Allogenic Blood Transfusion is Associated with Poor Perioperative and Long-Term Outcome in Esophageal Cancer

Perioperative blood transfusions associated with reduced survival in gastroesophageal cancers - A Swedish population-based study

BACKGROUND

Blood transfusion has been associated with decreased long-term survival in cancer patients, possibly due to various immunological factors. We aimed to evaluate if perioperative transfusions decrease survival in patients who undergo resection for esophageal or gastric cancer and to identify factors associated with such events.

METHODS

A population-based cohort study was conducted based on the Swedish National Registry for Esophageal and Gastric Cancer, which prospectively collects clinical data of patients with these tumors. Almost all patients (96 %) resected for esophageal or gastric cancer in Sweden between 2017 and 2022 were included. Survival data were acquired from the Swedish Cause of Death Registry. Multivariable Cox regression was used to calculate hazard ratios (HR) with 95 % confidence intervals (CI), adjusted for age, fitness, neoadjuvant therapy, surgical access, and pathological TNM stage.

RESULTS

Of all 1365 patients, 227 (17 %) received perioperative transfusions. Transfusion was associated with an increased risk of all-cause mortality within 3 years of surgery (adjusted HR 1.50, 95 % CI 1.17-1.91). To exclude the influence of surgery-related postoperative complications, a sensitivity analysis was performed excluding patients who died within 30 days of resection and the negative impact of transfusions on 3-year mortality remained (adjusted HR 1.30, 95 % CI 1.01-1.68). Increasing age, open surgery, esophagectomy, perioperative bleeding, and nodal tumor involvement were all associated with an increased likelihood of receiving transfusions.

CONCLUSION

Perioperative blood transfusions might have a negative impact on 3-year survival in patients who undergo surgery for esophageal or gastric cancer.

Thromboprophylaxis in oesophageal cancer patients-a study protocol for a randomised, controlled trial (TOP-RCT)

BACKGROUND

The purpose of the study is to examine if prolonged thromboprophylaxis decreases the risk of thrombosis after intended curative surgery for oesophageal cancer. Study results are expected to inform a guideline for thromboprophylaxis after oesophageal cancer surgery. The perspective is to reduce morbidity and mortality in this critically ill patient group. Thrombosis is the second-most common cause of cancer death after the cancer itself. The risk of thrombosis depends on the cancer type, and upper gastrointestinal cancers are considered high risk. This risk is further increased when patients undergo surgery. However, only few studies have investigated the peri- and postoperative coagulation profile in oesophageal cancer patients. Due to this lack of knowledge, prophylaxis is currently restricted to 5000 IU (international units) low-molecular weight heparin daily from surgery until discharge from hospital (approximately 10 days), whereas patients with gastric cancer receive 30 days of treatment. The present study examines whether a 30-day treatment is superior and safe, compared with the current standard treatment.

METHODS

The study is a randomised controlled trial. Inclusion is ongoing, and we aim to include 100 patients. Blood samples are drawn before and after surgery, and the coagulation is extensively examined. The primary endpoint is the difference in plasma levels of prothrombin fragment 1 + 2 (F1 + 2) 30 days after surgery between the intervention and the standard group. Furthermore, patients are examined with ultrasound to screen for asymptomatic venous thrombotic events (VTE). Secondary endpoints are incidence of bleeding, symptomatic and asymptomatic VTE and mortality 30 days 1 one year after surgery.

DISCUSSION

The study will provide valuable information on the perioperative coagulation profile and VTE risk of oesophageal cancer patients. The study seeks to aid in optimising the postoperative thromboprophylaxis, and the perspective is to reduce morbidity and mortality in this at-risk patient population.

TRIALS REGISTRATION

The trial was prospectively registered at the EU Clinical Trials Register with ID 2021-001335-24 on 30 June 2021 and at ClinicalTrials.gov with study identifier NCT05067153.

Risk factors for unplanned intensive care unit admission after esophagectomy: a retrospective cohort study of 628 patients with esophageal cancer

Introduction

Esophagectomy patients who experience unplanned ICU admission (UIA) may experience a heavier economic burden and worse clinical outcomes than those who experience routine intensive care unit (ICU) admission. The aim of this study was to identify the risk factors for postoperative UIA in patients who underwent esophagectomy.

Methods

We retrospectively included patients with esophageal cancer who underwent esophagectomy. The characteristics of postoperative UIA were described, and univariable and multivariable analyses were performed based on the logistic regression model. Furthermore, a recursive partitioning analysis was adopted to stratify the patients according to the risk of UIA.

