The association of perioperative blood transfusion with colorectal cancer recurrence

Cause-specific mortality associated with leukoreduced, buffy coat-depleted, or no blood transfusion after elective surgery for colorectal cancer: a posttrial 15-year follow-up study

BACKGROUND

We previously reported that both leukoreduced (LR) and buffy coat-depleted (BCD) blood transfusions had a detrimental effect on long-term overall survival in patients who underwent elective surgery for colorectal disease. This analysis investigates long-term cause-specific mortality in trial participants diagnosed with colorectal cancer (CRC).

STUDY DESIGN AND METHODS

We used the Danish Civil Registration System to follow 448 trial participants with CRC, from their enrollment in 1992 to 1995 until January 2007. A total of 108 patients were transfused with BCD blood, 94 with LR blood, and 246 did not receive a transfusion (NT). We reviewed death certificates for study patients who died during follow-up. Cause-of-death data were coded according to the International Classification of Diseases (ICD-8 and -10). The Charlson Comorbidity Index was used for risk adjustment.

RESULTS

A total of 43% of NT, 28% of BCD, and 27% of LR transfused patients were alive after 15 years of follow-up (p = 0.001 for transfused vs. NT patients). For LR-transfused versus NT patients the adjusted mortality ratio for death from rectal cancer was 1.81 (95% confidence interval [CI], 0.97-3.38), and for death from cardiovascular disease 2.12 (95% CI, 1.23-3.62). For BCD versus NT patients the adjusted mortality ratio for death from rectal cancer was 1.19 (95% CI, 0.61-2.33) and for cardiovascular disease it was 1.68 (95% CI, 0.97-2.91).

CONCLUSION

LR transfusion is associated with decreased long-term survival due to death from cardiovascular disease. A similar but weaker tendency was observed for BCD transfusion.

Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis

BACKGROUND

The impact of postoperative morbidity, and in particular infective complications on long-term outcomes, following hepatic resection for colorectal liver metastasis (CRLM) is not widely published.

OBJECTIVE

To evaluate the effect of postoperative complications on disease recurrence and overall survival in patients undergoing hepatic resection for CRLM.

METHODS

All patients undergoing hepatic resection for CRLM from January 1993 and March 2007 were identified, and postoperative complications analyzed. Patients who died of postoperative complications within 30 days of surgery were excluded form the study. Postoperative complications were graded using a validated system of classification. Complications were further classified into infective and noninfective complication groups and the primary end points of the study were disease free survival (DFS) and overall survival (OS) at 5 years.

RESULT

A total of 705 patients underwent hepatic resection in the study period. Median follow-up was 38 months. Operative morbidity and mortality were 28% and 3.6%, respectively. The total number of patients was 197 (28%) with complications, and 508 (72%) without complications. The 5 year DFS and OS for those with and without complications were: 13% versus 26% (P < 0.001) and 24% versus 37% (P < 0.001), respectively. Multivariate analysis showed inflammatory response to tumor score, blood transfusion, tumor number >8, and postoperative sepsis to be independent factors associated with DFS, and inflammatory response to tumor, tumor number >8, and postoperative sepsis to be independent predictors for OS. Intra-abdominal and respiratory infection but not wound infections were associated with poorer long-term outcomes.

CONCLUSIONS

Postoperative complications influence long-term outcomes in hepatic resection for CRLM. Specifically, postoperative sepsis is an independent predictor of disease free and overall survival. Thorough preoperative optimization, meticulous surgical technique and careful management in the postoperative period may reduce the incidence of these complications and influence long-term outcomes.

Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection

BACKGROUND

In perioperative management of hepatic resection for hepatocellular carcinoma, excessive blood loss and blood transfusion greatly influence postoperative complications and prognosis of the patients. We evaluated the influence of blood products use on postoperative recurrence and prognosis of patients with hepatocellular carcinoma.

METHODS

The subjects were 66 patients who underwent elective hepatic resection for hepatocellular carcinoma without concomitant microwave or radiofrequency ablation therapy nor other malignancies between January 2001 and June 2006. We retrospectively investigated the influence of the use of blood products including red cell concentration and fresh frozen plasma on recurrence of hepatocellular carcinoma and overall survival.

RESULTS

In multivariate analysis, the dose of blood products transfusion was a significant predictor of disease-free and overall survival. Both disease-free and overall survival rates of those who were given blood products were significantly worse than those who did not receive. On the other hand, in univariate analysis of disease-free and overall survival after hepatic resection and clinical variables, the amount of blood loss was not a significant predictor of recurrence or death.

CONCLUSION

Transfusion of blood products is associated with increased recurrence rate and worse survival after elective hepatic resection for patients with hepatocellular carcinoma.

Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer

Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of different types of complications: infectious complications, tumor recurrence, decreased survival. Even if there is clear evidence of transfusion-induced immunosuppression, it is difficult to demonstrate that transfusion is the only determinant factor that decisively affects the outcome. In any case there are several motivations to reduce the practice of blood transfusion. The advantages and drawbacks of different transfusion alternatives are reviewed here, emphasizing that surgeons and anesthetists who practice in centers with a high volume of liver resections, should be familiar with all the possible alternatives.

Pre and peri-operative erythropoietin for reducing allogeneic blood transfusions in colorectal cancer surgery

BACKGROUND

Patients with colorectal cancer are frequently anaemic and many receive allogeneic red blood cell transfusions peri and post-operatively. Transfusions are accompanied by complications and may increase the rate of recurrence in patients who have a colorectal resection. Recombinant erythropoietin was first used in dialysis patients and more recently in orthopedic surgery to facilitate autologous transfusions. Erythropoietin levels are thought to be lower in cancer patients and erythropoietin is widely used in chemotherapy to treat anaemia and improve quality of life. There may be adverse events associated with its use. Several studies have investigated erythropoietin in colorectal cancer surgery.

OBJECTIVES

The primary objective of this systematic review was to evaluate the efficacy of erythropoietin pre and peri-operatively, in reducing allogeneic blood transfusions in patients undergoing colorectal cancer surgery. Secondary objectives were to determine whether pre and peri-operative erythropoietin improves hematologic parameters (hemoglobin, hematocrit and reticulocyte count), quality of life, recurrence rate, and survival, without increasing the occurrence of thrombotic events and the peri-operative mortality.

SEARCH STRATEGY

A literature search was performed using MEDLINE, EMBASE, abstracts from the annual meetings of the American Society of Clinical Oncology and the American Society of Colon and Rectal Surgeons until May 2008.

SELECTION CRITERIA

Randomized controlled trials of erythropoietin versus placebo or no treatment/standard of care were eligible for inclusion. The study must have reported one of the primary or secondary outcomes and included anaemic patients undergoing surgery for colorectal cancer.

DATA COLLECTION AND ANALYSIS

The methodological quality of the trials was assessed using the information provided. Data were extracted and effect sizes were estimated and reported as relative risks(RR) and mean differences (MD) as appropriate.

