Dear Colleague,
You have been included in the Experts panel for the "E-AHPBA consensus statement on blood loss estimation in epato-bilio-pancreatic (HPB) surgery".
As anticipated in the Lyon meeting, the aim of this Delphi consensus by the European-African HPB Association (E-AHPBA) is to produce consensus statements on relevance, estimation method, and grading of intraoperative blood loss during HPB surgery.
Intraoperative blood loss (BL) is considered a key quality indicator and outcome metric in hepato-pancreato-biliary (HPB) surgery. Literature demonstrated that BL is directly correlated with morbidity and mortality. In striking contrast, despite potentially representing one of the few actionable risk factors for morbidity, there are no specific benchmarks for BL in HPB surgery, nor standardization of practice regarding its intraoperative assessment. The range of available approaches and the absence of a method identified as superior led to inconsistency and heterogeneity in the practice of BL estimation. According to a recent systematic review, most studies reporting intraoperative BL during liver and/or pancreatic surgery did not specify the used estimation method. Among the minority of studies reporting it, more than nine different options were described. Consequently, most of the available evidence proving a significant association between higher BL and worse perioperative outcomes did not include an empirical and systematic calculation of BL, affecting the reproducibility of the results and preventing an objective grading of BL clinical importance. It is strongly necessary to adopt a universal standard to ensure consistent reporting and reproducibility.
The final document will be reviewed by the E-AHPBA Scientific Committee. Likely to be published in HPB Journal, will hopefully form a cornerstone of management. PubMed citable authorship will be granted for all participants as collaborators of the study group.
Thank you for your collaboration,
Giampaolo Perri
Ernesto Sparrelid
Ajith Siriwardena
Giovanni Marchegiani
Please enter the required data.(Please note that the results of the questionnaire will be analysed anonymously).
1- Blood loss is a relevant intraoperative outcome metric in hepato-bilio-pancreatic surgery.
2- Blood loss should be systematically estimated.
3- Estimated blood loss represents an approximation and does not necessarily refer to blood only, but to the whole amount of fluid intraoperatively collected from the abdomen (i.e., blood, bile, peritoneal fluid/ascites).
4- The method of blood loss estimation should be clearly reported.
5- A standard, direct method for estimation of blood loss should be applied to ensure consistent reporting and reproducibility.
6- The suggested direct estimation method for blood loss is a calculation based on intraoperative suction fluid amounts (ml) minus the volume of saline solution used for irrigation (ml), plus the difference in weight between used operative gauzes and dry gauzes (considering 1 g = 1 ml of blood).
7- Any variation or corrective factor applied to the estimation should be specified (e.g., in case of common bile duct division, -25 ml/h from the time of division to exclude bile).
8- Indirect estimation methods (e.g., blood count-related formulas) are encouraged to complement direct estimation and for research purposes, but do not replace direct estimation.
9- The use of existing tools to measure intraoperative bleeding from a specific site (e.g., VIBe scale) complements, but does not replace, systematic estimation of the whole blood loss.
10- Clinical trials evaluating the grade of bleeding treated, assessing hemostasis, should adopt an intra-operative bleeding scale (e.g., VIBe scale).
11- Intraoperative blood loss can be graded as follow, based on quantity and severity: Null= 0-100 ml, no intraoperative transfusion; A= 101-500 ml, no intraoperative transfusion; B= >500, and/or intraoperative transfusion; C= any amount determining an intraoperative adverse event w/ life-threatening complication, transfusion needed.
12- Intraoperative blood loss affects the postoperative course after:
12.1- Pancreatic surgery
12.2- Major liver surgery
12.3- Minor liver surgery
13- Further prospective studies including a standardized estimation are needed to understand the relationship between blood loss and postoperative complications after hepato-bilio-pancreatic surgery.
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