BLOODLESS SURGERY

By John Langone

By every standard medical and logical, Henry Jackson, lying unconscious in a New Jersey hospital on his 32nd birthday, was finished. Massive internal hemorrhaging had drained him of 90% of his blood. His level of hemoglobin--the vital, oxygen-carrying compound in his red cells--had plummeted from a normal reading of 13 to an ominous 1.7, a number that one of his doctors characterized as "incompatible with survival." A blood transfusion could save him, but his wife, torn between her husband's life and their beliefs as Jehovah's Witnesses--a religious community that prohibits transfusions because of biblical references to the sacredness of blood--had refused. Eventually, at the urging of members of her community, and in the face of a hospital threat of a court order to thwart her, Claudette Jackson had Henry transferred to nearby Englewood Hospital's New Jersey Institute for the Advancement of Bloodless Medicine and Surgery.

It was an understandable choice. The institute is the leader among more than 50 in the U.S. that now practice bloodless surgery. Without using any donor blood at all, they offer a wide range of surgical procedures that would ordinarily include transfusions, along with techniques that dramatically reduce, or virtually eliminate, blood loss.

When Jackson was wheeled into the institute, Dr. Aryeh Shander, chief of anesthesiology and critical-care medicine, and his team moved swiftly. First, they essentially paralyzed the patient with drugs to reduce the demand for oxygen by his muscles, brain, lungs and other organs. Next, they gave him high-potency formulations of iron supplements and vitamins, plus "industrial doses" of a blood-building drug, synthetic erythropoietin, that stimulates the bone marrow to produce red blood cells. Finally, intravenous fluids were administered to goad what little circulation he had left.

Breathing on a ventilator, and without a drop of transfused blood flowing in his veins, Jackson gradually began to respond to the treatment. Within four days his blood count had risen significantly. Soon after, he was shaking his head in disbelief and telling his doctors, "If it wasn't for this, I wouldn't be here." It was around then that the first hospital called to ask whether Jackson was dead. With undisguised satisfaction, Shander told them, "He's not only not dead, but he's well and ready for discharge, and he'll soon be about his usual business."

If Shander, 49, an Israeli-born physician who majored in Asian languages as an undergraduate, is passionate about anything, it is blood. Not only because it is, as Goethe observed, "a very special juice," the fluid pumped by our hearts through arteries, veins and capillaries, and without which the body's cells would be starved of oxygen and nutrients; nor only because he knows blood transfusions save lives; nor simply because 70% of those transfusions are administered by anesthesiologists.

What concerns Shander most is how blood has become a convenient tool for his fellow anesthesiologists, and how it is sometimes used cavalierly when it need not be given at all. According to some estimates, 25% of U.S. transfusions are unnecessary. There are also indications that patients cannot tolerate levels of hemoglobin as high as previously thought and that young people especially have a built-in reserve of blood. These findings, Shander believes, support the need for a more sparing use of blood products. As one of the directors of the Englewood institute, he is convinced that withholding blood is a viable and preferable choice for most patients. It not only benefits many patients but also forces surgeons to pay closer attention to technique and tests their willingness to depart from tradition.

While most surgeons are willing to adopt minimally invasive, or noninvasive, procedures to control bleeding during an operation--such as laparoscopy, which requires tiny incisions, or ultrasound to destroy kidney stones--they usually stop short of transfusionless surgery. Some medical fundamentalists view it as a false promise with its own risks, but even doctors who acknowledge its value caution that it is not the panacea some physicians think it is. Certain situations--liver transplants, for example, and instances of trauma--will always require transfusions. Says Dr. Steven Gould, a surgeon at the University of Illinois at Chicago who advocates reduced surgical use of donated blood: "Some operations require four to six units, and when you get to that level, it's hard to imagine not getting any blood. We will never have a completely bloodless society for surgical patients."

Still, even as the practice seemingly thumbs its nose at mainstream medicine's historic reliance on transfusion (more than 14 million units were used in the U.S. last year alone), an increasing number of physicians are taking a harder look at bloodless medicine. According to the Jehovah's Witnesses, more than 75,000 doctors already practice bloodless surgery in the U.S. Also, more and more patients are clamoring for safer and more effective options than transfusions, either because of religious conviction or fear of contracting disease.

Medical technology has tried to answer the call. It has come up with a panoply of methods and machinery, some of them known for decades but refined and repackaged to fit today's needs and concerns. While bloodless techniques vary from hospital to hospital, they invariably begin with medicinal and nutritional approaches to increase a patient's blood count before surgery. Efforts are made to guard against unnecessary blood loss from tests, and standard blood drawings are either reduced or eliminated altogether. And since an intensive-care patient during an average stay must part with close to a liter of blood for testing--much of it unused and thrown out--microanalyzers have been developed to scrutinize tinier quantities of blood.

Erythropoietin is usually the drug of choice for bloodless medicine because of its stimulative effect on red-blood-cell production. Hormones and vitamin B12 are also prescribed to encourage cell production. Doctors may employ a hyperbaric chamber to flood patients' blood with higher concentrations of oxygen so that they can better withstand surgical procedures and low blood levels, while oximetry devices and other noninvasive monitoring equipment keep close watch over oxygen levels.

During surgery, bloodless practitioners often do everything they can to stave off any blood loss that might require a transfusion. Among the techniques: cryosurgery to freeze tissue to be removed, or use of a harmonic scalpel, a vibrating laser that simultaneously cuts tissue and clots blood. Brain surgeons treating tumors and repairing blood-vessel malformations are also using a state-of-the-art gamma "knife" that delivers a high dose of radiation to precise points in the head through tiny holes in a helmet that resembles a salon hair dryer.

