Bloodless Surgery

Posted 12 years ago

Last week, Pedro Ramirez from the MD Anderson Cancer Center described risk factors for prolonged hospital stay after laparoscopic surgery. More than half of patients had surgery for benign conditions. One in ten patients had “prolonged hospital stay” (more than 2 days in hospital after laparoscopic surgery).

Increased intraoperative blood loss was the main reason leading to long hospital stay and potentially could be influenced.

Pedro’s data and comments confirm a suspicion I had for some time. Patients who had higher than average blood loss during surgery recovered slightly slower (even if they had a laparoscopic procedure) than patients who lost close to no blood during their operation. Recovery is slower even if patients go home on day 1 or 2 after laparoscopic surgery if blood loss is slightly increased.

If this is so, how we can come closer to our goal of “bloodless surgery”.

One of the ways we can do this for example at hysterectomy is to selectively ligate the uterine arteries at the level of the internal iliac artery on the lateral pelvic wall. This procedure done prior to securing the uterine blood supply is extremely quick if you are used to it. A vascular clip or Ligasure are the way to go. The surgeon simply needs to open the lateral pelvic wall, identify the ureter, medialise it and develop the space between the ureter and the internal iliac artery. Then follow that space anteriorly and you will come across the uterine artery as it traverses from lateral to medial to find the uterus. The procedure is well worth in patients who need a hysterectomy where increased blood loss is anticipated (e.g., adenomyosis). For other procedures than hysterectomy this is obviously not a great option.

A non-surgical way is to use Tranexamic acid (TXA, widely marketed as Cyklokapron globally). TXA is a derivate of the amino acid Lysin and is antifibrinolytic. Fibrinolysis is the process of degradation of fibrin, a framework of blood clots. Hence it indirectly supports the formation of blood clots. TXA is widely used for the symptomatic treatment of menorrhagia.

Maybe TXA (given immediately preoperatively/prophylactic) can help us to minimise blood loss in elective surgery to improve recovery from surgery? A large meta-analysis () analysed the effect of prophylactic TXA on surgical bleeding and potential adverse events of TXA.

A total of 129 randomised clinical trials with more than 10,000 patients were included. According to this very large study TXA reduced the probability of receiving a blood transfusion by 38%. The effect of TXA on myocardial infarction, stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE) was uncertain. However, the risk of myocardial infarction, DVT and PE was slightly lower although not statistically significant (probably due to low numbers of statistical events).

In Gynaecology and Obstetrics a large study is underway to evaluate TXA in post partum haemorrhage. One of the possible complications of TXA is that fibroids may develop thrombosis, leading to necrosis, and potentially to emergency surgery. TXA is included in the WHO list of essential medication. It is inexpensive with potential high impact in low-income countries.

Last week, before I went to the IGCS meeting in Vancouver, Canada I encountered increased bleeding from a raw tumour area. The tumour was surgically not accessible; all I saw was a friable area that bled. The aim of the procedure was to obtain tumour tissue to establish a diagnosis to inform the medical oncologist. During the procedure I noticed some trickling of fresh blood from this tumour. I used a couple of small gauze pieces for compression but they soaked through quite quickly. I asked my anaesthetist to administer 1000 mg TXA slowly i.v. In addition I inserted 20 mg Floseal to the area in question and covered it with a haemostatic sponge. The bleeding settled instantly but obviously I cannot tell if it was due to TXA, Floseal or the combination of both.

I would feel more relaxed about TXA if research confirmed that the risk of thromboembolic complications is not increased with TXA. However, any prospective randomised clinical trial would require extremely large numbers of patients and I wonder if any trial could enrol that many patients. Maybe a registry such as SurgicalPerformance.com could be used to collect data on TXA as part of postmarketing research?