The HeLiX (Hemorrhage During Liver Resection: traneXamic Acid) Trial (HeLiX)

The HeLiX (Hemorrhage During Liver Resection: traneXamic Acid) Trial: Tranexamic Acid (TXA) Versus Placebo to Reduce Perioperative Blood Transfusion in Patients Undergoing Liver Resection: A Randomized Controlled Trial

This is a Phase III multicentre randomized controlled trial (RCT) to evaluate the impact of tranexamic acid (TXA) on perioperative blood transfusion in patients undergoing liver resection. The rationale for this study includes: (1) experimental evidence supporting the use of TXA in other surgical populations; (2) lack of evidence in patients undergoing liver resection; (3) clinical uncertainty and extensive support amongst hepatobiliary surgeons, anaesthesiologists, and hematologists for this proposed trial; (4) a feasible and efficient study design; and (5) the importance of the question: incidence of blood transfusion in patients undergoing liver resection is high, and the consequences serious. The sample size for this study is 1230 participants.Participants enrolled in the prior Vanguard study will proceed directly into the RCT.

Study Overview

• Status: Active, not recruiting
• Conditions: Cancer; Surgery; Tumour
• Intervention / Treatment: Drug: Tranexamic acid (TXA); Drug: Normal saline

Detailed Description

Purpose Compelling biological rationale and indirect evidence from other settings suggest that there is potential benefit to administering TXA to patients undergoing liver resection. A lack of consensus in the hepatobiliary community and lack of direct evidence in patients undergoing liver resection mandate a RCT.

Hypothesis To determine the impact of perioperative administration of TXA to patients undergoing liver resection on the need for blood transfusion and long-term survival.

Justification If TXA use in liver resection resulted in an important decrease in blood transfusions, clinical practice worldwide would be likely to change. Over 2000 patients in Canada undergo liver resection annually and could benefit from this simple, low-cost intervention. This intervention could easily be implemented in other countries, where many more patients undergo liver resection annually. Furthermore, TXA may be beneficial in other operative fields where bleeding is a major problem, including thoracic surgery, colorectal surgery, and many others.

Objectives

The primary outcome of the RCT will be:

1) Receipt of blood transfusion (% transfused): 7 days

The secondary outcomes of the RCT are:

1. Intraoperative blood loss will be assessed by adding the net weight of sponges and fluid suction (minus irrigation and intraoperative bile or other fluids in suction/sponge)
2. Total blood loss (postoperative day (POD)0 - POD7) will be assessed by Gross' formula, which uses the maximum postoperative decrease in the level of hemoglobin adjusted for the weight and height of the patient
3. Number of packed red blood cells (PRBC) units transfused (POD0 - POD7)
4. Postoperative incidence of symptomatic venous thromboembolic event confirmed with either computed tomography (CT) angiogram (for pulmonary embolism) or venous Doppler ultrasound (for deep venous thrombosis) (within 90 days of surgery)
5. Postoperative complications (within 90 days of surgery) will be determined using the Clavien-Dindo classification

6. Recurrence free survival (within 5 years of surgery) will be determined by review of patient medical record every 6 months until 5 years post-surgery

   a. Recurrence free survival is defined as the time from POD0 to the first event that is recurrent (local or distal) cancer or death (from any cause)

7. Overall survival (within 5 years of surgery) will be determined by review of patient medical record every 6 months until 5 years post-surgery

   a. Overall survival is defined as the time from date of POD0 to death from any cause

8. QOL will be determined by administering European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) -C30 and the QLQ- Liver Metastases Colorectal (LMC) 21 at baseline, 30 and 90 days following surgery
9. Perioperative mortality will be recorded between POD0 and POD7
10. Economic analysis will assess impact of TXA incorporation on health care resources and strategies for systematic utilization of TXA

Research Method This is a Phase III multicentre randomized controlled trial (RCT) to evaluate the impact of tranexamic acid (TXA) on perioperative blood transfusion in patients undergoing liver resection. The trial will conceal allocation, maximize possible blinding, independently assess the appropriateness of transfusion, use strategies to limit loss to follow-up and crossovers, and use a conservative stopping rule. Patients will be administered a single dose of study drug intravenously immediately after induction of anaesthesia, followed by infusion over eight hours.

