP transfusion and blood loss.(Table 4) Categorical

variables associated with rejection were: Induction immunosuppression, any RBC transfusion

(pre-intra and postoperative), any FFP transfusion (pre-intra and postoperative), RBC transfusion

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Table 2 Recipient, Surgical, and Donor Variables

Recipient variables Routine biopsy (n = 197)

Age (years) 49 (38-56)

BMI (kg/m2) 24 (22-26)

MELD score (lab-MELD) 16 (12-22)

GenderMaleFemale

113 (57%)84 (43%)

Indication for transplantationPostnecrotic cirrhosisBiliary cirrhosisAcute liver failureMetabolicMiscellaneous

109 (55%)56 (28%)14 (7%)9 (5%)9 (5%)

Immunosuppression Tacrolimus basedCyclosporin basedOther

83 (42%)105 (53%)9 (4.6%)

Induction Immunosuppression Induction therapy (endoxan, or simulect)No induction therapy

102 (52%)95 (48%)

Era (filtered RBC from 2002)1995-20012002-2004

137 (70%)60 (30%)

Rejection (max grade acc. to Banff biopsies <14 days)No rejectionGr 0-IGr IGr IIGr III

60 (31%)13 (7%)63 (32%)42 (21%)18 (9%)

Surgical variables

CIT (hr:min) a 8:54 (7:19-10:49)

WIT(min) b 51 (44-62)

Estimated total blood loss (l) 3.7 (1.8-7.1)

Caval Vein AnastomosisClassicalPiggyback

63 (32%)134 (68%)

Donor variables

Age (years) 45 (35-54)

GenderMaleFemale

96 (49%)101 (51%)

Type of donor liverDBDDCD

194 (99%)3 (1%)

Graft sizeFull sizeReduced size or split

192 (98%)5 (2%)

Data represent median with interquartile ranges (IQR) for continuous variables or numbers (percentages) for categorical variables.Abbreviations used; BMI: body mass index, CIT: cold ischemia time, DBD: donation after brain death, DCD: donation after circulatory death, WIT: warm ischemia time.a) Time from in situ flushing of the donor organ until the liver is removed from ice for implantation.b) Time from removal of liver from ice until reperfusion via portal vein, hepatic artery or both.

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Table 3: Transfusion data

Recipient variables Routine biopsy (n = 197)

Estimated total blood loss (l) 3.7 (1.8-7.1)

Preop RBC transfusion (units) 0 (0-0)

Intraop RBC transfusion (units) 3.3 (0-7.5)

Postop RBC transfusion (units) 1.0 (0-2.0)

Preop FFP transfusion (units) 0 (0-0)

Intraop FFP transfusion (units) 3.6 (0-9.9)

Postop FFP transfusion (units) 0 (0-1.0)

Preop PLT transfusion (units) 0 (0-0)

Intraop PLT transfusion (units) 0 (0-1)

Postop PLT transfusion (units) 0 (0-1)

Intraop RBC transfusionYesNo

138 (70%)59 (30%)

Intraop FFP transfusionYesNo

122 (63%)73 (37%)

RBC transfusion (pre, intra & postoperative)YesNo

165 (84%)32 (16%)

Any transfusion (pre, intra & postoperative)YesNo

170 (86%)27 (14%)

Data represent median with interquartile ranges (IQR) for continuous variables or numbers (percentages) for categorical variables.Abbreviations used: FFP: fresh frozen plasma, MELD: model of end-stage liver disease, PLT: platelets, RBC: red blood cells.

intraoperative and FFP transfusion intraoperative.

Multivariate analysis for reduced risk of acute rejection revealed the following independent

variables: intraoperative RBC transfusion (OR 2.811, 95% CI 1.258-6.280, P value =0.012) and

induction immunosuppression (OR 2.061, 95% CI 1.085-3.915, P value =0.027).(Table 5) We could

not show a dose-dependent correlation between intraoperative RBC transfusion and rejection in

the multivariate analysis.

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Table 4: Univariate analysis risk factors rejection 2 weeks biopsy

P value No rejection (n=60) Rejection (n=136)

Contin. Variables

Age (yrs) 0.217 50 (41-56) 48 (35-56)

MELD-score 0.553 17 (12-23) 16 (12-21)

CIT (hrs) 0.172 9:33 (7:22-11:24) 8:41 (7:17-10:32)

WIT (hrs) 0.144 56 (44-63) 50 (43-60)

Donorage (yrs) 0.883 45 (29-56) 46 (37-53)

Blood loss (L) 0.004 5.7 (2.5-10.8) 3.5 (1.4-6.8)

Intraop RBC (u) 0.001 5.8 (2.5-8.3) 2.5 (0-6.7)

Total RBC (u) 0.001 7.5 (4.1-11.6) 4.1 (1.2-9.3)

Intraop FFP (u) 0.007 5.4 (1.8-11.7) 1.8 (0-9.0)

Total FFP (u) 0.005 7.4 (2.8-15.4) 3.6 (0-10.0)

Intraop PLT (u) 0.361 0 (0-1.0) 0 (0-1.0)

Total PLT (u) 0.263 0 (0-2.0) 0 (0-1.0)

Operating time (in hrs including anesthesiology)

0.888 9:30 (8:15-11:29) 9:25 (8:00-11:12)

Categ. Variables

Gender Male Female

1.00035 (58%)25 (42%)

78 (57%)58 (43%)

MELD < 18> 18

0.41931 (54%)26 (46%)

81 (62%)50 (38%)

IndicationPostnecrotic CirrhosisBiliary CirrhosisAcute liver failureMetabolicMiscellaneous

0.39039 (65%)12 (20%)4 (7%)2 (3%)3 (5%)

69 (51%)44 (32%)10 (7%)7 (5%)6 (4%)

Piggyback Yes No

0.06935 (58%)25 (42%)

98 (72%)38 (28%)

Era (filtered RBC from 2002)1995-20012002-2004

0.40339 (65%)21 (35%)

97 (71%)39 (29%)

Previous abdominal surgeryYesNo

0.85513 (29%)47 (31%)

32 (23%)104 (77%)

Immunosuppression (1)Tacrolimus basedCyclosporin basedOther

0.43521 (35%)36 (60%)3 (5%)

61 (45%)69 (51%)6 (4%)

Induction Immunosuppression Induction (endoxan or simulect)No induction

0.00822 (37%)

38 (63%)

79 (58%)

57 (42%)

Any RBC transfusion a

YesNo

0.00357 (95%)3 (5%)

107 (79%)29 (21%)

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Table 5: Multivariate analyses for reduced risk of rejection (any grade)

Odds Ratio 95% CI P value

Intraoperative RBC (categ) 2.811 1.258-6.280 0.012

Induction Immunosuppression (categ) 2.061 1.085-3.915 0.027

Abbreviations used; categ: categorical variable

Any FFP transfusion a

YesNo

0.01348 (81%)11 (19%)

83 (62%)52 (38%)

RBC preopYesNo

0.7757 (12%)53 (88%)

14 (10%)122 (90%)

FFP preopYesNo

0.4745/60 (8%)55/60 (92%)

16/136 (12%)130/136 (88%)

RBC intraopYesNo

0.00451 (85%)9 (15%)

87 (64%)49 (36%)

FFP intraopYesNo

0.00646 (78%)13 (22%)

75 (56%)60 (44%)

RBC postopYesNo

0.77034 (57%)26 (43%)

74 (54%)62 (46%)

FFP postopYesNo

0.19621 (35%)39 (65%)

35 (26%)100 (74%)

CIT b

<10 hours≥10 hours

0.03732 (53%)28 (47%)

94 (69%)42 (31%)

WIT c

<40 min≥40 min

0.4168 (22%)52 (78%)

25 (19%)110 (81%)

Antifibrinolytic useYesNo

0.49717 (33%)35 (67%)

50 (39%)77 (61%)

Data represent median with interquartile ranges (IQR) for continuous variables or numbers (percentages) for categorical variables.Abbreviations used; CIT: cold ischemia time, DBD: donation after brain death, DCD: donation after circulatory death, FFP: fresh frozen plasma, MELD: model of end-stage liver disease, PLT: platelets RBC: red blood cells, WIT: warm ischemia time. a) Any transfusion preoperative (within 3 months before OLT), intraoperative and postoperative (until 1 week post OLT)b) Time from in situ flushing of the donor organ until the liver is removed from ice for implantation.c) Time from removal of liver from ice until reperfusion via portal vein, hepatic artery or both

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DISCUSSION

In kidney transplantation protective effects against acute rejection by preoperative RBC transfusion

have been described.12-15 In the field of OLT it has been difficult to analyze the effect of transfusion on

acute rejection by the simple fact that in previous decades all patients received RBC transfusion.1-3

Over the years anesthesiological and surgical improvements have made it possible to perform

OLT without transfusion of blood products.3-6 Since the late nineties OLT without RBC transfusion

was described.6 Previously we have reported 31% of adult primary OLT patients without any RBC

transfusion in the era 1997-2004.9 During this era it was our policy to perform routine liver biopsies

focusing on rejection in all patients, unless there were contraindications. This available data has

made it possible to show that there is an increased risk of acute rejection after OLT in patients

without intraoperative RBC transfusion.

Our results are in line with previous reports on the immunosuppressive effect of blood transfusion

in kidney, heart, and lung transplantation.17,18 The reduced rate of rejection associated with blood

transfusion appears more prominent in those patients that received blood transfusions prior

to transplantation, suggesting a preoperative development of ‘immune accomodation’ in these

patients. Here we demonstrate that absence of intraoperative RBC transfusion was associated with

an allmost 3-fold increased risk for rejection at 2 weeks in multivariable analysis. We could not show

any protective effect of preoperative RBC transfusion on the incidence of acute rejection. Although

this does not fully exclude an immunosuppressive effect of blood transfusions administered

more than 3 months prior to transplantation, our data favour the notion that intraoperative RBC

transfusion is associated with clinically relevant immunomodulatory effects, even in the presence

of adequate post-operative immunosuppression. A recent study showed more modest effects of

RBC transfusion on rejection of liver grafts, but importantly the mean RBC transfusion requirements

were substantially (~3-fold) higher in that study, and it is unclear from the published data whether

RBC-free transplants were present in that cohort.19

The immunomodulatory effects of blood transfusion are widely accepted and in the 1970s is

was standard policy in many centers to deliberately expose patients on the renal transplant list

to RBC transfusions with the aim to exploit the immunosuppressive effect of RBCs.20 Transfusion-

related immunomodulation (TRIM) also has established deleterious effects including an increased

recurrence rate of resected malignancies and an increased incidence of post-operative bacterial

infections. Although the mechanisms underlying TRIM have not been fully elucidated, a major

role for the pathogenesis is ascribed to leukocytes. Nevertheless, clinical studies on the effect of

leukoreduction on the detrimental effects of TRIM have been inconclusive. In our study, we could

not show a change in the incidence of acute rejection after introduction of leukofiltration from the

first of January 2002.

The beneficial effect of RBC transfusion during OLT is offset by significant undesired side effects of

RBC (and other blood product) transfusion. We and others have previously demonstrated that blood

product transfusion during OLT is dose-dependently associated with morbidity and mortality.8,9 As

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management of rejection after OLT is relatively easy, and as early clinical or subclinical rejection

has no long-term adverse effects,21 we remain in favor of a restrictive transfusion policy during OLT

as the benefits of RBC transfusion do not outweigh its detrimental effects. It will be of importance

to be aware of an elevated risk of rejection in those patients that receive little or no intraoperative

RBC transfusion. Those patients may require more intensive monitoring or a more aggressive initial

immunosuppressive regimen.

In conclusion, the choice of immunosuppressive regimen and the presence or absence of

intraoperative RBC transfusion are independent predictors of early rejection after OLT. The beneficial

immunosuppressive effect of RBC transfusion, however, does not outweigh its detrimental effect.

ACKNOWLEDGEMENTS

The authors are grateful for the support in data collection by Linda Weerink, medical student at the

department of surgery and Ans A. Hagenaars, research nurse at the department of anesthesiology.

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REFERENCES:

1. Bismuth H, Castaing D, Ericzon BG, Otte JB, Rolles K, Ringe B, et al. Hepatic transplantation in Europe. First Report of the European Liver Transplant Registry. Lancet 1987;2(8560):674-676.

2. Lewis JH, Bontempo FA, Cornell F, Kiss JE, Larson P, Ragni MV, et al. Blood use in liver transplantation. Transfusion 1987;27:222-225.


4. Porte RJ, Hendriks HG, Slooff MJ. Blood conservation in liver transplantation: The role of aprotinin. J Cardiothorac Vasc Anesth 2004;18(4 Suppl):31S-37S.

5. Massicotte L, Denault AY, Beaulieu D, Thibeault L, Hevesi Z, Nozza A, et al. Transfusion rate for 500 consecutive liver transplantations: experience of one liver transplantation center. Transplantation 2012;93:1276-1281.

6. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S, et al. Primary liver transplantation without transfusion of red blood cells. Surgery 1996;120:698-704.

7. Mor E, Jennings L, Gonwa TA, Holman MJ, Gibbs J, Solomon H, et al. The impact of operative bleeding on outcome in transplantation of the liver. Surg Gynecol Obstet 1993;176:219-227.


9. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, Slooff MJ, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg 2008;106:32-44.

10. Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg 2009;108:1083-1091.

11. Brand A. Immunological aspects of blood transfusions. Transpl Immunol 2002;10(2-3):183-190.

12. Opelz G, Sengar DP, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973;5:253-259.

13. Opelz G, Terasaki PI. Dominant effect of transfusions on kidney graft survival. Transplantation 1980;29:153-158.

14. Opelz G, Vanrenterghem Y, Kirste G, Gray DW, Horsburgh T, Lachance JG, et al. Prospective evaluation of pretransplant blood transfusions in cadaver kidney recipients. Transplantation 1997;63:964-967.

15. Higgins RM, Raymond NT, Krishnan NS, Veerasamy M, Rahmati M, Lam FT, et al. Acute rejection

after renal transplantation is reduced by approximately 50% by prior therapeutic blood transfusions, even in tacrolimus-treated patients. Transplantation 2004 15;77:469-471.

16. Banff schema for grading liver allograft rejection: an international consensus document. Hepatology 1997;25:658-663.

17. Fernandez FG, Jaramillo A, Ewald G, Rogers J, Pasque MK, Mohanakumar T, et al. Blood transfusions decrease the incidence of acute rejection in cardiac allograft recipients. J Heart Lung Transplant 2005;24(7 Suppl):S255-61.

18. Mason DP, Little SG, Nowicki ER, Batizy LH, Murthy SC, McNeill AM, et al. Temporal pattern of transfusion and its relation to rejection after lung transplantation. J Heart Lung Transplant 2009;28:558-563.

19. Dunn LK, Thiele RH, Ma JZ, Sawyer RG, Nemergut EC. Duration of red blood cell storage and outcomes

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following orthotopic liver transplantation. Liver Transpl 2012;18:475-481.

20. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev 2007;21:327-348.

21. Tippner C, Nashan B, Hoshino K, Schmidt-Sandte E, Akimaru K, Boker KH, et al. Clinical and subclinical acute rejection early after liver transplantation: contributing factors and relevance for the long-term course. Transplantation 2001;72:1122-1128

145

Increased post-reperfusion transfusion requirements in liver transplantation with

extended criteria donor graftsMarieke T. de Boer

Andrie C. WesterkampAad P. van den Berg

Ton LismanHerman G.D. Hendriks

Robert J. Porte

Submitted for publication

10

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ABSTRACT

Background: The use of extended criteria donor (ECD) grafts may reduce waiting list mortality in

orthotopic liver transplantation (OLT). ECD livers, however, are associated with increased risk of graft

failure and recipient morbidity. Aim of this study was to determine whether ECD liver grafts are

associated with increased blood loss and transfusion requirements after graft reperfusion.

Methods: A consecutive series of 318 primary adult liver transplant recipients was analyzed.

Recipient, donor and intraoperative transfusion requirements were available in a prospectively

collected database. Donor risk index (DRI) was calculated retrospectively. An ECD graft was defined

as DRI ≥1.7. Graft and patient survival were calculated according to the Kaplan Meyer method. Uni-

and multivariate analysis were performed to determine risk factors for post-reperfusion red blood

cell (RBC) transfusion.

Results: ECD livers were used in 36% of recipients. Graft survival rate at 1- and 5- year was 83% and

71%, respectively. Patient survival rate at 1- and 5-year was 88% and 80%, respectively. Completely

blood transfusion-free transplants were performed in 27% of patients. After uni- and multivariate

analysis the following variables were found to be independently associated with post-reperfusion

RBC transfusion requirements: DRI ≥1.7, female recipient, recipient age, and no aprotinin

administration.

Conclusion: The use of ECD grafts, defined as a DRI ≥1.7, is associated with significantly increased

intraoperative RBC transfusion requirements after graft reperfusion. This information can help

surgeons and anesthesiologist to be more prepared for increased blood loss when an ECD donor

liver is accepted for transplantation.

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Increased post-reperfusion transfusion requirements in liver transplantation with extended criteria donor grafts

10

INTRODUCTION

Orthotopic liver transplantation (OLT) is a successful treatment for patients with end-stage

liver failure caused by acute liver failure, chronic liver diseases, or several metabolic disorders.1-3

Although more OLTs were performed in the last decade, the imbalance between available donor

livers and candidates for OLT is still growing with an increased mortality rate on the waiting list

as consequence.4 Expanding the donor pool by accepting extended criteria donor (ECD) grafts is

a way to reduce the waiting list mortality.5,6 Several studies have shown that selective use of ECD

livers can result in acceptable survival rates after transplantation.5-9 Nevertheless, ECD livers are

clearly associated with higher postoperative morbidity such as higher incidence of primary non-

function (PNF) and initial poor function (IPF).10-13 One study describes a cumulative effect of ECD

criteria on the severity of preservation-reperfusion injury after liver transplantation.14 Furthermore,

reperfusion injury may lead to an increased release of fibrinolytic proteins from the donor liver,

potentially causing bleeding problems after graft reperfusion.15,16

We hypothesized that ECD liver grafts in general are associated with increased intra-operative

bleeding complications after reperfusion of the graft. The aim of the current study was to determine

the impact of ECD criteria of liver grafts on intraoperative blood transfusion requirements during

OLT, especially after graft reperfusion.

METHODS

Study population

Between the first of January 2000, and the 31st of December 2010, 572 patients underwent an OLT

at the University Medical Center of Groningen. After excluding pediatric recipients (age <18 yr; n

=171), retransplantations (n =79), and combined organ transplantations (n =8), 318 adult patients

undergoing a first transplant were identified and these patients were included in the current

study. Follow-up was complete until the 31st of December 2011. Characteristics of the patients,

including donor and recipient variables, as well data on blood loss and transfusion requirements

in the three separate stages of the OLT procedure (pre-anhepatic, anhepatic and postreperfusion)

were obtained from a prospectively maintained computer database. When necessary, the original

patient notes were reviewed for missing information. The maximum percentage of missing data

per variable was 9.7%. IRB approval to perform this retrospective study was waived. All data were

analyzed anonymously, no written informed consent was necessary in this type of research and was

waived by the IRB.

Surgical technique and anesthetic management

Surgical techniques, anesthetic management and blood transfusion policy in our center were

extensively described previously.17 Before 2007, aprotinin was administered in all patients, except

patients with known thrombophilia, who showed hypercoagulability on thrombelastography at

induction of anesthesia. Obviously, when aprotinin was taken of the market in 2007 we stopped

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using this antifibrinolytic drug. As has been described previously, the transfusion policy in our center

is characterized by a restrictive use of blood products, maintaining hematocrit levels between 0.25

and 0.30.2,17,18

Data collected for statistical analysis

ECD variables determined to be meaningful predictors of blood loss and transfusion requirements

in the postreperfusion stage (stage 3) were selected after review of the literature and clinical

experience. The following ECD variables were included: moderate graft macrovesicular steatosis

(30%-60%), type of donor (brain death versus donation after circulatory death), cause of donor brain

death (trauma versus cerebrovascular accident and other), graft type (full size versus partial grafts),

donor intensive care unit (ICU) stay >7 days, donor age >60 yr, and body mass index (BMI >28).

