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A patient with liver metastasis from colon cancer is scheduled to undergo resection of the lesions. According to a recent study, the administration of tranexamic acid during surgery will MOST likely result in which of the following outcomes in this patient?
(A) Less measured intraoperative blood loss X
(B) Less red blood cell transfusion X
(C) More postoperative complications ✔
Gain insight on this topic, and many others, with Summaries of Emerging Evidence (SEE) 2026 – Volume 42A, now available. The content is aggregated from 30 international medical journals to streamline your learning and improve your practice.
Tranexamic acid (TXA) has been used to reduce the need for blood transfusion during both cardiac and orthopedic surgeries, with studies showing the probability of receiving a blood transfusion is reduced by one-third. The mechanism of bleeding in cardiac and orthopedic surgery patients is from small vessels on the raw surface of the pericardium or bones whereas bleeding from a liver tumor resection is from large blood vessels. Existing evidence supports the idea that TXA does not increase the occurrence of venous thromboembolism (VTE), but little research has been done to support the use of TXA in patients undergoing cancer surgery in which the risk for VTE may be higher due to the clotting changes that occur with cancer.
A recent multicenter, placebo-controlled, clinical trial occurred over an 8-year period at 11 hepatopancreaticobiliary sites in Canada (10 sites) and the United States (1 site) in patients undergoing liver resection for colorectal liver metastasis. This trial, the Hemorrhage During Liver Resection: Tranexamic Acid (HeLiX) Trial, was conducted to assess the effect of TXA compared with placebo on red blood cell transfusion, intraoperative blood loss, and perioperative complications.
Patients included in the trial were 18 years of age or older and scheduled for liver resection (open or minimally invasive) for a cancer-related diagnosis (ie, precancer, suspected cancer, or definite cancer). The patients were randomized into either of 2 groups in a 1:1 ratio: TXA group or placebo group. Clinicians, data collectors, and patients were blinded as to which agent was to be administered. The TXA or placebo was given after induction but before surgical incision. An intravenous bolus dose of either 1 g of TXA in 10 mL of normal saline or 10 mL of normal saline alone was administered followed by an intravenous maintenance infusion of 1 g of TXA in a 250-mL bag of normal saline, or a 250-mL bag of normal saline alone for the placebo group, at 35 mL/h until the bag was empty. The surgical technique, use of topical hemostatic agents, and use of central or peripheral nerve blocks for pain management were left to the discretion of each surgical team. VTE prophylaxis was managed per the institution’s specific guidelines.
A total of 1,384 patients were initially randomized to receive either TXA (n = 694) or placebo (n = 690), but only 1,245 patients ultimately underwent liver resection (n = 619 in TXA group, n = 626 in placebo group). The primary outcome was red blood cell transfusion from the start of surgery through postoperative day 7. Secondary outcomes were the total volume of measured intraoperative blood loss and perioperative complications. Intraoperative blood loss was meticulously measured by adding the net weight of sponges and fluid suction (minus irrigation and intraoperative bile or other fluids in the suction and sponges). Total intraoperative blood loss was calculated using the Gross formula, which uses maximum postoperative decrease in hemoglobin level adjusted for the patient’s height and weight. The total number of red blood cell units transfused (days 0–7) was recorded. Postoperative complications were documented by the research staff at each site (days 0–90). They documented symptomatic VTE confirmed by either computed tomography angiogram (pulmonary embolus) or venous Doppler ultrasound within 90 days of surgery. Quality of life was measured at baseline, 30 days postoperatively, and 90 days postoperatively using the validated European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire. Perioperative mortality (days 0–7) was also documented.
The primary outcome of red blood cell transfusion (days 0–7) occurred in 101 patients (16.3%) in the TXA group and 91 patients (14.5%) in the placebo group (odds ratio [OR], 1.15; 95% CI, 0.84–1.56). There was no difference found in transfusion administration either intraoperatively or postoperatively. Regarding secondary outcomes, the intraoperative blood loss volume was not found to be different between the TXA and placebo groups (817.3 mL vs 836.7 mL). The total estimated blood loss over 7 postoperative days was also not found to be different between the TXA and placebo groups (1,504.0 mL vs 1,551.2 mL). The intraoperative and postoperative transfusion of other blood products was also not found to be different between groups.
The TXA group was more likely to have postoperative complications compared with the placebo group (271 [43.8%] vs 237 [37.9%]; OR, 1.28; 95% CI, 1.02–1.60). Major complications (grade ≥ III) as defined by the Clavien-Dindo classification system were greater in the TXA group compared with the placebo group (104 [16.8%] vs 78 [12.5%]; OR, 1.42; 95% CI, 1.03–1.95). These complications required treatment with anesthesia, involved organ dysfunction, or resulted in death. The reoperation rate was not found to be different between groups, and the occurrence of VTE was also not found to be different (31 [5.0%] vs 19 [3.0%]; OR, 1.68; 95% CI, 0.95–3.07).
In summary, a recent study on the use of TXA compared with placebo in cancer patients undergoing liver resection surgery found no difference in outcomes with regard to red blood cell transfusion and total blood loss. The TXA group had an increase in major and overall complication rates. The authors stated that these findings should prompt reconsideration of the routine use of TXA in liver resection.
Reference
Date of last update: January 13, 2026
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