Statistical Analysis Primary analysis will include only patients who underwent liver resection; patients who are randomized but do not receive liver resection (usually due to more advanced disease identified intraoperatively) will be excluded. A sensitivity analysis will be conducted whereby all randomized patients are included in the assessment of the primary outcome.

• Study Type: Interventional
• Enrollment (Actual): 1386
• Phase: Phase 3

Contacts and Locations

Study Locations

• Canada
  • Alberta
    • Calgary, Alberta, Canada, T2N 2T9
      • Foothills Hospital
  • British Colombia
    • Kelowna, British Colombia, Canada, V1Y 1T2
      • Kelowna General Hospital
  • Nova Scotia
    • Halifax, Nova Scotia, Canada, B3H 2YR
      • Queen Elizabeth II Health Sciences Centre
  • Ontario
    • Hamilton, Ontario, Canada, L8L 8E7
      • Hamilton Health Sciences
    • Kingston, Ontario, Canada, K7L 2V7
      • Kingston General Health Research Institute
    • London, Ontario, Canada, N6A 5W9
      • London Health Sciences Centre
    • Toronto, Ontario, Canada, M4N 3M5
      • Sunnybrook Health Sciences Centre
    • Toronto, Ontario, Canada, M5G 2C4
      • University Health Network
    • Toronto, Ontario, Canada, M6R 1B5
      • St. Joseph's Health Centre
  • Quebec
    • Montreal, Quebec, Canada, H3A 1A1
      • McGill University Health Centre
• United States
  • Minnesota
    • Rochester, Minnesota, United States
      • Mayo Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patient scheduled for open or laparoscopic liver surgery
• Age ≥18 years
• Cancer related diagnosis or indication (e.g. pre-cancer, suspicion of cancer, definite cancer)

Exclusion Criteria:

• Severe anemia (hemoglobin (Hgb) levels <90 g/l)
• Documented arterial or venous thrombosis at screening or in past three months (not including therapeutic portal vein embolization)
• Anticoagulants (other than low-molecular-weight heparin (LMWH) or heparin in prophylactic doses to prevent deep vein thrombosis), direct thrombin inhibitors or thrombolytic therapy administered or completed within last week
• Known disseminated intravascular coagulation
• Severe renal insufficiency (creatinine clearance (CrCl) <30 ml/min)
• History of seizure disorder
• Pregnant or lactating (a negative urine pregnancy test must be obtained for women of child bearing potential during the pretreatment evaluation)
• Acquired disturbance of colour vision
• Hypersensitivity to TXA or any of the ingredients
• Unable to receive blood products (i.e. difficulty with cross matching, refuses blood transfusion, or a past history of unexplained severe transfusion reaction)
• Previously enrolled in this study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Tranexamic acid (TXA); 1 g TXA bolus injection + 1 g TXA infusion from induction over 8 hours	Drug: Tranexamic acid (TXA); 1 g TXA bolus injection + 1 g TXA infusion from induction over 8 hours; Other Names: Cyklokapron
Placebo Comparator: Normal saline (0.9% sodium chloride); 1 g saline bolus injection + 1 g saline infusion from induction over 8 hours	Drug: Normal saline; 1 g saline bolus injection + 1 g saline infusion from induction over 8 hours; Other Names: 0.9% sodium chloride