The DRI was calculated according to Feng et al, with minor adjustments (we considered all donors

Caucasian and local).19 To identify an ECD graft, we used a DRI cut-off point of 1.7, as was done in

a recent study by Maluf et al.20 In addition, the following recipient and procedure related variables

were included in the analyses: age, gender, BMI, surgical technique (conventional versus piggyback),

use of aprotinin, cold ischemia time (CIT) >10hr, warm ischemia time (WIT) >40min, and type of

preservation fluid (HTK vs UW). The MELD-score was based on laboratory tests alone, disregarding

extra points for standard or non-standard exceptions. With respect to intra-operative transfusion

requirements, the following variables were analyzed in the three separate stages of the operation;

the number of units of allogeneic red blood cells (RBC; 1 U contained approximately 250mL), units of

fresh frozen plasma (FFP; 1 U contained approximately 300mL), and units of platelets concentrates

(PLT; 1 U contained approximately 150mL and was obtained from five donors). In addition to this,

we analyzed the differences between transfusion in stages 1&2 versus stage 3 (postreperfusion).

Selection of statistical models

Aim of this study was to analyze the effect of ECD variables on postreperfusion RBC transfusion.

Therefore, patients were stratified according to a relatively high RBC transfusion rate in the

postreperfusion stage, compared to the prereperfusion stages, representing patients who were

relatively stable until implantation of the graft. We decided to compare the group of patients

who required at least twice the amount of RBC transfused in the postreperfusion stage (stage 3)

compared to the prereperfusion stages (stage 1&2), with a minimal amount of 1 RBC unit in stage 3

to the patients that did not fulfil these criteria. The reason to choose a double amount instead of the

same amount is to compensate for blood loss in stage 1&2 that is corrected with RBC transfusion in

stage 3.

Secondary endpoints were impact of ECD variables, reflected by a DRI ≥1.7, on the incidence of

primary non function (PNF), initial poor function (IPF), and the need for relaparotomy. Graft and

patient survival were assessed at 1 and 5 years after transplantation. Graft survival was defined as

the time interval between transplantation and patient death or retransplantation. Patient survival

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was defined as the time interval between transplantation and patient death. PNF was defined as

non-life-sustaining function of the liver, requiring a retransplantation or leading to death within 7

days after OLT. IPF was defined as serum AST >2000U/l on any day between postoperative day 2-7

and a prothrombin time (PT) >16sec.


To examine the impact of ECD variables on intra-operative blood loss after graft reperfusion (Stage 3),

transfusion requirements were correlated with donor, recipient, and procedure related factors using

uni- and multivariate analysis. Missing data were treated according to listwise deletion approach.

Continuous variables were expressed as median and interquartile range (IQR). Categorical variables

were expressed as number and percentage. Comparisons of categorical variables between the

two study groups were performed with the use of Fisher’s exact test or Pearson chi-square test.

For comparison of continuous variables we used the Mann-Whitney U test. All statistical tests were

performed two-tailed.

All variables tested in the univariate analysis with a P value <0.10 were included in a multivariate

logistic regression analysis. A two-sided P value <0.05 was considered to indicate statistical

significance. Patient and graft survival rates were analyzed according to the Kaplan-Meier method.

Statistical analyses were performed with the use of PASW Statistics Software, version 19.0 (SPSS,

Chicago, IL).

RESULTS

Recipient characteristics

More than half of the recipients were male (58%), the median age was 53 years. (Table 1) Median

postoperative follow up was 6.3 years (range 3 months-12 years). Patients who received a liver graft

with a DRI ≥1.7 compared to DRI <1.7, were older (55 vs 51, P value 0.005), and were more often

female (50% vs 36%, P value 0.044).(Table 1) Four patients died during the transplantation procedure.

PNF was seen in 14 patients (4%), of whom 11 patients were retransplanted within one week, and

3 patients died before retransplantation. The incidence of IPF was 9.4% and a relaparotomy during

the admission for OLT was necessary in 82 (26%) patients. There was no significant difference in the

incidence of PNF, IPF and relaparotomy. (Table1) Patient survival rates at 1- and 5-year were 88% and

80%, respectively. One- and 5-year graft survival rates were 83% and 71%, respectively.

Donor characteristics

Median donor age was 49 years.(Table 1) Of all grafts, 36% had a DRI ≥1.7. In 4 patients the DRI could

not be calculated because of missing variables (1,3%). DCD (donation after circulatory death) grafts

were used in 17% of patients. Moderate macrovesicular steatosis (30-60%) was present in 20 (6%)

grafts. Reduced size or split grafts were used in 17 (5%) patients. In the DRI ≥1.7 group more of often

HTK was used (32% vs 16%, p-value < 0.001), which is probably explained by the fact that in the early

years HTK was used in DCD grafts.

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Table 1 Recipient, Surgical, and Donor Variables

Recipient variables (n = 318)Median (IQR) or N (percentage)

DRI <1,7n=199

DRI ≥1,7N=115

P value

Age (years) 53 (43-58) 51 (40-58) 55 (46-59) 0.005

BMI (kg/m2) 25 (23-28) 25 (22-27) 25 (23-28) 0.875

MELD score (lab-MELD) 15 (10-23) 15 (10-23) 14 (9-22) 0.332

Serum creatinine before OLT (μmol/L) a

89 (73-127) 87 (73-131) 91 (71-127) 0.997

Serum total bilirubin before OLT (μmol/L) b

51 (26-117) 52 (29-132) 46 (24-107) 0.273

INR before OLT 1.3 (1.2-1.7) 1.3 (1.2-1.7) 1.3 (1.2-1.7) 0.774

Time on waiting list (days) 203 (45-408) 216 (44-424) 194 (46-390) 0.768

GenderMaleFemale

186 (58%)132 (42%)

124 (62%)75 (38%)

58 (50%)57 (50%)

0.044

Indication for transplantationFulminant hepatic failureNon-cholestaticCholestaticMetabolicMalignantOther

26 (8%)

134 (42%)86 (27%)37 (12%)29 (9%)6 (2%)

18 (9%)

85 (43%)58 (29%)23 (12%)12 (6%)3 (2%)

8 (7%)

47 (41%)28 (24%)14 (12%)15 (13%)3 (3%)

0.335

Status on waiting listElectiveHigh urgency

292 (92%)26 (8%)

180 (90%)19 (10%)

107 (93%)8 (7%)

0.533

Donor variables (n=318)

Age (years) 49 (40-57) 44 (34-53) 60 (48-64) <0.001

BMI (kg/m2) 25 (22-26) 24 (22-26) 25 (23-26) 0.145Length of stay in intensive care unit (days)

1 (1-3) 1 (1-4) 1 (1-2) 0.467

DRI c 1.6 (1.3-1.9) 1.4 (1.2-1.5) 2.0 (1.8-2.2) <0.001

GenderMaleFemale

163 (51%)154 (49%)

111 (56%)88 (44%)

49 (43%)65 (57%)

0.034

Type of donor liver DBDDCD

264 (83%)54 (17%)

190 (95%)9 (5%)

71 (62%)44 (38%)

<0.001

Cause of donor deathTraumaCerebrovascular accidentOther

93 (29%)203 (64%)21 (7%)

79 (40%)108 (54%)11 (6%)

14 (12%)91 (79%)10 (9%)

<0.001

Graft sizeFull sizeReduced size or split

301 (95%)17 (5%)

196 (98%)3 (2%)

102 (89%)13 (11%)

<0.001

Macrovesicular steatosis NoSteatosis <30%30-60%

175 (59%)101 (34%)19 (6%)

115 (62%)61 (33%)10 (5%)

58 (54%)39 (37%)10 (9%)

0.286

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10

Organ preservation fluidHTKUW

68 (22%)236 (78%)

30 (16%)160 (84%)

36 (32%)75 (68%)

<0.001

Surgical variables

CIT (hr:min) d 7:45 (6:52-9:17)7:40(6:47-9:16)

8:01(7:05-9:34)

0.112

WIT(min) e 46 (40-53) 46 (40-54) 45 (39-50) 0.102

Estimated blood loss (L) fase 1&2 1.4 (0.7-3.0) 1.3 (0.6-3.0) 1.4 (0.7-2.9) 0.942

Estimated blood loss (L) fase 3 1.1 (0.6-2.5) 1.0 (0.6-2.2) 1.5 (0.6-3.0) 0.056

Estimated total blood loss (L) 3.0 (1.7-6.0) 2.5 (1.5-5.4) 3.1 (2.0-6.5) 0.064

Blood loss fase 3 >1.5 l<1.5 L≥1.5 L

169 (58%)123 (42%)

115 (64%)65 (36%)

54 (50%)55 (50%)

0.019

RBC transfusion fase 1&2 (U) 0 (0-4.0) 0 (0-4.0) 0 (0-4.0) 0.702

RBC transfusion fase 3 (U) 0 (0-3.0) 1.0 (0-7.0) 2.0 (0-4.0) 0.001

Total RBC transfusion (U) 3.0(0-8.0) 3.0 (0-7.0) 3 (0-9.0) 0.035

FFP transfusion fase 1&2 (U) 0 (0-2.0) 0 (0-2.0) 0 (0-2.0) 0.500

FFP transfusion fase 3 (U) 0 (0-2.0) 0 (0-1.0) 0 (0-3.2) 0.011

Total FFP transfusion (U) 0 (0-4.6) 0 (0-0) 0 (0-0) 0.135

PLT transfusion fase 1&2 (U) 0 (0-0) 0 (0-0) 0 (0-0) 0.642PLT transfusion fase 3(U)

0 (0-0) 0 (0-0) 0 (0-0) 0.114

Total PLT transfusion (U) 0 (0-0) 0 (0-0) 0 (0-1.0) 0.362

Aprotinin useYesNo

110 (36%)208 (64%)

73 (38%)118 (62%)

37 (34%)72 (66%)

0.534

Caval Vein AnastomosisClassicalPiggyback

40 (13%)278 (87%)

21 (11%)178 (89%)

(17 (15%)98 (85%)

0.285

Outcome parameters

PNFYesNo

298 (94%)20 (6%)

187 (94%)18 (6%)

109 (95%)11 (5%)

1.000

IPFYesNo

288 (91%)30 (9%)

180 (91%)18 (9%)

104 (90%)11 (10%)

1.000

RelaparotomyYesNo

82 (26%)236 (74%)

50 (25%)149 (75%)

30 (26%)85 (74%)

0.893

Data represent median with interquartile ranges (IQR) for continuous variables or numbers (percentages) for categorical variables.Abbreviations used; BMI: body mass index, OLT: orthotopic liver transplantation, MELD: model of end-stage liver disease, INR: international normalized ratio, HTK: Histidine-Tryptophane-Ketoglutarate, UW: University of Wisconsin, DCD: donation after circulatory death, DBD: donation after brain death. RBC: red blood cells. FFP: fresh frozen plasma. PLT: platelets. PNF: primary non function. IPF: initial poor function. L: liters. U: unitsa) Normal < 110 μmol/L, to convert the value for creatinine to mg/dL, divide by 88.4b) Normal 0-17 μmol/L, to convert the value for bilirubin to mg/dL, divide by 17.1c) DRI= Donor Risk Index according to Feng19. Because no data was available on region and race, all donors were considered local and caucasian.d) Time from in situ flushing of the donor organ until the liver is removed from ice for implantation.e) Time from removal of liver from ice until reperfusion via portal vein, hepatic artery or both.

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Blood loss and transfusion of blood products

Median blood loss in pre and postreperfusion was 1.4 and 1.1L respectively.(Table 1) The median

postreperfusion blood loss did not differ significantly when we compared the group with a DRI

<1.7 with the group ≥1.7, but in patients with a DRI ≥1.7 significantly more patients had blood loss

over 1.5L postreperfusion (50% vs 36 of patients, P value 0.019.(Table 1) In 95 (30%) of all transplant

procedures there was no need for RBC transfusion. In 86 (27%) of all transplants there was no need

for any blood product transfusion (red blood cell (RBC), fresh frozen plasma (FFP), or platelets

(PLT). In our model, 29% of patients required at least twice the amount of RBCs in stage 3 (post-

reperfusion) compared to stages 1&2 combined, or in case of no RBC requirements in stages 1&2

had at least 1 unit of RBC in stage 3.(Table 2)

Uni- and multivariate analysis of variables associated with RBC transfusion in the three

different models

Variables associated with an increased requirement of RBC transfusion after graft reperfusion are

summarized in Table 2. In our model (outcome parameter defined as RBC in stage 3 = at least 2 x

RBC stage 1&2, minimal 1 RBC unit in stage 3) the following variables were associated with increased

RBC transfusion requirements: DRI, graft type, age recipient > 60 years, female recipient, and no

aprotinin use. Variables with a P value < 0.10 were entered into a multivariate logistic regression

model. Multivariate analysis for increased RBC transfusion requirements in the postreperfusion

stage (stage 3) revealed the following independent variables: DRI, female recipient, recipient age,

and no aprotinin administration. (Table 3)

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Table 2: Univariate analysis for relatively high postreperfusion RBC transfusion a)

P valueNo Higher RBCN=222

Higher RBCN=90

Contin. Variables

Donor

DRI 0.029 1.5 (1.3-1.8) 1.7 (1.4-2.0)

Age (yrs) 0.194 48 (39-57) 48 (41-60)

ICU LOS (days) 0.400 1.0 (1.0-3.5) 1.0 (1.0-3.0)

BMI 0.832 24.2 (22.5-26.2) 24.2 (22.1-26.3)

Length (cm) 0.841 175 (168-180) 175 (168-180)

Weight (kg) 0.859 75 (65-85) 75 (65-85)

Recipient

CIT (hrs) 0.946 7:44 (6:53-9:17) 7:46 (6:44-9:34)

WIT (hrs) 0.608 45 (39-54) 47 (40-50)

Age (yrs) 0.101 52 (41-58) 54 (46-60)

BMI 0.400 24.8 (22.4-27.7) 25.8 (22.8-27.5)

Length (cm) 0.063 176 (168-182) 172 (166-188)

Weight (kg) 0.664 77 (67-85) 75 (65-86)

MELD-score 0.501 14.2 (9.8-22.2) 14.8 (9.8-28.6)

Categ. Variables

DonorDRI < 1,7 ≥ 1,7

0.009147 (67%)71 (33%)

46 (51%)44 (49%)

Age < 60 yrs > 60 yrs

0.104177 (80%)45 (20%)

64 (27%)26 (36%)

Gender Female Male

0.169114 (52%)107 (48%)

38 (42%)52 (58%)

COD Trauma Stroke Other

0.18971 (32%)136 (62%)14 (6%)

20 (22%)65 (72%)5 (26%)

ICU LOS< 7 days > 7 days

0.470189 (85%)33 (15%)

80 (89%)10 (11%)

Steatosis < 30% > 30%

0.748194 (94%)13 (6%)

76(93%)6 (7%)

Graft Fullsize Split/reduced

0.049214 (96%)8 (4%)

81 (90%)9 (10%)

Preservation HTK UW

0.64847(78%)166 (22%)

21 (75%)64 (25%)

DBDDCD

0.87038 (17%)184 (83%)

16 (18%)74 (82%)

Recipient

CIT < 10 hrs > 10 hrs

0.323184 (84%)35 (16%)

71 (79%)19 (21%)

WIT < 40 min > 40 min

0.47458 (27%)161(74%)

20 (22%)70 (78%)

Age < 60 yrs > 60 yrs

0.046182 (82%)40 (18%)

64 (71%)26 (29%)

Gender Female Male

0.00580 (36%)142 (64%)

48 (53%)42 (47%)

MELD < 20 > 20

0.407162 (73%)60 (27%)

61 (68%)29 (32%)

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Aprotinine No Yes

0.035124 (59%)85 (41%)

64 (73%)24 (27%)

Piggyback No Yes

0.70929 (13%)193 (87%)

10 (11%)80 (89%)

a) Outcome parameter is increased RBC requirement in stage 3, defined as at least 2 x RBC stage 1&2, minimal 1 RBC unit in stage 3.Data represent median with interquartile ranges (IQR) for continuous variables or numbers (percentages) for categorical variables.Abbreviations used; DRI: donor risk index, ICU LOS: intensive care unit length of stay, BMI: body mass index, CIT: cold ischemia time, WIT: warm ischemia time, MELD: model of end-stage liver disease, COD: cause of death, DBD: donation after brain death, DCD: donation after cardiac death, HTK: histidine-tryptophane-ketoglutarate, UW: University of Wisconsin, RBC: red blood cells.

Table 3. Multivariate analyses for relatively high postreperfusion RBC transfusion in liver transplantation

Odds Ratio 95% CI P value

Model 1 a

DRI (≥1.7) 1.777 1.048-3.013 0.033

Recipient age > 60 yr 1.852 1.001-3.425 0.049

Recipient gender (F) 1.846 1.095-3.114 0.022

No aprotinin 1.845 1.055-3.230 0.032

a) Outcome parameter is increased RBC requirement in stage 3, defined as at least 2 x RBC stage 1&2, minimal 1 RBC unit in stage 3.Abbreviations used: DRI, donor risk index; CI, confidence interval; CIT, cold ischemia time; MELD, model for end stage liver disease

DISCUSSION

In an era of increasing organ shortage, accepting ECD grafts seems a necessary way to reduce

waiting list mortality in liver transplantation. In general, ECD grafts are considered to be organs

with a greater risk of initial poor function or non-function and therefore they are associated with

an increased risk of postoperative recipient morbidity and mortality.21,22 The results of this study

indicate that the quality of the donor liver as reflected by the DRI has also an impact on RBC

transfusion requirements after graft reperfusion.

The effect of graft quality on posttransplant outcome has been analyzed extensively.10-13,19,20,23,24 So

far, not much emphasis has been put on the intraoperative effects of the use of ECD grafts. In one

study the short and long term outcomes after transplantation of steatotic liver grafts was studied.25

Investigators of this study found that the intraoperative RBC and FFP transfusion requirements were

significantly higher after transplantation of liver grafts with > 35% steatosis (n =22), compared to

grafts with < 5% steatosis (n =222). They also concluded that recipients of steatotic grafts required

increased resource use, including increased length of stay in the ICU and overall length of stay. In

our study, we did not find a relation between the grading of steatosis and intraoperative transfusion

requirements. This may be explained by the relative low number of grafts (only 6 % of our cohort)

with moderate (30%-60%) macrovesicular steatosis.

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It is evident that donor factors have no influence on blood loss and transfusion requirements during

the recipient hepatectomy phase. Previous studies have shown that various recipient factors are

associated with intraoperative blood loss and transfusion requirements in liver transplantation.26,27

Apparently, when considering the procedure as whole, recipient factors overshadow the influence

of donor factors on transfusion requirements. Probably a difficult hepatectomy with major blood

loss due to portal hypertension will affect blood loss and transfusion requirements during the

postreperfusion stage. But the other way around, after an uncomplicated, bloodless hepatectomy,

we hypothesized that quality of the liver graft is a risk factor for postreperfusion blood loss and

thus transfusion requirements. To detect the group of patients that were relatively stable until

implantation of the graft, but suffered from increased blood loss after graft reperfusion, we selected

the patients who had a relatively high RBC transfusion rate in the postreperfusion stage, compared

to the prereperfusion stages. To this end we used a model with doubling of the RBC requirements in

postreperfusion stage, compared to prereperfusion stages. This model showed that, in addition to

recipient factors and the use of aprotinin, the DRI was independently associated with the need for

RBC transfusions in the postreperfusion stage.

There is no clear definition of the features of an ECD liver, but in general high donor age, high grade

of steatosis, DCD (donation after cardiac death) grafts, partial grafts, or cerebrovascular cause of

death are considered ECD criteria.22,28 Donor risk scores, such as the DRI, have been developed to

quantify the risk associated with donor variables.19 To identify an ECD graft, we used the same DRI

cut-off point of 1.7, as was done in a recent study by Maluf et al.20 Since we considered all donors

in this study of the Caucasian race and local, our calculated DRI may have been underestimated in

some cases.