Results

A total of 628 patients were included in our final analysis, among whom 57 (9.1%) had an UIA. The patients in the UIA cohort had a higher rate of in-hospital mortality (P<0.001), longer hospital stay (P<0.001), and higher associated costs (P<0.001). Multivariable analysis showed that hybrid/open esophagectomy (OR=4.366, 95% CI=2.142 to 8.897, P<0.001), operation time (OR=1.006, 95% CI=1.002 to 1.011, P=0.007), intraoperative blood transfusion (OR=3.118, 95% CI=1.249 to 7.784, P=0.015) and the prognostic nutrition index (PNI) (OR=0.779, 95% CI=0.724 to 0.838, P<0.001) were independently associated with UIA.

Conclusions

We identified several critical independent perioperative risk factors that may increase the risk of UIA following esophagectomy, and the above risk factors should be the focus of attention to reduce the incidence of postoperative UIA.

Pre-operative anemia and peri-operative transfusion are associated with poor oncologic outcomes in cancers of the esophagus: potential impact of patient blood management on cancer outcomes

BACKGROUND

Both Red Blood Cell (RBC) transfusion and anemia are thought to negatively impact cancer survival. These effects have been reported with mixed findings in cancer of the esophagus. The potential impact of the application of restrictive transfusion strategies on this patient population has not been defined.

MATERIALS AND METHODS

We conducted a retrospective study of esophagectomies and studied cases based on whether they were anemic or were transfused peri-operatively. Clinical characteristics and known clinicopathologic prognosticators were compared between these groups. Survival was compared by Cox proportional hazard modeling. Post-operative transfusions were assessed for compliance with restrictive transfusion thresholds.

RESULTS

Three-hundred ninety-nine esophagectomy cases were reviewed and after exclusions 348 cases were analyzed. The median length of follow-up was 33 months (range 1-152 months). Sixty-four percent of patients were anemic pre-operatively and 22% were transfused. Transfusion and anemia were closely related to each other. Microcytic anemia was uncommon but was evaluated and treated in only 50% of cases. Most anemic patients had normocytic RBC parameters. Transfusion but not anemia was associated with a protracted/prolonged post-operative stay. Transfusion and anemia were both associated with reduced survival however only anemia was associated with decreased survival in multi-variable modeling. Sixty-eight percent of patients were transfused post-operatively and 11% were compliant with the restrictive threshold of 7 g/dL.

CONCLUSIONS

Pre-operative anemia and transfusion are closely associated, however only anemia was found to compromise survival in our esophageal cancer cohort, supporting the need for more aggressive evaluation and treatment of anemia. Adherence to restrictive transfusion guidelines offers an opportunity to reduce transfusion rates which may also improve short-term outcomes.

Perioperative Blood Transfusion Is Dose-Dependently Associated with Cancer Recurrence and Mortality after Head and Neck Cancer Surgery

BACKGROUND

The association between perioperative blood transfusion and cancer prognosis in patients with head and neck cancer (HNC) receiving surgery remains controversial.

METHODS

We designed a retrospective observational study of patients with HNC undergoing tumor resection surgery from 2014 to 2017 and followed them up until June 2020. An inverse probability of treatment weighting (IPTW) was applied to balance baseline patient characteristics in the exposed and unexposed groups. COX regression was used for the evaluation of tumor recurrence and overall survival.

RESULTS

A total of 683 patients were included; 192 of them (28.1%) received perioperative packed RBC transfusion. Perioperative blood transfusion was significantly associated with HNC recurrence (IPTW adjusted HR: 1.37, 95% CI: 1.1-1.7, p = 0.006) and all-cause mortality (IPTW adjusted HR: 1.37, 95% CI: 1.07-1.74, p = 0.011). Otherwise, there was an increased association with cancer recurrence in a dose-dependent manner.

CONCLUSION

Perioperative transfusion was associated with cancer recurrence and mortality after HNC tumor surgery.

Nomogram for prognosis of patients with esophageal squamous cell cancer after minimally invasive esophagectomy established based on non-textbook outcome

BACKGROUND

Non-textbook outcome (non-TO) represents a new prognostic evaluation index for surgical oncology. The present study aimed to develop new nomograms based on non-TO to predict the mortality and recurrence rate in patients with esophageal squamous cell cancer (ESCC) after minimally invasive esophagectomy (MIE).

METHODS

The study involved a retrospective analysis of 613 ESCC patients, from the prospectively maintained database from January 2011 to December 2018. All the included ESCC patients underwent MIE, and they were randomly (1:1) assigned to the training cohort (307 patients) and the validation cohort (306 patients). Kaplan-Meier survival analysis was used to analyze the differences recorded between overall survival (OS) and disease-free survival (DFS). In the case of the training cohort, the nomograms based on non-TO were developed using Cox regression, and the performance of these nomograms was calibrated and evaluated in the validation cohort.

