Adverse oncologic effects of intraoperative transfusion during pancreatectomy for left-sided pancreatic cancer: the need for strict transfusion policy

Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey

BACKGROUND

This study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes.

METHODS

A survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations.

RESULTS

The 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89-14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion.

CONCLUSION

Practices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.

Preoperative hemoglobin levels, extended resections and the body mass index influence survival after pancreaticoduodenectomy

PURPOSE

The negative influence of perioperative transfusion of packed red blood cells on the prognosis of various malignancies is the focus of recent research interest. The development of a propensity score for the prediction of perioperative transfusion of packed red blood cells (pRBCs) and the identification of independent risk factors for survival, that can either be known prior to or during surgery in patients undergoing pancreaticoduodenectomy for pancreatic head cancer are the two objectives of this study.

METHODS

Logistic regression analyses and Cox regression modeling were used to identify independent risk factors for perioperative transfusion of pRBCs and to determine individual risk factors for patient survival. A total of 101 adult patients who underwent surgery between 01/01/2016 and 12/31/2020 were investigated in a single-center retrospective analysis.

RESULTS

Preoperative hemoglobin levels (OR: 0.472, 95%-CI: 0.312-0.663, p < 0.001) and extended resections (OR: 4.720, 95%-CI: 1.819-13.296, p = 0.001) were identified as independent risk factors for perioperative transfusion of pRBCs, enabling the prediction of pRBC transfusion with high sensitivity and specificity (AUROC: 0.790). The logit of the derived propensity model for the transfusion of pRBCs (HR: 9.231, 95%CI: 3.083-28.118, p < 0.001) and preoperative Body Mass Index (BMI) (HR, 0.925; 95%-CI: 0.870-0.981, p = 0.008) were independent risk factors for survival.

CONCLUSIONS

Low preoperative hemoglobin levels, low BMI values, and extended resections are significant risk factors for survival that can be known and thus potentially be influenced prior to or during surgery. Patient blood management programs and prehabilitation programs should strive to increase preoperative hemoglobin levels and improve preoperative malnutrition.

Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree

Massive intraoperative blood loss (IBL) negatively influence outcomes after surgery for pancreatic ductal adenocarcinoma (PDAC). However, few data or predictive models are available for the identification of patients with a high risk for massive IBL. This study aimed to build a model for massive IBL prediction using a decision tree algorithm, which is one machine learning method. One hundred and seventy-five patients undergoing curative surgery for resectable PDAC at our facility between January 2007 and October 2020 were allocated to training (n = 128) and testing (n = 47) sets. Using the preoperatively available data of the patients (34 variables), we built a decision tree classification algorithm. Of the 175 patients, massive IBL occurred in 88 patients (50.3%). Binary logistic regression analysis indicated that alanine aminotransferase and distal pancreatectomy were significant predictors of massive IBL occurrence with an overall correct prediction rate of 70.3%. Decision tree analysis automatically selected 14 predictive variables. The best predictor was the surgical procedure. Though massive IBL was not common, the outcome of patients with distal pancreatectomy was secondarily split by glutamyl transpeptidase. Among patients who underwent PD (n = 83), diabetes mellitus (DM) was selected as the variable in the second split. Of the 21 patients with DM, massive IBL occurred in 85.7%. Decision tree sensitivity was 98.5% in the training data set and 100% in the testing data set. Our findings suggested that a decision tree can provide a new potential approach to predict massive IBL in surgery for resectable PDAC.

Details and Outcomes of Distal Pancreatectomy with Celiac Axis Resection Preserving the Left Gastric Arterial Flow

BACKGROUND

To describe the technical details and efficacy of distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) flow preservation for pancreatic ductal adenocarcinoma (PDAC).

METHOD

This single-center, retrospective analysis investigated short- and long-term outcomes of DP-CAR performed on 55 patients with PDAC from 2011 to 2019. Our method included LGA reconstruction after total resection of the CA (rDP-CAR group; 24 patients) or LGA preservation if the tumor invasion was away from its root (pDP-CAR group; 31 patients), a CA-first approach to reduce blood loss during dissection, and conservative drain management with or without jejunal serosal patching at the pancreatic stump.