Potential mechanisms for increased blood loss after graft reperfusion may be related increased

ischemia-reperfusion injury in ECD grafts. Briceno at al stated that poorer condition of the donor,

irrespective of the variable, seemed to be directly associated with poorer graft function.14 A poor graft

function may lead to a disturbed hemostatic balance and potentially lead to bleeding problems,29

Briceno et al correlated accumulation of ECD factors with ischemia-reperfusion injury. Risk factors

for severe ischemia-reperfusion injury were moderate to severe fatty infiltration, prolonged ICU

hospitalisation, CIT, high dosage of inotropic drugs in the donor, and older donors.14

Ischemia-reperfusion injury is associated with endothelial cell damage caused by high release of

toxic reactive oxygen species generated upon reintroduction of oxygen to ischemic tissues.30 A

key characteristic of ischemia reperfusion injury is the release of proteolytic enzymes, including

phagocyte proteases and endothelial cell derived thrombomodulin leading to coagulopathy and

hyperfibrinolysis.31,32 Two other studies suggest that increased reperfusion injury is accompanied

by an increased release of fibrinolytic proteins (i.e. tissue-type plasminogen activator) from the

donor graft, which may contribute to excessive blood loss in the last phase of the operation.15,16

In the current study, however, we identified DRI and no administration of the antifibrinolytic drug

aprotinin as variables that were both independently associated with increased blood loss after

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reperfusion. This finding indicates that excessive blood loss after reperfusion cannot simply be

ascribed to the release of tissue-type plasminogen activator alone. Other mechanism must play a

role as well. Nevertheless, focus of further research should lie in organ optimization and reduction

of preservation-reperfusion injury.

This study has some limitations. Due to its retrospective design, it is possible that we were not

able to address all the risk factors for blood loss or transfusion, for instance the presence of portal

hypertension or previous abdominal surgery in this cohort of patients, but we think we have

eliminated this factors as much as possible by using a model that focuses excessive postreperfusion

blood loss, compared to blood loss during hepatectomy.

In conclusion, the use of liver grafts with a DRI ≥1.7 is associated with significantly increased

intraoperative RBC transfusion requirements after graft perfusion. This information can help

surgeons and anesthesiologist to be more prepared for increased blood loss when an ECD liver with

a DRI ≥1.7 is accepted for transplantation.

ACKNOWLEDGEMENTS

The authors are grateful for the support in data collection by Ans A. Hagenaars, department of

Anesthesiology.

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REFERENCES

1. Starzl TE, Demetris AJ, Van Thiel D. Liver transplantation (1). N Engl J Med 1989;321:1014-1022.


3. Neuberger J. Liver transplantation. J Hepatol 2000;32(1 Suppl):198-207.

4. Oosterlee A, Rahmel A. Annual Report/ Eurotransplant International Foundation Leiden 2010; 2011.

5. Tector AJ, Mangus RS, Chestovich P, Vianna R, Fridell JA, Milgrom ML, Sanders C, Kwo PY. Use of extended criteria livers decreases wait time for liver transplantation without adversely impacting posttransplant survival. Ann Surg 2006;244:439-450.

6. Barshes NR, Horwitz IB, Franzini L, Vierling JM, Goss JA. Waitlist mortality decreases with increased use of extended criteria donor liver grafts at adult liver transplant centers. Am J Transplant 2007;7:1265-1270.

7. Alkofer B, Samstein B, Guarrera JV, Kin C, Jan D, Bellemare S, Kinkhabwala M, Brown R,Jr, Emond JC, Renz JF. Extended-donor criteria liver allografts. Semin Liver Dis 2006;26:221-233.

8. Harring TR, O’Mahony CA, Goss JA. Extended donors in liver transplantation. Clin Liver Dis 2011;15:879-900.

9. Renz JF, Kin C, Kinkhabwala M, Jan D, Varadarajan R, Goldstein M, Brown R,Jr, Emond JC. Utilization of extended donor criteria liver allografts maximizes donor use and patient access to liver transplantation. Ann Surg 2005;242:556-563.

10. Ploeg RJ, D’Alessandro AM, Knechtle SJ, Stegall MD, Pirsch JD, Hoffmann RM, Sasaki T, Sollinger HW, Belzer FO, Kalayoglu M. Risk factors for primary dysfunction after liver transplantation--a multivariate analysis. Transplantation 1993;55:807-813.

11. Silberhumer GR, Pokorny H, Hetz H, Herkner H, Rasoul-Rockenschaub S, Soliman T, Wekerle T, Berlakovich GA, Steininger R, Muehlbacher F. Combination of extended donor criteria and changes in the Model for End-Stage Liver Disease score predict patient survival and primary dysfunction in liver transplantation: a retrospective analysis. Transplantation 2007;83:588-592.

12. Angele MK, Rentsch M, Hartl WH, Wittmann B, Graeb C, Jauch KW, Loehe F. Effect of graft steatosis on liver function and organ survival after liver transplantation. Am J Surg 2008;195:214-220.

13. Strasberg SM, Howard TK, Molmenti EP, Hertl M. Selecting the donor liver: risk factors for poor function after orthotopic liver transplantation. Hepatology 1994;20(4 Pt 1):829-838.

14. Briceno J, Marchal T, Padillo J, Solorzano G, Pera C. Influence of marginal donors on liver preservation injury. Transplantation 2002;74:522-526.

15. Legnani C, Palareti G, Rodorigo G, Gozzetti G, Mazziotti A, Martinelli G, Zanello M, Sama C, Coccheri S. Protease activities, as well as plasminogen activators, contribute to the “lytic” state during orthotopic liver transplantation. Transplantation 1993;56:568-572.

16. Porte RJ, Bontempo FA, Knot EA, Lewis JH, Kang YG, Starzl TE. Systemic effects of tissue plasminogen activator-associated fibrinolysis and its relation to thrombin generation in orthotopic liver transplantation. Transplantation 1989;47:978-984.

17. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, Slooff MJ, Porte RJ. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg 2008;106:32-44

18. Hendriks HG, van der Meer J, de Wolf JT, Peeters PM, Porte RJ, de Jong K, Lip H, Post WJ, Slooff MJ. Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation. Transpl Int 2005;17:673-679.

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19. Feng S, Goodrich NP, Bragg-Gresham JL, Dykstra DM, Punch JD, DebRoy MA, Greenstein SM, Merion RM. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant 2006;6:783-790.

20. Maluf DG, Edwards EB, Kauffman HM. Utilization of extended donor criteria liver allograft: Is the elevated risk of failure independent of the model for end-stage liver disease score of the recipient?. Transplantation 2006;82:1653-1657.

21. Busuttil RW, Tanaka K. The utility of marginal donors in liver transplantation. Liver Transpl 2003;9:651-663.

22. Durand F, Renz JF, Alkofer B, Burra P, Clavien PA, Porte RJ, Freeman RB, Belghiti J. Report of the Paris consensus meeting on expanded criteria donors in liver transplantation. Liver Transpl 2008;14:1694-1707.

23. Cameron AM, Ghobrial RM, Yersiz H, Farmer DG, Lipshutz GS, Gordon SA, Zimmerman M, Hong J, Collins TE, Gornbein J, Amersi F, Weaver M, Cao C, Chen T, Hiatt JR, Busuttil RW. Optimal utilization of donor grafts with extended criteria: a single-center experience in over 1000 liver transplants. Ann Surg 2006;243:748-753.

24. Mittler J, Pascher A, Neuhaus P, Pratschke J. The utility of extended criteria donor organs in severely ill liver transplant recipients. Transplantation 2008;86:895-896.

25. Doyle MB, Vachharajani N, Wellen JR, Anderson CD, Lowell JA, Shenoy S, Brunt EM, Chapman WC. Short- and long-term outcomes after steatotic liver transplantation. Arch Surg 2010;145:653-660.

26. Araújo T, Cordeiro A, Proença P, Perdigoto R, Martins A, Barroso E. Predictive Variables Affecting Transfusion Requirements in Orthotopic Liver Transplantation. Transplant Proc 2010;42:1758-1759.

27. Steib A, Freys G, Lehmann C, Meyer C, Mahoudeau G. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth 2001;48:1075-1079.

28. Gastaca M. Extended criteria donors in liver transplantation: adapting donor quality and recipient. Transplant Proc 2009;41:975-979.


30. Rauen U, Elling B, Gizewski ER, Korth HG, Sustmann R, de Groot H. Involvement of reactive oxygen species in the preservation injury to cultured liver endothelial cells. Free Radic Biol Med 1997;22:17-24.

31. Riess H, Jochum M, Machleidt W, Himmelreich G, Blumhardt G, Roissaint R, Neuhaus P. Possible role of extracellularly released phagocyte proteinases in coagulation disorder during liver transplantation. Transplantation 1991;52:482-484.

32. Himmelreich G, Riewald M, Rosch R, Blumhard G, Neuhaus P, Roissant R, Riess H. Thrombomodulin: a marker for endothelial damage during orthotopic liver transplantation. Am J Hematol 1994;47:1-5.

APPENDICES 11

160

161

APPENDIX 1

Questionnaire used in Chapter 3 (in Dutch)

Topical hemostatic agents in liver surgery: Do we need them?

162

Chapter 11

Leverresecties in Nederland

Deze enquête wordt naar alle chirurgen in Nederland gestuurd. Indien u geen leverresecties uitvoert gaarne alleen vraag 1 beantwoorden.

1. Verricht u partiële leverresecties, gedefinieerd als verwijdering van 1 of meer segmenten van de lever? 0 Ja, ga door naar vraag 20 Nee, bedankt voor deelname aan deze enquête

_____________________________________________________________ 2. Wat voor type leverresecties voert u uit?

0 Ik beperk mij tot resectie van een wig of 1 segment van de lever0 Ik voer ook grotere resecties uit, maar geen hemihepatectomie0 Ik voer ook grotere resecties uit, inclusief (extended) hemihepatectomie

3. Hoeveel leverresecties verricht u (naar schatting) per jaar?(N.B. het gaat hier om uw persoonlijke aantallen en niet zo zeer om het totaal in uw maatschap of groep)

0 1 tot 5 per jaar0 5 tot 10 per jaar0 10 tot 20 per jaar0 Meer dan 20 leverresecties per jaar

4. a) Gebruikt u ook radio-frequency ablation (RFA) als lokale behandeling van tumoren in de lever?

0 Ja0 Nee

b) Indien ja, combineert u weleens RFA met een leverresectie? 0 Ja0 Nee

5. Past u inflow occlusie (Pringle manoeuvre) toe bij partiële leverresecties?

0 Nooit0 Altijd0 Afhankelijk van de grootte van de resectie0 Afhankelijk van bloedverlies besluit ik evt peroperatief toch nog inflow occlusie toe te passen

6. Zorgt u tijdens de operatie eerst voor devascularisatie van het te reseceren deel van de lever en gaat u daarna over tot transsectie van het parenchym?

0 Ja0 Nee, pas na transsectie van het parenchym neem ik de vascularisatie van het te reseceren leverdeel door.

7. Welke methoden past u toe om de transsectie van de lever uit te voeren? (meerdere antwoorden mogelijk, minimaal 1 antwoord wenselijk)

0 Argon0 CUSA0 Ultracision0 Waterjet

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Appendix 1

11

0 Tissuelink0 Klem-crush techniek0 Anders, namelijk _______________________________________________

8. a) Gebruikt u extra middelen om hemostase van het resectievlak te bewerkstelligen (en postoperatief te garanderen)?

0 Ja, ga door naar vraag 8b0 Nee, ga door naar vraag 9

b) Indien ja, 0 Incidenteel

0 Routinematig c) Welk soort middel(en) gebruikt u.(meerdere antwoorden mogelijk, minimaal 1 antwoord wenselijk)

0 Fibrinelijm (bijv. Tissucol)0 Gelatineachtige producten (bijv. Floseal)0 Cellulose producten (bijv. Surgicel)0 Collageenachtige producten (bijv. Novacol)0 Anders, namelijk _______________________________________________

9. Bent u van mening dat fibrinelijm minder resectieoppervlak gerelateerde complicaties geeft zoals nabloeding of gallekkage?

0 Ja, ik denk dat fibrinelijm complicaties vermindert0 Nee, ik geloof niet dat het werkt, en dus gebruik ik het niet 0 Weet niet, gebruik het voor de zekerheid

10. Voert u na de resectie een contrastonderzoek uit om eventuele gallekkage bij het resectievlak op te sporen?

0 Nooit0 Altijd0 Op indicatie

11. Houdt u tijdens een leverresectie rekening met de hoogte van de centraal veneuze druk?

0 Nee0 Ja, deze dient zo laag mogelijk te zijn0 Ja, de patiënt dient “goed gevuld” te zijn

12. Recent is binnen de Nederlandse Vereniging voor Heelkunde de Werkgroep Leverchirurgie opgericht. Doelstelling van deze werkgroep is in het kort het bevorderen van onderzoek en samenwerking binnen Nederland op het gebied van leverchirurgie. Bent u geïnteresseerd in de Werkgroep Leverchirurgie?

0 Ja, stuur mij vrijblijvend meer informatie0 Nee

Opmerkingen:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

164

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APPENDIX 2

Correspondence related to Chapter 5

Fibrin sealant for prevention of resection surface-related complications after liver resection. A randomized controlled trial

Letter to the editor and Reply to Letter. Annals of Surgery 2013

Letter to the editor and Reply to Letter. Annals of Surgery 2014

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Letter to the editor


in living liver donors

Jianyong Lei, Lunan Yan, Wentao Wang

To the Editor:

We read with great interest the article written by Boer et al.1 We would like to make the following

comments. In the 310 non-cirrhotic patients undergoing liver resection, the overall rate of resection

surface related complications was not different between the fibrin sealant group (24%) and no fibrin

sealant group (24%) and the bile leakage rate was the same between the 2 groups (14% for both).

Although the rate of fluid collection at the resection surface of 100 mL or more was higher in the

fibrin sealant group (28%) than that in the no fibrin sealant group (26%) (P value = 0.800), the rate

of reinterventions for resection surface-related complications (12% vs 10%, P value = 0.492) and

severity of complications also did not differ between the 2 groups.

The report focused on the efficacy of fibrin sealant in reducing resection surface- related complications

in liver surgery. Hence, we would like to discuss some of our own unpublished data on the subject.

We retrospectively collected the data of the 290 living donors from March 2002 to September 2012

and compared prophylactic application fibrin sealant to resection surface (168 cases, group 1) with

no application of fibrin sealant (122 cases, group 2). The 290 living donors included 241 right lobe

donors, 42 left lobe donors, and 7 left lateral lobe donors. Comparisons between 2 groups showed

no significant difference in baseline characteristic, graft size and surgical characteristics, and some

other results after donation. Overall rate of donor liver graft resection surface-related complication

was not different between the 2 groups: 14.9% (25 in 168 donors) in the fibrin sealant group and

14.8% (18 in 122 donors) in the no fibrin sealant group (P value = 0.976), which was lower than that

in de Boer’s report. As showed in Table 1, bile leakage was detected in 8,9% (15 in 168 donors) in the

fibrin sealant group, which was similar to the 9,0% (11 in 122 donors) in the no fibrin sealant group

(P value = 0.985). Most did not need any therapy except persistent drainage; only 3 (2 in group

1 and 1 in group 2) needed the endoscopic retrograde cholangiopancreatography for persistent

drainage. Color Doppler ultrasonography showed fluid collection at the resection surface of 100 mL

or more in 25.6% of patients (43 cases) in the fibrin sealant group and in 21.3% of controls (26 cases)

(P value = 0.399); 7 donors (4.2%) were diagnosed with intra-abdominal abscess after donation

in group 1 and 4 donors (3.3%) in group 2, but this difference did not reach statistical difference

(P value = 0.690). Two donors in group 1 and 1 donor in group 2 needed reoperation for abscess

debridement. Six donors suffered postoperative bleeding and 3 of them (1 case in group 1 and 2

cases in group 2) needed reoperation for bleeding. Three donors accepted successful conservative

treatment including hemostatic drugs and clotting materials. This difference did not reach statistical

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11

difference (P value =0.685). Meanwhile, there was no significant difference in the incidence of severe

postoperative resection surface-related complications between the 2 groups (3.0% in group 1 vs

3.3% in group 2, P value =0.884), and the overall complications of our donors had been described

in our previous report.2 There was no significant difference between the 2 groups in the other

complications.

As compared with the paper by de Boer et al, the overall rate of resection surface– related

complications, bile leakage rate, abscess and bleeding rate in our study were lower than that in

de Boer’s report. However, no significant difference on the resection surface-related complications

was observed between the fibrin sealant group and the control group in both reports. The possible

reasons for our lower resection surface-related complications were the inclusion criteria. In our

study, all of the donors were healthy individuals with no basic disease compared with de Boer’s

study. Most of the patients (75%) in de Boer’s study underwent liver resection because of colorectal

metastases, liver tumor, and other diseases, which may have led to more resection surface-related

complications. Meanwhile, the living donors’ resection procedures were regular hepatectomy, and

the resection surface in living donors was smaller than in de Boer’s patients, so smaller surface

possibly means less surface-related complications.3

Despite these differences, our conclusions were in accordance with de Boer’s. This retrospective

study shows that prophylactic application of fibrin sealant at the resection surface after living donor

liver resections does not lead to a reduction in the incidence or severity of resection surface-related

complications.

Table 1. Surface-related complication rate comparisons

Clavien Grade I Clavien Grade II Clavien Grade III

Complications Group 1 Group 2 Group 1 Group 2 Group 1 Group 2

Surface-related rate 12 (7.1%) 9 (7,4%) 8 (4,8%) 5 (4,1%) 5 (3,0%) 4 (3,3%)

Bile leakage 8 6 5 4 2 1

Abscess 4 3 1 0 2 1

Bleeding 0 0 2 1 1 2

REFERENCES1. de Boer MT, Klaase JM, Verhoef C, et al. Fibrin sealant for prevention of resection surface-related

complications after liver resection: a randomized controlled trial. Ann Surg 2012;256:229-234.2. Lei JY, Yan LN. Donor morbidity including biliary complications in living-donor liver transplantation: a

single center analysis of 283 cases. Transplantation 2012;94:e51-e52.3. Shindoh J, Mise Y, Satou S, et al. The intersegmental plane of the liver is not always flat-trick for anatomic

liver resection. Ann Surg 2010;25:917-922.

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Reply to the Letter by Jianyong Lei, et al.

Fibrin sealants do not prevent resection surface-related complications after liver resection

Marieke T. de Boer, and Robert J. Porte, for the FRESCO Trial Group

Reply:

We want to thank Lei and Yan for their interest in our study and for their interesting comments. In

a retrospective analysis of living donors for liver transplantation, Lei and Yan found no difference in

the incidence of resection surface-related complications, including bile leakage, between donors

in whom fibrin sealant was applied to the hepatic resection surface and those in whom no fibrin

sealant was used. These results are in accordance with those of our prospective, randomized

controlled trial.1

We agree with the suggestion made by Lei and Yan that the lower incidence of postoperative

complications in their series may be explained by excellent health status of living donors, compared

to patients with secondary and primary liver tumors, as were included in our study. However,

we believe the most important explanation for this difference in the rate of resection-related

complications between the two studies is the retrospective versus prospective design. It is very well

known that complications are underreported in retrospective studies. Nevertheless, the two studies

provide the same message: fibrin sealants do not prevent resection surface-related complications

after partial liver resections.

In an in vitro study, our group has recently found a good explanation why fibrin sealants are

ineffective in the preventions of postoperative bile leakage after liver resections.2 In this study, we

demonstrated that the presence of tissue-type plasminogen activator and other fibrinolytic proteins

in human bile results in rapid lysis of plasma clots and fibrin sealants.

REFERENCES

1. de Boer MT, Klaase JM, Verhoef C, van Dam RM, van Gulik TM, Molenaar IQ, Bosscha K, Dejong CH, Van der Jagt EJ, Porte RJ; FRESCO Trial Group. Fibrin sealant for prevention of resection surface-related complications after liver resection: a randomized controlled trial. Ann Surg 2012;256:229-234.


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Fibrin sealant for prevention of resection surface-related complications after liver resection:

A randomized controlled trial

Salomone Di Saverio, Michele Masetti, Matteo Zanello, Maria G. De Blasiis, Elio Jovine

To the Editor:

We read with great interest the results of the randomized controlled trial on “Fibrin Sealant Use

for Prevention of Resection Surface-Related Complications After Liver Resection” by de Boer et al.1

Although from our experience we might agree with the authors’ conclusions that fibrin sealant use

does not significantly influence the incidence and severity of surface-related complications after

liver resection, after looking carefully at the data of the present randomized controlled trial, we

have several concerns about a good balance between the 2 groups and percentages and statistical

significance given in the article. The generalizability of the results may therefore be affected and the

conclusions may not be strongly supported by the data.