RESULTS

Significant differences were recorded for 5-year OS and DFS between non-TO and TO groups (p < 0.05). Multivariate cox analysis revealed that non-TO, intraoperative bleeding, T stage, and N stage acted as independent risk factors that affected OS and DFS (p < 0.05). The results for multivariate regression were used to build non-TO-based nomograms to predict OS and DFS of patients with ESCC, the t-AUC curve analysis showed that the nomograms predicting OS and DFS were more accurate as compared to TNM staging, during the follow-up period in the training cohort and validation cohort. Further, the nomogram score was used to divide ESCC patients into low-, middle-, and high-risk groups and significant differences were recorded for OS and DFS between these three groups (p < 0.001).

CONCLUSIONS

Non-TO was identified as an independent prognostic factor for ESCC patients. The nomograms based on non-TO could availably predict OS and DFS in ESCC patients after MIE.

Impact of perioperative red blood cell transfusion, anemia of cancer and global health status on the prognosis of elderly patients with endometrial and ovarian cancer

Introduction

Perioperative red blood cell (RBC) transfusions have been associated with increased morbidity and worse oncological outcome in some solid neoplasms. In order to elucidate whether RBC transfusions themselves, the preoperative anemia of cancer (AOC), or the impaired global health status might explain this impact on patients with endometrial cancer (EC) or ovarian cancer (OC), we performed a retrospective, single-institution cohort study.

Materials and methods

Women older than 60 years with EC or OC were included. The influence of RBC transfusions, AOC, and frailty status determined by the G8 geriatric screening tool (G8 score), as well as the clinical-pathological cancer characteristics on progression-free survival (PFS) and overall survival (OS), was determined by using the Kaplan-Meier method and the Cox regression analyses.

Results

In total, 263 patients with EC (n = 152) and OC (n = 111) were included in the study. Patients with EC receiving RBC transfusions were faced with a significantly shorter 5-year PFS (79.8% vs. 26.0%; p < 0.001) and 5-year OS (82.6% vs. 25.7%; p < 0.001). In multivariable analyses, besides established clinical-pathological cancer characteristics, the RBC transfusions remained the only significant prognostic parameter for PFS (HR: 1.76; 95%-CI [1.01–3.07]) and OS (HR: 2.38; 95%-CI [1.50–3.78]). In OC, the G8 score stratified the cohort in terms of PFS rates (G8-non-frail 53.4% vs. G8-frail 16.7%; p = 0.010) and AOC stratified the cohort for 5-year OS estimates (non-anemic: 36.7% vs. anemic: 10.6%; p = 0.008). Multivariable Cox regression analyses determined the G8 score and FIGO stage as independent prognostic factors in terms of PFS (HR: 2.23; 95%-CI [1.16–4.32] and HR: 6.52; 95%-CI [1.51–28.07], respectively). For OS, only the TNM tumor stage retained independent significance (HR: 3.75; 95%-CI [1.87–7.53]).

Discussion

The results of this trial demonstrate the negative impact of RBC transfusions on the prognosis of patients with EC. Contrastingly, the prognosis of OC is altered by the preoperative global health status rather than AOC or RBC transfusions. In summary, we suggested a cumulatively restrictive transfusion management in G8-non-frail EC patients and postulated a more moderate transfusion management based on the treatment of symptomatic anemia without survival deficits in OC patients.

Evaluation of International Contemporary Operative Outcomes and Management Trends Associated With Esophagectomy: A 4-Year Study of >6000 Patients Using ECCG Definitions and the Online Esodata Database

OBJECTIVE

This study aims to verify the utility of international online datasets to benchmark and monitor treatment and outcomes in major oncologic procedures.

BACKGROUND

The Esophageal Complication Consensus Group (ECCG) has standardized the reporting of complications after esophagectomy within the web-based Esodata.org database. This study will utilize the Esodata dataset to update contemporary outcomes and to monitor trends in practice in an era of rapid technical change.

METHODS

This observational study, based on a prospectively developed specific database, updates esophagectomy outcomes collected between 2015 and 2018. Evolution in patient and operative demographics, treatment, complications, and quality outcome measures were compared between patients undergoing surgery in 2015 to 2016 and 2017 to 2018.

RESULTS

Between 2015 and 2018, 6022 esophagectomies from 39 centers were entered into Esodata. Most patients were male (78.3%) with median age 63. Patients having minimally invasive esophagectomy constituted 3177 (52.8%), a chest anastomosis 3838 (63.7%), neoadjuvant chemoradiotherapy 2834 (48.7%), and R0 resections 5441 (93.5%). For quality measures, 30- and 90-day mortality was 2.0% and 4.5%, readmissions 9.7%, transfusions 12%, escalation in care 22.1%, and discharge home 89.4%. Trends in quality measures between 2015 and 2016 (2407 patients) and 2017 and 2018 (3318 patients) demonstrated significant (P < 0.05) improvements in readmissions 11.1% to 8.5%, blood transfusions 14.3% to 10.2%, and escalation in care from 24.5% to 20% A significantly (P < 0.05) reduced incidence in pneumonia (15.3%-12.8%) and renal failure (1.0%-0.4%) was observed. Anastomotic leak rates increased from 11.7% to 13.1%, whereas leaks requiring surgery decreased 3.3% and 3.0%, respectively.