MAIN RESULTS

Four eligible studies were identified of ten retrieved in full. There were no statistically significant differences in the proportion of patients transfused between the erythropoietin group and control group. One of the studies showed a small difference in the median number of units transfused per patient favouring treatment. Reporting of hematologic parameters was varied however, there is no evidence for clinically significant changes. There were no significant differences in post-operative mortality or thrombotic events between groups. No included study evaluated recurrences, survival, or quality of life. Studies were of fair methodologic quality and the overall sample size was small therefore results should be interpreted with caution.

AUTHORS' CONCLUSIONS

There is no sufficient evidence to date to recommend pre and peri-operative erythropoietin use in colorectal cancer surgery.

The surgeon's role in immunotherapy

Immunotherapy in the multidisciplinary care of the cancer patient will play an increasingly important role in cancer therapy for solid tumors. Strategies to optimize surgical management for an effective immune response against tumors should be acknowledged and promoted by the surgical community. Immunotherapy can serve as a beneficial adjunct to surgical excision for high-risk and recurrent tumors, with the attraction of decreased toxicity and disability over current adjuvant treatment methods. It is important that surgeons recognize immunotherapy's potential and play an active role in developing immunotherapy treatment regimens, for without surgical involvement many of these therapies may never come to fruition. This article reviews the key roles that surgeons play in immunotherapy treatment and research.

Is fever protective in surgical patients with bloodstream infection?

BACKGROUND

Sepsis from bloodstream infection (BSI) is an important cause of morbidity and mortality among surgical patients. Our hypothesis was that fever and leukocytosis during BSI would be associated with gram-negative pathogens and worse outcomes among hospitalized surgical patients.

STUDY DESIGN

A prospectively collected dataset of all infections diagnosed on the adult general and trauma surgery services between December 1996 and December 2005 at the University of Virginia Hospital was reviewed. Fever was considered a temperature of > or = 38.5 degrees C, and leukocytosis was defined as a white blood cell count > or = 15,000/microL within 24 hours of treatment for infection. Logistic regression was used to identify predictors of fever and mortality.

RESULTS

Over 9 years, 823 BSIs were analyzed. One hundred forty-eight BSIs resulted in death (18.0%), and 541 (65.7%) patients were febrile at diagnosis; mortality for these two groups were 12.9% and 27.7%, respectively (p < 0.0001). Febrile patients had a trend toward fewer gram-negative infections (27.0% versus 31.9%, p = 0.13), 403 had a leukocytosis at diagnosis and 420 did not; mortality for the two groups was 19.1% and 16.9%, respectively (p = NS). Higher maximum temperature was protective against mortality in the logistic regression analysis (odds ratio = 0.60 per C degrees, p < 0.0001).

CONCLUSIONS

Among surgical patients with sepsis, fever during BSI was not associated with a gram-negative cause and correlated with survival, although increasing WBC had little effect. Mortality after BSI appears associated more with an initially blunted physiologic response than with a robust, proinflammatory response. In addition, a threshold for blood culture other than temperature > or = 38.5 degrees C should be considered.

Blood Transfusion and Risk of Metastatic Disease or Recurrence in Patients Undergoing Immediate TRAM Flap Breast Reconstruction: A Clinical Study and Meta-Analysis

BACKGROUND

The transfusion of blood products has a known immunomodulatory effect that may affect cancer recurrence. The present study examined whether blood transfusion is an independent risk factor for recurrence or development of metastatic disease among patients undergoing immediate breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap.

METHODS

Records of 103 patients who underwent mastectomy and immediate reconstruction with a TRAM flap between 1991 and 2001 were reviewed. A logistic regression analysis was used to identify independent risk factors for metastasis or recurrence. For the meta-analysis, all English-language studies regarding blood transfusion and breast cancer recurrence were reviewed, and 2 x 2 contingency tables were constructed from which a summary relative risk was calculated.

RESULTS

There were 57 free and 35 pedicle TRAM flaps. Forty-nine patients (48 percent) received perioperative transfusion of nonautologous blood. Twenty patients (19 percent) experienced metastatic disease or local recurrence. Follow-up ranged from 4 to 14 years (mean, 6.7 years). There was a higher observed rate of adverse outcome in patients who received transfusion, but this was not statistically significant (p = 0.90). Of the 11 articles identified by the meta-analysis, eight used a regression analysis controlling for the effect of stage and nodal status. The summary relative risk in these studies was 1.03 (95% CI, 0.90 to 1.26).

CONCLUSIONS

Perioperative blood transfusion does not seem to be an independent risk factor for metastasis or cancer recurrence in patients undergoing TRAM flap reconstruction. The observed correlation in this and prior studies may be due to the effect of other, more significant factors, such as tumor stage and nodal status.

Transfusion risks and transfusion-related pro-inflammatory responses

Despite improvements in blood screening and administration techniques, serious adverse events related to transfusion continue to occur, albeit at a much lower incidence. In addition to the development and implementation of new screening and blood purification/modification techniques and implementation of an optimal blood management program, the incidence and consequences of transfusion reactions can be reduced by a basic understanding of transfusion-related complications. Although acute hemolytic transfusion reactions, transfusion-associated anaphylaxis and sepsis, and transfusion-associated acute lung injury occur infrequently, diligence in administration of blood and monitoring for development of respective signs/symptoms can minimize the severity of these potentially life-threatening complications. In addition, emerging blood-banking techniques such as psoralen-UV inactivation of pathogens and use of patient identification systems may attenuate the incidence of adverse events related to transfusion. With respect to optimizing blood management by means of an effective blood management program involving pharmacologic and nonpharmacologic strategies, the ability to reduce use of blood products and to decrease operative time or re-exploration rates has important implications for disease prevention, blood inventory and costs, and overall health care costs.

Hematologic disorders associated with human immunodeficiency virus and AIDS

Nurses encounter patients with human immunodeficiency virus infection at various stages of their infection and in a variety of settings. This article focuses on the most common hematologic disorders associated with human immunodeficiency virus infection and acquired immunodeficiency syndrome, which can precipitate complications and frequently accompany hospitalization. It is important for nurses to have a solid foundation as to the cause of these disorders, their impact on quality of life and outcomes, and management strategies.

Impact of blood transfusions on recurrence and survival after rectal cancer surgery

PURPOSE

This study was designed to determine whether type or number of blood units transfused affected short-term and long-term outcome in patients undergoing surgery for rectal cancer. The number of perioperative blood units is associated with postoperative mortality and overall survival by some authors. In addition, allogenic perioperative blood transfusion has been postulated to produce host immunosuppression and has been reported to result in adverse outcome in patients with colorectal cancer. Autologous blood transfusion might improve results compared with allogenic transfusion.

METHODS

Clinical outcome for 597 patients undergoing surgery for rectal cancer was analyzed according to their transfusion status. Results for type (autologous or allogenic) and number of blood units transfused were recorded.

RESULTS

Blood transfusion was associated with increased postoperative mortality at 60 days. Patients who received > 3 units had a postoperative mortality of 6 percent compared with 1 percent for patients who received 1 to 3 units and 0 percent for patients who did not require transfusions. No difference was found between patients who received autologous or allogenic blood. Blood transfusions were also associated with impaired overall survival in a univariate analysis, but this finding was not confirmed in the multivariate analysis. The number or type of blood units transfused did not influence oncologic results. Local recurrence rates, distant metastases rates, and disease-free survival were not influenced by transfusion in our patients.