First of all, when looking at the baseline and surgical characteristics of the 2 study groups, there are

doubts raised on their homogeneity. Above all, a nearly significant and moreover clinically relevant

difference can be seen in the percentage of patients who underwent preoperative chemotherapy

less than 3 months before surgery. This is a well-known relevant risk factor for bleeding and surface-

related complications after liver resections2 because neoadjuvant chemotherapy can induce

damage to the remnant liver and is associated with an increased risk of vascular lesions, steatosis,

and steatohepatitis.3 The percentage of such patients in the fibrin sealant group is 19.2% (instead of

20% shown in the table) and 11% (instead of 12%) in the control group, and the P value is as follows:

χ2 test Pearson uncorrected, 0.044; χ2 Yates corrected, 0.064; χ2 Mantel-Haenszel, 0.045; and Fisher

exact test 2-tailed, 0.057.

Hence, the statistical significance is nearly borderline significant. The factor of parenchymal

transection technique does not allow a careful distinction between the 2 groups, and the

combination of many different techniques (such as the use of argon or diathermia and radio-

frequency transection devices or sealing devices) in the same group of electric coagulation-based

transection technique seems too much heterogeneous. Too many techniques are included in this

group, and a subgroup analysis would be beneficial to better understand the potential variability

and biases related to the transection techniques used.

The need of intraoperative red blood cell transfusion was 15% versus 9% (P value =ns), yet presented

a non-significant trend toward higher intraoperative bleeding in the fibrin sealant group. Perhaps,

the difference in the estimated intraoperative blood loss (675 mL vs 550 mL) seems to be more

significant than acknowledged by the authors, either clinically or statistically. Although the standard

deviation (SD) is not shown, even assuming the case when the SD value may be as high as 80% of

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Chapter 11

the median value (SD of 550 and 440, respectively), the 2-tailed P value equals 0.0280. For lower SD

values, the 2-tailed P value becomes increasingly significant.

If the fibrin sealant group had a relevant trend toward higher intraoperative bleeding and red blood

cell transfusion than the control group, this may ease coagulopathy and incidence of postoperative

bleeding and complications,4 as also already acknowledged by the same authors.5

Furthermore, differences in ASA (American Society of Anesthesiologists) scores and comorbidities

between the 2 groups are not shown but may have a role in the development of complications.

Perhaps, some degree of difference in ASA scores, comorbidities, and operative risk may be argued

because the mortality of the groups showed a non-statistically significant trend toward a slightly

higher mortality (in-hospital deaths 5 versus 1; 30 days 6 vs 1 day), and this may support the

hypotheses that the groups are not well balanced.

The overall bile leakage rate was 14% in both groups, but the incidence of bile leaks requiring

reintervention was declared to be 7% without statistical differences between the 2 groups. As far

as we can see from Table 2, the incidence of bile leakage of Clavien-Dindo classification grade 3 or

more, meaning these complications require an invasive reintervention,6 occurred in 14 patients of

the fibrin sealant group (9%) versus 6 patients (3.9%) of the control group (χ2 Yates corrected, P

value =0.11; χ2 Pearson uncorrected and Mantel-Haenszel, P value =0.069).

The incidence of bleeding at resection surface was 18 of 156 (11.5%) versus 11 of 154 (7%) (P value

=ns). These mild differences and a trend toward worse postoperative outcomes in the study group

are most probably unrelated to the use of fibrin sealant and may reflect a selection bias and a poor

balance of the groups with respect to risk factors for postoperative surface-related complications,

such as intraoperative bleeding and recent preoperative chemotherapy.

When looking at drain fluid analysis, the authors found that median bilirubin concentration in drain

fluid at day 1 was slightly lower in the sealant group, compared with the control group (Table 3).

Although this difference was statistically significant, clinical significance was minimal, as there

was no difference in the overall incidence of postoperative bile leakage. Total amount of drain

production during the first 3 postoperative days and the duration of drainage also did not differ

significantly between the 2 groups.

The authors then concluded, despite the lack of any clinically relevant difference in complications,

we did find a statistically significant lower bilirubin concentration in drain fluid at postoperative

day 1 in the fibrin sealant group, compared with the controls. This suggests that there may be a

minor effect of fibrin sealant that is short lasting and does not result in an overall clinically relevant

reduction of resection surface-related complications.

However, we have noted that the fibrin sealant group did have not only a significant lower bilirubin

concentration than controls (15 μmol/L vs 24 μmol/L) but also a relevant trend toward a mean drain

volume at days 1 to 3 (105 mL vs 138 mL) and the P value given does not seem to be reliable. After

calculation of the Student t test, assuming an SD value (not shown in the article) of as high as 80%

of the mean value, the 2-tailed P value equals 0.0052 and gains increased statistical significance

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11

for lower values of SD. Given these considerations on bilirubin concentration in the drain fluid

and the daily volume of drains, a definitive judgment on the efficacy of fibrin sealant in reducing

postoperative bile leakage cannot be made.

In conclusion, the results of the present study are less unambiguous than the authors claim. Although

we might agree on the real usefulness of fibrin sealant in preventing postoperative surface-related

complications, further well-powered and better balanced studies are needed.

REFERENCES

1. de Boer MT, Klaase JM, Verhoef C, et al. Fibrin sealant for prevention of resection surface-related complications after liver resection: a randomized controlled trial. Ann Surg 2012;256:229-234.

2. Karoui M, Penna C, Amin-Hashem M, et al. Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases. Ann Surg 2006;243:1-7.

3. Benoist S, Nordlinger B. The role of preoperative chemotherapy in patients with resectable colorectal liver metastases. Ann Surg Oncol 2009;16:2385-2390.

4. Konopke R, Kersting S, Bunk A, et al. Colorectal liver metastasis surgery: analysis of risk factors predicting postoperative complications in relation to the extent of resection. Int J Colorectal Dis 2009;24:687-697.

5. de Boer MT, Molenaar IQ, Porte RJ. Impact of blood loss on outcome after liver resection. Dig Surg 2007;24:259-264.

6. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a newproposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213.

Reply to the Letter by Salomone Di Saverio, et al.

Fibrin sealants do not prevent resection surface-related complications after liver resection

Marieke T. de Boer, and Robert J. Porte, for the FRESCO Trial Group

Reply:

We thank Di Saverio et al for their interest in our randomized controlled trial (RCT) on the prophylactic

use of fibrin sealants on the hepatic resection surface after partial liver resection1 and for their critical

comments. Di Saverio et al raise concerns about the baseline comparability of the 2 study groups

and about the statistical analyses in our study.

On the basis of an adequately powered RCT, we concluded that there are no statistically significant

differences in postoperative complications when fibrin sealants or no sealants are applied to the

hepatic resection surface.1 Our findings are in accordance with those of a similar RCT performed

by Figueras et al,2 who also did not find a beneficial effect of fibrin sealants after liver surgery.

Collectively, these 2 independent RCTs provide level 1 evidence. The comments voiced by Di Saverio

et al feel like ‘the world upside down’. They still believe fibrin sealants may be beneficial in the setting

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of liver surgery and they criticize our nonsignificant findings. Usually, the critique on an RCT is the

other way around and focuses on the lack of relevance of a positive (statistically significant) finding.

When comparing baseline characteristics of patients in the 2 study groups, we did not find a

statistically significant difference. As stated in the statistical paragraph of our article, we have used

nonparametric tests (Fisher exact or χ2 test for categorical variables and Mann-Whitney U test for

comparison of continuous variables), which are appropriate in a clinical setting and with variables

that are not normally distributed. As stated in the article, missing data were treated according to

a list-wise deletion approach. The distribution of patients with chemotherapy less than 3 months

before liver surgery was 30 of 154 (20%) patients in the fibrin sealant group and 17 of 148 (12%)

patients in the control group. This means that the percentages stated in Table 1 were correct, but

they took into account the missing data of 2 patients in the sealant group and 6 patients in the

control group. Statistical comparison resulted in a P value of 0.059 (Fisher exact test), which is not

statistically different.

Di Saverio et al state that there is a higher intraoperative bleeding tendency in the fibrin sealant

group, which may have caused coagulopathy and increased the incidence of postoperative bleeding

and complications. Intraoperative blood loss in the fibrin sealant group was 675 mL (interquartile

range =300-1140 mL) and 550 mL (interquartile range =300-1000 mL) in the control group. Although

this quantity may seem a bit higher in the fibrin sealant group, the difference was not statistically

significant (P value =0.302, Mann-Whitney U test). However, even more important we do not believe

that 125 ml does make any clinical difference in the risk of causing coagulopathy or in the risk of

developing postoperative complications.

The same is true for other outcome parameters such as bile leakage, bleeding complications at

the resection surface, and the amount of drain fluid production in the first 3 days. Although the

numbers may seem higher in the sealant group, there were no statistically significant differences.

On the basis of our study and the previous study reported by Figueras et al,2 we disagree with Di

Saverio et al that more studies on the efficacy of fibrin sealants in preventing resection surface-related

complications after liver surgery are needed. Of course, our prospective study has some limitations,

but we sincerely believe that the results are unequivocal and can lead to only one conclusion: fibrin

sealants do not reduce postoperative resection surface-related complications after partial liver

resection. This clinical evidence is in line with a recent in vitro study that has demonstrated that

human bile contains a significant amount of tissue-type plasminogen activator, which contributes

to the premature lysis of the fibrin clots and sealants.3 Therefore, a possible solution to the problem

of bile leakage after liver resection may, apart from further improvements in surgical techniques, lie

in the development of new synthetic sealants that have the capacity to seal small vessels and bile

ducts and are resistant tot the fibrinolytic activity of bile. The conventional fibrin sealants do not

seem sufficient for this purpose.3,4

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11

REFERENCES1. de Boer MT, Klaase JM, Verhoef C, van Dam RM, van Gulik TM, Molenaar IQ, Bosscha K, Dejong CH, Van

der Jagt EJ, Porte RJ; FRESCO Trial Group. Fibrin sealant for prevention of resection surface-related complications after liver resection: a randomized controlled trial. Ann Surg 2012;256:229-234.

2. Figueras J, Llado L, Miro M, Ramos E, Torras J, Fabregat J, Serrano T. Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients. Ann Surg 2007 Apr;245:536-542.


4. de Boer MT, Boonstra EA, Lisman T, Porte RJ. Role of fibrin sealants in liver surgery. Dig Surg 2012;29:54-61.

174

175

APPENDIX 3

Correspondence related to Chapter 7

The impact of intraoperative transfusion of platelets and red blood cells on survival after

liver transplantation

Letter to the editor and Reply to Letter. Anesthesia & Analgesia 2009

176

Chapter 11


Platelets and survival after liver transplantation

Chris Nixon, Kerry Gunn, Tom Main, and Yatin Young

To the Editor:

After publication of the article by De Boer et al.1 (and its citation in three recent reviews)2-4 relating

survival after orthotopic liver transplantation to blood products transfused, we analyzed our

own data. The actual 1-yr survival and 5-yr survival rates for these patients were 94% and 82%,

respectively. We have plotted survival in relation to transfused unit volumes as detailed by De Boer

et al. Table 1 compares the survival rates related to platelet and red cell transfusions in Groningen

and New Zealand. Our data do not confirm a dose-related increase in mortality in patients receiving

platelets. Red cell transfusion was associated with a small increase in mortality as reported widely by

others. We would classify our protocols for use of blood products as more liberal than the Groningen

group. We transfuse red cells to maintain hemoglobin at 75–85 g/L, and platelets according to

thromboelastography, clinical bleeding, and a platelet count <70 x 109/L. In common with most

centers, our trend over time is for reducing blood transfusion requirements.

Over the time of the data collection much has changed in both immunosuppression5 and blood

transfusion.2,6 Leukocyte depletion was introduced into clinical practice by the New Zealand blood

transfusion service in 2001, and we understand this change occurred in the Netherlands in 2002.

Thus, the first series reported from Groningen in which transfusion rates were higher would have

received blood products before the introduction of leukodepletion.

The use of platelet-pheresis and single donor platelet transfusions rather than random donor

platelet preparations along with leukocyte reduction strategies may decrease the infective and

immunological risk from platelet transfusions.6,7

We believe both countries have followed the Council of Europe guidelines for blood products and

are broadly comparable. We use a single 1 g dose of methylprednisolone at induction of anesthesia,

the authors state they give a low-dose protocol, which is not further defined.1

Finally, our data and probably those of De Boer refer only to blood products transfused during the

transplant operation and do not include blood products used for postoperative bleeding.

In conclusion, our data do not substantiate the effects of platelet transfusion on survival after

orthotopic liver transplantation. Reports of increased mortality after platelet administration are not

universal.8 We believe further review is justified to better define the true risk of platelet transfusion

in current practice.

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Appendix 3

11

Table 1. Survival Related to Platelet and Red Cell Transfusion in Groningen and New Zealand

Platelets(units)

Red cells(units)

0 >0-2 >2 0 >0-6 >6

Groningen 1 yr survival 89.2 75.6 55.0 88.0 86.7 78.1

New Zealand 1 yr survival 95.8 93.0 93.8 94.5 96.1 89.4

New Zealand 5 yr survival 81.0 87.7 78.3 86.2 82.2 78.6

REFERENCES

1. De Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HGD, Slooff MJH, Porte RJ.

The impact of intraoperative transfusion of platelets and red blood cells on survival after liver

transplantation. Anesth Analg 2008;106:32-44.

2. Ozier Y, Tsou M-Y. Changing trends in transfusion practice in liver transplantation. Curr Opin

Organ Transplant 2008;13:304-309.

3. Warnaar N, Lisman T, Porte RJ. The two tales of coagulation in liver transplantation. Curr Opin

Organ Transplant 2008;13:298-303.

4. Ozier Y, Klinck JR. Anaesthetic management of hepatic transplantation. Curr Opin Anaesthesiol

2008;21:391-400.

5 Meier-Kriesche H-U, Li S, Gruessner RWG, Bustami RT, Barr ML, Leichtman AB. Immunosuppression:

evolution in practice and trends, 1994-2004. Am J Clin Transpl 2006;6:1111-1131.

6. Vamvakas EC. Platelet transfusion and adverse outcomes. Lancet 2004;364:1736-8.

7. Ness P, Braine H, King K, Barrasso C, Kickler T, Fuller A, Blades N. Singledonor platelets reduce the

risk of septic platelet transfusion reactions. Transfusion 2001;41:857-861.

8. McGrath T, Colleen Gorman Koch CG, Xu M, Li L, Mihaljevic T, Figueroa P, Blackstone EH. Platelet

transfusion in cardiac surgery does not confer increased risk for adverse morbid outcomes. Ann

Thorac Surg 2008;86:543-553.

Reply to the Letter by Chris Nixon, et al.

Platelets and survival after liver transplantation

Marieke T. de Boer, and Robert J. Porte

Reply:

We congratulate Nixon et al.1 for the excellent survival rates in liver transplantation recipients. One

explanation for the lack of the same dose-related increase in mortality in patients receiving platelet

concentrates seen in our patients2 may lie in the type of platelets used.

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Chapter 11

There are two basic methods for producing platelets for transfusion: the “buffy-coat” method using

platelets derived from pooled random donors and the single donor pheresis-derived platelet-rich

plasma method.3 As we discussed in our article, there is evidence that the latter is associated with

a lower risk of immune-mediated and infectious complications than the former. In our program, it

is common practice to use pooled random donor “buffycoat” -derived platelets, and in a second

analysis, we have recently demonstrated that the lower survival rates in patients who received

platelets is explained by a significantly greater rate of early mortality because of acute lung injury

(4.4% vs 0.4%; P value =0.004).4 From the comment by Nixon et al., it seems that the group in

Auckland is using platelets collected by pheresis from single donors.

Altogether, the current results suggest that patients undergoing liver transplantation are at greater

risk for early mortality because of acute lung injury after receiving platelets derived from pooled

random donors, although this negative effect is not observed after transfusion of single donor

pheresis derived platelet concentrates. This is an important observation that deserves further

investigation and confirmation.

REFERENCES1. Nixon C, Gunn K, Main T, Young Y, McCall J. Platelets and Survival after Liver Transplantation. Anesth Analg

2009;108:1354-1355.2. de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HGD, Slooff MJH, Porte RJ. Impact

of intraoperative transfusion of platelets and red blood cell on survival after liver transplantation. Anesth Analg 2008;106:32-44.


4. Pereboom ITA, de Boer MT, Haagsma EB, Hendriks HGD, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg 2009;108:1083-1091.

179

Summary General Conclusions, Discussion

and Future Perspectives

12

180

Chapter 12

Summary Part 1

The first part of this thesis concerns the impact of blood loss and blood transfusion on short- and

long-term outcome in liver resections.

After a general introduction in chapter 1, a review was presented in chapter 2 on studies focusing

on blood loss and blood transfusion during liver surgery for the most prevalent malignant tumors of

the liver and the relationship with postoperative outcome. In other fields of surgery, perioperative

blood loss and transfusion have shown to have a negative impact on outcome. However, it has

been debated whether this is due to a real cause-effect relationship or whether this is the result of

more complicated surgery. The effect of blood loss and blood transfusion in resection of colorectal

metastasis, hepatocellular carcinoma (HCC), and cholangiocarcinoma was separately described.

Most studies were retrospective and have demonstrated a significant and clinically relevant

association between blood transfusion and postoperative outcome, especially on postoperative

infectious complications. Evidence on the effect of blood transfusion on tumor recurrence and

long-term mortality is less clear and evidence varies depending on the type of malignancy. For

early stages of HCC there is some evidence that blood transfusions may have an impact on tumor

recurrence. However, no such effect could be demonstrated for later stages of HCC, colorectal liver

metastasis, or cholangiocarcinoma.

In chapter 3 results of a Dutch national survey on the use of topical hemostatic agents in liver surgery

were described. Worldwide an increase is seen in partial liver resections for primary or secondary

hepatic malignancies. According to this survey among surgeons, topical hemostatic agents are

frequently used not only to lower intraoperative blood loss or shorten time to hemostasis, but also

with the aim to reduce resection surface-related complications, such as bile leakage, bleeding, and

abscess formation. Fibrin sealants were most frequently used

The subsequent chapter 4 provides a review of the literature on evidence of hemostatic and

biliostatic capacities of different fibrin sealants in liver surgery. Fibrin sealants are topical hemostatic

agents that are widely used in liver surgery. A systematic literature search was performed. Thirteen

comparative fibrin sealant studies were selected. These studies have shown a reduced time to

hemostasis when fibrin sealants were used. Only a few studies have been published that have

focused on postoperative resection surface-related complications, such as bile leakage, bleeding,

or abscess formation. In these studies there is no strong evidence that fibrin sealants reduce the

incidence of bile leakage, or resection surface-related complications in general. These data suggest

that fibrin sealants can be effective as an adjunct to achieve hemostasis but do not seem effective in

avoiding resection surface-related complications during liver resections.

The aim of chapter 5 was to study the effect of prophylactic use of fibrin sealants on the liver

resection surface. Results of a multicenter randomized clinical trial on the efficacy of fibrin sealants

in reducing resection surface related complications after partial liver resections were described. Bile

leakage, bleeding, and abscess formation are major resection surface-related complications after

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Summary. General Conclusions, Discussion and Future Perspectives

12

liver resection. In 310 non-cirrhotic patients undergoing liver resection, we compared prophylactic

application of fibrin sealant (156 patients) to the resection surface with no application of fibrin

sealant (154 patients). The overall rate of postoperative resection surface-related complications

was not different between the two groups. Bile leakage was detected in 14% of patients in the

fibrin sealant group and in 14% of controls. The rate of reinterventions for resection surface-related

complications and severity of complications did also not differ between the two groups. This

randomized multicenter trial showed that prophylactic application of fibrin sealant at the resection

surface after liver resections did not lead to a reduction in the incidence or severity of postoperative

bile leakage or other resection surface-related complications.

Summary Part 2

The second part of this thesis focuses on blood loss and transfusion requirements in liver

transplantation and the impact of blood loss and blood transfusion on short- and long-term

outcome in liver transplantation.