CONCLUSIONS

The Esodata database provides a valuable resource for assessing contemporary international outcomes. This study highlights an increased application of minimally invasive approaches, a high percentage of complications, improvements in pneumonia and key quality metrics, but with anastomotic leak rates still >10%.

Hemoglobin matters: Perioperative blood management for oncology patients

As the number of cancer cases rise each year in Canada, so does the number of surgical oncology cases. Surgery presents a unique and heightened stressor for the body already experiencing volatility from factors such as disease and treatments. Perioperative red blood cell (RBC) transfusions are critical to stabilize hemoglobin levels and correct anemia, as well as provide a buffer against anticipated intraoperative blood loss. Thoroughly examining and anticipating risk factors related to the potential need for perioperative blood transfusions is necessary to improve outcomes. Research evidence in recent years related to perioperative blood management of oncology patients has specifically recommended active, coordinated programs to reduce the need and amount of blood transfusions administered pre-, intra-, and post-surgery. Coordination between surgical oncologists and a local or provincial patient blood management (PBM) program is an important strategy that allows patients at risk of perioperative complications to be identified and receive early interventions and ongoing observation.

L’importance de l’hémoglobine : gestion périopératoire du sang pour les patients en oncologie

Au Canada, le nombre de cas de cancer augmente chaque année et, par conséquent, le nombre de patients en oncologie qui subissent une opération. La chirurgie cause un stress particulièrement intense à l’organisme déjà fragilisé par la maladie et les traitements. Les transfusions périopératoires de globules rouges sont essentielles pour stabiliser le taux d’hémoglobine et soigner l’anémie, ainsi que pour gérer la perte de sang attendue pendant l’opération. Il est nécessaire d’examiner en profondeur et d’anticiper les facteurs de risque associés aux transfusions sanguines périopératoires pour améliorer le devenir des patients. Ces dernières années, la recherche sur la gestion périopératoire du sang des patients en oncologie recommande tout spécialement la création de programmes d’intervention coordonnés pour réduire la nécessité et le nombre de transfusions sanguines administrées avant, pendant et après l’opération. Pour recenser les patients à risque de complications périopératoires et leur faire bénéficier d’interventions rapides et d’une observation continue, la bonne stratégie est de mettre en lien les chirurgiens oncologues avec un programme local ou provincial de conservation du sang.

Postoperative Natural Killer Cell Dysfunction: The Prime Suspect in the Case of Metastasis Following Curative Cancer Surgery

Surgical resection is the foundation for the curative treatment of solid tumors. However, metastatic recurrence due to the difficulty in eradicating micrometastases remain a feared outcome. Paradoxically, despite the beneficial effects of surgical removal of the primary tumor, the physiological stress resulting from surgical trauma serves to promote cancer recurrence and metastasis. The postoperative environment suppresses critical anti-tumor immune effector cells, including Natural Killer (NK) cells. The literature suggests that NK cells are critical mediators in the formation of metastases immediately following surgery. The following review will highlight the mechanisms that promote the formation of micrometastases by directly or indirectly inducing NK cell suppression following surgery. These include tissue hypoxia, neuroendocrine activation, hypercoagulation, the pro-inflammatory phase, and the anti-inflammatory phase. Perioperative therapeutic strategies designed to prevent or reverse NK cell dysfunction will also be examined for their potential to improve cancer outcomes by preventing surgery-induced metastases.

Natural Killer Cells: The Linchpin for Successful Cancer Immunotherapy

Cancer immunotherapy is a highly successful and rapidly evolving treatment modality that works by augmenting the body’s own immune system. While various immune stimulation strategies such as PD-1/PD-L1 or CTLA-4 checkpoint blockade result in robust responses, even in patients with advanced cancers, the overall response rate is low. While immune checkpoint inhibitors are known to enhance cytotoxic T cells’ antitumor response, current evidence suggests that immune responses independent of cytotoxic T cells, such as Natural Killer (NK) cells, play crucial role in the efficacy of immunotherapeutic interventions. NK cells hold a distinct role in potentiating the innate immune response and activating the adaptive immune system. This review highlights the importance of the early actions of the NK cell response and the pivotal role NK cells hold in priming the immune system and setting the stage for successful response to cancer immunotherapy. Yet, in many patients the NK cell compartment is compromised thus lowering the chances of successful outcomes of many immunotherapies. An overview of mechanisms that can drive NK cell dysfunction and hinder immunotherapy success is provided. Rather than relying on the likely dysfunctional endogenous NK cells to work with immunotherapies, adoptive allogeneic NK cell therapies provide a viable solution to increase response to immunotherapies. This review highlights the advances made in development of NK cell therapeutics for clinical application with evidence supporting their combinatorial application with other immune-oncology approaches to improve outcomes of immunotherapies.

