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Ploug M, Qvist N, Jacobsen BG, Kroijer R, Nielsen J, Knudsen T. The impact of iron deficiency on patients under evaluation for colorectal cancer, a prospective cross-sectional study. Scand J Gastroenterol 2024:1-7. [PMID: 38984797 DOI: 10.1080/00365521.2024.2373117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/22/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND AND OBJECTIVE Iron deficiency affects more than 60% of colorectal cancer patients at the time of diagnosis. Iron deficiency ultimately leads to anemia, but additionally, iron deficiency might impact other domains of colorectal cancer patients' health and well-being. The aim of this study was to evaluate the impact of iron deficiency on fatigue, quality of life, cognition, and physical ability in patients undergoing evaluation for colorectal cancer. METHODS Multicenter, prospective, observational cross-sectional study (2021-2023). Fatigue was the primary outcome, measured using the Focused Assessment of Cancer Treatment-Anemia questionnaire (FACT-An). Quality of Life, Cognition, Aerobe capacity, mobility, and peripheral muscle strength were tested as secondary outcomes. Multivariate analysis was performed to estimate the impact of iron deficiency on all outcomes. RESULTS Two hundred and one patients were analyzed, 57% being iron deficient. In multivariate regression analysis, iron deficiency was not associated with fatigue: FACT-An (r = -1.17, p = 0.57, 25% CI: -5.27 to 2.92). Results on quality of life, cognition, and mobility were non-significant and with small regression coefficients. Iron deficiency showed a nearly significant association with reduced hand-grip-strength (r = -3.47 kg, p = 0.06, 25%CI -7.03 to 0.08) and reduced 6 min walking distance (r = -40.36 m, p = 0.07, 25%CI: -84.73 to 4.00). CONCLUSION Iron deficiency in patients undergoing evaluation for colorectal cancer was not associated with fatigue, quality of life, or cognition, but might affect aerobic endurance and peripheral muscle strength to a degree that is clinically relevant.
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Affiliation(s)
- Magnus Ploug
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Surgical Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Odense, Denmark
| | - Niels Qvist
- University of Southern Denmark, Odense, Denmark
| | - Birgitte Gade Jacobsen
- Department of Surgical Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Odense, Denmark
| | - Rasmus Kroijer
- Department of Surgical Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Odense, Denmark
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Torben Knudsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Medical Gastroenterology, Esbjerg Hospital, University Hospital of Southern Denmark, Odense, Denmark
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Reflections on multiple strategies to reduce transfusion in cancer patients: A joint narrative. Transfus Apher Sci 2017; 56:322-329. [DOI: 10.1016/j.transci.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lan N, Stocchi L, Li Y, Shen B. Perioperative blood transfusion is associated with post-operative infectious complications in patients with Crohn's disease. Gastroenterol Rep (Oxf) 2017; 6:114-121. [PMID: 29780599 PMCID: PMC5952943 DOI: 10.1093/gastro/gox023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/20/2017] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
Background We have previously demonstrated that blood transfusion (BT) was associated with post-operative
complications in patients undergoing surgery for Crohn’s disease (CD), based on our institutional data registry. The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Methods All CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP. Variables were defined
according to the ACS NSQIP guidelines. The primary outcome was infectious complications, including superficial, deep and organ/space surgical site infection, wound dehiscence, urinary tract infection, pneumonia, systemic sepsis and septic shock. Multivariate analyses were performed to assess the risk factors for post-operative infections. Results All 10 100 eligible patients were included and 611 (6.0%) received perioperative BT. BT patients were older, lighter in weight and more likely to be functionally dependent. BT patients were more likely to have post-operative infectious
complications than those without BT, including superficial surgical site infection (SSI) (10.8% vs 7.4%, p=0.002), deep SSI (3.3% vs 1.6%, p=0.003), organ/space SSI (14.2% vs 5.4%, p<0.001), pneumonia (3.8% vs 1.3%, p<0.001), urinary tract infection (3.9% vs 2.2%, p=0.006), sepsis (11.5% vs 4.5%, p<0.001) and sepsis shock (3.1% vs 0.8%, p<0.001). Multivariate analysis showed that intra- and/or post-operative BT was an independent risk factor for post-operative infectious complications (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.8–2.7; p<0.001) and the risk increased with each administered unit of red blood cell (OR = 1.3, 95% CI: 1.2–1.5). Other independent factors were history of smoking, chronic heart disease, diabetes, hypertension and the use of corticosteroids. Pre-operative BT, however, was not found to be a risk factor to post-operative infections. Conclusions Intra- and/or post-operative, not pre-operative, BT was found to be associated with an increased risk for post-operative infectious complications in this CD cohort. Therefore, the timing and risks and benefits of BT should be carefully balanced.