Chapter 6 provides a review of the literature of clinical and research developments which have

contributed to a reduction in blood loss and transfusion requirements in liver transplantation. Blood

loss during liver transplantation has long been recognized as an important cause of morbidity and,

especially in the early days, also mortality. Blood transfusions are associated with an increased risk

of postoperative complications, such as infections, pulmonary complications, delayed recovery, and

a higher rate of reoperations. Many studies have been performed to elucidate the mechanisms of

increased blood loss in liver transplantation. Several randomized controlled studies have shown

effective strategies in reducing blood loss and transfusion requirements during liver transplantation.

In addition, improvements in surgical technique, anesthesiological care, and better graft preservation

methods have contributed to a steady decrease in blood transfusion requirements in most liver

transplant programs. Several centers are reporting liver transplantation without any need for blood

transfusion in up to 30% of their patients.

The study in chapter 7 assessed the impact of transfusion of various blood products on outcome

after orthotopic liver transplantation (OLT) in 433 adult patients. The proportion of patients

receiving transfusion of any blood component decreased from 100% in the period 1989-1996 to

74% in the period 1997-2004. In uni- and multivariate analyses the indication for transplantation,

transfusion of platelets, and RBC were highly dominant in predicting one-year patient survival.

These risk factors were independent from well-accepted indices of disease, such as the MELD score

and Karnofsky score. The effect on one-year survival was dose-related with a hazard ratio of 1.377

per unit of platelets (P value =0.01) and 1.057 per unit of RBC (P value =0.001). The main finding

of this study was that, in addition to RBC, platelet transfusions are an independent risk factor for

survival after OLT.

The subsequent chapter 8 focuses on the specific causes of mortality and graft loss in relation to

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platelet transfusions during OLT. In a series of 449 consecutive adult patients undergoing a first

OLT we studied the causes of patient death and graft failure in patients who did or did not receive

perioperative platelet transfusions. Patient and graft survival were both significantly reduced in

patients who did or did not receive platelet transfusions (74% vs. 92%, and 69% vs. 85%, respectively

at one year; P value <0.001). A significant higher early mortality rate due to acute lung injury was

seen in patients who received platelet transfusions (4.4% vs 0.4%; P value =0.004). The main cause of

graft loss in patients that received platelet transfusions was patient death with a functioning graft.

These findings suggest that platelet transfusions are an important risk factor for mortality after OLT.

The current study extends previous described observations by identifying acute lung injury as the

main determinant of increased mortality.

In chapter 9 results of a retrospective study on a possible relation between blood transfusion and

the incidence of acute rejection after liver transplantation were described. Blood transfusion is

generally considered to be harmful, although in kidney transplantation early reports have suggested

a protective effect of RBC transfusion on the incidence of rejection after kidney transplantation.

Between 1995 and 2004, 292 primary liver transplantations in adults were performed. Specific reason

to select this decade is that at that time it was our policy to perform a routine liver biopsy after OLT,

if the clinical condition would allow this. All patients who underwent a biopsy within 2 weeks were

included. Patients who died or were retransplanted <7 days after OLT were excluded. In total, 197

patients had a biopsy within 2 weeks after OLT. Fifty-nine (30%) patients did not receive any RBC

transfusion during OLT. Sixty (31%) patients did not show any signs of acute rejection. Multivariate

analysis for reduced risk of acute rejection (any Banff grade) revealed the following independent

variables: intraoperative RBC transfusion and induction immunosuppression. This study suggests

that there is an increased risk of developing acute rejection after OLT when patients do not receive

any RBC transfusion during OLT.

In chapter 10 we studied the impact of extended criteria donor (ECD) liver grafts on intraoperative

transfusion requirements during liver transplantation. The use of ECD grafts may reduce waiting list

mortality in OLT. ECD livers, however, are associated with increased risk of graft failure and recipient

morbidity. A consecutive series of 318 primary adult liver transplant recipients was analyzed. An

ECD graft was defined as DRI ≥1.7. ECD livers were used in 115 (36%) recipients. In 95 (30%) of all

transplant procedures there was no need for RBC transfusion. After uni- and multivariate analysis

the following variables were found to be independently associated with post-reperfusion RBC

transfusion requirements: DRI ≥1.7, female recipient, recipient age, and no aprotinin administration.

The use of ECD grafts, defined as a DRI ≥1.7, was associated with significantly increased intraoperative

RBC transfusion requirements after graft reperfusion.

In chapter 11, 3 appendices are added: appendix 1 contains the questionnaire used in chapter 3.

In appendix 2 correspondence related to chapter 5 is described. In appendix 3 correspondence

related to chapter 7 is described.

In chapter 12, the current chapter, the results of this thesis are summarized and discussed.

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GENERAL CONCLUSIONS, DISCUSSION AND FUTURE PERSPECTIVES

PART 1 Blood transfusion in liver resection and the effect on short- and long-term outcome

1) Blood transfusions are an independent risk factor for postoperative morbidity and mortality in liver

resections. There is limited evidence on the effect of intraoperative blood transfusion on oncological

outcome in liver resections for hepatobiliary malignancies. (Chapter 2)

Improvements in surgical techniques used for hepatic resection and optimization of perioperative

patient management have led to significant improvement in short- and long-term outcome.

Despite these improvements blood loss during liver resection remains a problem that is usually

treated with allogeneic red blood cell (RBC) transfusion. RBC transfusions have been identified as

independent risk factor for postoperative morbidity and mortality after liver resections. In several

cancers, like gastric, colon, lung, and soft tissue carcinomas, an adverse effect of RBC transfusion on

tumor recurrence has been reported. In this review a similar adverse effect was described in liver

resection studies in early hepatocellular carcinoma (HCC), but there was no such evidence in late

stages of HCC, colorectal liver metastasis, or cholangiocarcinoma. Apart from the fact that there may

not be an effect of RBC transfusion on long-term outcome in hepatobiliary malignancies, this lack

of evidence may also be explained by several other factors like the retrospective design of studies,

low patients numbers, high transfusion rates in previous studies, contradicting results between

studies, the fact that long-term outcome is influenced by (stronger) tumor-related factors, and also

heterogeneity of patient groups.

A more recent retrospective HCC study by Sugita et al. describes a significant worse cancer related

survival and disease free survival in patients with tumors >5 cm who received intraoperative RBC

transfusion, compared to patients who did not receive RBC transfusion (5-year cancer related

survival 25,4% vs 68,5% and 5-year disease free survival 30.6% vs 0%).1 Furthermore, they describe

a significant lower lymphocyte count 1 day after liver resection in patients who received RBC

transfusions compared to the patients who did not (881/mm3 vs 1081/mm3). This effect was not

seen on day 3 and 7. They suggest that the immunosuppressive effect of RBC transfusion influences

residual HCC cells in the liver and does not so much influence multicentric cancer development.1

It’s generally accepted that blood transfusions have an immunosuppressive effect.2 Although the

exact underlying mechanism is unknown, several studies have suggested suppression of host

immunity via a reduction in natural killer cells, cytotoxic T-cells, IL2 receptor-positive cells and

helper T-cell function, and an increase in suppressor T cells.3,4 Many of these effects are thought to be

related to the residual amounts of donor leukocytes within the stored blood as well as preservation-

related changes in erythrocytes.5 Nowadays blood transfusions in most developed countries are

leukocyte depleted, posing the question whether part of the immunosuppressive effect of a blood

transfusion is eliminated.

A few randomized studies in colorectal cancer have been performed that compare the long-term

outcome and cancer recurrence after leukocyte containing (buffy coat depleted) RBC transfusions

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with leukocyte depleted RBC transfusions. They found no difference in cancer recurrence at short-

term and five-year follow-up.6-8 No such trials have been performed in hepatobiliary malignances.

Other strategies to reduce risks of allogeneic transfusions are reducing storage time of blood and the

use autologues blood transfusion. Methods for autologues blood transfusion include preoperative

blood donation, intraoperative blood salvage using cell-saver techniques, or intraoperative

normovolemic hemodilution. Although these methods seem promising, a matched pair analysis

by Park et al. between allogeneic and autologues transfused patients in hepatectomy, did not show

any benefit for autologues transfusions considering perioperative complications.9

Intraoperative blood salvage autotransfusion (IBSA) during liver resection theoretically increases

the risk of tumor cell dissemination. Based on this theoretical risk and one case report published

in 1975,10 the American Medical Association Council of Scientific Affairs in 1986 recommended

against the use of IBSA.11 In practice, a few studies have now shown that there may not be a risk

but there may even be a benefit in the use of IBSA compared to allogeneic RBC transfusion.12-14 In

this discussion the balance should be weighed between the risk of tumor recurrence by allogeneic

transfusion by immunosuppressive effects and the risk of tumor cell spread by IBSA.

Normovolemic hemodilution is not common practice in our institution partly because of required

training of the operating team but probably more important the lack of necessity with a transfusion

incidence of around 10% in liver. For the future it might be interesting to develop a model that

predicts the necessity of blood donation, like was described by Tomimaru et al. in liver resections

for HCC.15

Hemostatic agents

2) Topical hemostatic agents are used on a large scale in liver surgery. The most frequently used agents

are fibrin sealants. These agents are not only used for hemostasis, but are also used with the aim to

reduce resection surface-related complications. (Chapter 3) Several studies have shown a reduced time

to hemostasis when fibrin sealants are used. There is no clear evidence in literature that fibrin sealants

reduce resection surface-related complications. (Chapter 4) In a Dutch multicenter randomized controlled

trial fibrin sealants did not reduce resection surface-related complications. (Chapter 5)

In liver surgery hemostatic agents can never replace meticulous surgical hemostasis, but can

be used as an adjunct to achieve hemostasis. It seems a logical method to apply fibrin sealants

(hemostatic agents that contain active components that mimic endogenous coagulation) as a fixing

layer to the resection plane to reduce the risk of resection surface-related complications, like bile

leakage, bleeding, or abscess formation. Studies show conflicting results when looked at the effect

on resection surface-related complications. Most of the studies that show a positive effect of fibrin

sealants on resection surface-related complications are not powered for this endpoint. With our

study, now two large randomized controlled trials both do not show an effect of fibrin sealants

on the incidence of resection surface-related complications.16,17 The answer to the question why

fibrin sealants are not effective in reducing bile leakage may be derived from an in vitro study in

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which the effect of bile on stability of fibrin clots was examined.18 Basically, this study shows that

bile contains fibrinolytic activity (mediated by tissue-type plasminogen activator and plasminogen

in bile) leading to premature lysis of fibrin clots. With this evidence we think we can state that there

is no place for prophylactic use of fibrin sealants in liver resections.

Limitation of our randomized study is that we only investigated one fibrin sealant. These results

cannot automatically be translated to other sealants. Although, based on minor differences in

composition of commercially available fibrin sealants, we do not believe that the outcome would

have been different with other fibrin sealants. Nevertheless, we did not compare fibrin sealants with

newer, so-called carrier-bound fibrin sealants that consist of a solid matrix (e.g. collagen fleece) with

an active hemostatic layer containing thrombin and fibrinogen. Again, a fibrin clot is formed on

this matrix, which may be affected by the fibrinolytic capacity of bile, but we cannot draw these

conclusions without new in vitro and clinical evidence. So far only small series have been published

on the efficacy of the carrier-bound fibrin sealants in liver surgery.19-21 Primary endpoint of two

of these comparative studies (carrier-bound FS vs Argon and carrier-bound FS vs no treatment)

focused on hemorrhage and not on bile leakage.19,20 In both studies bile leakage incidence did

not differ between groups. The third study was a small comparative retrospective study on the

incidence of bile leakage after split liver transplantation comparing a carrier-bound fibrin sealant

with a fibrin sealant. This study describes a bile leak incidence of 6,3% vs 43.7%, but the groups were

small containing only 16 patients per arm.21

Another combination of fibrin sealant with a matrix product called PGA (Polyglycolic Acid) felt shows

promising results in the reduction of bile leakage.22,23 But again these studies were underpowered

and not randomized.

So where do we go from here? The incidence of bile leakage should be reduced to the minimum.

Bile leakage in liver resections is described in 1-14% of the cases, leading to additional interventions,

prolonged hospital stay, mortality and higher costs. Recently, a large retrospective study describing

a consecutive cohort of 1001 liver resections without biliary reconstruction was published.24 The

incidence of clinically relevant bile leakage was 8%. Bile leakage was proved to have a significant

negative impact on hospital stay (16 vs 9 days, P value <0.001) and one-year mortality (11 vs 5%,

P value =0.03). The incidence of bile leakage may be reduced by applying a bile leakage test,24-26

although this preventive effect is debated by Ijichi et al, who performed a randomized controlled

trial on the effect of biliary leakage test on the incidence of bile leakage.25 They showed no

difference in bile leakage in the group who had a bile leakage test compared to the group that

did not get a bile leakage test during liver resection. Several authors describe independent risk

factors for bile leakage mainly in large retrospective cohorts: advanced age,27 wide resection surface

area,27 exposure Glisson’s sheath/ central resection/ S4 or S8 subsegmentectomy,27-29 bilioenteric

anastomosis, preoperative chemotherapy,24 major hepatectomy,24 two stage hepatectomy,24

selective clamping technique,24 R1/R2 resection,24 and the absence of a bile leakage test24,26

In the future prevention of bile leakage requires a tailor made surgical strategy and research should

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focus on the group of patients with increased risk of bile leakage. New large randomized studies

powered for resection surface-related complications, or bile leakage only, are necessary in the field

of carrier-bound sealants (whether they are ready-made or home-made). However, considering the

fact that bile contains fibrinolytic capacities, a possible solution to the problem of bile leakage after

liver resection may lie in the development of safe and ready to use synthetic sealants instead of

fibrin sealants.

PART 2 Blood loss and transfusion requirements in liver transplantation and the impact of

blood loss and blood transfusion on short- and long-term outcome in liver transplantation.

3) Surgical, pharmacological, and anesthesiological factors have led to a steady decrease in blood

transfusion requirements in most liver transplant programs over the years. Several centers are now

reporting liver transplantation without any need for blood transfusion in up to 30% of their patients.

(Chapter 6) RBC and platelet transfusions are both independent risk factors for survival after OLT. (Chapter

7) Lower survival rates in patients who received platelets were attributed to a significantly higher rate of

early mortality because of a higher incidence of acute lung injury. (Chapter 8)

In liver transplantation, extensive clinical and experimental research has led to the identification of

independent risk factors and mechanisms of increased blood loss in patients undergoing OLT. Blood

loss in OLT is influenced by multiple factors, such as preoperative condition, surgical technique,

organ preservation, hemostatic disorders occurring during OLT, and anesthesiological care. Progress

in these fields has led to a remarkable reduction in blood loss and thus transfusion requirements in

OLT. Median intraoperative RBC transfusion requirement in adult patients who received a first liver

transplant in our center declined steadily from around 20 units in the late 1980s to 2 units in the

year 2003.

Our studies have shown that both intraoperative RBC and platelet transfusion are independent risk

factors for survival after OLT. As previously described, blood transfusions have an immunosuppressive

effect.2 Platelets seem to play a complicated role, not just being important in hemostasis but they

also contain many cytokines and vasoactive and inflammatory mediators, which are rapidly released

on activation, and which make platelet transfusions theoretically proinflammatory.30 Patients

who received platelet transfusions suffered more from acute lung injury (ALI) or acute respiratory

distress syndrome (ARDS). The adverse effect of platelet transfusion is due to a systemic response.

Passive transfer of antileukocyte antibodies in plasma-rich blood products (like platelets)31 and

accumulation of inflammatory mediators in stored platelets32 may lead to ALI or ARDS.

It is not known whether leukocyte reduction techniques and reducing storage duration will

eliminate the negative effects of RBC and platelet transfusion. Whether a potential negative effect of

platelet transfusion can be attributed to the harvesting technique, a ‘one-donor’ pheresis technique

versus ‘pooled-donor’ whole-blood technique (platelet-rich plasma or buffycoat based) remains to

be debated.

Whether we can extrapolate the reduction in transfusion rate described in the previous decade to

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the current situation remains a subject for research. The use of the antifibrinolytic agent aprotinin

was stopped in 2007, because of market withdrawal after the publication of a large prospective

observational study in cardiothoracic surgery by Mangano et al, and the BART study, which

described an association between aprotinin and serious end-organ damage.33,34 The use of the

antifibrinolytic drug aprotinin was first described by Neuhaus et al. in 1989.35 From then on aprotinin

was almost routinely used in our institution. The efficacy of aprotinin in reducing RBC transfusion

requirements by around 30% during OLT has been proven by randomized placebo controlled

studies.36,37 A retrospective study from our center shows that the proportion of patients without RBC

transfusion decreased from 39% in the aprotinin era (2000-2007) to 21 % in the post-aprotinin era

(2007-2013, P value <0.001). The median amount of RBC transfusion increased from 2 (interquartile

range =0-6) in the aprotinin era, to 4 units (interquartile range =1-9) in the post-aprotinin era (P

value <0.001). (Unpublished data F. Arshad) Since the withdrawal of aprotinin we have not routinely

changed to the administration of tranexamic acid, another effective antifibrinolytic agent, even

though previous studies have shown that tranexamic acid is comparable to aprotinin in terms of

reducing blood loss and in terms of side effects.38,39 This may explain the difference with another

recent retrospective cohort study, showing no difference in RBC transfusion after the withdrawal of

aprotinin.40 In this study tranexamic acid was used after aprotinin withdrawal in 62% of cases.

The reason not to change to routine use of another antifibrinolytic drug such as tranexamic acid in

our institution can be explained by a growing awareness of the concept of ‘rebalanced hemostasis’

in cirrhotic patients. The average cirrhotic patient appears to be in a hemostatic balance with

adequate hemostatic function despite abnormal coagulation tests.41,42 During OLT the balance

may be turned to either hypocoagulation or hypercoagulation, making patients with cirrhosis both

prone to bleeding as well as thromboembolic complications.42

Although we have not found a clear relation between antifibrinolytic drugs and thromboembolic

complications,43 it seems logical to only administer antifibrinolytic drugs when there are signs of

hyperfibrinolysis during OLT. The best way to avoid blood loss and hemostatic imbalance during

OLT is probably to obtain a fluid restrictive policy, because administration of fluids results in a

further increase in portal and central venous pressure, which promotes bleeding during surgical

exploration.41,44-46

Furthermore, there is a growing sense that as transfusion requirements for liver transplantation

continue to drop, and the number of patients transplanted without RBC transfusion increases, the

balance between risks and benefits of antifibrinolytic therapy in OLT is changing. At many institutions

there is a move away from routine use of antifibrinolytic agents to a more select prophylaxis or

treatment only.

In a current multicenter randomized study we aim to investigate whether the preoperative

administration of prothrombin complex concentrate, a low volume pro-hemostatic product,

in cirrhotic patients undergoing liver transplantation, is a safe and effective method to reduce

perioperative blood loss and transfusion requirements.47 Prothrombin complex concentrate (PCC)

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does not only contain procoagulant factor such as factor II, VII, IX, and X, but also contains protein C

and S, which are critical anticoagulant proteins. This gives the theoretical advantage that PCC ‘adds

weight to both sides of the hemostatic balance’.

4) There is an increased risk of developing acute rejection after OLT when patients do not receive any RBC

transfusion during OLT. (Chapter 9)

Anesthesiological and surgical improvements in liver transplantation have made it possible to perform

liver transplantation without transfusion of blood products.48 Early reports in kidney transplantation

have suggested a protective effect of RBC transfusion on the incidence of rejection.49-52 In our study

we demonstrated after multivariate analysis that absence of intraoperative RBC transfusion was

associated with an almost 3-fold increased risk for rejection at 2 weeks. We could not show any

protective effect of preoperative RBC transfusion on the incidence of acute rejection as has been

shown in kidney transplantation. The beneficial effect of RBC transfusion during OLT is offset by

significant undesired side effects of RBC (and other blood product) transfusion. We and others have

previously demonstrated that blood product transfusion during OLT is dose-dependently associated

with morbidity and mortality.53,54 Since management of rejection after OLT is relatively easy, and

as early clinical or subclinical rejection has no long-term adverse effects,55 we remain in favor of

a restrictive transfusion policy during OLT as the benefits of RBC transfusion do not outweigh its

detrimental effects. Nevertheless, it is important for clinicians to be aware of the elevated risk of

rejection in those patients that do not receive intraoperative RBC transfusion. Those patients may

require more intensive monitoring or a more aggressive initial immunosuppressive therapy.