Minimizing postoperative pulmonary complications in thoracic surgery patients

PURPOSE OF REVIEW

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

RECENT FINDINGS

There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

SUMMARY

The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Red blood cell transfusions and the survival in patients with cancer undergoing curative surgery: a systematic review and meta-analysis

Allogenic red blood cell transfusions exert a potential detrimental effect on the survival when delivered to cancer patients undergoing surgery with curative intent. We performed a systematic review and meta-analysis to assess the association between perioperative allogenic red blood cell transfusions and risk of death as well as relapse after surgery for localized solid tumors. PubMed, the Cochrane Library, and EMBASE were searched from inception to March 2019 for studies reporting the outcome of patients receiving transfusions during radical surgery for non-metastatic cancer. Risk of death and relapse were pooled to provide an adjusted hazard ratio with a 95% confidence interval [hazard ratio (HR) (95% confidence interval {CI})]. Mortality and relapse associated with perioperative transfusion due to cancer surgery were evaluated among participants (n = 123 studies). Overall, RBC transfusions were associated with an increased risk of death [HR = 1.50 (95% CI 1.42-1.57), p < 0.01] and relapse [HR = 1.36 (95% CI 1.26-1.46), p < 0.01]. The survival was reduced even in cancer at early stages [HR = 1.45 (1.36-1.55), p < 0.01]. In cancer patients undergoing surgery, red blood cell transfusions reduced the survival and increased the risk of relapse. Transfusions based on patients' blood management policy should be performed by applying a more restrictive policy, and the planned preoperative administration of iron, if necessary, should be pursued.

Perioperative Transfusions for Gastroesophageal Cancers: Risk Factors and Short- and Long-Term Outcomes

BACKGROUND

Perioperative blood transfusions have been associated with increased morbidity and poorer oncologic outcomes for numerous surgical procedures. However, this issue is understudied among patients with gastroesophageal malignancies. The objective was to clarify the risk factors and impact of perioperative transfusions on quality of life and surgical and oncologic outcomes among patients undergoing gastric and esophageal cancer surgery.

METHODS

Patients undergoing curative-intent resections for gastroesophageal cancers between 2010 and 2018 were included. Perioperative blood transfusion was defined as any transfusion within 24 h pre-operatively, during surgery, or the primary post-operative hospitalization period. Patient and tumor characteristics, surgical and oncological outcomes, and quality of life were compared.

RESULTS

A total of 435 patients were included. Perioperative transfusions occurred in 184 (42%). Anemia, blood loss, female sex, open surgical approach, and operative time emerged as independent risk factors for transfusions. Factors found to be independently associated with overall survival were neoadjuvant therapy, tumor size and stage, major complications, and mortality. Transfusions did not independently impact overall survival, disease-free survival, or quality of life.

CONCLUSIONS

Perioperative transfusions did not impact oncologic outcomes or quality of life among patients undergoing curative-intent surgery for gastroesophageal cancers.

Impact of intraoperative allogenic and autologous transfusion on immune function and prognosis in patients with hepatocellular carcinoma

The effect of intraoperative blood transfusion on the immune function and prognosis of hepatocellular carcinoma (HCC) has not been fully investigated. The aim of this study was to evaluate the effects of intraoperative autologous blood transfusion and allogeneic blood transfusion on immune function and prognosis in surgically treated HCC patients. One hundred fourteen primary hepatic carcinoma patients who would undergo selective operations were divided into two groups, 35 patients in the experimental group received intraoperative autologous blood transfusion and 79 patients in the control group received allogeneic blood transfusion. The amount of serum T lymphocyte subsets, natural killer (NK) cells and immunoglobulin before and after operation, as well as the recurrence-free survival (RFS) were compared. Results shown that, there was no significant difference in the level of immunocytes and immunoglobulin between the two groups before treatment (P > .05). At 1 day after surgery, there were significant differences in T lymphocyte, NK cells and immunoglobulin levels before and after transfusion. CD3+, CD4+, CD4+/CD8+, and NK cells in autologous transfusion group were significantly higher than those in allogeneic transfusion group (P < .05); the level of IgG, IgM, and IgA in allogeneic transfusion group were significantly lower than those before operation (P < .05), the level of IgG, IgM, and IgA in autologous transfusion group did not significantly fluctuate, and significantly higher than those of allogeneic transfusion group (P < .05). At 5 days after surgery, all indexes of autologous transfusion group recovered to the preoperative level, the levels of CD3+, CD4+, CD4+/CD8+, NK cells, IgG, IgM, and IgA were significantly higher than those of allogeneic transfusion group (P < .05). The follow-up results showed that the RFS of autologous transfusion group was significantly higher than that of allogeneic transfusion group (P < .05). In conclusion, compared with allogeneic blood transfusion, intraoperative autologous blood transfusion possessed less impact on immune function, it may even improve immune function and RFS in HCC patients after surgery. Therefore, HCC patients should be recommended to receive autologous blood transfusion instead of allogeneic blood transfusion when they need blood transfusion during the perioperative period.

