Blood loss is a significant concern during liver surgery, with around 25% to 33% of patients undergoing major liver operations requiring a transfusion. Cancer is the most common reason for these surgeries, and receiving a transfusion during or shortly after surgery may increase the risk of cancer recurrence. Now, a large clinical trial has found that removing 10% of a patient's blood before surgery and returning it afterward reduced the need for transfusions by half. This method, known as hypovolemic phlebotomy, could potentially prevent one in every 11 patients from needing a transfusion during major liver surgery.

In the largest trial of its kind, researchers at The Ottawa Hospital (Ottawa, ON, Canada) enrolled 446 patients undergoing major liver surgery at four Canadian hospitals between 2018 and 2023. Once under anesthesia, the patients were randomly assigned to either the hypovolemic phlebotomy group or the usual care group. The anesthesiologist was the only person aware of the patient’s group assignment. In the hypovolemic phlebotomy group, the anesthesiologist removed approximately 450 mL of blood (equivalent to one blood donation) before surgery and stored it in a blood bag. If the patient required a transfusion during surgery, their own blood was used first, and if not, the blood was re-infused after surgery.

According to data from the hospital’s blood bank and patient medical records, 7.6% of the patients who underwent hypovolemic phlebotomy (17 of 223) required a transfusion within 30 days after surgery, compared to 16.1% (36 of 223) in the usual care group. The procedure did not result in more complications than usual care, as reported in The Lancet Gastroenterology & Hepatology. Surgeons also noted that hypovolemic phlebotomy made the surgery easier by reducing the amount of blood in the surgical area. The median estimated blood loss was 670 mL in the hypovolemic phlebotomy group, compared to 800 mL in the usual care group. This technique is currently being tested in liver transplantation and may eventually be explored for other surgeries involving significant blood loss.

“Blood loss is a major concern in liver surgery. Taking out half a liter of blood right before major liver surgery is the best thing we’ve found so far for reducing blood loss and transfusions,” said co-lead author Dr. Guillaume Martel from The Ottawa Hospital. “It works by lowering the blood pressure in the liver. It’s safe, simple, inexpensive, and should be considered for any liver surgery with a high risk of bleeding.” 

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