5) The use of extended criteria donor (ECD) grafts is associated with significantly increased intraoperative

RBC transfusion requirements after graft reperfusion. (Chapter 10)

In an era of increasing organ shortage, accepting ECD grafts seems a necessary way to reduce

mortality on the waiting list in liver transplantation. In general, ECD grafts are considered to be

organs with a higher risk of initial poor function or non-function and are associated with an increased

risk of postoperative recipient morbidity and mortality.56,57 The results of our study indicate that the

poor quality of the donor liver, as reflected by the donor risk index (DRI), has an impact on RBC

transfusion requirements after graft reperfusion.

There is no clear definition of the features of an ECD liver, but in general high donor age, high grade

of steatosis, DCD (donation after circulatory death) grafts, partial grafts, or cerebrovascular cause of

death are considered ECD criteria.57,58 Donor risk scores, such as the DRI, have been developed to

quantify the risk associated with donor variables.59 In this study a DRI cut-off point of 1.7 was used

to identify an ECD graft, as was previously done in a study by Maluf et al.60 Whether this is a right

assumption may be a subject of debate.

Potential mechanisms for increased blood loss after graft reperfusion may be related increased

ischemia-reperfusion injury in ECD grafts.61 Increased reperfusion injury is accompanied by a high

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release of fibrinolytic proteins from the donor graft, which may contribute to excessive blood loss in

the last phase of the operation.62,63

Focus of future research should lie in organ optimization and reduction of preservation-

reperfusion injury. New strategies are the use of extracorporal membrane oxygenation (ECMO)

and normothermic regional perfusion in DCD donors.64,65 Ex-vivo pharmacological conditioning

of the liver,66,67 or pharmacological conditioning in the recipient,68,69 have demonstrated efficacy

in reducing ischemia reperfusion injury. But most exciting seems the regained interest in ex-situ

machine perfusion (MP) techniques the last couple of years, which has now recently moved to

the clinical setting. Advantages of MP over standard cold storage include continuous supply of

metabolites and oxygen, washout of waste products, assessment of viability,70 and intraoperative

therapeutic interventions. Only few clinical trials have been published on the use of MP in liver

transplantation,71,72 but the first results are promising. No clinical trials on normothermic machine

perfusion are published yet, but technically it is feasible.73 So far it is not clear what the optimal

temperature is for MP, and there is a pressing need for multicenter clinical trials that can verify the

early clinical experience with these new ex-situ MP techniques.

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36. Porte RJ, Molenaar IQ, Begliomini B, et al. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. EMSALT Study Group. Lancet 2000;355:1303-1309.

37. Findlay JY, Rettke SR, Ereth MH, Plevak DJ, Krom RA, Kufner RP. Aprotinin reduces red blood cell transfusion in orthotopic liver transplantation: a prospective, randomized, double-blind study. Liver Transpl 2001;7:802-807.

38. Ickx BE, van der Linden PJ, Melot C, et al. Comparison of the effects of aprotinin and tranexamic acid on blood loss and red blood cell transfusion requirements during the late stages of liver transplantation. Transfusion 2006;46:595-605.

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40. Schofield N, Sugavanam A, Thompson K, Mallett SV. No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin. Liver Transpl 2014;20:584-590.


42. Warnaar N, Lisman T, Porte RJ. The two tales of coagulation in liver transplantation. Curr Opin Organ Transplant 2008;13:298-303.

43. Warnaar N, Mallett SV, Klinck JR, et al. Aprotinin and the risk of thrombotic complications after liver transplantation: a retrospective analysis of 1492 patients. Liver Transpl 2009;15:747-753.

44. Massicotte L, Beaulieu D, Thibeault L, et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008;85:956-962.

45. Feng ZY, Xu X, Zhu SM, Bein B, Zheng SS. Effects of low central venous pressure during preanhepatic phase on blood loss and liver and renal function in liver transplantation. World J Surg 2010;34:1864-1873.

46. Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl 2006;12:117-123.

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49. Opelz G, Sengar DP, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973;5:253-259.

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51. Opelz G, Vanrenterghem Y, Kirste G, et al. Prospective evaluation of pretransplant blood transfusions in cadaver kidney recipients. Transplantation 1997;63:964-967.

52. Higgins RM, Raymond NT, Krishnan NS, et al. Acute rejection after renal transplantation is reduced by approximately 50% by prior therapeutic blood transfusions, even in tacrolimus-treated patients. Transplantation 2004;77:469-471.

53. Ramos E, Dalmau A, Sabate A, et al. Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them. Liver Transpl 2003;9:1320-1327.

54. de Boer MT, Christensen MC, Asmussen M, et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg 2008;106:32-44.

55. Tippner C, Nashan B, Hoshino K, et al. Clinical and subclinical acute rejection early after liver transplantation: contributing factors and relevance for the long-term course. Transplantation 2001;72:1122-1128.

56. Bismuth H, Castaing D, Ericzon BG, et al. Hepatic transplantation in Europe. First Report of the European Liver Transplant Registry. Lancet 1987;2:674-676.

57. Durand F, Renz JF, Alkofer B, et al. Report of the Paris consensus meeting on expanded criteria donors in liver transplantation. Liver Transpl 2008;14:1694-1707.

58. Gastaca M. Extended criteria donors in liver transplantation: adapting donor quality and recipient.

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59. Feng S, Goodrich NP, Bragg-Gresham JL, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant 2006;6:783-790.

60. Maluf DG, Edwards EB, Kauffman HM. Utilization of extended donor criteria liver allograft: Is the elevated risk of failure independent of the model for end-stage liver disease score of the recipient? Transplantation 2006;82:1653-1657.

61. Briceno J, Marchal T, Padillo J, Solorzano G, Pera C. Influence of marginal donors on liver preservation injury. Transplantation 2002;74:522-526.

62. Legnani C, Palareti G, Rodorigo G, Gozzetti G, Mazziotti A, Martinelli G, Zanello M, Sama C, Coccheri S. Protease activities, as well as plasminogen activators, contribute to the “lytic” state during orthotopic liver transplantation. Transplantation 1993;56:568-572.

63. Porte RJ, Bontempo FA, Knot EA, Lewis JH, Kang YG, Starzl TE. Systemic effects of tissue plasminogen activator-associated fibrinolysis and its relation to thrombin generation in orthotopic liver transplantation. Transplantation 1989;47:978-984.

64. Fondevila C, Hessheimer AJ, Ruiz A, et al. Liver transplant using donors after unexpected cardiac death: novel preservation protocol and acceptance criteria. Am J Transplant 2007;7:1849-1855.

65. Oniscu GC, Randle LV, Muiesan P, et al. In situ normothermic regional perfusion for controlled donation after circulatory death-the United kingdom experience. Am J Transplant 2014;14:2846-2854.

66. Busuttil RW, Lipshutz GS, Kupiec-Weglinski JW, et al. rPSGL-Ig for improvement of early liver allograft function: a double-blind, placebo-controlled, single-center phase II study. Am J Transplant 2011;11:786-797.

67. Baskin-Bey ES, Washburn K, Feng S, et al. Clinical Trial of the Pan-Caspase Inhibitor, IDN-6556, in Human Liver Preservation Injury. Am J Transplant 2007;7:218-225.

68. Lang JD,Jr, Teng X, Chumley P, et al. Inhaled NO accelerates restoration of liver function in adults following orthotopic liver transplantation. J Clin Invest 2007;117:2583-2591.

69. Beck-Schimmer B, Breitenstein S, Urech S, et al. A randomized controlled trial on pharmacological preconditioning in liver surgery using a volatile anesthetic. Ann Surg 2008;248:909-918.

70. Sutton ME, Op den Dries S, Karimian N, et al. Criteria for Viability Assessment of Discarded Human Donor Livers during Ex Vivo Normothermic Machine Perfusion. PLoS One 2014;9:e110642.

71. Guarrera JV, Henry SD, Samstein B, et al. Hypothermic machine preservation in human liver transplantation: the first clinical series. Am J Transplant 2010;10:372-381.

72. Dutkowski P, Schlegel A, de Oliveira M, Mullhaupt B, Neff F, Clavien PA. HOPE for human liver grafts obtained from donors after cardiac death. J Hepatol 2014;60:765-772.

73. op den Dries S, Karimian N, Sutton ME, et al. Ex vivo normothermic machine perfusion and viability testing of discarded human donor livers. Am J Transplant 2013;13:1327-1335.

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195

Nederlandse samenvatting

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Dit proefschrift beschrijft in twee delen de korte en lange termijn effecten van bloedverlies

en bloedtransfusie bij patiënten die leverchirurgie (deel 1) of een levertransplantatie (deel 2)

ondergaan.

Hoofdstuk 1 dient als algemene inleiding en beschrijft de opzet van dit proefschrift. Leverchirurgie

is een relatief jong vak. De eerste publicatie van een anatomische resectie van de rechter leverhelft

werd beschreven in 1952, de eerste succesvolle levertransplantatie werd beschreven in 1968.

De lever is een goed doorbloed parenchymateus orgaan en speelt een belangrijke rol in de

productie van stollingsfactoren. Het verrichten van resecties van een groot deel van de lever, of het

transplanteren van een lever voor eindstadium leverziekte, kan gepaard gaan met veel bloedverlies

waarbij het geven van bloedtransfusies noodzakelijk kan zijn. Chirurgische, anesthesiologische,

en medicamenteuze ontwikkelingen en veranderde inzichten rondom het perioperatief beleid,

hebben de afgelopen decennia geleid tot verbetering van resultaten en een toename van het aantal

leveroperaties en levertransplantaties. Tegenwoordig is een leverresectie de standaard behandeling

voor de meeste tumoren in de lever, en is levertransplantatie vaak de enige behandelingsoptie voor

een patiënt met een eindstadium leverziekte. Ondanks deze ontwikkelingen blijven bloedverlies

en bloedtransfusie een probleem bij leveroperaties en zijn ze een voorspeller voor postoperatieve

morbiditeit en mortaliteit.

DEEL 1 Studies bij leverresecties

In Hoofdstuk 2 wordt een overzicht gegeven van studies naar het effect van bloedverlies

en bloedtransfusie op postoperatieve en oncologische uitkomsten bij leverresecties voor

hepatocellulair carcinoom (HCC), colorectale levermetastasen en cholangiocarcinoom. In het

algemeen worden bloedverlies en bloedtransfusie gezien als risicofactoren voor postoperatieve

morbiditeit en mortaliteit. Het is echter de vraag of hier sprake is van een direct causaal verband of

dat er bij deze patiënten toch sprake is van meer complexe operaties vergeleken met de operaties die

niet gepaard gingen met bloedverlies en/of bloedtransfusie. De meeste studies waren retrospectief

en lieten een significant effect zien van bloedtransfusie op postoperatieve complicaties, waarbij

vooral meer infectieuze complicaties werden gezien. Bewijs voor een effect van bloedtransfusie op

de kans op tumor recidief is minder evident waarbij verschil moet worden gemaakt tussen de drie

soorten onderzochte tumoren. Er lijkt een verhoogde kans op tumor recidief te bestaan bij vroege

stadia HCC (I-II) na intra-operatieve bloedtransfusies. Dit effect kon echter niet worden aangetoond

voor de verder gevorderde stadia HCC (III-IV), colorectale levermetastasen of cholangiocarcinoom.

In Hoofdstuk 3 wordt het gebruik van hemostatische hulpmiddelen bij leverresecties in Nederland

beschreven. Dit werd onderzocht door middel van een landelijke enquête die naar alle chirurgen

in Nederland werd gestuurd. Uit deze enquête bleek dat hemostatische hulpmiddelen veel worden

gebruikt tijdens leverresecties. Fibrine sealants worden het meest toegepast. Deze middelen

worden niet alleen gebruikt voor hemostatische doeleinden maar worden ook vaak ingezet met

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als doel postoperatieve resectievlak-gerelateerde complicaties, zoals gallekkage, abcesvorming of

nabloeding te voorkomen.

In Hoofdstuk 4 bespreken we een systematisch overzicht van studies naar hemostatische en

biliostatische effecten van verschillende hemostatische middelen bij leverresecties. Dertien

vergelijkende studies werden geïncludeerd. Deze studies laten zien dat het gebruik van fibrine

sealants leidt tot snellere hemostase. Elf van deze studies hebben gekeken naar het effect van deze

middelen op postoperatieve resectievlak-gerelateerde complicaties. Deze studies laten geen evident

bewijs zien voor een reductie van postoperatieve resectievlak-gerelateerde complicaties wanneer

fibrine sealants worden gebruikt. Deze data suggereren dat fibrine sealants effectief kunnen zijn

als hemostatisch middel bij leverresecties, maar dat ze niet effectief zijn in het verminderen van

postoperatieve resectievlak-gerelateerde complicaties.

In Hoofdstuk 5 worden de resultaten beschreven van een Nederlandse gerandomiseerde studie

(FRESCO trial) naar het effect van profylactisch gebruik van fibrine sealants op de incidentie van

resectievlak-gerelateerde complicaties. Bij 310 niet-cirrotische patiënten die een leverresectie

ondergingen werd gerandomiseerd tussen wel (156 patiënten) of geen (154 patiënten) gebruik

van fibrine sealant op het resectievlak van de lever. De incidentie van postoperatieve resectievlak-

gerelateerde complicaties tussen beide groepen verschilde niet. Gallekkage werd in beide groepen

bij 14% van de patiënten gediagnostiseerd. Het aantal reïnterventies en de ernst van complicaties

verschilde eveneens niet tussen beide groepen. Deze gerandomiseerde studie laat zien dat het

profylactisch gebruik van fibrine sealants op het resectievlak van de lever niet leidt tot minder

resectievlak-gerelateerde complicaties. Het routinematig gebruiken van fibrine sealants op het

resectievlak van de lever moet dan ook worden ontraden.

DEEL 2 Studies bij levertransplantaties

In Hoofdstuk 6 wordt een overzicht gegeven van klinische en onderzoeks ontwikkelingen die

hebben bijgedragen aan vermindering van bloedverlies en bloedtransfusiebehoefte tijdens

levertransplantaties. Bloedverlies tijdens levertransplantaties is een belangrijke risicofactor voor

morbiditeit en leidde vooral in de vroege jaren van levertransplantatie nogal eens tot mortaliteit.

Bloedtransfusies zijn geassocieerd met een verhoogd risico op postoperatieve complicaties,

zoals infecties, pulmonale complicaties, vertraagd herstel en een hogere incidentie van re-

operaties. Stollingsproblemen en portale hypertensie kunnen tijdens transplantatie leiden tot

verhoogd bloedverlies. Eind jaren ‘80 van de twintigste eeuw werd het mechanisme achter

primaire hyperfibrinolyse ontdekt, één van de oorzaken van verhoogd bloedverlies tijdens

levertransplantaties. Het gebruik van antifibrinolytische medicijnen leidt tot een reductie van

het bloedverlies met ongeveer 30%. Daarnaast hebben chirurgische en anesthesiologische

vernieuwingen en betere orgaanpreservatie technieken geleid tot geleidelijke vermindering

van bloedverlies en bloedtransfusie. Meerdere centra rapporteren levertransplantatie zonder

bloedtransfusie bij ca. 30% van hun patiënten.

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In Hoofdstuk 7 wordt een retrospectieve studie beschreven bij 433 volwassen patiënten naar

het effect van de verschillende bloedproducten op de uitkomsten na levertransplantatie. Het

percentage patiënten dat een transfusie kreeg verminderde van 100% in de periode 1989-1996 naar

74% in de periode 1997-2004. Na uni- en multivariate analyse bleken de indicatie voor transplantatie,

transfusie van rode bloedcellen (RBCs) of transfusie van trombocyten onafhankelijke risicofactoren

voor 1-jaars patiëntoverleving. Het effect op de 1-jaars overleving was dosis gerelateerd met

een hazard ratio van 1.377 per eenheid trombocytentransfusie (P waarde =0.01) en 1.057 per

eenheid RBC (P waarde =0.001). Concluderend blijkt uit deze studie dat niet alleen RBCs maar ook

trombocytentransfusie een negatieve impact hebben op overleving na levertransplantatie.

In Hoofdstuk 8 wordt verder ingegaan op de specifieke oorzaken van mortaliteit en transplantaatfalen

in relatie tot trombocytentransfusie tijdens levertransplantatie. We beschrijven een serie van 449

opeenvolgende volwassen patiënten die een primaire levertransplantatie ondergingen. Patiënt-

en transplantaatoverleving waren beide significant lager bij patiënten die trombocytentransfusie

kregen vergeleken met patiënten die geen trombocytentransfusie kregen (74% vs. 92%, en 69%

vs. 85%, respectievelijk na 1-jaar; P waarde <0.001). Patiënten die trombocytentransfusie kregen

hadden een significant hogere vroege mortaliteit ten gevolge van acute longschade (4.4% vs 0.4%;

P waarde =0.004). De resultaten van deze studie suggereren dat trombocytentransfusie, door de

associatie met transfusie-gerelateerde acute longschade, een belangrijke risicofactor is voor het

optreden van mortaliteit na levertransplantatie.

In Hoofdstuk 9 wordt een retrospectieve studie beschreven naar het effect van bloedtransfusie op

de incidentie van acute afstoting na levertransplantatie. Het geven van bloedtransfusies wordt in

het algemeen beschouwd als een schadelijke interventie. Onderzoek verricht in de jaren ‘80 en ’90

van de twintigste eeuw naar preoperatieve bloedtransfusies bij niertransplantaties beschrijft echter

een beschermend effect van bloedtransfusies op het ontwikkelen van afstoting na transplantatie.

In de periode van 1995 tot en met 2004 werden 292 primaire levertransplantaties bij volwassenen

verricht in ons centrum. Dit cohort vormde de basis voor een onderzoek naar de invloed van

bloedtransfusie op het optreden van afstoting na levertransplantatie. Dit decennium werd

gekozen omdat tijdens deze periode routinematig een leverbiopsie werd verricht na transplantatie,

uiteraard alleen als de klinische toestand van de patiënt dit toeliet. Alle patiënten die tot 2 weken

na levertransplantatie een leverbiopsie kregen werden geïncludeerd. Patiënten die overleden of

werden geretransplanteerd binnen 1 week na transplantatie werden geëxcludeerd. In totaal werd

bij 197 patiënten een leverbiopt gedaan binnen 2 weken na transplantatie. Bij zestig (31%) patiënten

werden geen tekenen van afstoting in het leverbiopt geconstateerd. Negenenvijftig (30%) patiënten

kregen geen RBC transfusie tijdens de transplantatie. Na uni- en multivariate analyse bleken de

volgende variabelen onafhankelijke beschermende factoren tegen afstoting: intra-operatieve RBC

transfusie en het geven van inductie-immunosuppressiva. Op basis van dit onderzoek concluderen

we dat patiënten die geen bloedtransfusie nodig hebben gehad tijdens de levertransplantatie een

hogere kans hebben op het krijgen acute afstoting na de transplantatie.

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In Hoofdstuk 10 wordt een retrospectief onderzoek beschreven naar de invloed van het gebruik van

extended criteria donor (ECD) levers op het intra-operatief bloedverlies tijdens levertransplantatie.

Vanwege het tekort aan donororganen en de noodzaak om sterfte op de wachtlijst te verminderen

worden wereldwijd in toenemende mate donorlevers gebruikt voor transplantatie die van

iets mindere kwaliteit zijn, de zogenaamde ECD levers. Het gebruik van ECD levers is echter

geassocieerd met een verhoogd risico op transplantaatfalen en een verhoogde kans op mortaliteit.

We beschrijven een serie van 318 opeenvolgende primaire levertransplantaties bij volwassenen.

Een ECD lever werd gedefinieerd als een orgaan met een donor risk index (DRI) ≥1.7. ECD levers

werden gebruikt bij 36% van de ontvangers. Bij 27% van de patiënten verliep de levertransplantatie

zonder bloedtransfusie. Na uni- en multivariate analyse bleken de volgende factoren onafhankelijk

geassocieerd met verhoogde post-reperfusie transfusie behoefte: DRI ≥1.7, vrouwelijke ontvanger,

leeftijd van de ontvanger en het niet geven van aprotinine tijdens de transplantatie. We concluderen

dat er een associatie bestaat tussen het gebruik van ECD levers en verhoogde post-reperfusie

transfusiebehoefte.

