Major Surgery Without Blood

NOT long ago, blood transfusion was considered a routine part of major surgery. Nearly all doctors felt that they had to use it.

Today this is no longer the case. A growing number of doctors now recognize that they can operate successfully without administering blood. They have developed new techniques to do so. And these new methods are very much appreciated by the increasing number of patients who do not want blood transfusions.

Too, doctors have discovered that the new methods are superior to the older ones in certain important respects. Thus, as a general rule, they now often recommend these new procedures to their patients.

Why the Trend?

Why this trend toward bloodless surgery? Some reasons are noted in an Associated Press dispatch that states: “Two goals of bloodless surgery are to avoid potential hazards from transfusions, including transmitting the liver disease, hepatitis, and to reduce the need for blood donors.”

Blood-transfusion dangers are now widely acknowledged. As reported by Awake! in its May 22, 1974, issue, each year thousands of people are killed and tens of thousands of others are injured by blood transfusions. This is due to factors such as blood-carried contaminants and diseases (particularly hepatitis), technical errors (for instance, mismatched blood) and allergic reactions. Experts frankly admit that no known tests can totally eliminate these hazards. That is why Dr. Stanley Dudrick, chief surgeon in a Philadelphia hospital, says: “We don’t throw around a bottle of blood willy-nilly anymore.”

However, there is another reason why new techniques have been developed to eliminate transfusion of blood in surgery. As the Palo Alto Times of California notes: “The need to develop surgical techniques which did not require blood transfusions was stimulated in part by limitations on usual forms of surgery imposed by the faith of Jehovah’s Witnesses, whose religion opposes transfusion of donor blood.”

Jehovah’s witnesses will not take blood. They reject this form of medical treatment because God’s Word, the Holy Bible, requires Christians to “abstain . . . from blood.” (Acts 15:20) Hence, they look for doctors who will provide some alternative treatment when they are in need of surgery.

At first, nearly all doctors who were not Jehovah’s witnesses refused to perform the more difficult operations without blood. But gradually some came to appreciate the need to help Jehovah’s witnesses as best they could and accepted the challenge of finding ways of operating without using blood. As the new methods proved successful, more doctors began using them.

Many of these doctors are well known in their local communities. In the United States the names of many of them are now included on a list kept at the headquarters of Jehovah’s witnesses in Brooklyn. Such a list does not imply an endorsement of the doctor but is kept for the convenience of persons who need an operation but do not know a surgeon who will perform it without blood.

Can the new methods be used in all kinds of operations? Yes. And such operations include the most delicate and complicated types on vital organs.

“Bloodless” Open-Heart Surgery

At one time doctors considered it unthinkable to perform open-heart surgery without having the option of using blood. It is of interest, therefore, to see how bloodless heart surgery developed over the years.

Among the pioneers in the field were teams of Houston, Texas, doctors. They appreciated that simply refusing to operate on Jehovah’s witnesses was unreasonable, as, in some cases, this refusal would amount to an automatic death sentence.

Thus, in 1962 these doctors began devising methods to take the cases of Jehovah’s witnesses that other doctors had refused. One of the early reports on such surgery was contained in The American Journal of Cardiology of June 1964. In an article entitled “Open Heart Surgery in Jehovah’s Witnesses,” Drs. Denton A. Cooley, E. Stanley Crawford, James F. Howell and Arthur C. Beall, Jr., explained some of their bloodless techniques.

To enable the surgical team to operate on it, the heart may actually be stopped for a period of time. The pumping action is taken over by a “heart-lung” machine, which maintains the flow of blood and its vital oxygen to all parts of the body. It had been the usual practice to use about three pints of blood to prime its pumps and fill its tubing and blood reservoir before the machine was connected to the patient. What did these doctors use instead? They reported:

“The technic developed in our clinic also permits the use of 5% dextrose [a simple sugar] in distilled water to prime the extracorporeal [outside the body] unit without addition of blood. The solution contains 25 mg. of heparin per 1,000 ml. of solution to prevent fibrin depositions in the oxygenator. Priming volume consists of 20 to 30 ml. dextrose solution per kilogram body weight [about two quarts for a 150 pound person].”

