Should Cell Salvage be Used in Liver Resection and Transplantation? A Systematic Review and Meta-Analysis

Introduction: Intraoperative red blood cell (RBC) transfusions are common in liver surgery and associated with increased morbidity. Intraoperative blood salvage and autotransfusion (IBSA) can be utilized to minimize transfusion. A theoretical risk of cancer dissemination has restrained IBSA adoption in oncologic surgery. The objective of this work is to evaluate the effect of IBSA use on RBC transfusion and survival outcomes in liver surgery. Methods: Electronic databases were searched from inception until May 2021. Studies comparing IBSA to no IBSA use in liver resection or transplantation for any indication, were included. Screening, data extraction, and risk of bias assessment were conducted in duplicate independently. The primary outcome was intraoperative allogeneic RBC transfusion. Secondary outcomes included overall survival (OS) and disease-free survival (DFS). Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. Results: A total of 21 observational studies were included (16 transplant, 5 resection, n=3,433 patients). Seventeen studies incorporated cancer indications. In transplant (n=9), IBSA was associated with decreased RBC transfusion (MD –1.74 units [-3.13, -0.36], p=0.01, I2=86%, very-low certainty). Too few resection studies reported on transfusion for meta-analysis. No significant difference existed in OS or DFS in liver transplant (HR 1.12 [0.75, 1.68], p=0.59, I2=0%; HR 0.93 [0.57, 1.48], p=0.75, I2=0%) and liver resection (HR 0.69 [0.45, 1.05], p=0.08, I2=0%; HR 0.93 [0.59, 1.45], p=0.74, I2=0%). Conclusion: IBSA may reduce intraoperative allogeneic RBC transfusion, without compromising oncologic outcomes. The evidence base supporting these findings is extremely limited in size and quality.