Hoofdstuk 11 bestaat uit 3 appendices beschreven met aanvullende informatie.

1) De enquête naar het gebruik van hemostatische hulpmiddelen die werd beschreven in hoofdstuk

3

2) Twee ingezonden brieven en de reactie hierop betreffende de Nederlandse gerandomiseerde

multicenter studie (FRESCO trial) naar het effect van fibrin sealants op resectievlak gerelateerde

complicaties zoals beschreven in hoofdstuk 5

3) Een ingezonden brief en de reactie hierop betreffende de retrospectieve studie naar het effect

van verschillende bloedproducten op de uitkomsten bij levertransplantatie zoals beschreven in

hoofdstuk 7

In Hoofdstuk 12 wordt gediscussieerd over de relevante resultaten en conclusies van de

verschillende studies en worden toekomstige ontwikkelingen besproken.

Deel 1 Studies bij leverresecties

1) Bloedtransfusie is een onafhankelijke risicofactor voor postoperatieve morbiditeit en mortaliteit

na leverresecties. Er is beperkt bewijs dat bloedtransfusie effect heeft op oncologische uitkomsten na

leverresecties voor primaire of secundaire levertumoren. (hoofdstuk 2)

Bloedtransfusies hebben een immunosuppressieve werking. Het onderliggende mechanisme

is niet exact bekend. Wel wordt dit effect vooral toegeschreven aan de circulerende leukocyten

in het donorbloed en mogelijk is er ook een relatie met preservatie-gerelateerde schade van

RBCs. Tegenwoordig worden in de meeste landen leukocyt-arme bloedtransfusies gegeven. Of

hiermee de immunosuppressieve bijwerking van bloedtransfusie is geëlimineerd blijft de vraag.

Gerandomiseerde studies op het gebied van colorectaal carcinoom hebben geen verschil in

kankerrecidief laten zien tussen patiënten die leukocytenbevattende dan wel leukocyten-arme RBC

transfusies kregen. Dergelijk onderzoek is niet verricht bij patiënten met een levertumor.

Andere strategieën om schadelijke effecten van bloedtransfusie te verminderen zijn het reduceren

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van de bewaarduur van bloedtransfusies en het gebruiken van autoloog bloed, bijvoorbeeld door

preoperatieve donatie, intra-operatief gebruik van cell-saver technieken, of het toepassen van

normovolemische hemodilutie.

2) Hemostatische hulpmiddelen worden in Nederland veelvuldig gebruikt tijdens leverresecties. De

meest gebruikte hemostatische hulpmiddelen zijn fibrine sealants. Deze middelen worden niet alleen

toegepast voor hemostatische doeleinden maar worden ook ingezet ter preventie van resectievlak-

gerelateerde complicaties. (hoofdstuk 3) Fibrine sealants zijn effectief als hemostatisch hulpmiddel

tijdens leverresecties. Er is echter geen bewijs dat fibrine sealants andere resectievlak-gerelateerde

complicaties voorkomen.(hoofdstuk 4) Een Nederlandse multicenter gerandomiseerde studie naar het

effect van fibrine sealants ter preventie van postoperatieve resectievlak-gerelateerde complicaties liet

zien dat fibrine sealants niet effectief zijn in het verminderen van resectievlak-gerelateerde complicaties.

(hoofdstuk 5)

Het lijkt een logische gedachte om fibrine sealants te gebruiken als een afdichtende laag op het

resectievlak van de lever om zo het risico op resectievlak-gerelateerde complicaties (gallekkage,

nabloeding en abcesvorming) te voorkomen. Een aantal studies hebben gekeken naar effect

van fibrine sealants op resectievlak-gerelateerde complicaties en laten tegenstrijdige resultaten

zien. Studies die wel een effect suggereren waren niet groot genoeg om voldoende statistische

‘power’ te hebben om dit eindpunt goed te kunnen beoordelen. Naast de beschreven prospectief

gerandomiseerde studie is internationaal nog een grote gerandomiseerde studie gepubliceerd die

geen effect liet zien op resectievlak gerelateerde complicaties.

Een mogelijke verklaring voor het feit dat fibrine sealants niet effectief zijn om gallekkage te

voorkomen komt uit een in vitro studie. Deze studie onderzocht het effect van gal op de stabiliteit

van fibrine sealants. Deze studie liet zien dat gal fibrinolytische eigenschappen (gemedieerd door

tissue-type plasminogen activator en plasminogeen in de gal) bezit die zorgen voor de afbraak van

de fibrine sealant. De uitkomsten van deze in vitro studie en de klinische studies in acht nemend,

vinden we dat er geen plaats is voor routinematig gebruik van fibrine sealants bij leverresecties.

Een beperking van onze gerandomiseerde studie is dat we maar één soort fibrine sealant hebben

onderzocht. Dit betekent dat de resultaten niet automatisch kunnen worden vertaald naar andere

hemostatische middelen. Inmiddels zijn er nieuwe middelen op de markt, zogenaamde carrier-

bound fibrine sealants, die een solide matrix hebben in combinatie met een actieve hemostatische

bedekking die trombine en fibrinogeen bevat. Ook bij deze middelen wordt een fibrine stolsel

gevormd, die theoretisch zouden kunnen worden afgebroken door de fibrinolytische activiteit van

gal, maar deze conclusie kunnen we niet trekken zonder klinisch of in vitro bewijs.

Postoperatieve resectievlak-gerelateerde complicaties, in het bijzonder gallekkage, zijn

verantwoordelijk voor een vertraagd herstel na leverresecties. Afhankelijk van de gradering van de

gallekkage wordt deze complicatie beschreven bij 1-14% van de patiënten die een leverresectie

ondergaan. Postoperatieve gallekkage leidt tot reïnterventies, verlengde opnameduur, hogere

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mortaliteit en hogere kosten. Uit verschillende studies zijn de volgende risicofactoren voor gallekkage

geïdentificeerd: de oudere patiënt, een groot resectie oppervlak, centrale resecties of grote extra-

anatomische resecties, resectie in combinatie met een biliodigestieve anastomose, preoperatieve

chemotherapie, two-stage hepatectomie, het gebruik maken van selectieve bloedinflow occlusie

technieken, irradicale resectie en het achterwege laten van een intra-operatieve gallekkage test.

Verminderen van postoperatieve gallekkage in de toekomst vereist een tailor-made aanpak.

Toekomstige gerandomiseerde studies naar nieuwe carrier-bound sealants dienen idealiter

van voldoende omvang te zijn om het eindpunt gallekkage incidentie verantwoord te kunnen

beoordelen (‘statistische power’). Gezien het feit dat gal fibrinolytisch is zijn carrier-bound sealants

met een synthetische sealant theoretisch veelbelovender dan carrier-bound fibrine sealants.

Deel 2 Studies bij levertransplantaties

3) Chirurgische, farmacologische en anesthesiologische vernieuwingen hebben over de jaren geleid

tot een geleidelijke vermindering van bloedtransfusie behoefte tijdens levertransplantaties. Meerdere

centra rapporteren levertransplantatie zonder bloedtransfusie bij ca. 30% van hun patiënten.

(hoofdstuk 6) RBC- en trombocytentransfusie zijn beide onafhankelijke risicofactoren voor sterfte na

levertransplantatie. (hoofdstuk 7) Verhoogde vroege mortaliteit na levertransplantatie bij patiënten die

trombocytentransfusie kregen tijdens transplantatie kan worden toegeschreven aan vroege mortaliteit

ten gevolge van transfusie-gerelateerde acute longschade. (hoofdstuk 8)

Het is de vraag of de besproken reductie in bloedverlies en bloedtransfusie ook geldt voor de

situatie anno 2015. Het routinematig gebruik van het antifibrinolytische middel aprotinine werd

gestaakt in 2007, nadat het van de markt werd gehaald naar aanleiding van een aantal negatieve

publicaties die een verband lieten zien tussen aprotinine en eind-orgaanschade na cardio-thoracale

ingrepen. Eerder gepubliceerde gerandomiseerde studies naar gebruik van aprotinine versus

placebo bij levertransplantaties lieten een 30% reductie in RBC transfusie zien bij patiënten die

aprotinine kregen.

Ongepubliceerde data uit ons centrum laten zien aan dat het transfusievrije percentage na staken

van aprotinine significant gedaald is van 39% (2000-2007) naar 21% (2008-2013). Het aantal RBC

transfusies steeg significant van mediaan 2 (2000-2007) naar 4 units (2008-2013). (ongepubliceerde

data F. Arshad) Stijging in transfusiebehoefte kan mogelijk deels verklaard worden doordat we

niet routinematig zijn overgegaan op het geven van een alternatief effectief antifibrinolyticum,

bijvoorbeeld tranexaminezuur. Reden om dit niet routinematig te doen is het groeiende besef

dat er bij een cirrotische patiënt sprake is van ‘rebalanced hemostasis’, welke ook kan leiden tot

stollingsactivatie. De gemiddelde patiënt met cirrose blijkt in een hemostatische balans te

zijn ondanks abnormale stollingstesten. Tijdens een levertransplantatie kan de balans tussen

hypocoagulatie en hypercoagulatie gemakkelijk doorslaan en aanleiding geven tot bloeding maar

ook aanleiding geven tot trombo-embolische complicaties. Hoewel er geen duidelijke relatie bestaat

tussen antifibrinolytica en trombo-embolische complicaties, lijkt het logisch alleen antifibrinolytica

202202


te geven wanneer er sprake is van hyperfibrinolyse. Deze tendens wordt ook beschreven in de

internationale literatuur.

De beste manier om bloedverlies en hemostatische disbalans tijdens een levertransplantatie

te voorkomen is waarschijnlijk een restrictief infusiebeleid, om stijging in portale en centraal

veneuze druk te voorkomen. Op dit moment wordt een internationale placebo-gecontroleerde

gerandomiseerde studie verricht waarbij het effect van protrombine complex concentraat (PCC),

een laag-volume pro-hemostatisch product, op perioperatief bloedverlies bij levertransplantaties

wordt onderzocht. PCC bevat niet alleen procoagulante factoren (factor II, VII, IX, en X), maar ook

anticoagulante factoren (proteïne C en S). Theoretisch voordeel van het geven van PCC bij cirrotische

patiënten is dat het gewicht aan beide zijden van de balans versterkt, waardoor deze patiënt minder

snel uit zijn hemostatische balans raakt.

Zoals eerder besproken hebben bloedtransfusies een immunosuppressieve werking.

Bloedplaatjes spelen een complexe rol. Naast een hemostatische functie bevatten plaatjes

veel cytokines en vasoactieve inflammatoire mediatoren, die vrijkomen na activatie, waardoor

trombocytentransfusies moeten worden beschouwd als pro- inflammatoir. Patiënten die

trombocytentransfusie kregen tijdens een levertransplantatie ontwikkelden relatief vaak acute

longschade (ALI) of een acute respiratory distress (ARDS) beeld. Dit kan verklaard worden door een

systemische respons waarbij antilichamen tegen leukocyten, maar ook inflammatoire mediatoren in

gepreserveerde bloedplaatjes, een rol spelen. Het is niet duidelijk of leukocytenreductietechnieken

of het verminderen van de bewaarduur van bloedproducten deze negatieve effecten van RBC- en

trombocytentransfusie kan wegnemen.

4) Er bestaat een verhoogd risico op acute afstoting na levertransplantatie wanneer de patiënt geen RBC

transfusie kreeg tijdens de transplantatie. (hoofdstuk 9)

In ons onderzoek toonden we aan dat de afwezigheid van intra-operatieve RBC transfusie

geassocieerd is met een bijna 3-voudig verhoogd risico op histologisch bewezen acute afstoting

binnen 2 weken na transplantatie. We konden geen beschermend effect aantonen van preoperatieve

RBC transfusies op acute afstoting, zoals eerder wel werd gezien bij niertransplantaties. Dit

beschermende effect van RBC transfusie op afstoting moet worden afgewogen tegen de nadelen

van RBC transfusie. Meerdere studies laten zien dat bloedtransfusies tijdens levertransplantatie

geassocieerd zijn met verhoogde morbiditeit en mortaliteit. De behandeling van acute afstoting

is tegenwoordig simpel en effectief. Acute klinische of subklinische afstoting is niet geassocieerd

met slechte lange termijn resultaten. Wij blijven dan ook de voorkeur geven aan een restrictief

transfusiebeleid omdat de voordelen van RBC transfusie niet opwegen tegen de nadelen. We

adviseren wel om alert te zijn op acute afstoting bij patiënten die geen RBC transfusie kregen tijdens

de levertransplantatie, waarbij het van belang kan zijn om bij deze patiënten een iets agressiever

immuunsuppressie beleid te voeren.

203203


5) Het gebruik van ECD levers is geassocieerd met een verhoogde post-reperfusie transfusie behoefte.

(hoofdstuk 10)

Het accepteren van ECD levers vermindert het overlijdenspercentage van patiënten die op de

wachtlijst staan voor een levertransplantatie. Over het algemeen worden ECD levers echter gezien

als organen met een hoger risico op primaire transplantaatdisfunctie en primaire non-functie van

de lever na transplantatie. Er is tot nu toe geen duidelijke definitie voor een ECD lever, maar hoge

donor leeftijd, ernstige steatose, DCD levers (donatie na circulatoire dood), partiële levers, en CVA

als doodsoorzaak bij de donor worden algemeen beschouwd als ECD factoren. Donor risk scores,

zoals de donor risk index (DRI), zijn ontwikkeld om het risico geassocieerd met donorvariabelen

te kwantificeren. In deze studie werd een DRI afkapwaarde van 1.7 gebruikt om een ECD lever te

definiëren, zoals eerder in een gepubliceerde studie was gedaan. We weten uiteraard niet of dit een

terechte aanname is.

De resultaten van deze studie suggereren dat het transplanteren van een ECD lever, uitgedrukt

als DRI ≥1.7, een negatieve impact heeft op RBC transfusiebehoefte na reperfusie van de lever. Dit

negatieve effect kan waarschijnlijk worden verklaard door eerder geleverd bewijs dat ischemie-

reperfusie schade ernstiger is naarmate de kwaliteit van de lever slechter is. Ischemie-reperfusie

schade kan aanleiding geven tot coagulopathie en hyperfibrinolyse.

Focus van toekomstig onderzoek is verbeteren van de kwaliteit van organen en verminderen van

de ischemie-reperfusie schade. Nieuwe strategieën zijn het gebruik van extracorporele membraan

oxygenatie (ECMO) en normotherme regionale perfusie bij DCD donoren. Ex-vivo farmacologische

conditionering van de lever of de ontvanger is bewezen zinvol gebleken in het verminderen van de

ischemie-reperfusie schade. De meest veelbelovende ontwikkeling is echter de hernieuwde interesse

in ex-situ machine perfusie (MP), die inmiddels toepasbaar is in de klinische setting. Voordelen van

MP ten opzichte van de traditionele statische koude bewaarmethode zijn: de mogelijkheid om

voedingstoffen en zuurstof toe te dienen, afvalproducten te verwijderen, de functie van de lever te

testen en therapeutische interventies te doen. Er zijn nog maar een paar klinische trials over MP bij

levertransplantatie gepubliceerd, maar de eerste resultaten zijn veelbelovend.

204

205

List of publications

206

Publications

List of publications

Westerkamp AC, de Boer MT, van den Berg AP, Gouw AS, Porte RJ. Similar outcome after

transplantation of moderate macrovesicular steatotic and nonsteatotic livers when the cold

ischemia time is kept very short. Transpl Int. 2014 Dec 29. [Epub ahead of print]

Sutton ME, op den Dries S, Karimian N, Weeder PD, de Boer MT, Wiersema-Buist J, Gouw AS,

Leuvenink HG, Lisman T, Porte RJ. Criteria for viability assessment of discarded human donor

livers during ex vivo normothermic machine perfusion. PLoS One. 2014 Nov 4;9:e110642

Van De Wauwer C, Verschuuren EA, Nossent GD, van der Bij W, den Hamer IJ, Klinkenberg TJ, van

den Berg AP, de Boer MT, Mariani MA, Erasmus ME. A staged approach for a lung-liver transplant

patient using ex vivo reconditioned lungs first followed by an urgent liver transplantation.

Transpl Int. 2015 Jan;28:129-133.

de Boer MT, Porte RJ; for the FRESCO Trial Group. Reply to Letter: Fibrin sealants do not prevent

resection surface-related complications after liver resection. Ann Surg. 2014 Mar 18. [Epub ahead

of print]

Beenen E, van Roest MH, Sieders E, Peeters PM, Porte RJ, de Boer MT, de Jong KP. Staging

laparoscopy in patients scheduled for pancreaticoduodenectomy minimizes hospitalization in

the remaining life time when metastatic carcinoma is found. Eur J Surg Oncol. 2014;40:989-994.

Op den Dries S, Sutton ME, Karimian N, de Boer MT, Wiersema-Buist J, Gouw AS, Leuvenink HG,

Lisman T, Porte RJ. Hypothermic oxygenated machine perfusion prevents arteriolonecrosis of the

peribiliary plexus in pig livers donated after circulatory death. PLoS One. 2014 Feb 14;9:e88521.

Dello SA, Kele PG, Porte RJ, van Dam RM, Klaase JM, Verhoef C, van Gulik T, Molenaar Q, Bosscha

K, van der Jagt EJ, Dejong CH, de Boer MT. Influence of preoperative chemotherapy on CT

volumetric liver regeneration following right hemihepatectomy. World J Surg. 2014;38:497-504.

de Boer MT, Porte RJ.Reply to Letter: Fibrin sealants do not prevent resection surface-related

complications after liver resection. Ann Surg. 2013 Oct 3. [Epub ahead of print]

Vos JJ, Scheeren TW, Lukes DJ, de Boer MT, Hendriks HG, Wietasch JK.Intraoperative ICG

plasma disappearance rate helps to predict absence of early postoperative complications after

orthotopic liver transplantation. J Clin Monit Comput. 2013;27:591-598.

Kele PG, van der Jagt EJ, Gouw AS, Lisman T, Porte RJ, de Boer MT.The impact of hepatic steatosis

on liver regeneration after partial hepatectomy. Liver Int. 2013;33:469-475.

Boonstra EA, de Boer MT, Sieders E, Peeters PM, de Jong KP, Slooff MJ, Porte RJ.Risk factors for

central bile duct injury complicating partial liver resection.Br J Surg. 2012 ;99:256-262.

Werker PMN, de Boer MT. Microchirurgische inzet bij levertransplantaties bij jonge kinderen.

Ned Tijdschrift voor Plastische Chirurgie 2013;3:113-114.

Lisman T, Pittau G, Leite FJ, de Boer MT, Meijer K, Kluin-Nelemans HC, Huls G, Te Boome LC,

Kuball J, Nowak G, Fan ST, Azoulay D, Porte RJ. The circulating platelet count is not dictated by

the liver, but may be determined in part by the bone marrow: analyses from human liver and

stem cell transplantations. J Thromb Haemost. 2012;10:1624-1630.

207

Publications

de Boer MT, Klaase JM, Verhoef C, van Dam RM, van Gulik TM, Molenaar IQ, Bosscha K, Dejong

CH, Van der Jagt EJ, Porte RJ; for the FRESCO Trial Group. Fibrin sealant for prevention of resection

surface-related complications after liver resection: A randomized controlled trial. Ann Surg. 2012

Aug;256:229-234.

Kele PG, de Boer MT, van der Jagt EJ, Lisman T, Porte RJ. Early hepatic regeneration index

and completeness of regeneration at 6 months after partial hepatectomy. Br J Surg. 2012

Aug;99:1113-1119.

Boonstra EA Adelmeijer J, Verkade HJ, de Boer MT, Porte RJ, Lisman T. Fibrinolytic proteins in

human bile accelerate lysis of plasma clots and induce breakdown of fibrin sealants. Ann Surg.

2012 Aug;256:306-312.

de Boer MT, Boonstra EA, Lisman T, Porte RJ. The role of fibrin sealants in liver surgery. Dig Surg

2012;29:54-61.