Impact of perioperative blood transfusion on survival in pancreatic neuroendocrine tumor patients: analysis from the US Neuroendocrine Study Group

BACKGROUND

Packed red blood cell (PRBC) transfusion has been associated with worse survival in multiple malignancies but its impact on pancreatic neuroendocrine tumors (PNETs) is unknown. The aim of this study was to determine the impact of PRBC transfusion on survival following PNET resection.

METHODS

A retrospective cohort study of PNET patients was performed using the US Neuroendocrine Tumor Study Group database. Demographic and clinical factors were compared. Kaplan-Meier and log-rank analyses were performed. Factors associated with transfusion, overall (OS), recurrence-free (RFS) and progression-free survival (PFS) were assessed by logistic regression.

RESULTS

Of 1129 patients with surgically resected PNETs, 156 (13.8%) received perioperative PRBC transfusion. Transfused patients had higher ASA Class, lower preoperative hemoglobin, larger tumors, more nodal involvement, and increased major complications (all p < 0.010). Transfused patients had worse median OS (116 vs 150 months, p < 0.001), worse RFS (83 vs 128 months, p < 0.01) in curatively resected (n = 1047), and worse PFS (11 vs 24 months, p = 0.110) in non-curatively resected (n = 82) patients. On multivariable analysis, transfusion was associated with worse OS (HR 1.80, p = 0.011) when controlling for TNM stage, tumor grade, final resection status, and pre-operative anemia.

CONCLUSION

PRBC transfusion is associated with worse survival for patients undergoing PNET resection.

Epidural analgesia and avoidance of blood transfusion are associated with reduced mortality in patients with postoperative pulmonary complications following thoracotomic esophagectomy: a retrospective cohort study of 335 patients

Background

Postoperative pulmonary complications (PPCs) represent the most frequent complications after esophagectomy. The aim of this study was to identify modifiable risk factors for PPCs and 90-days mortality related to PPCs after esophagectomy in esophageal cancer patients.

Methods

This is a single center retrospective cohort study of 335 patients suffering from esophageal cancer who underwent esophagectomy between 1996 and 2014 at a university hospital center. Statistical processing was conducted using univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs and mortality.

Results

The incidence of PPCs was 52% (175/335) and the 90-days mortality rate of patients with PPCs was 8% (26/335) in this study cohort. The univariate and multivariate analysis revealed the following independent risk factors for PPCs and its associated mortality. ASA score ≥ 3 was the only independent patient-specific risk factor for the incidence of PPCs and 90-days mortality of patients with an odds ratio for PPCs being 1.7 (1.1–2.6 95% CI) and an odds ratio of 2.6 (1.1–6.2 95% CI) for 90-days mortality. The multivariate approach depicted two independent procedural risk factors including transfusion of packed red blood cells (PRBCs) odds ratio of 1.9 (1.2–3 95% CI) for PPCs and an odds ratio of 5.0 (2.0–12.6 95% CI) for 90-days mortality; absence of thoracic epidural anesthesia (TEA) revealed the highest odds ratio 2.0 (1.01–3.8 95% CI) for PPCs and an odds ratio of 3.9 (1.6–9.7 95% CI) for 90-days mortality.

Conclusion

In esophageal cancer patients undergoing esophagectomy via thoracotomy, epidural analgesia and the avoidance of intraoperative blood transfusion are significantly associated with a reduced 90-days mortality related to PPCs.

Laparoscopic pancreaticoduodenectomy: are the best times coming?

Background

The introduction of laparoscopic technology has greatly promoted the development of surgery, and the trend of minimally invasive surgery is becoming more and more obvious. However, there is no consensus as to whether laparoscopic pancreaticoduodenectomy (LPD) should be performed routinely.

Main body

We summarized the development of laparoscopic pancreaticoduodenectomy (LPD) in recent years by comparing with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD) and evaluated its feasibility, perioperative, and long-term outcomes including operation time, length of hospital stay, estimated blood loss, and overall survival. Then, several relevant issues and challenges were discussed in depth.

