Bloodless surgery

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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 (blood from other people) and they also make use of pre-donated blood for autologous transfusion (blood pre-donated by the patient). [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.

Contents

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 (born 1955) was the first surgeon to perform a bloodless bone marrow transplant. [11]

In 1988, 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.[ contradictory ] 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.[ citation needed ] 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.[ citation needed ] 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, patients who do not receive blood products during hospitalization often recover more quickly, experience fewer complications, and are able to be discharged home more quickly.

See also

Related Research Articles

<span class="mw-page-title-main">Blood transfusion</span> Intravenous transference of blood products

Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells, white blood cells, plasma, platelets, and other clotting factors.

<span class="mw-page-title-main">Denton Cooley</span> American heart and cardiothoracic surgeon (1920–2016)

Denton Arthur Cooley was an American cardiothoracic surgeon famous for performing the first implantation of a total artificial heart. Cooley was also the founder and surgeon in-chief of The Texas Heart Institute, chief of Cardiovascular Surgery at clinical partner Baylor St. Luke's Medical Center, consultant in Cardiovascular Surgery at Texas Children's Hospital and a clinical professor of Surgery at the University of Texas Health Science Center at Houston.

<span class="mw-page-title-main">Cardiac surgery</span> Type of surgery performed on the heart

Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease ; to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and atherosclerosis. It also includes heart transplantation.

<span class="mw-page-title-main">Microsurgery</span>

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Chin augmentation using surgical implants can alter the underlying structure of the face, providing better balance to the facial features. The specific medical terms mentoplasty and genioplasty are used to refer to the reduction and addition of material to a patient's chin. This can take the form of chin height reduction or chin rounding by osteotomy, or chin augmentation using implants. Improving the facial balance is commonly performed by enhancing the chin using an implant inserted through the mouth. The goal is to provide a suitable projection of the chin as well as the correct height of the chin which is in balance with the other facial features.

Jehovah's Witnesses believe that the Bible prohibits Christians from accepting blood transfusions. Their literature states that, "'abstaining from ... blood' means not accepting blood transfusions and not donating or storing their own blood for transfusion." The belief is based on an interpretation of scripture that differs from other Christian denominations. It is one of the doctrines for which Jehovah's Witnesses are best known.

Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person.

<span class="mw-page-title-main">Arterial switch operation</span> Open heart surgical procedure

Arterial switch operation (ASO) or arterial switch, is an open heart surgical procedure used to correct dextro-transposition of the great arteries (d-TGA).

Intraoperative blood salvage (IOS), also known as cell salvage, is a specific type of autologous blood transfusion. Specifically IOS is a medical procedure involving recovering blood lost during surgery and re-infusing it into the patient. It is a major form of autotransfusion.

Ronald Lapin was an Israeli-born American surgeon, best 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. He completed medical school in New York City and established his practice in Orange County, CA, in the 1970s, where he lived until his death.

Autotransfusion is a process wherein a person receives their own blood for a transfusion, instead of banked allogenic (separate-donor) blood. There are two main kinds of autotransfusion: Blood can be autologously "pre-donated" before a surgery, or alternatively, it can be collected during and after the surgery using an intraoperative blood salvage device. The latter form of autotransfusion is utilized in surgeries where there is expected a large volume blood loss – e.g. aneurysm, total joint replacement, and spinal surgeries. The effectiveness, safety, and cost-savings of intraoperative cell salvage in people who are undergoing thoracic or abdominal surgery following trauma is not known.

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A retained surgical instrument is any item inadvertently left behind in a patient’s body in the course of surgery. There are few books about it and it is thought to be underreported. As a preventable medical error, it occurs more frequently than "wrong site" surgery. The consequences of retained surgical tools include injury, repeated surgery, excess monetary cost, loss of hospital credibility and in some cases the death of the patient.

Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.

Billroth Hospitals is a hospital chain which is based in Chennai, Tamil Nadu, India. It was founded by Dr. V. Jeganathan on 30 November 1990. Billroth Hospital has its branches in Shenoy Nagar, R A Puram, and Tiruvallur.

Facial Autologous Muscular Injection is also known as Fat Autograft Muscular Injection, as Autologous Fat Injection, as Micro-lipoinjection, as Fat Transfer and as Facial Autologous Mesenchymal Integration, abbreviated as FAMI. The technique is a non-incisional pan-facial rejuvenation procedure using the patient'own stem cells from fat deposits. FAMI is an Adult stem cell procedure used to address the loss of volume in the face due to aging or surgery repair in restoring facial muscles, bone surfaces and very deep fat pads. The procedure involves removing adult stem cells of fatty tissue from lower body, and refining it to be able to re-inject living adipose stem cells into specific areas of the face without incision. FAMI is an outpatient procedure and an alternative to artificial fillers, blepharoplasty or various face lifts. The procedure does not require general anesthesia and risks of an allergic reaction are minimal due to the use of the patient's own tissue used as the facial injection.

<span class="mw-page-title-main">Sharad Panday</span> Indian heart surgeon

Sharad Pandey was an Indian heart surgeon. He was on the team of surgeons who performed the first-ever heart transplant in India at the King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College in Mumbai. He was a specialist in bloodless heart surgery, and was an early exponent of bloodless open heart surgery in India.

Retrograde autologous priming (RAP) is a means to effectively and safely restrict the hemodilution caused by the direct homologous blood transfusion and reduce the blood transfusion requirements during cardiac surgery. It is also generally considered a blood conservation method used in most patients during the cardiopulmonary bypass (CPB). The processing of RAP includes three main steps, and the entire procedure of RAP could be completed within 5 to 8 minutes. This technique is proposed by Panico in 1960 for the first time and restated by Rosengart in 1998 to eliminate or reduce the risk of hemodilution during CPB. Moreover, to precisely determine the clinical efficacy of RAP, many related studies were conducted. Most results of researches indicate that RAP is available to provide some benefits to reducing the requirements for red blood cell transfusion. However, there are still some studies showing a failure of RAP to limit the hemodilution after the open heart operation.

References

  1. ↑ The New York Times October 26, 1902, pg. 7
  2. ↑ The New York Times September 10, 1906, pg. 1
  3. ↑ The New York Times December 25, 1902, pg. 3
  4. ↑ The New York Times November 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 (1977). "Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion". JAMA. 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. 1 2 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. ↑ Langone, John (October 1997). "Bloodless Surgery". Time .
  15. ↑ Mamula, Kris B. (27 March 2006). "'Bloodless' surgical program attracts new patients to AGH".
  16. ↑ Radnofsky, Louise. "Hospitals Say Bloodless Surgery Is Often Cheaper and Better for Patients". WSJ. Retrieved 2023-04-11.
  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.

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