Pre-operative preparation is the key in managing advanced pancreatic carcinoma in Jehovah Witness

P. Bucher, T. Nguyen, J. Sierra, F. Cavalero

Objective

Jehovah Witness may represent a challenge, when formally refusing blood transfusion, and need an major abdominal surgery such as radical resection of locally advanced pancreatic cancer. Although morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, peri-operative transfusions are often needed especially when vascular resection is indicated. Here, we review the preoperative planning and preparation as well as overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion.

Methods

We present the case of a jehovah witness patient, formally refusing transfusion, but accepting the use of cell saver if needed peri-operativelly, who presented a locally advanced cephalic pancreatic carcinoma with portal vein infiltration. She presented with a jaundice and pre-operative biopsy confirmed the diagnosis of pancreatic carcinoma. Her hemoglobin level were at 119g/L at presentation. Pre-operative treatment combining EPO, folate, vitamin B12, iron and prophylactic anticoagulation with LMWH was introduced.

Results

A Jehovah witness patient presented with relative anemia, 119g/L, when advanced pancreatic carcinoma was detected, but after 4 weeks of treatment combining EPO, folate, vitamin B12 and iron, her hemoglobin level were at 164g/L. We thus undergo radical pancreaticoduodenectomy with partial portal vein resection. Blood lost were estimated at 50mL, and cell saver was not used. After two post-operative day her hemoglobin level were at 153g/L, and a two weeks post-surgery at 157g/L. Owing to excellent post-operative recovery, adjuvant therapy was started at 5 weeks post-surgery, while her hemoglobin level was at 151g/L. She supported her adjuvant therapy uneventfully and never presented sign of anemia. At 9 months post-surgery, she is fine without sing of residual or recurrent disease and hemoglobin level are at 134g/L.

Conclusion

These strategies, once in place, may be able to reduce transfusions needs in all patients having major resections for malignancy and should probably be used more frequently at least in frail patients. They may allow to reduced transfusion rate, facilitate recovery and adjuvant therapy administration in frail oncologic patients.