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Affiliation(s)
- Nan Lan
- Center for Inflammatory Bowel Disease, and Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Yi Li
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, and Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Casans Francés R, Ripollés Melchor J, Calvo Vecino JM. Is it time to integrate patient blood management in ERAS guidelines? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:61-63. [PMID: 25605130 DOI: 10.1016/j.redar.2014.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 12/13/2014] [Accepted: 12/16/2014] [Indexed: 06/04/2023]
Affiliation(s)
- R Casans Francés
- Department of Anesthesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM)/ERAS-Spain.
| | - J Ripollés Melchor
- Department of Anesthesia, Hospital Universitario Infanta Leonor, Madrid, Spain; Grupo Español de Rehabilitación Multimodal (GERM)/ERAS-Spain
| | - J M Calvo Vecino
- Department of Anesthesia, Hospital Universitario Infanta Leonor, Madrid, Spain; Grupo Español de Rehabilitación Multimodal (GERM)/ERAS-Spain
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Marventano S, Grosso G, Mistretta A, Bogusz-Czerniewicz M, Ferranti R, Nolfo F, Giorgianni G, Rametta S, Drago F, Basile F, Biondi A. Evaluation of four comorbidity indices and Charlson comorbidity index adjustment for colorectal cancer patients. Int J Colorectal Dis 2014; 29:1159-69. [PMID: 25064390 DOI: 10.1007/s00384-014-1972-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Cancer survival is related not only to primary malignancy but also to concomitant nonmalignant diseases. The aim of this study was to investigate the prognostic capacity of four comorbidity indices [the Charlson comorbidity index (CCI), the Elixhauser method, the National Institute on Aging (NIA) and National Cancer Institute (NCI) comorbidity index, and the Adult Comorbidity Evaluation-27 (ACE-27)] for both cancer-related and all-cause mortality among colorectal cancer patients. A modified version of the CCI adapted for colorectal cancer patients was also built. METHODS The study population comprised 468 cases of colorectal cancer diagnosed between 1 January 2000 and 31 December 2010 at a community hospital. Data were prospectively collected and abstracted from patients' clinical records. Kaplan-Meier method and multivariate logistic regression models were performed for survival and risk of death analysis. RESULTS Only moderate or severe renal disease [hazard ratio (HR) 2.71, 95% confidence interval (CI) 1.11-6.63] and AIDS (HR 3.27, 95% CI 1.23-8.68) were independently associated with cancer-specific mortality, with a population attributable risk of 5.18 and 4.36%, respectively. For each index, the highest comorbidity burden was significantly associated with poorer overall survival (NIA/NCI: HR 2.14, 95% CI 1.14-4.01; Elixhauser: HR 1.98, 95% CI 1.09-1.42; ACE-27: HR 1.78, 95% CI 1.07-1.23; CCI: HR 1.68, 95% CI 1.05-1.42) and cancer-specific survival. The modified version of the CCI resulted in a higher predictive power compared with other indices studied (cancer-specific mortality HR = 2.37, 95% CI 1.37-4.08). CONCLUSIONS The comorbidity assessment tools provided better prognostic prevision of prospective outcome of colorectal cancer patients than single comorbid conditions.
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Affiliation(s)
- Stefano Marventano
- Department "G. F. Ingrassia," Section of Hygiene and Public Health, University of Catania, Catania, Italy
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Predictive factors for perioperative blood transfusions in laparoscopic colorectal surgery. Int J Colorectal Dis 2014; 29:723-8. [PMID: 24736986 DOI: 10.1007/s00384-014-1854-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Allogeneic perioperative blood transfusion (PBT) has been associated with higher rates of postoperative complications in patients undergoing colorectal surgery and increased tumor recurrence in cancer patients. Our aim is to evaluate possible predictive factors for PBT, specifically, in patients undergoing laparoscopic colorectal surgery, in order to identify patients who could benefit from alternatives to allogenic PBT such as erythropoietin administration, autologous blood transfusion, and possibly preoperative blood transfusion. METHODS Five hundred patients who underwent laparoscopic colorectal surgery between the years 2003 and 2011 were reviewed. Patient demographics and clinicopathologic variables were collected prospectively. Other clinical data were collected directly from the computerized records of the in-hospital blood bank. PBT was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. The associations between PBT and patient variables were assessed by univariate and multivariate analyses. RESULTS Of the 500 patients, 134 patients (26.8 %) received PBT. Multivariate analysis revealed four preoperative variables as significant risk factors for PBT: preoperative hemoglobin (P = 0.001), lower rectal surgery (P = 0.009), Charlson comorbidity score (P = 0.001), and malignancy (P = 0.024). CONCLUSIONS Preoperative Charlson score, hemoglobin level, carcinoma, and lower rectum pathologies were found to be independent risk factors for PBT in patients undergoing laparoscopic colorectal surgery. Evaluation of these risk factors prior to surgery may be helpful in selecting the patients who could benefit from possible alternatives to perioperative allogeneic blood transfusion and help constitute guidelines for a more responsible use of these alternatives.