RESULTS

Among the study patients, 23 had locally advanced PDAC and 22 had borderline resectable PDAC. Median operation duration was 443 min (248-810), estimated blood loss was 600 mL (150-2280), and incidence of transfusion was 2%. Ischemic complications occurred exclusively in the rDP-CAR group, including two patients with ischemic gastropathy (8%) and three patients with findings of liver ischemia on computed tomography (13%). One patient underwent relaparotomy for stomach perforations, and 19 patients (35%) had pancreatic fistula, including 8 patients who underwent conservative drain placement for more than 3 weeks without specific symptoms. There were no Clavien-Dindo grade 4 or higher postoperative complications. Preoperative therapy showed improved 3-year overall survival rates than without (54% vs. 37%, p = 0.027).

CONCLUSIONS

Using the standardized technique, DP-CAR was safely performed with no mortality and acceptable long-term survival.

Chronological analysis of surgical and oncological outcomes after the treatment of perihilar cholangiocarcinoma

Backgrounds/Aims

Despite advances in surgical techniques and perioperative supportive care, radical resection of hilar cholangiocarcinoma is the only modality that can achieve long-term survival. We chronologically investigated surgical and oncological outcomes of hilar cholangiocarcinoma and analyzed the factors affecting overall survival.

Methods

We retrospectively enrolled 165 patients with hilar cholangiocarcinoma who underwent liver resection with a curative intent. The patients were divided into groups based on the period when the surgery was performed: period I (2005-2011) and period II (2012-2018). The clinicopathological characteristics, perioperative outcomes, and survival outcomes were analyzed.

Results

The patients’ age, serum CA19-9 levels, and serum bilirubin levels at diagnosis were significantly higher in the period I group. There were no differences in pathological characteristics such as tumor stage, histopathologic status, and resection status. However, perioperative outcomes, such as estimated blood loss (1528.8 vs. 1034.1 mL, p=0.020) and postoperative severe complication rate (51.3% vs. 26.4%, p=0.022), were significantly lower in the period II group. Regression analysis demonstrated that period I (hazard ratio [HR]=1.591; 95% confidence interval [CI]=1.049-2.414; p=0.029), preoperative serum bilirubin at diagnosis (HR=1.585; 95% CI=1.058-2.374; p=0.026), and tumor stage (III, IV) (HR=1.671; 95% CI: 1.133-2.464; p=0.010) were significantly associated with poor prognosis. The 5-year survival rate was better in the period II patients than in the period I patients (35.1% vs. 21.0%, p=0.0071).

Conclusions

The surgical and oncological outcomes were better in period II. Preoperative serum bilirubin and advanced tumor stage were associated with poor prognosis in patients with hilar cholangiocarcinoma.

Multivisceral resection for adenocarcinoma of the pancreatic body and tail-a retrospective single-center analysis

BACKGROUND

Adenocarcinoma of the pancreatic body and tail is associated with a dismal prognosis. As patients frequently present themselves with locally advanced tumors, extended surgery including multivisceral resection is often necessary in order to achieve tumor-free resection margins. The aim of this study was to identify prognostic factors for postoperative morbidity and mortality and to evaluate the influence of multivisceral resections on patient outcome.

METHODS

This is a retrospective analysis of 94 patients undergoing resection of adenocarcinoma located in the pancreatic body and/or tail between April 1995 and December 2016 at our institution. Uni- and multivariable Cox regression analysis was conducted to identify independent prognostic factors for postoperative survival.

RESULTS

Multivisceral resections, including partial resections of the liver, the large and small intestines, the stomach, the left kidney and adrenal gland, and major vessels, were carried out in 47 patients (50.0%). The median postoperative follow-up time was 12.90 (0.16-220.92) months. Median Kaplan-Meier survival after resection was 12.78 months with 1-, 3-, and 5-year survival rates of 53.2%, 15.8%, and 9.0%. Multivariable Cox regression identified coeliac trunk resection (p = 0.027), portal vein resection (p = 0.010), intraoperative blood transfusions (p = 0.005), and lymph node ratio in percentage (p = 0.001) as independent risk factors for survival. Although postoperative complications requiring surgical revision were observed more frequently after multivisceral resections (14.9 versus 2.1%; p = 0.029), postoperative survival was not significantly inferior when compared to patients undergoing standard distal or subtotal pancreatectomy (12.35 versus 13.87 months; p = 0.377).

CONCLUSIONS

Our data indicates that multivisceral resection in cases of locally advanced pancreatic carcinoma of the body and/or tail is justified, as it is not associated with increased mortality and can even facilitate long-term survival, albeit with an increase in postoperative morbidity. Simultaneous resections of major vessels, however, should be considered carefully, as they are associated with inferior survival.