Also, since no blood could be used during the operation, the surgeons had to be more meticulous, giving more than the usual attention to “hemostasis.” This is the checking of the flow of blood from severed vessels. From this need there has developed a number of new techniques now widely used.

Where artificial grafts were needed to replace a worn-out artery, special pre-clotted materials were used to prevent blood leakage. And various salt and sugar solutions were fed into the patient’s veins during the surgery.

The continued experience with Jehovah’s witnesses confirmed the beliefs of these early pioneers in bloodless surgery. Then, after nearly a decade of bloodless open-heart operations, a report was issued by The American Journal of Cardiology of February 1972 on the work of these Houston doctors. It covered in particular the surgery performed at the Texas Heart Institute of St. Luke’s–Texas Children’s Hospitals in Houston. Written by doctors John R. Zaorski, Grady L. Hallman and Denton A. Cooley, the report said, in part:

“Since 1962 bloodless prime has been routinely utilized in more than 5,000 operations at this institution with excellent results; and several hundred of these operations were performed electively without blood transfusions in patients most of whom were not Jehovah’s Witnesses. . . .

“The Jehovah’s Witness patients in this series received the same treatment as all other patients except that all Witness patients received injectable iron before and after operation, and no blood was held in reserve for them at the blood bank. The only fluid they received was the priming solution and intravenously administered dextrose in dilute saline or Ringer’s lactate solution.”

The report showed that in the entire period covered, only one of Jehovah’s witnesses died where the cause was “attributed to anemia.” This death came three days after the operation.

The general conclusion of this report was as follows: “We believe that our experience demonstrates the feasibility of open heart surgery in Jehovah’s Witnesses and, moreover, indicates that blood transfusion can and should be used sparingly to reduce morbidity and mortality in all patients.”

Others Begin Using New Methods

As experience was gained and publicized, other surgeons began to use similar bloodless (transfusionless) methods in open-heart cases as a service to Jehovah’s witnesses. For instance, in 1970 Dr. Charles W. Pearce performed bloodless open-heart surgery on one of Jehovah’s witnesses in Methodist Hospital in New Orleans. Dr. Pearce, who served several years as an investigator for the American Heart Association, was assisted in the operation by Dr. White Gibson. Regarding this surgery, an interesting account on the front page of The Sentry News of Slidell, Louisiana, relates:

“Many resident doctors and visiting doctors could not understand how it could be performed and were allowed in the operating room to witness this unusual operation. So many, in fact, that the hospital ran out of surgical gowns.”

The fact that other doctors could not understand how it could be done demonstrates the urgent need for doctors to keep up-to-date with improved surgical techniques. Also, it shows the need of their not rejecting all techniques that depart from what are considered “usual and accepted” methods.

In the case of this patient, observed by so many other doctors, amazement was expressed at the speedy recovery. In fact, a nurse’s aid nicknamed him “Speedy.” Only ten days after the operation, he was discharged from the hospital. The news report stated of the bloodless surgery experiences of Dr. Pearce:

“The surgeon said he believes the method used has proven a boon not only to Jehovah’s Witnesses but to most patients undergoing open heart surgery.

“‘We recently used this technique in 100 consecutive open heart operations for congenital heart defects,’ he explained, ‘and there was only one mortality.’

“The famed surgeon said that this method without the use of blood virtually eliminates the possibility of infectious hepatitis. He said it also reduces the possibility of an allergic reaction . . . that it reduces the more serious reactions of shock . . .

“When blood is used, the functions of the heart, lungs and kidneys sometimes become impaired during the early period following open heart surgery, Dr. Pearce explained. ‘But with the technique used . . . the function of these organs is nearly always satisfactory,’ he added.”

More Widespread Now

Reports from all over the world show that in the past few years, bloodless surgery in the more difficult operations, such as open-heart cases, has become quite widespread and accepted in highly regarded medical institutions. For instance, a Johannesburg, South Africa, heart specialist performed one on a fourteen-year-old girl, one of Jehovah’s witnesses. The Sunday Times there reported that she made a “fantastic recovery,” spending only one day in the intensive-care ward.