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Muñoz M, Gómez-Ramírez S, Martín-Montañez E, Auerbach M. Perioperative anemia management in colorectal cancer patients: A pragmatic approach. World J Gastroenterol 2014; 20:1972-1985. [PMID: 24587673 PMCID: PMC3934467 DOI: 10.3748/wjg.v20.i8.1972] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/11/2013] [Accepted: 01/20/2014] [Indexed: 02/07/2023] Open
Abstract
Anemia, usually due to iron deficiency, is highly prevalent among patients with colorectal cancer. Inflammatory cytokines lead to iron restricted erythropoiesis further decreasing iron availability and impairing iron utilization. Preoperative anemia predicts for decreased survival. Allogeneic blood transfusion is widely used to correct anemia and is associated with poorer surgical outcomes, increased post-operative nosocomial infections, longer hospital stays, increased rates of cancer recurrence and perioperative venous thromboembolism. Infections are more likely to occur in those with low preoperative serum ferritin level compared to those with normal levels. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management, minimizes or eliminates allogeneic blood transfusion. This includes restrictive transfusion policy, thromboprophylaxis and anemia management to improve outcomes. Normalization of preoperative hemoglobin levels is a World Health Organization recommendation. Iron repletion should be routinely ordered when indicated. Oral iron is poorly tolerated with low adherence based on published evidence. Intravenous iron is safe and effective but is frequently avoided due to misinformation and misinterpretation concerning the incidence and clinical nature of minor infusion reactions. Serious adverse events with intravenous iron are extremely rare. Newer formulations allow complete replacement dosing in 15-60 min markedly facilitating care. Erythropoiesis stimulating agents may improve response rates. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management used to minimize or eliminate allogeneic blood transfusion is indicated to improve outcomes.
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Halabi WJ, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, Pigazzi A, Stamos MJ. Blood transfusions in colorectal cancer surgery: incidence, outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis. Am J Surg 2013; 206:1024-32; discussion 1032-3. [PMID: 24296103 DOI: 10.1016/j.amjsurg.2013.10.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 10/03/2013] [Accepted: 10/03/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Data analyzing the short-term outcomes and predictors of blood transfusions (BTs) in colorectal cancer (CRC) surgery are limited. METHODS The American College of Surgeons National Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed. Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative and operative variables. RESULTS A total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs. Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This effect was "dose dependent," as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53), lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60) compared with those receiving 1 to 2 U. Predictors of BT were hematocrit <38%, open surgery, proctectomy, low platelet count, American Society of Anesthesiologists class IV or V, total colectomy, metastatic cancer, emergency, ascites, and infection. All P values were < .05. CONCLUSIONS BTs are associated with worse short-term outcomes after CRC surgery. Knowledge of predictive factors will help in risk stratification and counseling.
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Affiliation(s)
- Wissam J Halabi
- Department of Surgery, University of California, Irvine, School of Medicine, 333 City Blvd West, Suite 700, Orange, CA 92868, USA
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Fjørtoft I, Furnes B, Hausken T, Storli KE, Eide GE, Søndenaa K. Pre-operative anaemia in colon cancer patients became normal after more than a year post-operatively but did not influence oncological outcome in the final analysis. Scand J Gastroenterol 2013; 48:663-71. [PMID: 23534433 DOI: 10.3109/00365521.2013.781216] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pre-operative anaemia has been related to adverse outcomes after surgical management of colorectal cancer. How various factors may contribute to anaemia and also its post-operative recovery has not been extensively investigated. METHODS Two hundred and thirty five colon cancer patients treated surgically in a community teaching hospital in Norway between 2007 and 2009 were prospectively examined. RESULTS Anaemia was detected in 53.8%, which was dependent on tumour location, albumin level and female gender. More than 60% of all patients were overweight or obese. Pre-operative BMI was negatively associated with age and positively associated with albumin level (p = 0.018 for both). Haemoglobin levels slowly returned to normal during the first year in significant incremental steps, coincidental with an increase in BMI. At 6 months post-operative, age, albumin, female gender and TNM stage (p = 0.010; p = 0.020; p < 0.001; p = 0.028, respectively) were significantly connected with anaemia, whereas only age and albumin (p = 0.016; p = 0.004, respectively) were associated with a reduced BMI. Pre-operative anaemia gave a significantly worse overall survival (p = 0.040) in the univariate analysis but was not significant in the multivariate analysis. CONCLUSION Beside the influence of tumour location, it appeared that pre-operative Hgb had some relation to a reduced nutritional state. The post-operative recovery of anaemia was more closely related to an improved nutritional state. The relation between anaemia and oncological outcome should undergo further studies.
