Dose matters: incremental association of perioperative blood transfusion with morbidity and mortality after hepatectomy.

Abstract

Background: Perioperative blood transfusion is associated with adverse outcomes after hepatectomy, but the effect of transfusion volume remains poorly characterized. We evaluated the dose-dependent association between perioperative transfusion and postoperative morbidity and mortality after hepatectomy.

Methods: Adult patients undergoing hepatectomy from 2019 to 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program hepatectomy-targeted database. Patients were stratified by transfusion status and extent of resection (minor vs major hepatectomy). Multivariable logistic regression assessed the independent association between transfusion and 30-day outcomes. A dose-response analysis categorized patients by transfusion volume (0, 1, 2, or ≥3 units).

Results: Among 15,139 patients undergoing hepatectomy, 1599 (10.6%) received perioperative transfusions. Transfusion was more common after major hepatectomy than after minor hepatectomy (17.3% vs 7.8%; P <.001). After adjustment, transfusion independently increased 30-day mortality after both minor (odds ratio [OR], 2.49; 95% CI, 1.48-4.19) and major hepatectomy (OR, 1.67; 95% CI, 1.10-2.53). Transfusion was also associated with increased odds of posthepatectomy liver failure (minor OR, 2.82; major OR, 2.11), bile leak (minor OR, 1.35; major OR, 1.54), pneumonia, prolonged mechanical ventilation, acute renal failure, myocardial infarction, cardiac arrest, and reoperation (all P <.05). A dose-dependent analysis demonstrated that transfusion of a single unit was not independently associated with increased morbidity or mortality. However, transfusion of 2 units significantly increased mortality (OR, 2.3; 95% CI, 1.36-3.88) and morbidity (OR, 1.52; 95% CI, 1.23-1.88), with further risk escalation among patients receiving ≥3 units.

Conclusion: Perioperative transfusion is independently associated with mortality and morbidity after hepatectomy in a dose-dependent manner. Adverse outcomes become apparent at a threshold of 2 transfused units, supporting restrictive transfusion strategies in hepatic surgery.