Development and validation of a novel nomogram for predicting the prognosis of patients with resected pancreatic adenocarcinoma

The survival prediction for patients with resected pancreatic adenocarcinoma by using the Tumor-Node-Metastasis (TNM) staging system remains limited. A nomogram is a efficient tool that can be used to predict the outcome of patients with various types of malignancy. The present study aimed to develop and validate a nomogram for patients with resected pancreatic adenocarcinoma. A total of 368 patients (258 in the training set and 110 in the validation set) who underwent pancreatic adenocarcinoma resection at the China National Cancer Center between January 2008 and October 2018 were included in the present study. The nomogram was established according to the results from Cox multivariate analysis, which was validated by discrimination and calibration. The area under the receiver operating characteristic curve (AUC) was determined to assess the accuracy of survival predictions. The results from multivariate analysis in the training set demonstrated that blood transfusion, T-stage, N-stage, tumor grade, capsule invasion, carbohydrate antigen 199, neutrophil percentage and adjuvant therapy were independent prognostic factors for overall survival (OS; all P<0.05). Subsequently, a nomogram predicting the 1-year, 3-year and 5-year OS rates, with favorable calibration, was established based on the independent prognostic factors. The concordance indices of the nomogram were higher compared with the TNM staging system in both training and validation sets. Furthermore, a clear risk stratification system based on the nomogram was used to classify patients into the three following groups: Low-risk group (≤168), moderate-risk group (168–255) and high-risk group (>255). The risk stratification system demonstrated an improved ability in predicting the 1-year, 3-year and 5-year OS rates compared with the TNM system (AUC, 0.758, 0.709 and 0.672 vs. AUC, 0.614, 0.604 and 0.568; all P<0.05). The present study developed and validated a nomogram for patients with resected pancreatic adenocarcinoma by including additional independent prognostic factors, including tumor marker, immune index, surgical information, pathological data and adjuvant therapy. Taken together, the results from the present study indicated an improved performance of the nomogram in predicting the prognosis of patients with resected pancreatic adenocarcinoma compared with the TNM staging system.

Yonsei Criteria, a Potential Linkage to Intratumoral Foxp3⁺/CD8⁺ Ratio for the Prediction of Oncologic Outcomes in Resected Left-Sided Pancreatic Cancer

PURPOSE

This study sought to investigate associations among Yonsei criteria (tumor confined to the pancreas, intact fascia layer between the distal pancreas and the left adrenal gland and kidney, and tumor located more than 1-2 cm from the celiac axis) and tumor infiltrating lymphocytes in pancreatic cancer.

MATERIALS AND METHODS

Patients who underwent curative distal pancreatectomy due to left-sided pancreatic cancer from January 2000 to December 2011 were enrolled. Follow-up was completed September 30, 2015.

RESULTS

Fifty patients were enrolled. Having ≥ two metastatic lymph nodes (LNs, p=0.002), intraoperative transfusion (p=0.011), low levels of tumor infiltrating CD8⁺ T-cells (p=0.001), and a high Foxp3⁺/CD8⁺ ratio (p=0.009) were independent risk factors for disease-free survival. Not satisfying the Yonsei criteria (p=0.021), having ≥ two metastatic LNs (p=0.032), low levels of tumor infiltrating CD8⁺ T-cells (p=0.040) and a high Foxp3⁺/CD8⁺ ratio (p=0.032) were associated with unfavorable overall survival. High levels of CA19-9 and not satisfying the Yonsei criteria were significantly associated with a high Foxp3⁺/CD8⁺ ratio [Exp(β)=3.558; 95% confidence inverval: 1.000-12.658; p=0.050].

CONCLUSION

Yonsei criteria may be clinically detectable biologic marker with which to predict immunologic status and survival in pancreatic cancer patients.

