Hysterectomies are performed thousands of times a year in hospitals across the country, but Lilly Lopez went off the beaten path by refusing a blood transfusion during her procedure.
"I don't trust (the blood supply) out there," said Lopez, who requested a bloodless hysterectomy at Long Island College Hospital in Brooklyn last June. The facility's New York Center for Bloodless Medicine and Surgery has been performing such procedures since 1996.
Gerald Finnegan, a New York City Fire Department lieutenant, underwent a transfusion-free prostate procedure last April at Brookdale Hospital Medical Center, also in Brooklyn. Like Long Island College, Brookdale has been performing bloodless prostate surgeries-considered a fairly blood-intensive procedure-routinely for the past couple of years.
"It wasn't an issue with me, but I felt pretty relieved," said Finnegan, who went kayaking in New York's Jamaica Bay three weeks after his surgery.
Lopez and Finnegan represent an increasing number of patients who undergo bloodless, or transfusion-free, surgery every year at hospitals that have programs dedicated to the process.
In this clinical situation, low price and high quality go hand-in-hand. The procedure has often proved to be less costly than surgeries with transfusions and has led to quicker recoveries, according to studies and physicians interviewed for this article.
Patients are learning about bloodless surgical options through marketing by hospitals, many of which are for-profit facilities.
Thomas Crimi, M.D., a Brookdale anesthesiologist who spearheaded the hospital's bloodless surgery program, said recirculating a patient's blood saves about $150 per unit, not counting treatments for postoperative complications. Bypassing blood donated by the patient before a procedure saves money too, since storage can cost as much as $110 per unit.
Paul Potter, M.D., an associate staff member with the Cleveland Clinic's anesthesiology department, presented a paper at a recent conference on bloodless surgery in Chicago. His study concluded that using the protocol 50% of the time could save the healthcare industry up to $3.7 billion a year. That includes savings of about $400 to $1,400 for every unit of transfused blood from outside donors, factoring in the extra costs of treating postoperative fevers and infections.
"Anyone who loses five liters of blood or less can get away with a bloodless procedure," said Potter, who noted that even blood-intensive procedures such as liver resections and cardiac surgery can be performed without transfusions. "We have to face the fact that aside from the immune responses from transfused blood, half of the blood that is donated by either a patient or a volunteer gets thrown away. This new process could be far more economical."
Some hospital chains, such as Santa Barbara, Calif.-based Tenet Healthcare Corp., have aggressively pursued bloodless surgery. Tenet offers the procedure in 28 of its hospitals and adds several new facilities a year to its list.
"Bloodless surgery allows us to offer patients more of a choice," said Tenet spokesman Don Klausmeyer.
Decreasing blood flow seems to increase Tenet's cash flow. According to Randy Henderson, bloodless surgery coordinator at Tenet's USC University Hospital in Los Angeles and St. Luke Medical Center in Pasadena, Calif., some HMOs have authorized payments for patients even though the hospitals are out of network.
"We've also been able to obtain authorizations for out-of-state payers," Henderson said. "Most of the major HMOs already pay for it and are starting to recognize this as a specialty for which they're more amenable to have their patients bypass the traditional networks."
Tenet co-sponsored the Chicago bloodless surgery conference, which drew more than 500 attendees from around the country last month. A similar regional conference was held in Los Angeles in September and was sponsored by Good Samaritan Hospital in Los Angeles, which has performed bloodless surgery during much of the past decade.
Bloodless surgery was developed in the early 1970s to treat Jehovah's Witnesses, who shun transfusions because they believe blood is a sacred substance to be discarded once it leaves the body. But the performance of bloodless surgery has slowly crossed over to mainstream patients in recent years. Fear of contracting such deadly diseases as AIDS and hepatitis C has helped influence patients, observers agree.
"More and more patients have shown a concern over the blood supply, and more surgeons have shown concerns over shortages of blood," Henderson said.
According to Henderson, some 300 bloodless procedures will be performed this year at USC-University, nearly double the figure in 1996. He projected that 500 bloodless surgeries will be performed at the hospital in 1998.
The techniques behind bloodless surgery are fairly straightforward. Surgeons use ultrasonic "harmonic" scalpels and argon beam coagulators, which stanch bleeding as incisions are made. Blood lost during surgery is recycled in "cell saver" machines that collect blood, cleanse it and return it to the body. In a process known as hemodilution, blood can be collected from the patient just before incisions are made and replaced by intravenous fluids. The blood is then returned to the body during the procedure. Those processes are often coupled with a drug administered before surgery to stimulate blood cell production.
Although bloodless surgery is so new that few concrete numbers have been compiled, the number of hospital-based programs have mushroomed from 14 in 1996 to 78 today, according to the National Association of Bloodless Medicine and Surgery, an affiliate organization of Creighton University Medical Associates medical group in Omaha, Neb.
"There's been more of a demand from the public, and not necessarily from Jehovah's Witnesses," said Joan Wyatt, the association's immediate past president. Wyatt, a registered nurse, helped establish Tenet's program at St. Joseph Hospital in Omaha.
Indeed, at some institutions like Brookdale and St. Luke, as many as a quarter of bloodless procedures are performed on patients who request them for nonreligious reasons.
However, most institutions still report that only 10% to 15% of patients request bloodless surgery for other than religious reasons, although facilities such as St. Luke and Brookdale report rates as high as 25%.
While patients can breathe easier knowing they will not receive another person's blood, hospital staff know that the extra preparations are often offset by more favorable outcomes.
While hard statistics are few, it's "observed that the recovery times are better for bloodless surgery," said Emily Rossi, who coordinates Long Island College's bloodless surgery program.
Said Brookdale's Crimi: "It's well known that when you receive someone else's blood you are decreasing your own immunity" by introducing pathogens into the body.
Various studies suggest that up to one-third of patients who receive traditional, or homologous, transfusions suffer from postoperative complications, such as a fever or secondary infection.
Massachussetts General Hospital and the pathology department at Harvard University's medical school performed one of the few studies regarding hospital stays and bloodless surgery. It appeared in the February issue of Archives of Pathological Laboratory Medicine. An examination of 478 consecutive colorectal cancer resections at Massachusetts General concluded that the average length of stay was reduced 40% among patients who underwent the procedure without transfusion, from 16.7 days to 10.3 days.
Charges were similarly reduced, from $28,101 to $15,978. After adjusting for 20 factors, the study concluded that every unit of blood transfused increased the stay by 1.3%, while charges increased 2%.
But surgeons are still not leaping into the process.
Terrence Sacchi, M.D., chief of Long Island College's cardiology division, said: "Some physicians are very reticent. I've spoken to some who don't want to treat their patients in this manner, and many patients do come to us because they've been refused treatment elsewhere. Doctors don't want to be told there are limitations and that conditions are set. They feel their hands are being tied."
Potter of the Cleveland Clinic concurred: "All these new techniques are not being taught, so you present them to an anesthesiologist, and they're skeptical."
Both doctors agreed that education is the key.
For example, bloodless procedures are being taught to third-year anesthesiology residents at the Cleveland Clinic as an elective that is part of a one-month rotation period in the operating room. About three-quarters of those eligible have signed up, according to Potter.
The big message is better education, he said. "This is not rocket science. You just have to think."