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Receipt of blood transfusion (% transfused): 7 days	Receipt of one or more RBC transfusions between Day 0 and Day 7	7 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intraoperative blood loss	Intraoperative blood loss will be assessed by adding the net weight of sponges and fluid suction (minus irrigation and intraoperative bile or other fluids in suction/sponge)	7 days
Total blood loss	Total blood loss (postoperative day (POD)0 - POD7) will be assessed by Gross' formula, which uses the maximum postoperative decrease in the level of hemoglobin adjusted for the weight and height of the patient	7 days
Number of packed red blood cells (PRBC) units transfused	Number of packed red blood cells (PRBC) units transfused (POD0 - POD7)	7 days
Postoperative incidence of symptomatic venous thromboembolic event	Postoperative incidence of symptomatic venous thromboembolic event confirmed with either computed tomography (CT) angiogram (for pulmonary embolism) or venous Doppler ultrasound (for deep venous thrombosis) (within 90 days of surgery)	90 days
Postoperative complications assessed using Clavien-Dindo Grading System	Postoperative complications (within 90 days of surgery) will be determined using the Clavien-Dindo classification	90 days
Recurrence Free Survival (within 5 years of surgery)	Disease recurrence is defined as the clinical presence of cancer that has either been confirmed by biopsy, has had treatment initiated, or is documented in the treating physician's notes. Five year disease recurrence from day of surgery will be evaluated approximately every 6 months until 5 years via medical record review.	60 months
Overall Survival (within 5 years of surgery)	Overall survival is defined as the time from date of surgery to death from any cause. It will be determined by review of patient medical record every 6 months until 5 years post-surgery.	60 months
Quality of Life (QOL) Assessment using European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30	QOL will be determined by administering the EORTC QLQ-C30 at baseline, 30 and 90 days following surgery.	Baseline, 30 days, 90 days
Quality of Life (QOL) Assessment using European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-Liver Module (LM)C21 Questionnaire	QOL will be determined by administering QLQ-LMC21 at baseline, 30 and 90 days following surgery.	Baseline, 30 days, 90 days
Perioperative mortality	Perioperative mortality will be recorded between POD0 and POD7	7 days
Compare the cost of tranexamic acid (TXA) versus placebo on perioperative blood transfusion in patients undergoing liver resection	Economic analysis will assess impact of TXA incorporation on health care resources and strategies for systematic utilization of TXA. The analysis will be using data collected in the randomized controlled trial from a societal perspective.The output of the economic analysis is the incremental cost of TXA compared to placebo (control group).	90 days

Collaborators and Investigators

• Sponsor: Sunnybrook Health Sciences Centre
• Collaborators: HepatoPancreaticoBiliary (HPB) Concept Team
• Investigators: Principal Investigator: Paul Karanicolas, MD PhD, Sunnybrook Health Sciences Centre

Publications and helpful links

General Publications

• Karanicolas PJ, Lin Y, McCluskey S, Roke R, Tarshis J, Thorpe KE, Ball CG, Chaudhury P, Cleary SP, Dixon E, Eeson G, Moulton CA, Nanji S, Porter G, Ruo L, Skaro AI, Tsang M, Wei AC, Guyatt G; HepatoPancreaticoBiliary Community of Surgical ONcologists: Clinical, Evaluative, and Prospective Trials (HPB CONCEPT) Team. Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial. BMJ Open. 2022 Feb 24;12(2):e058850. doi: 10.1136/bmjopen-2021-058850.

Study record dates

Study Major Dates

• Study Start (Actual): November 1, 2014
• Primary Completion (Actual): August 1, 2022
• Study Completion (Anticipated): August 1, 2027

Study Registration Dates

• First Submitted: October 7, 2014
• First Submitted That Met QC Criteria: October 7, 2014
• First Posted (Estimate): October 10, 2014

Study Record Updates

• Last Update Posted (Actual): October 26, 2022
• Last Update Submitted That Met QC Criteria: October 25, 2022
• Last Verified: October 1, 2022

More Information

Terms related to this study

• Keywords: blood loss; outcome; feasibility; blood transfusion; liver resection
• Additional Relevant MeSH Terms: Pathologic Processes; Hemorrhage; Molecular Mechanisms of Pharmacological Action; Fibrin Modulating Agents; Antifibrinolytic Agents; Hemostatics; Coagulants; Tranexamic Acid
• Other Study ID Numbers: 244-2014

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No