CONCLUSIONS

Increased numbers of blood units were associated with postoperative mortality. However, there is no reason, with respect to cancer recurrence or disease-free survival, to use a program of transfusion with autologous blood in patients undergoing surgery for rectal cancer.

The influence of allogenic blood transfusion in patients having free-flap primary surgery for oral and oropharyngeal squamous cell carcinoma

The influence of perioperative blood transfusion in oral and oropharyngeal squamous cell carcinoma remains uncertain. It is believed that blood transfusion downregulates the immune system and may have an influence on cancer recurrence and survival. In all, 559 consecutive patients undergoing primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and 2002 were included in this study. Known prognostic variables along with transfusion details were obtained from head and neck cancer and blood transfusion service databases, respectively. Adjusting for relevant prognostic factors in Cox regression, the hazard ratio for patients having 3 or more transfused units relative to those not transfused was 1.52 (95% confidence interval (CI) 0.93–2.47) for disease-specific and 1.52 (95% CI 1.05–2.22) for overall mortality. Blood transfusion of 3 or more units might confer a worse prognosis in patients undergoing primary surgery for oral and oropharyngeal squamous cell carcinoma. Therefore, every effort should be made to limit the amount of blood transfused to the minimum requirement.

Long-term safety of autotransfusion during hepatectomy for hepatocellular carcinoma

PURPOSE

To evaluate the long-term safety of autotransfusion (AT) in hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Between 1988 and 1989, 46 patients with HCC underwent hepatectomy with AT (group 1). For a comparison, we matched 50 patients with HCC who underwent hepatectomy, and received homologous but not autologous blood (group 2). The 10-year cumulative survival curves and cancer-free curves of the two groups were examined, and the pattern of recurrence was compared.

RESULTS

Group 1 had a significantly higher cumulative 10-year survival rate than group 2, at 20% vs 8%, respectively (P < 0.05). Among the patients who underwent curative resection, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 27% vs 11% (P < 0.05) and 13% vs 0% (P < 0.05), respectively. Among the patients with stage I-II HCC, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 30% vs 5% (P < 0.01) and 20% vs 5% (P < 0.05), respectively. However, the rates were similar among patients with stage III-IV disease in both groups. The pattern of recurrence in the two groups was similar.

CONCLUSION

Autotransfusion promoted survival in patients undergoing hepatectomy for stage I or II HCC.

The Effects of Perioperative Blood Transfusion on Morbidity and Mortality After Esophagectomy

The effect of blood transfusion on outcomes in esophageal surgery remains controversial. The contrasting conclusions drawn from a number of retrospective analyses with different methodologies create a landscape that is difficult to interpret. Because of the scope of esophageal resection, the need for blood transfusion cannot be eliminated. What recommendations then, if any, can be made for the practicing surgeon? First, surgeons and anesthesiologists need to reevaluate their transfusion thresholds. The age-old practice of keeping the hemoglobin above 10 g/dL has very little evidence-based support. A multicenter, randomized, controlled clinical trial in Canada demonstrated that a restrictive strategy of blood transfusion, in which patients were transfused only for a hemoglobin level of less than 7 g/dL, was at least as effective as and possibly was superior to a liberal transfusion strategy in critically ill patients. It has also been estimated that more than 25% of patients undergoing colorectal resections may receive at least one unit of unnecessary blood. Further, the immediate reduction in the hemoglobin concentration caused by the normovolemic hemodilution associated with surgery and crystalloid fluid replacement is not associated with any increased morbidity or mortality. If these data are examined in the context of the results of Langley and Tachibana indicating that a threshold amount of blood needs to be transfused to impact outcomes, it becomes even more important to limit transfusion to only the amount that is essential. Thus, surgeons and anesthesiologists should adopt a more stringent set of requirements for blood transfusion. Second, with the proven feasibility and reduction in infectious complications associated with autologous blood-donation programs, any patient who meets the criteria discussed here should be encouraged to participate in such a program. Although the effect of autologous blood on cancer outcomes remains unclear, the other advantages certainly make such a program worthy of consideration. This discussion leads to a final point, namely that patients should be encouraged, whenever possible, to participate in clinical trial research. The only way that the community of surgeons treating patients who have esophageal cancer can hope to address properly the question of how blood transfusion affects outcomes is with well-designed clinical trials. A large, multicenter, randomized trial (level I) would be ideal. Short of such a trial, inclusion criteria and study methodology should be discussed among various institutions to avoid the differences in studies that make direct comparisons of results among different investigators difficult and potentially meaningless. This measure would at least allow different level II to IV data to be compared directly with some validity.

Perioperative blood transfusions for the recurrence of colorectal cancer

BACKGROUND

The improvement of renal allograft survival by pre-transplantation transfusions alerted the medical community to the potential detrimental effect of transfusions in patients being treated for cancer.

OBJECTIVES

The present meta-analysis aims to evaluate the role of perioperative blood transfusions (PBT) on colorectal cancer recurrence. This is accomplished by validating the results of a previously published meta-analysis (Amato 1998); and by updating it to December 2004.

SEARCH STRATEGY

Published papers were retrieved using Medline, EMBASE, the Cochrane Library, controlled trials web-based registries, or the CCG Trial Database. The search strategy used was: {colon OR rectal OR colorectal} WITH {cancer OR tumor OR neoplasm} AND transfusion. The tendency not to publish negative trials was balanced by inspecting the proceedings of international congresses.

SELECTION CRITERIA

Patients undergoing curative resection of colorectal cancer (classified either as Dukes stages A-C, Astler-Coller stages A-C2, or TNM stages T1-3a/N0-1/M0) were included if they had received any amount of blood products within one month of surgery. Excluded were patients with distant metastases at surgery, and studies with short follow-up or with no data.

DATA COLLECTION AND ANALYSIS

A specific form was developed for data collection. Data extraction was cross-checked, using the most recent publication in case of repetitive ones. Papers' quality was ranked using the method by Evans and Pollock. Odds ratios (OR, with 95% confidence intervals) were computed for each study, and pooled estimates were generated by RevMan (version 4.2). When available, data were stratified for risk factors of cancer recurrence.

MAIN RESULTS

The findings of the 1998 meta-analysis were confirmed, with small variations in some estimates. Updating it through December 2004 led to the identification of 237 references. Two-hundred and one of them were excluded because they analyzed survival (n=22), were repetitive (n=26), letters/reviews (n=66) or had no data (n=87). Thirty-six studies on 12,127 patients were included: 23 showed a detrimental effect of PBT; 22 used also multivariable analyses, and 14 found PBT to be an independent prognostic factor. Pooled estimates of PBT effect on colorectal cancer recurrence yielded overall OR of 1.42 (95% CI, 1.20 to 1.67) against transfused patients in randomized controlled studies. Stratified meta-analyses confirmed these findings, also when stratifying patients by site and stage of disease. The PBT effect was observed regardless of timing, type, and in a dose-related fashion, although heterogeneity was detected. Data on surgical techniques was not available for further analysis.

