Bloodless surgery

Bloodless surgery is a non-invasive surgical method developed by orthopedic surgeon, Adolf Lorenz, who was known as "the bloodless surgeon of Vienna".[1][2][3][4] His medical practice was a consequence of his severe allergy to carbolic acid routinely used in operating rooms of the era. His condition forced him to become a "dry surgeon".[5] Contemporary usage of the term refers to both invasive and noninvasive medical techniques and protocols.[6] The expression does not mean surgery that makes no use of blood or blood transfusion. Rather, it refers to surgery performed without transfusion of allogeneic blood.[7][8] Champions of bloodless surgery do, however, transfuse products made from allogeneic blood and they also make use of pre-donated blood for autologous transfusion.[9] Interest in bloodless surgery has arisen for several reasons. Jehovah's Witnesses reject blood transfusions on religious grounds; others may be concerned about bloodborne diseases, such as hepatitis and AIDS.

History

During the early 1960s, American heart surgeon Denton Cooley successfully performed numerous bloodless open-heart surgeries on Jehovah's Witness patients. Fifteen years later, he and his associate published a report of more than 500 cardiac surgeries in this population, documenting that cardiac surgery could be safely performed without blood transfusion.[10]

Ron Lapin (1941–1995) was an American surgeon, who became interested in bloodless surgery in the mid-1970s. He was known as a "bloodless surgeon" due to his willingness to perform surgeries on severely anemic Jehovah's Witness patients without the use of blood transfusions.

Patricia A. Ford (1955–) was the first surgeon to perform a bloodless bone marrow transplant.[11]

In 1998, Professor James Isbister, a haematologist from Australia, first proposed a paradigm shift back to a patient focus. In 2005, he penned an article in the journal, 'Updates in Blood Conservation and Transfusion alternatives'. In this article Prof. Isbister coined the term 'patient blood management', noting that the focus should be changed from the product to the patient.

Principles

Several principles of bloodless surgery have been published.[12]

Preoperative techniques such as erythropoietin (EPO) or iron administration are designed to stimulate the patient's own erythropoiesis.

In surgery, control of bleeding is achieved with the use of laser or sonic scalpels, minimally invasive surgical techniques, electrosurgery and electrocautery, low central venous pressure anesthesia (for select cases), or suture ligation of vessels.[13] Other methods include the use of blood substitutes, which at present do not carry oxygen but expand the volume of the blood to prevent shock. Blood substitutes which do carry oxygen, such as PolyHeme, are also under development. Many doctors view acute normovolemic hemodilution, a form of storage of a patient's own blood, as a pillar of "bloodless surgery" but the technique is not an option for patients who refuse autologous blood transfusions.

Intraoperative blood salvage is a technique which recycles and cleans blood from a patient during an operation and redirects it into the patient's body.

Postoperatively, surgeons seek to minimize further blood loss by continuing administration of medications to augment blood cell mass and minimizing the number of blood draws and the quantity of blood drawn for testing, for example, by using pediatric blood tubes for adult patients.[13] HBOC's such as Polyheme and Hemepure have been discontinued due to severe adverse reactions including death. South Africa was the only country where they were legally authorized as standard treatment but they are no longer available.

Benefits

Bloodless medicine appeals to many doctors because it carries low risk of post-operative infection when compared with procedures requiring blood transfusion. Additionally, it may be economically beneficial in some countries. For example, the cost of blood in the US hovers around $500 a unit, including testing.[14] These costs are further increased as, according to Jan Hoffman (an administrator for the blood conservation program at Geisinger Medical Center in Danville, Pennsylvania), hospitals must pick up the tab for the first three units of blood infused per patient per calendar year. By contrast, hospitals may be reimbursed for drugs that boost a patient's red blood cell count, a treatment approach often used before and after surgery to reduce the need for a blood transfusion. However, such payments are highly contingent upon negotiations with insurance companies. Geisinger Medical Center began a blood conservation program in 2005 and reported a recorded savings of $273,000 in its first six months of operation.[15] The Cleveland Clinic lowered their direct costs from US$35.5 million in 2009 to $26.4 million in 2012—a savings of nearly $10 million over 3 years.[16]

Health risks appear to be another contributing factor in their appeal, especially in light of recent studies that suggest that blood transfusions can increase the risk of complications and reduce survival rates.[17][18] Thus the recovery rate is faster with bloodless surgery, allowing the patient to leave earlier.

The shift away from standard transfusion practice to Patient Blood Management is gaining momentum worldwide. Organisations such as the International Foundation for Patient Blood Management are at the forefront of this shift along with many others.

See also
  • Knocking, a documentary on Jehovah's Witnesses that features a bloodless liver transplant

References
  1. The New York Times Oct 26, 1902, pg. 7
  2. The New York Times Sep 10, 1906, pg. 1
  3. New York Times Dec 25, 1902, pg. 3
  4. New York Times Nov 22, 1926, pg. 3
  5. Jackson et al., Baylor University Medical Center Proceedings, January 2004; 17(1): 3–7.
  6. Farmer S, Webb D, Your Body Your Choice The layman's complete guide to bloodless medicine and surgery, 2000, pgs. Preface, 11, 16.
  7. Farmer S, Webb D, Your Body Your Choice The layman's complete guide to bloodless medicine and surgery, 2000, pgs. 11, 14, 75.
  8. Dailey, John F, Dailey's Notes on Blood Fourth Edition, 2002 pg. 198.
  9. Farmer S, Webb D, Your Body Your Choice The layman's complete guide to bloodless medicine and surgery, 2000, pgs. 144–5.
  10. Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion. JAMA. 1977;232:1256-1258.
  11. "Philly doctor a pioneer of bloodless treatment". Retrieved 2015-09-18.
  12. Goher et al., Ann R Coll Surg Engl 2005; 87: 3–14.
  13. Magner, David; Ouellette, James R.; Lee, Joseph R.; Colquhoun, Steven; Lo, Simon; Nissen, Nicholas N. (May 2006). "Pancreaticoduodenectomy after neoadjuvant therapy in a Jehovah's witness with locally advanced pancreatic cancer: case report and approach to avoid transfusion". The American Surgeon. 72 (5): 435–437. doi:10.1177/000313480607200514. PMID 16719200. S2CID 2446222.
  14. Time Magazine, Bloodless Surgery, by John Langone, October 1997; pg. 5 .
  15. Mamula, Kris B. (27 March 2006). "'Bloodless' surgical program attracts new patients to AGH".
  16. Cleveland Clinic- Wall Street Journal http://online.wsj.com/article/SB10001424127887323494504578340962879110432.html?mod=wsj_streaming_stream
  17. McMillan D, Brady P, Foot C, Levy R, Thomson A (2011). "The team focus on improving blood transfusion". J Extra Corpor Technol. 43 (1): P65-7. PMC 4680100. PMID 21449243.
  18. Pieracci FM, Witt J, Moore EE, Burlew CC, Johnson J, Biffl WL, Barnett CC Jr, Bensard DD (2012). "Early death and late morbidity after blood transfusion of injured children: a pilot study". J Pediatr Surg. 47 (8): 1587–91. doi:10.1016/j.jpedsurg.2012.02.011. PMID 22901922.

Sources
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