Still, except for such techniques as radiosurgery, virtually no surgery is completely bloodless. The blood that is shed during operations at places like Englewood may be suctioned out by cell-saving machinery, cleaned and then returned to the patient's body. Red blood cells can also be saved through hemodilution. In this procedure, hemoglobin-rich blood is pumped unit by unit from a vein and replaced by an equal number of units of a nonblood fluid to expand the volume to normal; the patient's own drawn blood is held for use after surgery. In another technique, doctors may use albumin, a protein found in plasma that is acceptable to many who refuse transfusions on religious grounds, to maintain or increase blood volume, or to manage an underlying medical condition. Says Shander: "They used to tell us, 'Give 'em a couple of bottles of blood--it won't hurt; it's good for what ails them.' Well, that might be easier, but I've learned to rely on less, with better results."

Since the Englewood program began in 1994, it has performed more than 1,500 bloodless procedures, twice that of any other institution. Most of them have been major operations that usually involve extensive blood loss and transfusions: liver resections, hip replacements, abdominal aortic aneurysms, hysterectomies and brain surgery. "From a medical point of view, there are no technical barriers to performing bloodless surgeries," says Dr. Sharo Raissi, a cardiac surgeon at Brotman Medical Center, one of a dozen hospitals in Los Angeles that offer such services. "There is no limit as to what can be done for patients, from open-heart surgery even to transplants."

In one especially difficult case that Shander oversaw at Englewood, 11-year-old Cristali Rodriguez came in with a rare pancreatic tumor, one of only 300 documented cases worldwide. Doctors in Philadelphia had declined to perform a Whipple procedure, a complex reconstruction of the digestive tract rarely performed on a child. Rodriguez's parents had refused a blood transfusion, and the girl's doctors felt that without it the operation was even more risky. Undeterred, Englewood surgeons did a 10-hour bloodless Whipple. There were no major complications, and a week later Cristali was eating pizza. Soon after her discharge, she was back in school.

Up to now, Jehovah's Witnesses, who have long demanded equal medical care without having to compromise their religious beliefs, have made up some 90% of those who seek the bloodless techniques. But increasing numbers of other patients today refuse transfusions out of fear of blood-borne diseases such as AIDS and hepatitis, not to mention unidentified viruses.

Their concern is not always misplaced. Blood transfusions, while safer today than in the past, are not risk free. The chance of contracting AIDS from a unit of blood, for instance, is 1 in 500,000, and 1 in 103,000 for hepatitis C, according to the National Institutes of Health. The risk becomes greater as more units are transfused. "If you get 10 units of blood, the risk of HIV infection becomes 1 in 50,000," says George Nemo, leader of a group investigating transfusion medicine at the National Heart, Lung and Blood Institute. "If you're in an automobile accident, and you need 100 units, you're down to one in 5,000." Even when donor blood is deemed safe, if blood of the wrong group is transfused by mistake, recipients may suffer kidney failure, shock and clotting difficulties. Differences between donor and recipient platelets, white cells and plasma proteins can also cause reactions. Even donating one's own blood for use during surgery can be hazardous if the blood is mishandled.

Other factors make bloodless surgery increasingly attractive. Transfusions can suppress the immune system, for example, leaving a patient open to infection, slower healing and a longer recovery time. "Also, banked blood, after it's cooled and stored, doesn't have the capability of fresh blood to transport oxygen," says Shander. "We're just beginning to understand what it is we do when we give a transfusion." Finally, there is the cost: at around $500 for each transfusion, plus administrative add-ons, the total bill comes to between $1 billion and $2 billion annually, more than enough incentive to consider alternatives. Already, Englewood Hospital's managers claim, they have cut blood usage 20% and racked up savings in labor costs by lowering infection rates and shortening hospital stays.

But for surgeons who are queasy about operating without a transfusion backup, the operating field is not black and white. The jury is still out on whether it is safe to withhold blood, and large-scale clinical trials have yet to be performed. Last year an nih-funded study tried to get some answers. Dr. Jeffrey Carson, chief of the division of general internal medicine at the Robert Wood Johnson Medical School in New Brunswick, N.J., studied records of 1,950 bloodless-surgery patients in an effort to determine the relationship between patients' hemoglobin levels and the risk of dying or developing complications after surgery.

The results were mixed. The mortality rate was an encouragingly low 3.2%, but Carson also discovered that the risk of complications or death was higher in people with heart disease. "In some circumstances," he says, "blood is lifesaving. When people get very low blood levels, their risk of running into trouble is substantial, and if you're old or have cardiovascular disease, that risk may be even greater. So I recommend caution."

Shander is not put off by such fears. "Medicine is very conservative," he says, "which can be good, since it protects doctors against going along with every unproved technique that comes along. But it's imperative that we develop a mind-set where we look at refusing blood not as an obstacle but as a challenge."

One way of responding to the challenge might well be the development of artificial blood. The quest for a blood substitute reaches back to the 17th century, when scientists tried to transfuse animal blood and other products into humans. Several blood substitutes are undergoing clinical trials in the U.S. and Europe, and one, which seems to carry oxygen like its genuine counterpart, has been tested successfully in heart-surgery patients in Europe.

But for Shander, the problem is a more personal one. "When we're challenged, we extend ourselves," he says. "Some of my colleagues have adopted bloodless medicine purely as a technique. Others have learned that it also has an impact on ethical and humanistic values. I feel that once you become philosophically committed to practicing bloodless surgery, the benefits to patient and physician alike become more and more apparent. Those are my greatest rewards."

--With reporting by Dan Cray/Los Angeles

With reporting by Dan Cray/Los Angeles