Conclusion

The perioperative and long-term outcomes of LPD are no worse and even better in length of hospital stay and estimated blood loss than OPD and RPD except for a few reports. Though with strict control of indications, standardized training, and learning, ensuring safety and reducing cost are still and will always the keys to the healthy development of LPD; the best times for it are coming.

Perioperative Mortality in Cancer Esophagus-a Case Control Study at a High-Volume Regional Cancer Center in South India

Surgery for esophageal cancers carries high rates of morbidity and mortality despite improvements in perioperative care especially with increasingly safe anesthesia and postoperative ICU care. A case control study was conducted on 713 patients operated for esophageal cancer over a period of 8 years (2009-2016). Multiple preoperative, intraoperative, and postoperative clinical and laboratory parameters were compared between patients who succumbed to the surgery, i.e., 30-day mortality, and those who did not. Of the preoperative parameters, age > 58.5 years (p = 0.01), history of dysphagia with significant weight loss (p = 0.028), diabetes (p = 0.002), ischemic cardiac disease (p = 0.0001), low FEV1 < 69.5% (p = 0.036), preoperative length of hospital stay > 6.94 days (p = 0.001), involvement of gastroesophageal junction (p = 0.04), and ASA score > 2 (p = 0.002) were significantly associated with perioperative mortality. Intraoperatively, blood loss (p = 0.003), intraoperative (p = 0.015) and postoperative (p = 0.0001) blood transfusion, splenectomy (p = 0.0001), and excessive intraoperative intravenous fluids (p = 0.003) were associated with mortality. Decreased postoperative day 1 serum albumin level < 2.38 mg/dl (p = 0.0001), increased ICU stay > 7.32 days (SD+/- = 6.28, p = 0.03), number of positive lymph nodes > 2.97 (SD+/- = 4.19, p = 0.013), conduit necrosis (p = 0.0001), recurrent laryngeal nerve palsy (p = 0.013), pulmonary venous thromboembolism (p = 0.0001), multiple organ dysfunction syndrome (p = 0.0001), LRTI (p = 0.0001), arrhythmia (p = 0.005), sepsis (p = 0.0001), and ARDS (p = 0.0001) were the postoperative complications that were significantly associated with mortality. Comprehensive patient care involving preoperative optimization, improved surgical skills, rigorous intraoperative fluid management, and dedicated intensive care units will continue to play a major role in further minimizing mortality and morbidity associated with esophageal cancer surgeries.

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.

Effect of perioperative blood transfusion on the long-term survival of patients undergoing esophagectomy for esophageal cancer: a systematic review and meta-analysis

Perioperative blood transfusion has been linked to poorer long-term survival in patients undergoing esophagectomy, presumably due to its potential immunomodulatory effects. This review aims to summarize existing evidence relating to the influence of blood transfusion on long-term survival following esophagectomy for esophageal cancer. A systematic literature search (up to February 2017) was conducted for studies reporting the effects of perioperative blood transfusion on survival following esophagectomy for esophageal cancer. Meta-analysis was used to summate survival outcomes. Twenty observational studies met the criteria for inclusion. Eighteen of these studies compared the outcomes of patients who received allogenic blood transfusion to patients who did not receive this intervention. Meta-analysis of outcomes revealed that allogenic blood transfusion significantly reduced long-term survival (HR = 1.49; 95% CI 1.26 to 1.76; P < 0.001). There appeared to be a dose-related response with patients who received ≥3 units of blood having lower long-term survival compared to patient who received between 0 and 2 units (HR = 1.59; 95% CI 1.31 to 1.93; P < 0.001). Two studies comparing patients who received allogenic versus autologous blood transfusion showed superior survival in the latter group. Factors associated with the requirement for perioperative blood transfusion included: intraoperative blood loss; preoperative hemoglobin; operative approach; operative time, and; presences of advanced disease. These findings indicate that perioperative blood transfusion is associated with significantly worse long-term survival in patients undergoing esophagectomy for esophageal cancer. Autologous donation of blood, meticulous intraoperative hemostasis, and avoidance of unnecessary transfusions may prevent additional deaths attributed to this intervention.

Perioperative blood transfusion has no effect on overall survival after esophageal resection for esophageal squamous cell carcinoma: A retrospective cohort study

BACKGROUND

The impact of perioperative blood transfusion (PBT) on the prognosis of esophageal cancer patients remains inconclusive. The purpose of this study was to assess the association between PBT and survival in esophageal squamous cell carcinoma (ESCC) patients.

MATERIALS AND METHODS

In this retrospective study, patients with ESCC who underwent esophageal resection from January 2008 to December 2011 were analyzed. The overall survival and postoperative outcomes between PBT and non-PBT patients were compared using Cox regression and propensity score matching (PSM) analysis.

