Dose Matters: Incremental Association of Perioperative Blood Transfusion with Morbidity and Mortality After Hepatectomy.

BACKGROUND

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

METHODS

Adult patients undergoing hepatectomy from 2019-2021 were identified from the ACS-NSQIP hepatectomy-targeted database. Patients were stratified by transfusion status and extent of resection (minor versus 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, 1,599 (10.6%) received perioperative transfusions. Transfusion was more common following major hepatectomy than minor hepatectomy (17.3% vs. 7.8%, p<0.001). After adjustment, transfusion independently increased 30-day mortality following both minor (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 post-hepatectomy 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<0.05). Dose-dependent analysis demonstrated that transfusion of a single unit was not independently associated with increased morbidity or mortality. However, transfusion of two units significantly increased mortality (OR 2.30, 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.

CONCLUSIONS

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