Application of Perioperative Transfusion Trigger Score in Patients Undergoing Surgical Treatment of Malignant Tumor

The present study aimed to investigate the clinical effects of the brand new perioperative transfusion trigger score (POTTS) system in patients undergoing malignant tumor surgeries. 442 cases of patients diagnosed with malignant tumor were randomly selected (from January 2012 to December 2016) from Zunyi Medical University and were divided into 3 experimental groups. Patients in the POTTS group were transfused by the POTTS guideline perioperatively, while patients in the 7-10 g group were treated by the traditional transfusion guidelines existed (restrictive transfusion strategy), patients in the 10 g group should be transfused to keep the Hb level no less than 10 g/dL (liberal transfusion strategy). Baseline information, operation time, bleeding volume, transfusion amount, incision healing time, postoperative complications, metastasis and recurrence were observed and recorded. Postoperative short-term mortality was comparable of the 3 groups, 3 cases of death all occurred in 10 g group, there was no significant difference in the incidence of postoperative complications, including infectious complications and coagulation related complications. Follow-up to date, there were 25 cases, 29 cases and 29 cases of tumor recurrence and metastasis in the three groups, but no statistical difference observed. The present findings show that the POTTS transfusion system is more advantageous with regard to save blood and relieve economic burdens of patients, and does not affect the long-term recurrence and metastasis rate of malignant tumor.

Intraoperative Transfusion is Independently Associated with a Worse Prognosis in Resected Pancreatic Cancer-a Retrospective Cohort Analysis

BACKGROUNDS

Investigate whether intraoperative transfusion is a negative prognostic factor for oncologic outcomes of resected pancreatic cancer.

METHODS

From June 2004 to January 2014, the medical records of 305 patients were retrospectively reviewed, who underwent pancreatoduodenectomy, pylorus preserving pancreatoduodenectomy, total pancreatectomy, distal pancreatectomy for pancreatic cancer. Patients diagnosed with metastatic disease (n = 3) and locally advanced diseases (n = 15) were excluded during the analysis, and total of 287 patients were analyzed.

RESULTS

The recurrence and disease-specific survival rates of the patients who received intraoperative transfusion showed poorer survival outcomes compared to those who did not (P = 0.031, P = 0.010). Through multivariate analysis, T status (HR (hazard ratio) = 2.04, [95% CI (confidence interval): 1.13-3.68], P = 0.018), N status (HR = 1.46 [95% CI: 1.00-2.12], P = 0.045), adjuvant chemotherapy (HR = 0.51, [95% CI: 0.35-0.75], P = 0.001), intraoperative transfusion (HR = 1.94 [95% CI: 1.23-3.07], P = 0.004) were independent prognostic factors of disease-specific survival after surgery. As well, adjuvant chemotherapy (HR = 0.67, [95% CI: 0.46-0.97], P = 0.035) was independently associated with tumor recurrence. Estimated blood loss was one of the most powerful factors associated with intraoperative transfusion (P < 0.001).

CONCLUSIONS

Intraoperative transfusion can be considered as an independent prognostic factor of resected pancreatic cancer. As well, it can be avoided by following strict transfusion policy and using advanced surgical techniques to minimize bleeding during surgery.

Prediction of survival after left-sided pancreatic resection for adenocarcinoma: Introduction of a new prognostic score

BACKGROUND

Due to the clinically unapparent course the entity of left-sided pancreatic adenocarcinoma is often diagnosed at advanced stages, resulting in small numbers of patients qualifying for pancreatectomy. This study strives to develop a prognostic model for survival after left-sided pancreatic resection.

METHODS

A total of 54 patients were analyzed. Pre- and intra-operative predictive factors for 18-month mortality were identified with multivariable binary logistic regression analysis and compiled into a prognostic model. The applicability was evaluated by assessment of the area under the receiver operating characteristic curve (AUROC). The model was internally validated applying a randomized backwards bootstrapping analysis.

RESULTS

The 18-month mortality rate was 74.1% (n = 40). Mean survival was 19.1 months. A prognostic model for 18-month mortality after left sided-pancreatectomy showed an AUROC >0.800: 18-month mortality risk in% = Exp(Y) / (1 + Exp(Y)) with y= -0.927 + (1.724, if CA 19-9 elevated, otherwise 0) + (1.212 × number of intra-operative transfused packed red blood cells) + (2.771, if prior abdominal surgery, otherwise 0) - (3.612, if gastric resection, otherwise 0) This model was internally validated in 40 randomized backwards bootstrapping steps with AUROCs ranging from 0.757 to 0.971.

CONCLUSIONS

The 18-month mortality risk for patients after left-sided pancreatectomy for adenocarcinoma of the pancreatic body can be assessed with the number of intra-operatively transfused packed red blood cells, elevated CA 19-9 levels, additional gastric resection and prior abdominal surgeries in the patient's history.