AUTHORS' CONCLUSIONS

This updated meta-analysis confirms the previous findings. All analyses support the hypothesis that PBT have a detrimental effect on the recurrence of curable colorectal cancers. However, since heterogeneity was detected and conclusions on the effect of surgical technique could not be drawn, a causal relationship cannot still be claimed. Carefully restricted indications for PBT seems necessary.

Results of a protocol of transfusion threshold and surgical technique on transfusion requirements in burn patients

INTRODUCTION

Blood loss and high rates of transfusion in burn centers remains an area of ongoing concern. Blood use brings the risk of infection, adverse reaction, and immunosuppression.

METHODS

A protocol to reduce blood loss and blood use was implemented. Analysis included 3-year periods before and after institution of the protocol. All patients were transfused for a hemoglobin below 8.0 gm/dL.

RESULTS

Operations per admission did not change during the two time periods (0.78 in each). Overall units transfused per operation decreased from 1.56+/-0.06 to 1.25+/-0.14 units after instituting the protocol (p<0.05). Also, units transfused per admission decreased from 1.21+/-0.15 to 0.96+/-0.06 units of blood (p<0.05). This was noticed particularly in burns of less than 20% surface area, declining from 386 to 46 units after protocol institution, from 0.37 to 0.04 units per admission, and from 0.79 to 0.08 units per operation in this group of smallest burns. There was no change noted in the larger burns.

CONCLUSIONS

This study suggests that a defined protocol of hemostasis, technique, and transfusion trigger should be implemented in the process of burn excision and grafting. This will help especially those patients with the smallest burns, essentially eliminating transfusion need in that group.

Preoperative Epoetin Alfa in Colorectal Surgery: A Randomized, Controlled Study

BACKGROUND

Colorectal cancer patients are often anemic before surgery, and this leads to an increased requirement for allogeneic blood transfusion. This may result in transfusion-induced immunosuppression, which in turn leads to increased morbidity and possibly an increased rate of tumor relapse. We investigated the possible benefits of perioperative epoetin alfa administration in anemic patients to correct hemoglobin levels and reduce transfusion needs.

METHODS

A total of 223 colorectal cancer patients with anemia scheduled for surgery were randomized to a group that received epoetin alfa 150 or 300 IU/kg/day subcutaneously for 12 days (day -10 to +1) or to a control group. All received iron (200 mg/day by mouth) for 10 days before surgery. Hemoglobin levels, hematocrit, and the number of blood units transfused were recorded.

RESULTS

A total of 204 patients were eligible for analysis. Mean hemoglobin levels and hematocrit were significantly higher in the 300 IU/kg group than in the control group, both 1 day before surgery (hemoglobin, P = .008; hematocrit, P = .0005) and 1 day after surgery (hemoglobin, P = .011; hematocrit, P = .0008). Blood loss during and after surgery was similar in all groups. Patients who received epoetin alfa 300 IU/kg required significantly fewer perioperative transfusion units than control patients (.81 vs. 1.32; P = .016) and significantly fewer postoperative units (.87 vs. 1.33; P = .023). There were no significant differences in the number of units in the 150 IU/kg group.

CONCLUSIONS

Preoperative epoetin alfa (300 IU/day) increases hemoglobin levels and hematocrit in colorectal surgery patients. These effects are associated with a reduced need for perioperative and postoperative transfusions.

One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome

BACKGROUND

Many reports on blood loss and transfusion requirements during hepatectomy for metastatic liver cancer or hepatocellular carcinoma have been published; however, there are no reports on these issues in hepatectomy for biliary hilar malignancy. The aim of this study was to review our experience with blood loss and perioperative blood requirements in 100 consecutive hepatectomies for biliary hilar malignancy.

METHODS

One hundred consecutive hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for hilar malignancies were performed, including 81 perihilar cholangiocarcinomas and 19 advanced gallbladder carcinomas involving the hepatic hilus. Fifty-eight hilar resections were combined with other organ and/or vascular resection. Data on preoperative blood donation, intraoperative blood loss, and perioperative transfusion were collected and analyzed.

RESULTS

Preoperative autologous blood donation was possible in 73 patients (3.4 +/- 1.2 U). Intraoperative blood loss was 1850 +/- 1000 mL (range, 677-5900 mL), and it was < 2000 mL in 62 patients. Intraoperatively, only 7 of the 73 patients (10%) who donated blood received transfusion of unheated, homologous blood products (packed red blood cells or fresh frozen plasma), whereas 18 the 23 patients (67%) without donation received homologous transfusions. Only 16 patients received transfusion postoperatively, and overall, 35 patients received unheated homologous blood products. Total serum bilirubin concentrations after hepatectomy in patients receiving autologous blood transfusion only was similar to those in patients who did not receive transfusion. The incidence of postoperative complications was higher in the 35 patients who received perioperative homologous transfusion than in 65 patients who did not (94% vs 52%; P <.0001). The mortality rate (including all deaths) was 3% (myocardial infarction, intra-abdominal bleeding, and liver failure, 1 patient each).

CONCLUSIONS

Despite the technical difficulties arising from hepatectomy for biliary hilar malignancy, approximately two thirds of hepatectomies can be performed in an experienced center without perioperative homologous blood transfusion using preoperative blood donation.

Pulmonary adenocarcinoma is associated with poor long-term survival after surgical resection. Effect of allogeneic blood transfusion

BACKGROUND

The significance of allogeneic blood transfusion in the prognosis of patients with nonsmall lung carcinoma (NSCLC) remains controversial. Reports have suggested that patients with adenocarcinoma have a worse prognosis from cancer than patients with squamous cell carcinoma (SCC), but this evidence is lacking in NSCLC. The objective of the current study was to elucidate the correlation between perioperative allogeneic blood transfusion and the prognosis in patients with adenocarcinoma and SCC.

METHODS

The study group comprised 329 consecutive patients (172 men and 157 women) with a mean age of 67 years who underwent lung resection between 1996 and 2003 in 1 unit. The clinicopathologic and survival data were compared between 62 patients (42.7%) with adenocarcinoma and 58 patients (48.3%) with SCC who received a perioperative blood transfusion and 83 patients (57.3 %) with adenocarcinoma and 126 patients (61.3%) with SCC who did not.

RESULTS

The overall surgical mortality rate was 3.9% (13 deaths). The median surgical blood loss was 380 mL (range, 125-4500 mL). The mean blood transfusion received was 1.9 U (range, 0-8 U). The overall actuarial 1, 3, and 5-year survival rates in the adenocarcinoma and SCC groups were 82.3%, 49.6%, and 19.4% and 87.9%, 71.7%, and 32.7%, respectively (P = 0.021). Multivariate analysis demonstrated that the factors that appeared to be independent prognostic factors in both groups were T-classification (P < 0.001), lymph node metastasis (P < 0.001), and postoperative complications (P = 0.029). Perioperative blood transfusion was not an independent prognostic indicator in either group.

CONCLUSIONS

The current study demonstrated that long-term survival in patients with adenocarcinoma of the lung was significantly worse compared with patients with SCC, but was independent of allogeneic perioperative blood transfusion. The results reaffirmed the importance of tumor invasion and lymph node involvement in the overall poor prognosis of these patients.

Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery

OBJECTIVES

A recent study showed less bleeding and need of transfusion after total mesorectal excision (TME) compared with conventional rectal cancer surgery. The aim of this study was to evaluate this result in more details.

PATIENTS AND METHODS

Comparison of transfusion history in rectal cancer resections in two different multicentre-studies. Two hundred and forty-six patients were operated in the period 1991-93 with a conventional technique and 311 patients were operated with TME-technique in the period 1996-98. Peri-operative data, including blood transfusion from one month before until one month after the operation, was recorded prospectively.

RESULTS

The median intra-operative blood loss was 1000 ml, range 50-6000 ml, before, and 550 ml, range 10-6000 ml (P < 0.001) after introduction of TME. The overall peri-operative transfusion rate was reduced from 73% to 43% (P < 0.001). When adjusted for blood loss, age, gender, weight, and type of resection, TME significantly reduced the risk of receiving intra or postoperative blood transfusion by 0.4 (CI: 0.3-0.6). The variability in blood loss among 12 TME-centres was more than 400% and not correlated with transfusion requirements within the centres.

CONCLUSION

TME results in a reduced blood loss and a reduction of blood transfusion, but additional factors others than blood loss seems to influence the decision of transfusion.

Blood transfusion practice today

In trying to develop a cohesive and logical transfusion strategy, one must try to keep all of the previously mentioned information in mind. While recognizing that RBC transfusions are an integral part of care for critically ill patients, one also must recognize that there are large amounts of data that associate multiple transfusions of allogeneic blood with increased risk of morbidity and mortality. Some data exist showing causation and association, such as studies demonstrating the immunomodulatory effects of allogeneic transfusions. In addition, the blood supply is a limited resource that should not be used indiscriminately. It therefore behooves clinicians to subject each unit of blood transfused to scrutiny. In all likelihood, patients who are not actively bleeding and who are not hypovolemic probably get little to no benefit from allogeneic blood transfusions while their hemoglobin is greater than 7 g/dL. They do, however, get needless exposure to a potentially toxic substance. Although it is the authors' hope that more research will be performed to clarify the risks and benefits of blood transfusion, the authors also hope that knowledge of already published studies will continue to spread and replace the unfounded practices of the past.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

OBJECTIVE

To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer.

SUMMARY BACKGROUND DATA

Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies.

METHODS

Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed.

RESULTS

Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome.

CONCLUSIONS

Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

OBJECTIVE

To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer.

SUMMARY BACKGROUND DATA

Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies.

METHODS

Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed.

RESULTS

Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome.

CONCLUSIONS

Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.

The use of tourniquets in the excision of unexsanguinated extremity burn wounds

PURPOSE

Tangential excision of burns is complicated by blood loss. Tourniquet use decreases blood loss, but adequacy of excision has been questioned. An attempt was made to assess the value of not exsanguinating the limb prior to tourniquet inflation to improve visualization of bleeding points and subsequent engraftment.

METHODS

Eleven excisions of bilateral extremity wounds were performed. One limb was excised without the benefit of a tourniquet, the other with tourniquet but without exsanguination. Tangential excision was performed, hemostasis achieved, and blood loss quantified. Engraftment of skin was assessed at first dressing change and at initial follow-up after discharge.

RESULTS

Area of burn was the same, 4.8% with tourniquet, 5.1% without (P=0.38). Overall blood loss was less with tourniquet control, 100-259 cm(3) (P=0.002); as was blood loss per area, 0.19-0.58 cc/cm(2) (P=0.04). Graft take was similar, 98.2% early and 98.1% later with tourniquet, with 98.2 and 96.8% take without (P>0.1).

CONCLUSIONS

Tourniquet use in the unexsanquinated extremity reduced blood loss without affecting engraftment.

Preoperative Anemia in Colon Cancer: Assessment of Risk Factors

Anemia is common in cancer patients and is associated with reduced survival. Recent studies document that treatment of anemia with blood transfusion in cancer patients is associated with increased infection risk, tumor recurrence, and mortality. We therefore investigated the incidence of preoperative anemia in colorectal cancer and assessed risk factors for anemia. Prospective data were collected on 311 patients diagnosed with colorectal cancer over a 6-year period from 1994 through 1999. Patients were stratified by age, gender, presenting complaint, preoperative hematocrit, American Joint Committee on Cancer (AJCC) stage, and TNM classification. Discrete variables were compared using Pearson's Chi-square analysis. Continuous variables were compared using Student's t test. Differences were considered significant when P < 0.05. The mean age of the study cohort was 67 ± 9.2 with 98 per cent of the study population being male. The mean AJCC stage was 2.2 ± 1.2 and the mean preoperative hematocrit was 35 ± 7.9 with an incidence of 46.1 per cent. The most common presenting complaints were hematochezia (n = 59), anemia (n = 51), heme-occult-positive stool (n = 33), bowel obstruction (n = 26), abdominal pain (n = 21), and palpable mass (n = 13). Preoperative anemia was most common in patients with right colon cancer with an incidence of 57.6 per cent followed by left colon cancer (42.2%) and rectal cancer (29.8%). Patients with right colon cancer had significantly lower preoperative hematocrits compared with left colon cancer (33 ± 8.5 vs 36 ± 7.4; P < 0.01) and rectal cancer (33 ± 8.5 vs 38 ± 6.0; P < 0.0001). Patients with right colon cancer also had significantly increased stage at presentation compared with left colon cancer (2.3 ± 1.3 vs 2.1 ± 1.2; P < 0.02). Age was not a significant risk factor for preoperative anemia in colorectal cancer. We conclude that there is a high incidence of anemia in patients with colon cancer. Patients with right colon cancer had significantly lower preoperative hematocrits and higher stage of cancer at diagnosis. Complete colon evaluation with colonoscopy is warranted in patients with anemia to improve earlier diagnosis of right colon cancer. A clinical trial of preoperative treatment of anemic colorectal cancer patients with recombinant human erythropoietin is warranted.

The influence of perioperative blood transfusion on survival after esophageal resection for carcinoma

BACKGROUND

There is evidence that perioperative blood transfusion may lead to immunosuppression. Our aim was to determine whether blood transfusion influenced survival after esophagectomy for carcinoma.

METHODS

The study group comprised 234 consecutive patients (175 men and 59 women) with a mean age of 66 years who underwent esophagectomy for carcinoma by one surgeon between 1988 and 1998. The impact of 41 variables on survival was determined by means of univariate and multivariate analysis. Follow-up was complete (mean follow-up, 19.2 months; standard deviation, 16 months; range, 0 to 129 months).

RESULTS

The operative mortality rate was 5.6% (13 deaths). Median operative blood loss was 700 mL (range, 150 to 7,000 mL). One hundred sixty-one patients (68.8%) received a blood transfusion postoperatively (mean transfusion, 2.6 units; range, 0 to 12 units). Overall actuarial 1-year, 3-year, and 5-year survival rates inclusive of operative mortality were 58.1%, 28.5%, and 16.1%, respectively. On univariate analysis, positive lymph nodes, pathological TNM stage, transfusion of more than 3 units of blood, incomplete resection, poor tumor cell differentiation, longer tumor, greater weight loss, male sex, and adenocarcinoma were significant (p < 0.05) negative factors for survival. On Cox proportional hazards regression analysis, after excluding operative mortality, lymph node involvement (p = 0.001), incomplete resection (p = 0.0001), poor tumor cell differentiation (p = 0.04), and transfusion of more than 3 units of blood (p = 0.04) were independent adverse predictors of late survival.