In Spokane, Washington, a team of surgeons now performs open-heart operations on Jehovah’s witnesses without using blood. The Seattle Times describes their method: “The physicians adopted a no-blood priming technique using a dextrose (sugar) and water solution alone or the sugar-and-water solution with Ringer’s lactate (a common therapeutic solution of sodium chloride, potassium chloride and calcium chloride).” They noted that there had been no negative results.

In San Francisco a fifty-four-year-old patient was badly in need of a heart operation. He was one of Jehovah’s witnesses. It was Dr. Elias Hanna and his team’s first experience with such bloodless surgery in an open-heart case. After the less than an hour-and-a-quarter-long operation, Dr. Hanna said of the patient: “He’s doing phenomenally well for all the work we did on him.”

In a letter that Dr. Jerome H. Kay of Los Angeles wrote to Awake! magazine in November 1973, he also noted that his team now performs bloodless open-heart surgery on the majority of all his patients. Dr. Kay added: “It has been a pleasure operating upon patients who are Jehovah’s Witnesses. We do not give these patients any blood or blood substitutes.”

It is obvious that if such complex operations as those involving the heart can be performed successfully without blood, others can too. This has proved to be the case. Now fortified by the experience and success of others, more doctors than ever are studying the new techniques and applying them.

Other Operations Without Blood

In Wellington, New Zealand, a fifteen-year-old girl had a brain tumor removed in a complex operation with no blood used. The operation was a complete success, and she was allowed to return home only one week later!

In Milwaukee, doctors operated on a sixteen-year-old who had torn a main artery in his chest. He had lost more than a quart of blood and would lose more during surgery. The Detroit Free Press reported that doctors “used salt water to replace his lost blood while they used a dacron tube to replace the torn part of his aorta.” When surgery was completed, the patient’s red-blood-cell count was only one third of normal. But doctors said that with iron supplements and a high protein diet the youth’s body would replace his lost blood in a few weeks.

The New York State Journal of Medicine contained an article entitled “Extensive Urologic Surgery Without Blood Transfusion.” It was written by Doctors Philip R. Roen and Francesca Velcek from the Department of Urology at St. Barnabas Hospital in New York. The doctors said:

“Our experiences with Jehovah’s Witnesses requiring operative procedures has demonstrated to us that blood transfusions are not necessarily essential even when hemoglobin levels are low—as low as 5 Gm. per 100 ml. in one of our cases!

“This indicates that this experience in avoiding blood transfusion may be applicable to an overwhelming percentage of cases even if the patient will permit such blood transfusion. The only requirement is a careful and more meticulous operative technic. We have adopted this approach in all our cases, and blood transfusion is a most unusual event in our hands. . . .

“Although special technics to reduce bleeding and operative risk have been employed by others, such as induced hypothermia, deliberately induced hypotension, use of colloid blood expanders, and so on, we have not resorted to such measures. The surgical attack has been that of a most meticulous operative technic with emphasis on sparing every milliliter of blood possible and replacement of blood loss with simple crystalloid solution, namely, lactated Ringer’s solution. The results have been most satisfactory.

“It is gratifying, moreover, not to have to be concerned about such complications of whole-blood transfusion as allergic or hemolytic reactions, renal shutdown, and hepatitis.”

What specific “formula” do these doctors use to replace the blood lost before or during surgery? They say:

“Our own method in caring for these patients has been that of employing only lactated Ringer’s solution for blood replacement. No specific formula is employed, but we generally use three times the volume of this fluid over the sustained blood loss. . . .

“Although isotonic dextrose solution and isotonic saline solution are widely used, a ‘balanced’ formulation is better—Ringer’s solution contains potassium and calcium in addition to sodium and chloride. It must be noted that the calcium and potassium are present only in ‘physiologic’ concentration and this preparation is not designed for replacing deficits of these ions.

“‘Improved’ Ringer’s solution contains sodium lactate. The customary Ringer’s solution has a slight acidifying effect; the lactated Ringer’s tends to overcome this acidifying influence and is therefore the preferred crystalloid solution for intravenous administration.”

