Hepatobiliary surgery and nutrition | 2021
French editorial from the ACHBPT: blood salvage and autotransfusion during liver transplantation for advanced hepatocellular carcinoma.
Abstract
HepatoBiliary Surg Nutr 2021;10(3):367-369 | http://dx.doi.org/10.21037/hbsn-21-182 We read with great interest the recently (Annals of Surgery, March, 2021) published article by Kwon and collaborators (1) about the effects of autotransfusion of salvaged blood with single leukoreduction for liver transplant recipients with advanced hepatocellular carcinoma (HCC). This retrospective study assessed the impact of autotransfusion of salvaged blood with post-transplant tumor recurrence. Liver transplantation (LT) remains a major surgical procedure, in which significant blood loss is often caused by collateral vessels due to portal hypertension, impaired coagulation and vascular procedures on major vascular axes. Consequently, transfusion of homologous blood products is often needed during LTs, and often in very large amounts. The allogeneic red blood cells (RBCs) transfusion has known adverse effects such as metabolic disturbances, transfusion reactions, circulatory overload, microchimerism, post-transplant HCC recurrence, surgical site infection, coagulopathy, acute lung injury and mortality (1,2). Moreover, if allogeneic blood transfusion is used, there is a risk of immunomodulation, alloimmunization and rarely of transfusion-associated graft versus host disease (3). Thus, the need for RBC transfusion may be reduced with the use of intraoperative blood salvage autotransfusion. The principle of this autotransfusion is to collect the blood from the surgical site and re-infuses autologous blood to reduce the use of allogeneic RBCs (4). The safety of autotransfusion in cancer surgery has been a controversial concern. It could present the theoretical risk of spread neoplastic cells when it is used in cancer surgery (5). This issue remains a concern because the American Medical Council, in its report on autologous blood transfusion in 1986 promulgated a contraindication to the use of cell saver in cancer surgery based on a single case report in 1975, where a 52-year-old patient undergoing pneumonectomy was found to have malignant cells in salvaged blood (3,6). This dogma has become obsolete because since then, many authors have shown that the use of autologous blood in cancer patients can be safely used and does not impact the risk of neoplastic recurrence (1,3,7), event in HCC patients after LT (5,8). Moreover, in advanced HCC patients, who have greater metastatic potential, the uncertainty remains on the need of a single or a double-filtered leukoreduction during the treatment of the collected blood (9-11). This concern has never been assessed while the requirement of double-filtered leukoreduction delays the preparation of autologous blood and possibly increases the use of allogeneic RBCs (1). In this monocentric retrospective study, 349 patients who underwent living donor LT for advanced HCC were included between May 2002 and December 2017. The primary etiology of HCC in this cohort was hepatitis B virus, which is known as the first cause of HCC in Asia. There were no significant differences between autotransfusion group and nonautotransfusion group regarding tumor biology, pretransplant tumor treatment, patients with HCC beyond the Milan criteria, number and size of nodules, tumor vascular invasion, Edmondson Grading, downstaging and AFP level. In Asiatic cohorts, French Editorial from the ACHBPT