Warnaar N, Polak WG, de Jong KP, de Boer MT, Verkade HJ, Sieders E, Peeters PM, Porte RJ.

Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver

transplantation. Liver Transpl 2010;16:847-855

Alkozai EM, Nijsten MW, de Jong KP, de Boer MT, Peeters PM, Slooff MJ, Porte RJ, Lisman T.

Immediate postoperative low platelet count is associated with delayed liver function recovery

after partial liver resection. Ann Surg 2010;251:300-306

Ijtsma AJ, van der Hilst CS, de Boer MT, de Jong KP, Peeters PM, Porte RJ, Slooff MJ. The clinical

relevance of the anhepatic phase during liver transplantation.Liver Transpl. 2009 ;15:1050-1055

Boonstra EA, Molenaar IQ, Porte RJ, de Boer MT. Topical hemostatic agents in liver surgery: Do

we need them? HPB 2009;11:306-310

Pereboom IT, de Boer MT, Haagsma EB, van der Heide F, Porcelijn L, Lisman T, Porte RJ.Transmission

of idiopathic thrombocytopenic purpura during orthotopic liver transplantation. Transpl Int.

2010;23:236-238.

Stoot JH, van Dam RM, Busch O, van Hillegersberg R, de Boer MT, Olde Damink SW, Bemelmans

MH, Dejong CH. The effect of a multimodal ‘fast track’ programme on laparoscopic liver surgery-

a multicenter pilot study. HPB. 2009;11:140-144.

Warnaar N, Mallett SV, Klinck JR, de Boer MT, Rolando N, Burroughs AK, Jamieson NV, Rolles

K, Porte RJ. Aprotinin and the risk of thrombotic complications after liver transplantation: a

retrospective analysis of 1492 patients. Liver Transpl. 2009;15:747-753

IJtsma AJ, Boevé LM, van der Hilst CS, de Boer MT, de Jong KP, Peeters PM, Gouw AS, Porte RJ,

Slooff MJ. The survival paradox of elderly patients after major liver resections. J Gastrointest Surg.

2008;12:2196-2203.

Pereboom ITA, de Boer MT, Haagsma EB, Hendriks HGD, Lisman T, Porte RJ. Platelet transfusion

during liver transplantation is associated with increased postoperative mortality due to acute

lung injury. Anesth Analg. 2009 Apr;108:1083-1091.

de Boer MT, Christensen MC, Asmussen M, van der Hilst CS, Hendriks HG, Slooff MJ, Porte

208

Publications

RJ. Impact of intraoperative transfusion of platelets and red blood cells on survival after liver

transplantation. Anesth Analg. 2008;106:32-44.

Warnaar N, Mallett SV, de Boer MT, Burroughs AK, Nijsten MW, Slooff MJ, Rolles K, Porte RJ. The

impact of aprotinin on renal function after liver transplantation: an analysis of 1043 patients. Am

J Transplant. 2007;7:2378-2387.

Pereboom ITA, de Boer MT, Molenaar IQ. Aprotinin and nafamostat mesilate in liver surgery:

effect on blood loss. Dig Surg. 2007;24:282-287.

de Boer MT, Molenaar IQ, Porte RJ. The impact of bloodloss on outcome after liver resection. Dig

Surg. 2007;24:259-264.

de Boer MT, Molenaar IQ, Hendriks HG, Slooff MJ, Porte RJ. Minimizing blood loss in liver

transplantation: progress through research and evolution of techniques. Dig Surg 2005;22:265-

275.

Evans JD, de Boer MT, Mayor P, Guy AJ. Pseudoaneurysm of the medial inferior genicular artery

following anterior cruciate ligament reconstruction. Ann R Coll Surg Engl 2000;82:182-184.

de Boer MT, Evans JD, Mayor P, Guy AJ. An aneurysm at the back of a thigh: a rare presentation

of a congenitally persistent sciatic artery. Eur J Vasc Endovasc Surg 2000;19:99-100.

de Boer MT, Mastboom WJB, de Graaff R. Two patients with osteochondroma of the cervical

spine. Ned Tijdschr Geneeskd 1999;143:525-529.

de Boer MT, van der Linden PJQ. Immunologic subfertility in a man after a gunshot wound. Ned

Tijdschr Obstetrie Gynaecol 1998;111:20-22.

209

Dankwoord

210

Dankwoord

Opgelucht, trots en blij: Mijn boekje is eindelijk af!

Maar het was nooit gelukt zonder hulp, maar vooral ook geduld en steun van velen. In het bijzonder

wil ik de volgende personen bedanken:

Professor dr. R.J. Porte. Robert, promotor, baas, collega en vriend! Je enthousiasme (ook buiten

je werk) is aanstekelijk! Logisch dat ik op je afstapte. Wat begon als een leuk en simpel idee voor

klinisch onderzoek nu meer dan 10 jaar geleden werd geleidelijk toch iets groters. De FRESCO

studie kwam landelijk van de grond: ik wist eigenlijk niet waar ik aan begon: een ‘hedendaagse’

prospectieve gerandomiseerde multicenter studie. Aansturen van zo’n studie is niet zozeer een

wetenschappelijke als wel een logistieke uitdaging. De dagelijkse HPB kliniek en mijn interesses

voor al het andere maakten dat ik niet altijd focus kon houden. Jouw sturing en positieve benadering

hebben er absoluut voor gezorgd dat ik niet het bijltje erbij neergooide. Jij bezit de gave om een

ingewikkeld probleem simpel te maken, (of in ieder geval te laten lijken). Meerdere keren heb je me

moeten afremmen, maar soms ook motiveren. Uiteindelijk is doorzettingsvermogen en discipline

nodig voor het afronden van een promotieonderzoek, ik kan zeggen dat het mij uiteindelijk is gelukt.

Maar dit was niet gelukt zonder jou. Robert, ontzettend bedankt! Ik kijk uit naar onze toekomstige

samenwerking (en straks eindelijk zonder ‘promotiedruk’)!.

Professor dr. T. Lisman. Beste Ton, je bent geen medicus maar het is wonderbaarlijk hoe jij je kunt

verplaatsen in de klinische praktijk, en anderzijds die verfrissende blik houdt van een buitenstaander.

Je bent een rasechte wetenschapper die alleen maar kansen ziet. Vooral bij de laatste loodjes heb

je me ontzettend geholpen met goede ideeën en snelle revisies. Ik had me geen betere tweede

promotor kunnen wensen.

Beoordelingscommissie/ Assessment committee: Professor dr. C.M. Lo, Professor dr. E.

Heineman. Professor dr. T.M. van Gulik.

Dear Professor Lo, in 2008 I had the opportunity to visit your HPB and Liver Transplantation

Department at the Queen Mary Hospital in Hong Kong. This was an amazing experience. I really

enjoyed to watch and learn from your surgical skills, the anatomical lessons of professor dr. S.T.

Fan, your perfectly trained team, the protocolized living donor procedures, the ward rounds, your

(sometimes philosophical) approach to problems, and of course life in Hong Kong. It’s a great honor

for me that you were part of the assessment committee and that you will be present at the PhD

ceremony.

Beste Erik, hoofd van onze afdeling en binnenkort voorzitter van de Nederlandse Vereniging voor

Heelkunde. Altijd een lach en een luisterend oor! Je hebt de afgelopen jaren onze afdeling op een

hoger plan gebracht. Met je ideeën over leiderschap, opleiding, transparantie, mindfulness en ‘eco-

vs egosysteem’ ben je vernieuwend voor de chirurgie. Nee niet ‘soft’: voor mij ben je hèt voorbeeld

van een moderne chirurg. Ik ben trots dat je in mijn beoordelings- en promotiecommisie zit.

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Dankwoord

Beste Thomas, waarde collega HPB chirurg. Jouw onderzoek beperkt zich niet tot HPB chirurgie

maar is veel breder, zo zijn ook jouw interesses. Binnen Nederland en internationaal speel je een

belangrijke rol in multicenter samenwerking en onderzoek op het gebied van HPB chirurgie. Je bent

er altijd en je hebt altijd verfrissende ideeën. Dat bewonder ik enorm en ik ben dan ook trots dat je

in mijn beoordelings- en promotiecommisie zit.

Robert Porte, Paul Peeters, Koert de Jong, Ger Sieders, Ruben de Kleine en Joris Erdmann: Staf

HPB en Levertransplantatie.

Lieve collega’s, wat ben ik een bevoorrecht mens dat ik met jullie mag werken en dat we als team

zulke fantastische dingen doen. Ik besef me dat ik best wat van jullie heb gevraagd de afgelopen

jaren. Dank voor jullie hulp en begrip! Het is nog niet meteen over, sorry, eerst nog Parijs.. Paul

jouw ongelooflijke toewijding, chirurgische kennis en forse dosis zelfkritiek maken jou misschien

wel de beste chirurg van Nederland. Je naderende pensioen vult mij met ongeloof en maakt me

ongeduldig: we moeten in die korte tijd nog zoveel van je leren! Koert, onze kritische innovator,

naast de ‘grote HPB’ begeef jij je op het terrein van navigatie en robotarmen. Ik hoop dat de wereld

snel je fantastische RFA resultaten te zien krijgt. O ja, thanks for the hammer! Ger my ‘roomy’, af

en toe ‘zoemen’, altijd geduldig, zelfs tot op het niveau van de punt en de komma. Dank je voor

je revisies. Je bent er weer helemaal gelukkig! Ruben, bewonderenswaardig hoe jij jezelf hebt

ontwikkeld in de afgelopen jaren. Des temeer reden dat ook jij er een keer aan moet geloven, als ik

het kan..Joris, jonge hond, jonge vader, wat mooi dat je net bij onze club gekomen bent! We gaan

veel mooie dingen doen in de toekomst. Ook jij succes met je naderende promotie!

Professor dr. M.J.H. Slooff. Beste Maarten, ik was het eerste ‘artefactje’ bij de HPB en

Levertransplantatie, bedankt voor je vertrouwen! Ja we hebben veel gelachen..Maar ik heb vooral

respect voor de manier waarop jij deze afdeling hebt opgebouwd, jouw stempel is gedrukt, je bent

nog steeds een beetje bij ons. Bedankt voor je steun en je wijze warme woorden elke keer als ik je

spreek.

Dr. I.Q. Molenaar. Quintus, alias de ‘speld’ of ‘naald’, aanwezig was je, wat een mooie tijd. Jammer

dat je vertrok naar Utrecht, maar hé, dan had ik nu niet gezeten waar ik zit. De reis met Carlijn en

jou (en later Robert) in 2005 naar San Francisco en LA heeft mij gestimuleerd om vooral wetenschap

te doen: als dat dit soort mooie reisjes met zich meebrengt..Fantastisch om te zien hoe jij je plek

bij de HPB chirurgie in het UMCU hebt gevonden en hoe serieus jouw wetenschappelijke carrière

is gegroeid. Jij doorzag dat mijn onderzoek niet altijd even voortvarend ging en ik dank je voor je

oplossing: het spiegeltje..Die heeft nu zijn werk gedaan! Ik zal ‘m doorgeven als t mag?

Dr. H.G.D. Hendriks. Beste Herman, het succes van het Groningse restrictieve transfusiebeleid

bij levertransplantaties is natuurlijk eigenlijk, ik geef toe, vooral ook de verdienste van de

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Dankwoord

anesthesiologie. Maar de sleutel tot succes is dat het groene doek niet al te hoog is opgetrokken,

we zien een levertransplantatie als team-effort: een gezamenlijk meestal nachtelijk project! Bedankt

voor je inspiratie en hulp bij revisies van artikelen. En vooral ook voor de muzikale afleiding tijdens

het opereren!

Dr. A.P. van den Berg. Beste Aad, hepatoloog van het eerste uur en rots in de branding. Bedankt

dat je altijd klaar staat om te helpen. Natuurlijk gerelateerd aan dit proefschrift maar ik wil je ook

bedanken voor je onmisbare inzet voor het living donor programma!

Fresco co-auteurs: Joost Klaase, Kees Verhoef, Ronald van Dam, Thomas van Gulik, Quintus

Molenaar, Koop Bosscha, Kees Dejong, en Eric van der Jagt. Ik wil jullie allemaal bedanken voor

jullie enorme inzet om de FRESCO studie tot een goed einde te brengen. En het is gelukt! Het was de

eerste multicenter studie bij leverresecties gesteund door de Werkgroep Leverchirurgie. Ik hoop

dat er nog vele studies zullen volgen!

Jan Bottema. Beste Jan, stille kracht! Dank je voor je hulp bij het monitoren, data verzamelen, en

al die ‘susar’ faxen..

Petra Kele. Beste Petra, bedankt voor al je volume metingen. Dat vereist nogal wat geduld..Mooi

dat we er voor allebei iets moois uit gehaald hebben.

Anna van der Pool, Ninos Ayez, Simon Dello, Matthanja Bieze, Nienke van den Esschert, Ilona

Hollander, Marielle Jippes en Anja Stam: Een multicenter gerandomiseerde studie kun je niet

doen zonder de lokale onderzoekers of data managers. Ik weet dat dit vaak ‘voor wat hoort wat’ is.

De meeste mensen zitten hier niet op te wachten. Ik wil jullie allemaal bedanken voor jullie enorme

steun bij het aanleveren van data. Ook voor jullie gastvrijheid bij mijn bezoekjes. Zonder jullie was

de FRESCO studie niet gelukt!

Ilona Pereboom en Liesbeth Boonstra. Beste Ilona en Liesbeth, jullie hielpen mij beide met het

verzamelen van data voor de FRESCO studie naast jullie eigen onderzoek. Een vervelende klus, dat

begrijp ik, maar jullie waren onmisbaar! Mooi dat jullie nu beide terug zijn in het UMCG voor jullie

laatste opleidingsfase, en super dat ik daarbij ben!

Andrie Westerkamp. Beste Andrie, je hebt me vaak geholpen met het opzoeken van missende

data en het aanvullen van de ECD database. Heel erg bedankt en veel succes met jouw opleiding

en je promotie!

Fraukje Ponds. Beste Fraukje, jij hebt destijds nadat je leverstudent was, je tanden gezet in de

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Dankwoord

rejectiedata. Het was best complex! Dank je voor je hulp! En nu jaren later voor je revisie op niveau.

Heel veel succes met je promotieonderzoek en straks een opleidingsplek MDL(het lukt je!)

Ans Hagenaars. Beste Ans, bedankt dat ik de basis van bijna al mijn databases van je kreeg: de

bloedverlies en -transfusiedata!

Danielle Nijkamp. Lieve Daan, ik leerde je eigenlijk pas echt kennen tijdens onze spontane reis

naar Australië (en dat allemaal door die drankjes bij de tennisbaan). Wat een energie en organisatie

talent. En je laat je niet afremmen! Fantastisch dat je me helpt!

Marloes Vegelin. Lieve Loes, mijn vriendinnetje vanaf het begin van de studie. We deden alles

samen. En al woon je nu wat verder weg en is ons leven ieder zijn eigen richting op gegaan, nog

steeds ben jij diezelfde Loes met wie ik lach en huil. Dank voor je altijd nuchtere kijk en hulp! Onze

specifieke taak voor deze promotie is bijna volbracht.. En daarna tijd voor andere leuke dingen!

Wijnand van Smeden. Lieve Wijnand, er is al zoveel gezegd. Maar..een dag niet gelachen..! Bedankt

dat je er altijd voor me was: I know i(t) wasn’t always easy.. Bedankt voor je enorme steun en je

vriendschap!

Mijn paranimfen Annemarie Nijboer en Carlijn Buis. De cirkel is rond, ik was jullie paranimf, nu

zijn jullie van mij! Ik ben apetrots: twee stoere chirurgen die mij terzijde staan!

Lieve Annemarie: ik vind mezelf best een wereldburger maar jij bent de overtreffende trap. Wie had

gedacht dat jij je de Duitse taal ooit eigen zou maken? Het is maar goed dat ik die weddenschap

nooit ben aangegaan. Dus ook jij verbaast mij iedere keer! Ik heb enorme bewondering voor de

stappen die jij hebt gezet. Laten we samen nog veel mooie reizen maken!

Lieve Carlijn, wat fantastisch dat we na jaren weer samen zijn nu jij je opleiding hebt afgerond en

koos voor de HPB. Ik heb nu al zin in al onze plannen voor de toekomst. En ooit doen wij samen de

èchte tocht der tochten!

Familie, vrienden en collega’s, al die mensen die ik niet heb genoemd maar die er wel altijd voor

me waren en hun interesse toonden. Vooral ook bedankt voor jullie begrip dat ik niet altijd overal bij

kon zijn, of maar ‘even’. Het wordt beter!

Mijn ouders, lieve heit en mem, H&M, mijn grootste sponsor! Jullie onvoorwaardelijke steun en

liefde, en de nuchtere opvoeding op de ‘pleats’ hebben mij gemaakt tot wie ik nu ben, en daar ben

ik trots op! Lieve Piet, Dieks, Coby. Laura, Rixt en Elske, ik word altijd blij van jullie. Gelukkig is het

‘promotie’ stemmetje in mijn achterhoofd straks verdwenen: wat vaker terug naar Tjalleberd!

En tot slot: mijn lieve Beppe, prachtige vrouw, in mijn hart bent u erbij!

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Curriculum Vitae

Marieke de Boer was born on April 30th, 1973 in Heerenveen, the Netherlands. After attending

primary school “de Anjewier” in Tjalleberd and high school “De Rijksscholengemeenschap” in

Heerenveen, she moved to Groningen to study Medicine at the University of Groningen in 1991. She

followed her clinical rotations in the Deventer Ziekenhuizen in Deventer and the Medisch Spectrum

Twente in Enschede. In May 1998, Marieke graduated cum laude from medical school. Her desire

to travel made her move to the UK temporarily. She worked as a locum surgical house officer in

several surgical departments in hospitals around London and finally worked as a house officer in

vascular surgery in the Leighton Hospital in Crewe under the guidance of Mr. A.J. Guy. Back in the

Netherlands, she started her surgical training in September 1999 in the Medisch Spectrum Twente

in Enschede, under the guidance of professor dr. P.A.M. Vierhout and later dr. W.J.B. Mastboom. In

September 2003 she moved back to Groningen to finish the last two years of her surgical training

under guidance of professor dr. H.J. ten Duis. Marieke showed her interest in HPB surgery and liver

transplantation, started clinical research with professor dr. R.J. Porte and applied for a fellowship

‘HPB surgery and Liver Transplantation’ under guidance of professor dr. M.J.H. Slooff. Her fellowship

started the end of 2005 and in 2007 she was appointed as a staff member at the department of

HPB Surgery and Liver Transplantation. Because of her interest in living donor liver transplantation

Marieke traveled to Hong Kong in 2008 for a 4 month honorary clinical fellowship at the HPB and

Liver Transplantation department of the Queen Mary Hospital, under guidance of professor dr. C.M.

Lo and professor dr. S.T. Fan. Marieke is currently working as a staff member in the HPB surgery

and Liver Transplantation department under guidance of professor dr. R.J. Porte. She is program

director of minimally invasive HPB surgery and living donor liver transplantation in the University

Medical Center Groningen.

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List of Abbreviations

ALI acute lung injury

ARDS acute respiratory distress syndrome

CIT cold ischemia time

CTP Child Turcotte Pugh score

CUSA cavitron ultrasonic surgical aspirator

CVP central venous pressure

DBD donation after brain death

DCD donation after circulatory death

DRI donor risk index

ECD extended criteria donor

FFP fresh frozen plasma

FS fibrin sealant

HCC hepatocellular carcinoma

HTK histidine-tryptophan-ketoglutarate

IPF initial poor function

MELD model for end-stage liver disease

MP machine perfusion

OLT orthotopic liver transplantation

PAI-1 plasminogen activator inhibitor type 1

PC platelet count

PGA polyglycolic acid

PNF primary non-function

PLT platelet transfusion

RBC red blood cells

TEG thromboelastogram

t-PA tissue-type plasminogen activator

TRALI transfusion related acute lung injury

TRIM transfusion related immunomodulation

UW Univerisity of Wisconsin

WIT warm ischemia time

University of Groningen Impact of hemostasis and blood ... · blood loss and transfusion requirements in liver transplantation over the years. It is well known that blood transfusions

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