Also, extensive abdominal operations, such as resections (removal) of the stomach and intestines in cases of malignant disease now have been done many times without the use of blood.

Probing Questions

In view of such successes, the following comment of Doctors Roen and Velcek is worthy of note. They said: “In most instances physicians and hospital authorities have refused operation on Jehovah’s Witnesses because of the problem of blood transfusions. We contend that it is wrong to deny operations to these people, no matter how extensive the contemplated surgery.”

These doctors cite case after case of Witnesses being refused surgery elsewhere, then coming to St. Barnabas Hospital and being operated on successfully without blood. The successes in bloodless surgery performed by other skilled surgeons all over the world confirm their conclusion.

Indeed, it must be said that today doctors who still refuse to operate on Jehovah’s witnesses unless blood is used betray themselves. While no doubt they are sincere, one now has to ask: Why do they refuse? Are they not familiar with what leading, highly respected surgeons are doing in other parts of the world, or in their own country, even in their own state or city? Is it possible that their past training and conditioning has made them close-minded, unwilling to progress with the latest developments in the field of medicine? May it be, in some cases, that they simply lack confidence in their skill? Or could religious prejudice even enter into the matter?

In the light of modern developments in medicine, there is no excuse for any doctor to try to force blood transfusions on people who do not want them.

Additional Procedures

Nor do the above examples exhaust the methods now used or under investigation in bloodless surgery. Another practice that has proved very useful has to do with building up the patient’s blood well before, when time permits, and also after surgery. Various nutrients are given to the patient, such as iron, vitamins and amino acids. In this way, although there may be blood loss during surgery, the remaining blood will be better able to carry the load. The nutrients will also help the body to replace lost blood. One doctor who uses this adjunct to the actual operation stated: “It is amazing how fast patients come around” in response to the buildup.

Another procedure has been worked on by Dr. James E. Eckenhoff, dean of Northwestern University Medical School. This involves hypotension, lowering of blood pressure to reduce blood loss. It is said to be useful in surgery of the head and neck and upper extremities, in neurosurgery and in plastic surgery.

Then there is the form of bloodless surgery called cryosurgery. This involves using extreme cold to lessen blood loss. It has been used to remove malignancies and to treat certain other conditions. One of the doctors who have worked on this method is Dr. Irving S. Cooper of St. Barnabas Hospital in New York.

Another idea was originated by New York physicist Lewis Balamuth. He was awarded a patent for a scalpel that vibrates at very high speed, over 30,000 strokes a second. The distance covered by the stroke is only about five thousandths of an inch. The blood vessels cut are at the same time cauterized, closed off by the heat of friction. This method is said to be useful in eliminating the need to tie off certain severed veins and arteries, and may represent an improvement over electro-cautery techniques in use by many surgeons for the past several years.

Fluorocarbons

Also of interest is a development that is still in the experimental stage. It has to do with the body’s need for oxygen. Normally, this need is taken care of by the red blood cells, which pick up oxygen from the lungs. The heart pumps the oxygenated blood throughout the body, where the oxygen is released to the billions of cells that require it for their normal functioning. However, the plasma volume expanders used now cannot carry oxygen. Thus, when there is very great blood loss, the body’s ability to transport oxygen is impaired.

The experiments involve what are called fluorocarbons capable of carrying oxygen. These are organic compounds in which all hydrogen atoms have been replaced by fluorine. One drawback has been their tendency to accumulate in body tissues with unpredictable effects. However, Science magazine reports that newer fluorocarbons have been devised that are rapidly eliminated from the bodies of experimental animals.

Scientists caution, however, that at this time it is not possible to relate these experiments on animals to practical effects in humans. Also, they note that these fluorocarbons are far from being total blood substitutes. Blood contains hundreds of other chemicals and structures besides the red cells with their oxygen-carrying capacity. So whether such research will ever result in practical help for humans remains to be proved.

Thus, it can be seen from all such efforts mentioned here, and others too, that good work is being done to honor the wishes of patients who do not want transfusions of blood. Already highly skilled surgeons have devised methods of eliminating blood during surgery, with very gratifying results. As more work is done in this direction, further beneficial results can be expected.