Rates of Serious Complications Estimated by the ACS-NSQIP Surgical Risk Calculator in Predicting Oncologic Outcomes of Patients Treated with Pancreaticoduodenectomy for Pancreatic Head Cancer

BACKGROUND

The purpose of this study was to validate the predictive value of the oncologic outcome in addition to the validation of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator in patients treated with pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) for pancreatic head cancer.

METHODS

From June 2005 to December 2014, 199 patients underwent PD or PPPD for pancreatic head cancer. Medical records were retrospectively reviewed for investigating general patient characteristics and any comorbid diseases. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. In a propensity score matching analysis, disease-free survival (DFS) and overall survival (OS) were estimated according to calculated severe complication rate (CSCR).

RESULTS

The CSCR > 17.9% (n = 69) and CSCR < 17.9% (n = 130) groups were significantly different considering number of the retrieved lymph nodes (22.95 ± 14.0 vs 18.80 ± 10.1, p = 0.029), histologic grade (p = 0.0235), and incidence of lymphovascular invasion (p = 0.026). The CSCR < 17.9% group had longer DFS (17.0 vs. 11.0 months, p = 0.015), but the OS was similar between the groups (39.0 vs. 23.0 months, p = 0.48). In the 1:2 propensity score analysis, the CSCR < 17.9% group had longer DFS and OS (DFS 26.0 vs. 11.0 months, p = 0.009; OS 44.0 vs. 26.0 months, p = 0.023).

CONCLUSION

The ACS NSQIP surgical risk calculator predicts surgical risk in patients with pancreatic head cancer who undergo PD or PPPD. Furthermore, this tool can help predict the prognosis of surgically treated pancreatic head cancer.

Patient Blood Management improves outcome in oncologic surgery

Background

Patient Blood Management (PBM) is a systematic quality improving clinical model to reduce anemia and avoid transfusions in all kinds of clinical settings. Here, we investigated the potential of PBM in oncologic surgery and hypothesized that PBM improves 2-year overall survival (OS).

Methods

Retrospective analysis of patients 2 years before and after PBM implementation. The primary endpoint was OS at 2 years after surgery. We identified a sample size of 824 to detect a 10% improvement in survival in the PBM group.

Results

The analysis comprised of 836 patients that underwent oncologic surgery, 389 before and 447 after PBM, was implemented. Patients in the PBM+ presented significantly more frequent with normal hemoglobin values before surgery than PBM− (56.6 vs. 35.7%; p < 0.001). The number of transfusions was significantly reduced from 5.5 ± 11.1 to 3.0 ± 6.9 units/patient (p < 0.001); moreover, the percentage of patients being transfused during the clinic stay was significantly reduced from 62.4 to 40.9% (p < 0.001). Two-year OS was significantly better in the PBM+ and increased from 67.0 to 80.1% (p = 0.001). A normal hemoglobin value (> 12 g/dl in female and > 13 g/dl in male) before surgery (HR 0.43, 95% CI 0.29–0.65, p < 0.001) was the only independent predictive factor positively affecting survival.

Conclusions

PBM is a quality improvement tool that is associated with better mid-term surgical oncologic outcome. The root cause for improvement is the increase of patients entering surgery with normal hemoglobin values.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1456-9) contains supplementary material, which is available to authorized users.

Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities

Anemia is present in more than half of cancer patients and appears to be an independent prognostic factor of short- and long-term adverse outcomes. It increases in the advanced period of cancer and perioperatively, in patients with solid tumors who undergo surgery. As a result, allogeneic red blood cell (RBC) transfusion is an indispensable treatment in cancer. However, its safety remains controversial, based on several laboratory and clinical data reporting a linkage with increased risk for cancer recurrence, infection and cancer-related mortality. Immunological, inflammatory and thrombotic reactions mediated by the residual leukocytes and platelets, the stored RBCs per se, the biological response modifiers and the plasticizer of the unit may underlie infection and tumor-promoting effects. Although the causality between transfusion and infection has been established, the effects of transfusion on cancer recurrence remain confusing; this is mainly due to the extreme biological heterogeneity that characterizes RBC donations and cancer context. In fact, the functional interplay between donation-associated factors and recipient characteristics, including tumor biology per se, inflammation, infection, coagulation and immune activation state and competence may synergistically and individually define the clinical impact of each transfusion in any given cancer patient. Our understanding of how the potential risk is mediated is important to make RBC transfusion safer and to pave the way for novel, promising and highly personalized strategies for the treatment of anemia in surgical cancer patients.