RESULTS

A total of 935 patients were enrolled in this study. Before PSM, the 5-year overall survival rates in PBT and non-PBT patients were 48.4% and 56.3% (P = 0.001), respectively. The postoperative infection rate in PBT patients was 32.32%, which exceeded the rate of 24.22% in non-PBT patients (P = 0.008). PSM created 306 pairs of patients. After PSM, the 5-year overall survival rates in PBT and non-PBT patients were 49.4% and 51.0% (P = 0.334), respectively. The postoperative infection rate in PBT patients was 31.04%, which was higher than the rate of 26.47% in non-PBT patients (P = 0.105). Multivariable Cox regression analyses showed that PBT was not an independent risk factor for overall survival (HR: 0.792, 95% CI: 0.615-1.021, P = 0.072).

CONCLUSION

Perioperative blood transfusion has no effect on the overall survival of ESCC patients.

Prognostic Significance of Blood Transfusion in Elderly Patients with Primary Diffuse Large B-Cell Lymphoma

The current study sought to evaluate whether blood transfusions affect survival of elderly patients with primary diffuse large B-cell lymphoma (DLBCL). A total of 104 patients aged 60 years and over were enrolled and divided into two groups: 24 patients who received transfusions and 80 patients who did not. Statistical analyses showed significant differences in LDH levels, platelet (Plt) counts, and hemoglobin (Hb) and albumin (Alb) levels between the two groups. Univariate analyses showed that LDH level ≥ 245 IU/L, cell of origin (germinal center/nongerminal center), and blood transfusion were associated with both overall survival (OS) and progression-free survival (PFS). Higher IPI (3–5), Alb level < 35 g/L, and rituximab usage were associated with OS. Appearance of B symptoms was associated with PFS. Multivariate analyses showed that cell of origin and rituximab usage were independent factors for OS and LDH level was an independent factor for PFS. Blood transfusion was an independent factor for PFS, but not for OS. Our preliminary results suggested that elderly patients with primary DLBCL may benefit from a restrictive blood transfusion strategy.

Perioperative red blood cell transfusion in orofacial surgery

In the field of orofacial surgery, a red blood cell transfusion (RBCT) is occasionally required during double jaw and oral cancer surgery. However, the question remains whether the effect of RBCT during the perioperative period is beneficial or harmful. The answer to this question remains challenging. In the field of orofacial surgery, transfusion is performed for the purpose of oxygen transfer to hypoxic tissues and plasma volume expansion when there is bleeding. However, there are various risks, such as infectious complications (viral and bacterial), transfusion-related acute lung injury, ABO and non-ABO associated hemolytic transfusion reactions, febrile non-hemolytic transfusion reactions, transfusion associated graft-versus-host disease, transfusion associated circulatory overload, and hypersensitivity transfusion reaction including anaphylaxis and transfusion-related immune-modulation. Many studies and guidelines have suggested RBCT is considered when hemoglobin levels recorded are 7 g/dL for general patients and 8-9 g/dL for patients with cardiovascular disease or hemodynamically unstable patients. However, RBCT is occasionally an essential treatment during surgeries and it is often required in emergency cases. We need to comprehensively consider postoperative bleeding, different clinical situations, the level of intra- and postoperative patient monitoring, and various problems that may arise from a transfusion, in the perspective of patient safety. Since orofacial surgery has an especially high risk of bleeding due to the complex structures involved and the extensive vascular distribution, measures to prevent bleeding should be taken and the conditions for a transfusion should be optimized and appropriate in order to promote patient safety.

Dysfunctional Natural Killer Cells in the Aftermath of Cancer Surgery

The physiological changes that occur immediately following cancer surgeries initiate a chain of events that ultimately result in a short pro-, followed by a prolonged anti-, inflammatory period. Natural Killer (NK) cells are severely affected during this period in the recovering cancer patient. NK cells play a crucial role in anti-tumour immunity because of their innate ability to differentiate between malignant versus normal cells. Therefore, an opportunity arises in the aftermath of cancer surgery for residual cancer cells, including distant metastases, to gain a foothold in the absence of NK cell surveillance. Here, we describe the post-operative environment and how the release of sympathetic stress-related factors (e.g., cortisol, prostaglandins, catecholamines), anti-inflammatory cytokines (e.g., IL-6, TGF-β), and myeloid derived suppressor cells, mediate NK cell dysfunction. A snapshot of current and recently completed clinical trials specifically addressing NK cell dysfunction post-surgery is also discussed. In collecting and summarizing results from these different aspects of the surgical stress response, a comprehensive view of the NK cell suppressive effects of surgery is presented. Peri-operative therapies to mitigate NK cell suppression in the post-operative period could improve curative outcomes following cancer surgery.

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.