CONCLUSIONS

In addition to reaffirming the importance of completeness of resection and nodal involvement, this study demonstrates that blood transfusion (more than 3 units) may have a significant adverse effect on late survival after esophageal resection for carcinoma. Every effort should be made to limit the amount of transfused blood to the absolutely essential requirements.

Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery

BACKGROUND

Previous studies on patients with hip fractures and in patients with colorectal cancer have documented that perioperative transfusion is associated with a significant increase in postoperative infection rate. Therefore, we sought to investigate the incidence of preoperative and postoperative anemia in noncardiac surgical patients and to determine if transfusion is an independent risk factor for infection and adverse outcome postoperatively.

METHODS

Prospective data from the National Veterans Administration Surgical Quality Improvement Program (NSQIP) was collected on 6301 noncardiac surgical patients at the Veterans Affairs Maryland Healthcare System from 1995 to 2000.

RESULTS

The mean age of the study cohort was 61 +/- 13. Descriptive data revealed 95% were male, 44% used tobacco, 19% were diabetic, 9% had COPD, 9% used alcohol, 3% used steroids, 1.7% had a diagnosis of cancer, and 1.2% had ascites. Preoperative anemia (hematocrit less than 36) was found in 33.9% and postoperative anemia was found in 84.1% of the study cohort. In the postoperative period, 32.5% of patients had a hematocrit of 26-30, and 26.5% had a hematocrit of 21-25. Mean units of blood transfused in the perioperative period ranged from 0.1 +/- 0.9 in patients without anemia to 2.7 +/- 2.9 in those with anemia. Incidence of pneumonia increased from 2.6 to 5% with increasing degree of anemia. Multiple logistic regression analysis documented that low preoperative hematocrit, low postoperative hematocrit, and increased blood transfusion rates were associated with increased mortality (P < 0.01), increased postoperative pneumonia (P < or = 0.05), and increased hospital length of stay (P < 0.05).

CONCLUSION

There is a high incidence of preoperative and postoperative anemia in surgical patients, with a coincident increase in blood utilization. These factors are associated with increased risk for perioperative infection and adverse outcome (mortality) in surgical patients. Consideration should be given to preoperative diagnosis and correction of anemia with iron, vitamin B12, folate supplementation, or administration of recombinant human erythropoietin.

Association of bacterial infection and red blood cell transfusion after coronary artery bypass surgery

BACKGROUND

Previous studies have shown an association between red blood cell transfusions (RBC) and bacterial infections following coronary artery bypass graft (CABG) surgery. We sought to assess whether there is an independent effect of RBC on the incidence of bacterial infections.

METHODS

This was a prospective cohort study of 533 CABG patients over a 7-month period. Subjects were followed from time of CABG until 30 days postoperatively. Data were collected on patient and treatment characteristics, surgical management, and transfusion incidence.

RESULTS

Seventy-five (14.1%) of 533 patients developed a bacterial infection. After controlling for patient and disease characteristics, invasive treatments, surgical time, and the transfusion of other substances, the adjusted rates of bacterial infection were 4.8% for no RBC transfusion, 15.2% with one to two units, 22.1% with three to five units, and 29.0% with greater than or equal to six units, (p(trend) < 0.001). Diabetes was the only patient or disease factor significantly associated with bacterial infection (p < 0.001).

CONCLUSIONS

RBC transfusions were independently associated with a higher incidence of post-CABG bacterial infections. The risk of infection increased in proportion to the number of units of RBC transfused.

Significance of allogenic blood transfusion on decreased survival in patients with esophageal carcinoma

BACKGROUND

To the authors' knowledge, the significance of allogenic blood transfusion in the prognosis of patients with esophageal carcinoma remains controversial. The objective of the current study was to elucidate the correlation, if any, between intraoperative allogenic blood transfusion and prognosis in patients with esophageal carcinoma.

METHODS

Two hundred fifty-nine patients with esophageal carcinoma who had undergone esophagectomy and reconstruction were studied. The clinicopathologic data and survival were compared between the 87 patients (33.6%) who received an intraoperative allogenic blood transfusion and the 172 patients (66.4%) who did not.

RESULTS

Multivariate analysis demonstrated that the factors that appeared to independently determine prognosis in patients with esophageal carcinoma were the depth of the tumor (P = 0.0001), lymph node metastasis (P < 0.0001), lymphatic invasion (P = 0.0002), venous invasion (P = 0.0008), and the occurrence of postoperative complications (P = 0.034). Intraoperative allogenic blood transfusion was not found to be an independent prognostic indicator.

CONCLUSIONS

In the current study, an advanced stage of disease at the time of surgery, which resulted in the need for blood transfusion and the occurrence of postoperative complications, appeared to worsen the prognosis in patients with esophageal carcinoma.

Storage time of transfused blood and disease recurrence after colorectal cancer surgery

BACKGROUND

Perioperative blood transfusion and subsequent development of postoperative infectious complications may lead to poor prognosis of patients with colorectal cancer. It has been suggested that the development of postoperative infectious complications may be related to the storage time of the transfused blood. Therefore, we studied the relationship between blood storage time and the development of disease recurrence and long-term survival after colorectal cancer surgery.

METHODS

Preoperative and postoperative data were prospectively recorded in 740 patients undergoing elective resection for primary colorectal cancer. None of the patients received preoperative or postoperative chemotherapy or radiation therapy. Endpoints were overall survival and disease recurrence in the subgroup of patients operated on with curative intention who also survived the first 30 days after operation. Storage of buffy-coat-depleted red cells suspended in saline, adenine, glucose, and mannitol blood for 21 days was used as cut-off point.

RESULTS

Median follow-up was 6.8 years (range, 5.4 years to 7.9 years), and median overall survival was 4.6 years for 288 nontransfused patients and 3.0 years for 452 transfused patients (P = 0.004). The survival of patients receiving blood exclusively stored < 21 days was 2.5 years. For patients receiving any blood stored > or = 21 days, survival was 3.7 years (P = 0.12). Among patients with curative resection (n = 532), the hazard ratio of disease recurrence was 1.5 (95 percent CI; 1.1 to 2.2) and 1.0 (95 percent CI; 0.7 to 1.4) in the two transfused groups, respectively, compared with the nontransfused group after multivariable correction for patient age, gender, colonic/rectal tumor localization, Dukes classification, blood loss, and postoperative infectious complications.

CONCLUSION

Transfusion of buffy-coat-depleted red cells suspended in saline, adenine, glucose, and mannitol blood stored for < 21 days may be an independent risk factor for development of recurrence after elective colorectal cancer surgery.

