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The purpose of this retrospective review of the charts of 51 Jehovah's Witness patients, who underwent surgery without blood transfusions, was to compare two study groups (major surgery vs minor-medium surgery).We compared the following variables: age, sex, length of stay, type of surgical operation, use of intraoperative red cell salvaging devices, hemodilution, number of drainages and their stay, postoperative blood loss, complications, need of reoperation and mortality rate. Between medical variables we focused on blood production therapy and nutritional support (administration of iron, folate, erythropoietin and albumin) and blood tests (at the first day of admission; intraoperative; at the first postoperative day; at the discharge).In the two study groups, we detected statistically significant differences in the following variables: total of postoperative blood loss (p0.00001), complications rate (p = 0.0122) and in Hgb values (intraoperative: p = 0.0197; at the first postoperative day: p = 0.0028; at the discharge: p = 0.0100).The aims of a bloodless surgery program are: 1) minimize blood loss, reducing iatrogenic anemia and intraoperative hemorrhage loss; 2) maximize blood production by administration of erythropoietin, iron and folate; 3) maximize cardiac output by alternatives to blood transfusions, as crystalloids, colloids and blood substitutes; 4) increase oxygen content; 5) decrease metabolic rate. We focused on advantages and disadvantages of the suggested procedures. Most interesting techniques are the normovolemic hemodilution and the intraoperative red cell salvaging devices, indispensable in emergency.A close team-work between surgeons, anesthesiologists and hematologists is determinant in a reference center that guarantees experience, organization, professionality, respect for the patients' will and, above all, low morbidity and mortality rates, as those reported by our series.

It has been reported that patients who refuse blood transfusions, such as Jehovah's witnesses, can undergo major surgery. In a review of the literature, however, we critically examined the severity of anaemia in relation to operative mortality and morbidity rates. We report three cases of Jehovah's witnesses who underwent major surgery and presented complication during the postoperative period. Case 1: a 50-year-old man with oesophageal achalasia who underwent Heller's myotomy and Nissen's fundoplication. The postoperative period was complicated by massive haemorrhage and the patient was reoperated on postoperative day 1. After four years, he underwent total oesophagectomy because of severe chronic oesophagitis. On postoperative day 13 the patient suffered anteroseptal myocardial ischaemia, which was treated with medical therapy. Case 2: a 40-year-old man, admitted for ulcerative rectocolitis, who underwent total colectomy. On postoperative day 1 he presented massive haemorrhage and shock. He was reoperated and the postoperative period was complicated by myocardial ischaemia, renal failure and an enterocutaneous fistula. Case 3: a 65-year-old woman with ulcerative rectocolitis who underwent total colectomy and a temporary ileostomy. She suffered venous thrombosis of the lower limbs and pulmonary oedema. The patient died 14 months after surgery as a result of massive haemolysis by cryoagglutinins and cardiac arrest.