Patient Blood Management in Hepatobiliary and Pancreatic Surgery

Yun Kyung Jung; Dongho Choi

doi:10.7599/hmr.2018.38.1.56

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Jung and Choi: Patient Blood Management in Hepatobiliary and Pancreatic Surgery

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Hanyang Med Rev 2018;38(1):56-61.

Published online: 26 March 2018

DOI: https://doi.org/10.7599/hmr.2018.38.1.56

Patient Blood Management in Hepatobiliary and Pancreatic Surgery

Yun Kyung Jung, Dongho Choi

Division of HBP Surgery, Department of Surgery, Department of Surgery, Hanyang University College of Medicine, Seoul, Korea

Corresponding Author: Dongho Choi Division of HBP Surgery, Department of Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdonggu, Seoul, Korea Tel: +82-2-2290-8449 Fax: +82-2-2281-0224 E-mail: crane87@hanyang.ac.kr

Received 13 October 2017 Revised 23 January 2018 Accepted 27 February 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Despite improved perioperative management and surgical techniques, patients undergoing hepatobiliary and pancreatic (HBP) surgery often need to be transfused. Although disadvantages of transfusion and advantages of patient blood management (PBM) have been recognized, study results of the effects of PBM in HBP surgery are rare. The aim of this article was to review the current status of PBM in Korea in patients having HBP surgery. PBM in HBP surgery consists of increasing preoperative hemoglobin level, preoperative blood conservation, and preoperative autologous blood donation. The main intraoperative modalities used to conserve blood in recent studies were autologous techniques of acute normovolemic hemodilution and intraoperative cell salvage (Cell Saver^®). In postoperative PBM, blood augmentation with erythropoietin and iron are also used depending on the postoperative hemoglobin level. Advances in surgical, anesthesiologic and pharmacologic strategies have contributed to a reduction of blood loss during HBP surgery in all patients.

Keywords: Blood management, PBM, Transfusion

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Fig. 1.

Preoperative protocol for HBP patients (‘Rule of 12’, Hanyang University). Figure presents the strategy for preoperative management according to preoperative hemoglobin. Eporon^®, Ferinject^®, Cosmofer^® and Venoferum^® are used selectively according to preoperative hemoglobin, and the target for determining the treatment plan is set at 12 g/L hemoglobin. *Before giving erythropoietin or iron sulfate, we examine anemia data to evaluate and identify the cause of anemia. Data include iron, total ironbinding capacity, ferritin, reticulocytes, peripheral blood cell morphology. ^†Eporon^®: Erythropoietin, Ferinject^®: Iron carboxymaltose, Monofer^®: Iron isomaltoside, Cosmofer^®: Iron dextran, Venoferum^®: Iron sucrose.

Table 1.

Principles of management for transfusion-free HBP surgery

Preoperative	Increasing preoperative Hb levels
Preoperative	Preoperative blood conservation/preoperative autologous blood donation (PAD)
Intraoperative	Acute normovolemic hemodilution
	Intraoperative cell salvage (Cell Saver^®)
	Surgical skills such as inflow occlusion
	Anesthetic techniques such as the use of the low CVP
Postoperative	Blood augmentation
	Prophylaxis against stress ulceration
	Minimization of blood testing

Table 2.

New methods and materials for transfusion-free HBP surgery

Surgical	External drainage (e.g., pancreatic duct drain-age)
Surgical	New instruments (e.g., Harmonic scalpel, LigaSure, Gyrus, Aqua- mantys, TissueLink)
Anesthesiologic	Intraoperative fluid management (e.g., fluid contraction)
Pharmacologic	Topical hemostatic agents
	Antifibrinolytics (e.g., Aprotinin, Tranexamic acid)
	Procoagulants (e.g., Recombinant factor VIIa)

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