title: Advances in hepatectomy technique: Toward zero transfusions in the modern era of liver surgery.
abstract: BACKGROUND
  Perioperative blood transfusions suppress immunity and increase hospital costs. Despite multiple improvements in perioperative care, rates of transfusion during/after hepatectomy are reported to range from 25 to 50%. The purpose of this study was to determine the current risk factors for perihepatectomy transfusion by assessing the impact of recent technical advances in liver surgery on transfusion rates.
  
  
  METHODS
  Using our prospectively maintained hepatobiliary tumor database from a high-volume center, a modern cohort of 2,249 hepatectomies (2004-2013) were identified. Patient and operative characteristics were compared between 2 time periods, 2004-2008 (n = 1,139) and 2009-2013 (n = 1,110). Throughout the study interval, transfusions were given based on clinical assessment and not triggered by laboratory thresholds.
  
  
  RESULTS
  Compared with the early cohort, the recent cohort had more patients with an American Society of Anesthesiologists score of ≥ 3 (79 vs 74%), preoperative chemotherapy (73 vs 68%), and a lesser median preoperative hemoglobin (12.9 vs 13.1 mg/dL) and platelet (215,000 vs 243,000) values (all P < .001). Despite these adverse risk factors, with an increasing use of the 2-surgeon resection technique (63 vs 50%), estimated blood loss (309 vs 394 mL), transfusion rates (6 vs 15%), and duration of stay (7.0 vs 8.4 days) were decreased (all P < .001) with no change in overall morbidity or mortality. Multivariate analysis of the recent cohort determined that the independent risk factors associated with transfusion were preoperative anemia and >350 mL of blood loss. The only independent factor associated with less transfusion was use of the 2-surgeon technique for hepatic parenchymal transection.
  
  
  CONCLUSIONS
  With the exception of patients with moderate to severe preoperative anemia requiring major hepatectomy, recent technical advances have decreased significantly the need for transfusion in liver surgery.
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Ryan W
authors.initials: RW
authors.lastname: Day
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Kristoffer W
authors.initials: KW
authors.lastname: Brudvik
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Claudius
authors.initials: C
authors.lastname: Conrad
authors.affiliation: Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Vijaya
authors.initials: V
authors.lastname: Gottumukkala
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Yun-Shin
authors.initials: YS
authors.lastname: Chun
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Matthew H
authors.initials: MH
authors.lastname: Katz
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: taaloia@mdanderson.org.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
mesh_terms: D000367:Age Factors; D000368:Aged; D000704:Analysis of Variance; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D016009:Chi-Square Distribution; D015331:Cohort Studies; D016208:Databases, Factual; D058625:End Stage Liver Disease / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058996:Quality Improvement; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D015996:Survival Rate; D013781:Texas; D065227:Transfusion Reaction; D016896:Treatment Outcome