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Affiliation(s)
- Ingrid Fjørtoft
- Department of Clinical Medicine, University of Norway, Bergen, Norway
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Barr PJ, Donnelly M, Morris K, Parker M, Cardwell C, Bailie KEM. The epidemiology of red cell transfusion. Vox Sang 2011; 99:239-50. [PMID: 20576024 DOI: 10.1111/j.1423-0410.2010.01349.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Understanding of the clinical usage of red cells is limited despite its importance in transfusion practice improvement and planning for blood supply requirements. Previous studies have described red cell use based upon ICD and hospital discharge codes; however, such approaches are open to misclassification. This study addresses this limitation by undertaking an epidemiological analysis of red cell use using case note review. MATERIALS AND METHODS Patient, disease and contextual factors were extracted from the medical records of a randomly selected sample of hospital patients in Northern Ireland who received a red cell transfusion during 2005 (n=1474). RESULTS Transfused patients received a total of 3804 units (median of two units per transfusion episode). Most transfusions occurred in a medical setting (71%). Patients undergoing treatment for gastrointestinal conditions were responsible for the majority of the demand (29% of transfusion episodes; 34% of red cell units). The presence of bleeding and abnormal tests of coagulation were associated with receiving larger transfusions (≥ 3 units), while patients undergoing orthopaedic surgery and those with a haemoglobin level over 7 g/dl had the lowest risk of receiving ≥ 3 units in any one transfusion episode. CONCLUSION The majority of red cells are now prescribed in a medical setting. With an ageing population and increasing therapeutic interventions, the demand for blood is likely to increase despite efforts to reduce usage by eliminating inappropriate transfusions through education and behaviour change. The post-transfusion target (and therefore the number of units to transfuse) for any given clinical situation as well as guidance on a 'safe' transfusion threshold should be considered in future guidelines.
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Affiliation(s)
- P J Barr
- Centre for Excellence in Public Health, Queens University Belfast, Belfast, UK.
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Madrazo González Z, García Barrasa A, Rafecas Renau A. Anemia, hierro, transfusión y alternativas terapéuticas. Revisión desde una perspectiva quirúrgica. Cir Esp 2010; 88:358-68. [DOI: 10.1016/j.ciresp.2010.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 11/27/2009] [Accepted: 03/12/2010] [Indexed: 12/31/2022]
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Quinn M, Drummond RJ, Ross F, Murray J, Murphy J, Macdonald A. Short course pre-operative ferrous sulphate supplementation--is it worthwhile in patients with colorectal cancer? Ann R Coll Surg Engl 2010; 92:569-72. [PMID: 20573311 DOI: 10.1308/003588410x12699663904277] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Pre-operative anaemia is well recognised in patients presenting with colorectal cancer (CRC). While the benefits of long-term FeSO4 supplementation on Fe deficiency anaemia are well established, it is not known if short-course supplementation (2-3 weeks) impacts significantly on pre-operative haemoglobin (Hb) levels. This study examines the impact of short-term, oral FeSO4 supplementation on patients undergoing surgery for CRC. PATIENTS AND METHODS All patients with CRC presenting to a single surgeon were included. At diagnosis, baseline Hb and blood film were checked on all patients who then received 200 mg tds of FeSO4. Haemoglobin was rechecked pre-operatively and daily postoperatively. Patients requiring pre-operative blood transfusions were excluded from analysis. RESULTS Between 1 January 2004 and 31 December 2006, 117 patients were identified, 14 of whom were excluded. Patients received a median of 39 days' treatment with FeSO4. Fifty-eight (56.3%) patients were anaemic at presentation gaining a mean of 1.73 g/dl (P<0.001) from short-course FeSO4 supplementation. Right-sided tumours (lower mean Hb at presentation; P=0.008) responded more to FeSO4 when compared to left-sided tumours (P<0.017). Increase in Hb was unrelated to pathological stage. The transfusion rate for all curative resections was 0.69 units/patient. For the historical cohort (patients undergoing curative resection between 1 January 2001 and 31 December 2003), the mean transfusion rate fell from 1.69 units/patient. CONCLUSIONS Routine short-course supplementation with iron offers improved pre-operative Hb prior to surgery in CRC, especially in right-sided lesions and those with presenting anaemia.
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Affiliation(s)
- Martha Quinn
- Department of Surgery, Monklands Hospital, Airdrie, UK
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