Reduced blood loss during burn surgery

The purpose of this study was to investigate the use of subcutaneous injection of burn wounds and skin graft donor sites with an adrenaline-saline solution to reduce blood loss during burn surgery. This retrospective study reviewed the requirements of blood products in 30 randomly selected adult patients with more than 10% body area burned, who had at least one burn operation at a university regional burn center, between January 1991 and June 1997. Patients were matched by age and percent body area burned and stratified according to the surgical technique in two groups. In Group 1, 15 patients received the modified tumescent surgical technique: subcutaneous injection of adrenaline (1 part/million in warm saline solution) into the subcutaneous tissue of the donor sites for autologous skin graft and areas of burn eschar to be excised, combined with pneumatic tourniquets in extremities and saline-adrenaline soaked nonadherent pads. In Group 2, 15 patients received the traditional surgical technique: soaked gauze compresses with an adrenaline-thrombin solution (1 ml of 1:1,000 adrenaline, thrombin 10,000 units, and 1 L of normal saline). Outcome measures, transfusion of blood products, operating time and complications between the two patient groups were analyzed using the Wilcoxon 2-sample test. The two patient groups were not different by age (40.4 +/- 19.4 vs 38.9 +/- 17.9), percent total body area burned (27.6 +/- 15.4 vs 32.8 +/- 13.4), or percent full thickness burn (7.0 +/- 8.5 vs 11.5 +/- 8.5). The modified tumescent surgical technique significantly reduced mean total blood units transfused per patient (7.9 +/- 11.5 vs 15.7 +/- 12.9 units; P = .031), and the mean blood units transfused intraoperatively per patient (4.7 +/- 7.8 vs 8.9 +/- 8.0 units; P = .026). The modified tumescent surgical technique significantly reduced the intraoperative and total blood transfusion requirements in our thermally injured patients.

Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group

BACKGROUND

The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis.

METHODS

Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications.

RESULTS

Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors.

CONCLUSION

Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.

Prognostic significance of peri-operative blood transfusion following radical resection for oesophageal carcinoma

INTRODUCTION

Peri-operative allogeneic blood transfusion may exert an immunomodulatory effect and has been associated with early recurrence and decreased survival following resection for several gastro-intestinal malignancies. The aim of this study was to evaluate the prognostic influence of transfusion requirements following radical oesophagectomy for cancer.

METHODS

A consecutive series of 235 patients undergoing subtotal oesophagectomy with two-field lymphadenectomy in a single centre from April 1990 to June 1999 were studied.

RESULTS

The median age was 64 years (30-79) with a male to female ratio of 3:1. The predominant histological subtype was adenocarcinoma (n = 154) compared to squamous carcinoma (n = 81). To avoid the influence of surgical complications data were excluded from the 5.5% of patients suffering in-hospital mortality. In the remaining patients, median blood loss was 900 ml (200-5500) with 46% (103/222) requiring transfusion (median 3 units, range 2-21). Median survival of non-transfused patients was 36 months compared to only 19 months for those receiving transfusion (log-rank = 4.44; 1 df, P = 0.0352). Non-transfused patients had significantly higher 2 and 5-year survival rates of 62% and 41% respectively in contrast to only 40% and 25% in those receiving blood transfusion. Even after stratification of results according to disease stage or the presence of major complications, survival was significantly worse in those receiving transfusion. Multivariate analysis demonstrated that in addition to nodal status, > 4 units transfusion was an independent prognostic indicator.

CONCLUSION

Post-operative transfusion is associated with a significantly worse prognosis following radical oesophagectomy. Meticulous haemostasis and avoidance of unnecessary transfusion may prove oncologically beneficial.

Rectal cancer recurrence: factors and mechanisms

OBJECTIVE

There have been significant developments in treatment for rectal carcinoma, both in surgical and adjuvant therapy. They may however have associated morbidity and hence individualized therapy for rectal cancer is desirable, to optimize treatment but avoid over-treatment for cases where the risk of recurrence is low.

MATERIALS AND METHODS

A literature review was undertaken of the reported incidence of recurrence of rectal carcinoma following curative surgery, factors which predispose to recurrence and proposed mechanisms for recurrence, and the evidence for each critically evaluated.

RESULTS

The incidence of local recurrence of rectal carcinoma following curative resection ranges from 2.6% to 32%, with an average of 15%. Tumour stage is the strongest predictor of tumour recurrence. Upstaging using molecular biology may predict increased risk of recurrence but is not yet proven. Histological factors including differentiation and vascular invasion increase recurrence but are imprecise. Tumour microvascular density and vascular endothelial growth factor (VEGF) levels may be predictive but need refinement. Adequate resection margins are important but recurrence may occur despite this. Tumour cell spillage and distant dissemination may be a mechanism for tumour recurrence following curative resection, but further research is required before this could be applied clinically.

CONCLUSION

Recurrence of rectal cancer remains a significant problem following 'curative' surgery. Multiple factors may influence recurrence risk, though currently however only tumour stage and histological resection margins have demonstrated sufficient importance for management decisions to be made upon them.

The influence of perioperative blood transfusion on intrahepatic recurrence after curative resection of hepatocellular carcinoma

OBJECTIVE

This study retrospectively evaluated the association between perioperative blood transfusion and intrahepatic recurrence in patients with hepatocellular carcinoma (HCC) who had undergone curative hepatic resections.

METHODS

Hepatic resection was performed with curative intent in 195 patients with primary HCC between 1985 and 1996. Patients who had received perioperative blood transfusion (transfused group: n = 117) and those who had no perioperative blood transfusion (nontransfused group: n = 78) were compared in terms of conventional prognostic variables and cancer-free survival by the univariate and multivariate analyses.

RESULTS

The 1-, 3-, and 5-yr cancer-free survival rates in the nontransfused and transfused groups were 83.4% and 67.9%, 43.0% and 36.7%, and 23.1% and 24.6%, respectively (p = 0.175). Multivariate analysis of prognostic factors in all patients revealed that vascular invasion, tumor size (> or =5 cm), and Child's class were independent factors for intrahepatic recurrence. Further analyses in various stratified groups showed that perioperative blood transfusion was an independent predictor of prognosis in HCC patients with portal vein invasion (RR: 2.8, p = 0.0038). The 1-, 3-, and 5-yr survival rates in the nontransfused and transfused groups with portal vein invasion were 71.9% and 41.6%, 54.5% and 10.9%, and 26% and 0%, respectively (p = 0.0003).

CONCLUSIONS

We conclude that perioperative blood transfusions enhance the risk of intrahepatic recurrence of HCC in patients with portal vein invasion. As well, the more difficult surgery and the increased manipulation of the liver that occur in these cases create a greater possibility of tumor dissemination.

Soluble vascular endothelial growth factor in various blood transfusion components

BACKGROUND

Blood transfusion may reduce survival after curative surgery for solid tumors. This may be related to extracellular content of cancer growth factors present in transfusion components. Vascular endothelial growth factor (VEGF) is a potent stimulator of angiogenesis in solid tumors. The potential content of VEGF in various blood components for transfusion was evaluated.

