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Background: Controversy persists regarding the consequences of perioperative transfusion of red blood cells on postoperative outcomes. Studies have shown both that blood transfusion is an independent risk factor for post-operative morbidity, mortality, and decreased long term survival after resections for cancer though others have shown no correlation. Recent data suggest that the proinflammatory state and immunosuppressive effects of blood transfusions on outcomes are not only related to blood transfusion product, but also to the storage time of transfused blood product, with older blood (stored for longer time) related to higher postoperative complications and mortality. We wondered whether RBC storage time affected the outcome of patients undergoing resection of HCC.Methods: Retrospective review of all non-cirrhotic patients undergoing liver resection for hepatocellular carcinoma at a single institution from 1985 to 2006. The aims of this study were to assess whether storage time of transfused red blood cells is a risk factor for increased morbidity after liver resection for HCC, and whether it is associated with short-term and long-term mortality.Results: A total of 146 non-cirrhotic patients underwent liver resection for HCC during the study period. Sixty eight of these patients had perioperative RBC transfusion (16 patients “fresh” blood, 52 patients “old” blood). Postoperative morbidity rates differed significantly by group status, patients who received: no blood, “fresh” blood, and “old” blood - 23.1%, 31.3%, 44.2% respectively (p=0.03); group status was also significantly associated with postoperative mortality - 0% no transfusion, 0% fresh blood group, 9.6% old blood group (p=0.01). The 2-year cumulative probability of recurrent disease was 56% (“fresh” blood), 52% (“old” blood), and 55% (no transfusion), p=0.60. There was no significant association of patient group with post-discharge long-term survival (p=0.21), five year survival of 40% (“fresh” blood), 28% (“old” blood), and 48% (no transfusion).Conclusions: Perioperative transfusion of RBC stored for more than sixteen days was associated with increased postoperative morbidity and mortality after hepatic resection for HCC. Storage time of transfused RBC does not seem to be associated with increased cancer recurrence in this group of patients. Patients who received perioperative RBC transfusion had somewhat lower long term survival.