STUDY DESIGN AND METHODS

Soluble VEGF (sVEGF, isotype 165) was determined by an enzyme-linked immunosorbent assay (EIA) in serum and plasma samples and in lysed cells from healthy volunteers. Subsequently, total content of sVEGF was determined in nonfiltered and prestorage white cell-reduced whole blood (WB), buffy coat-depleted saline-adenine-glucose-mannitol (SAGM) blood, platelet-rich plasma (PRP), and buffy coat-derived platelet (BCP) pools obtained from volunteer, healthy blood donors. As a control, total content of platelet-derived soluble plasminogen activator inhibitor type 1 (sPAI-1) was determined by an EIA in the same samples. Finally, the extracellular accumulation of sVEGF was determined in nonfiltered WB and SAGM blood during storage for 35 days and in BCP pools during storage for 7 days.

RESULTS

In the healthy volunteers, median total sVEGF content was 97 (range, 20-303) pg per mL in serum and 19 (13-37) pg per mL in plasma (n = 12, p < 0.002) and 445 (280-990) pg per mL in lysed cells. Median total sPAI-1 content was 94 (64-127) ng per mL in serum, 8 (6-11) ng per mL in citrated plasma, and 95 (78-123) ng per mL in lysed cells. In SAGM blood, the median total sVEGF content was 25.3 (3.3-48.4) ng per unit in nonfiltered units and undetectable in white cell-reduced units. Median total sVEGF content was 29.2 (24.8-124.9) ng per unit in nonfiltered PRP and 28.7 (24.5-118.6) ng per unit in white cell-reduced PRP. The sVEGF accumulated significantly in WB, SAGM blood, and BCP pools, depending on the storage time.

CONCLUSION

The sVEGF (isotype 165) appears to be present in various blood transfusion components, depending on storage time.

Immunologic changes after transfusion of autologous or allogeneic buffy coat-poor versus white cell-reduced blood to patients undergoing arthroplasty. I. Proliferative T-cell responses and the balance of helper and suppressor T cells

BACKGROUND

Donor white cells (WBCs) contained in red cell (RBC) transfusions are thought to provoke down-regulation of T-cell-mediated immunity. This study investigated this topic in otherwise healthy patients receiving buffy coat-depleted or WBC-filtered RBCs and undergoing standardized perioperative management.

STUDY DESIGN AND METHODS

Patients undergoing elective orthopedic surgery (primary hip and knee replacement surgery) were enrolled in a prospective study. Perioperative changes in T-cell proliferation (stimulation with phytohemagglutinin and mixed lymphocyte culture) and T-cell balance (T-lymphocytes, helper T cells, and suppressor T cells) were compared after random assignment to allogeneic buffy coat-depleted (Group 2, n = 8) or WBC-reduced RBC (Group 3, n = 11) transfusion regimens. Recipients of autologous buffy coat-depleted RBC transfusions (n = 15) served as controls (Group 1).

RESULTS

Compared to that in autologous transfusion recipients, alloantigen-induced T-cell proliferation was significantly reduced in recipients of allogeneic WBC-reduced RBCs (Day 3, p = 0.0274). After the transfusion of allogeneic buffy coat-depleted RBCs, a weak trend toward decreased T-cell proliferation was observed (p = 0.0933) and the numbers of CD4+ T cells were also significantly lower (Day 7, p = 0.0389). On Day 10, alloantigen-induced T-cell proliferation remained significantly below baseline after transfusion of WBC-reduced RBCs (p = 0.05), the numbers of CD3+ cells decreased in allogeneic RBC recipients (Group 2, p = 0.078; Group 3, p = 0.05), and those of CD8+ cells decreased significantly after the transfusion of allogeneic buffy coat-depleted RBCs (p = 0.0234) concomitant with an increased CD4:CD8 ratio (p = 0.0391).

CONCLUSION

Results of the present study confirm the hypothesis of impaired T-cell-mediated immunity after allogeneic transfusion.

Influence of perioperative whole blood transfusions on lymphocyte subpopulations in patients with stage II breast cancer

Preliminary reports have suggested an adverse relationship between blood transfusion and survival after surgery in patients with solid tumour. One might postulate that from these studies, perioperative blood transfusions alter host immune defences. We therefore examined the influence of homologous whole blood transfusion on circulating lymphocyte subpopulations in transfused patients compared with non-transfused patients. Fifty-one women with Stage II breast cancer who underwent surgical procedures were studied. Patients were classified into two groups on the basis of whether or not they had received blood transfusion. The lymphocyte subpopulations were analyzed by flow cytometry before cancer surgery and three weeks after the operation. CD3+, CD4+, CD8+, and CD20+ cells as the lymphocyte subsets were quantitated using appropriate monoclonal antibodies. No significant differences between pre- and postoperative lymphocyte subset levels were seen in non-transfused patients. However, there was a statistically significant increase in the CD8+ cell count; decreasing CD4+ cell count and decreased CD3+ cells levels were observed in the transfused group (P < 0.05). Although these early results of the study suggest that the blood transfusions could be associated with alterations in lymphocyte populations, additional studies are needed to elucidate the possible mechanism of the transfusion-induced immunological modulations.

Prognostic significance of perioperative blood transfusions in resectable thoracic esophageal cancer

OBJECTIVE

The perioperative blood transfusions have been associated with tumor recurrence and decreased survival in various types of alimentary tract cancer. There exist, however, contradictory studies showing no relationship between blood transfusions and survival. For patients with esophageal cancer, only one report suggested that blood transfusions did not by itself decrease the chance of cure after esophagectomy.

METHODS

Among 235 patients with primary squamous cell carcinoma of the thoracic esophagus between December 1979 and March 1998, 143 patients (60.9%) underwent esophagectomy with curative intent (RO). To exclude the effects of surgery-related postoperative complications, 14 patients who died within 90 days during the hospital stay were excluded. Thus, clinicopathological characteristics and prognostic factors were retrospectively investigated between patients with no or few transfusions (< or = 2 units) (n = 58), and much transfused patients (> or = 3 units) (n = 71).

RESULTS

Sixty-three patients are alive and free of cancer, and 66 patients are dead. A total of 98 patients (76%) received blood transfusions, whereas 31 patients (24%) had no transfusion. The amount of blood transfused was 1 or 2 units in 27 patients (27.6%), 3 or 4 units in 33 (33.7%), 5 or 6 units in 20 (20.4%), and > or = 7 units in 18 (18.4%). The 5-yr survival rate for patients with no or few transfusions was 69%, whereas that for much transfused patients was 31.7% (p < 0.0001). The much transfused patients had more prominent ulcerative tumor, longer time of operation, more estimated blood loss, and more marked blood vessel invasion than the group with no or few transfusions. The factors influencing survival rate were tumor location, Borrmann classification, size of tumor, depth of invasion, number of lymph node metastases, time of operation, amount of blood transfusions, lymph vessel invasion, and blood vessel invasion. Among those nine significant variables verified by univariate analysis, independent prognostic factors for survival determined by multivariate analysis were number of lymph node metastasis (0 or 1 vs > or = 2, p < 0.0001), amount of blood transfusions (< or = 2 units vs > or = 3 units, p < 0.0001), and blood vessel invasion (marked vs non-marked, p = 0.0207).

CONCLUSIONS

There is an association between high amount of blood transfusions and decreased survival for patients with resectable esophageal cancer. To improve the prognosis, surgeons must be careful to reduce blood loss during esophagectomy with extensive lymph node dissection and subsequently must minimize blood transfusions.