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Zuckerman J, Coburn N, Callum J, Mahar AL, Zuk V, Lin Y, McLeod R, Turgeon AF, Zhao H, Pearsall E, Martel G, Hallet J. Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis. Ann Surg Oncol 2020; 28:29-38. [PMID: 33165719 DOI: 10.1245/s10434-020-09291-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/30/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published over the past 10 years supports restrictive transfusion practices and blood conservation programs. Whether transfusion practices have changed remains unclear. We describe temporal RBC transfusion trends in a large North American population who underwent gastrointestinal cancer surgery. METHODS We conducted a population-based retrospective cohort study of patients who underwent gastrointestinal cancer resection between 2007 and 2018 using health administrative datasets. The outcome was RBC transfusion during hospitalization. Temporal transfusion trends were analyzed with Cochran-Armitage tests. Multivariable regression assessed the association between year of diagnosis and likelihood of RBC transfusion while controlling for confounding. RESULTS Of 79,764 patients undergoing gastrointestinal cancer resection, the median age was 69 years old (interquartile range (IQR) 60-78 years) and 55.5% were male. The most frequent procedures were colectomy (52.8%) and proctectomy (23.0%). A total of 18,175 patients (23%) received RBC transfusion. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p < 0.001). After adjusting for patient, procedure, and hospital factors, the most recent time period (2015-2018) was associated with a reduced likelihood of receiving RBC transfusion [relative risk 0.86 (95% confidence interval: 0.83-0.89)] relative to the intermediate time period (2011-2014). CONCLUSION Over 11 years, we observed decreased RBC transfusion use and reduced likelihood of transfusion in patients undergoing gastrointestinal cancer resection. This information provides a foundation to further examine transfusion appropriateness or explore if additional transfusion minimization in surgical patients can be achieved.
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Affiliation(s)
- Jesse Zuckerman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Natalie Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada
| | - Victoria Zuk
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Robin McLeod
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Québec City, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Canada
| | | | - Emily Pearsall
- Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Julie Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada. .,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada. .,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada.
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2
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Seegmiller CJ, Borgert AJ, Kallies KJ, Jarman BT. Is Chief Resident Autonomy Safe for Patients? An Analysis of Quality in Training Initiative (QITI) Data to Assess Chief Resident Performance. JOURNAL OF SURGICAL EDUCATION 2020; 77:e164-e171. [PMID: 32768382 DOI: 10.1016/j.jsurg.2020.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/17/2020] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE A chief resident service (CRS) provides a unique environment to assess competence throughout all aspects of patient care. The American College of Surgeons National Surgical Quality Improvement Program and Quality in Training Initiative databases are utilized to assess patient outcomes by individual residents with institutional and national comparisons. We hypothesized that residents on the CRS would have equivalent patient care outcomes to peers not on CRS and to chief residents nationally. DESIGN An institutional National Surgical Quality Improvement Program database was queried from 2014 to 2019 for operations performed on the CRS. Thirty-day complications were compared between CRS and non-CRS postgraduate year (PGY)-5 residents. Quality in Training Initiative reports were used to compare residents on CRS to national PGY-5 residents. Statistical analysis included chi-square tests, and multivariate logistic regression. SETTING Independent academic medical center. PARTICIPANTS Chief general surgery residents. RESULTS A total of 1031 cases were included in the analysis; 562 while off CRS and 469 while on CRS. Thirty-day outcomes were similar for CRS vs non-CRS cases for any complication (8% vs 12%, p = 0.05), unplanned readmissions (6% vs 5%, p = 0.58), and mortality (2% vs 2%, p = 0.99). Adjusting for patient and operative risk factors and procedure type, the rate of any complication after an operation on CRS vs off CRS was similar (odds ratio = 1.46, 95%confidence interval 0.82-2.60; p = 0.20). CRS residents had higher rates of postoperative renal failure (1.3% vs 0.5%, p = 0.008), but lower rates of organ space surgical site infection (0.6% vs 2.9%, p < 0.001), myocardial infarction (0 vs 0.6%, p = 0.04), pneumonia (0.3% vs 1.6%, p = 0.006), septic shock (0.1% vs 1.0%, p = 0.02), transfusion (2.7% vs 8.3%, p < 0.001), and fewer unplanned readmissions (6.1% vs 8.4%, p = 0.029) when compared to PGY-5 residents nationally. CONCLUSIONS Patient care outcomes provided by PGY-5 residents on a CRS are comparable to those on non-CRS rotations and to PGY-5 residents nationally.
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Affiliation(s)
- Colby J Seegmiller
- General Surgery Residency, Department of Medical Education, Gundersen Health System, La Crosse, Wisconsin
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin
| | - Benjamin T Jarman
- Department of General Surgery, Gundersen Health System, La Crosse, Wisconsin.
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Aguilar-Nascimento JE, Zampieri-Filho JP, Bordin JO. Implications of perioperative allogeneic red blood cell transfusion on the immune-inflammatory response. Hematol Transfus Cell Ther 2020; 43:58-64. [PMID: 32532624 PMCID: PMC7910182 DOI: 10.1016/j.htct.2020.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 12/24/2022] Open
Abstract
Background The allogeneic transfusion-related immunomodulation (TRIM) may be responsible for an increase in survival of renal transplants but in contrast it could increase the rate of bacterial infections or the recurrence rate of tumors post-operatively. Objective This review focuses in the implications of perioperative allogeneic transfusions on the immune-inflammatory response of surgical transfused patients. Results ABTs modify immune functions in recipients including decrease of the number of lymphocytes; decrease the CD4 cells; decrease the CD4/CD8 T-cell ratio; decrease NK cells; and decrease the lymphocyte response to mitogens. TRIM effects may be mediated by allogeneic white cells present in blood products; soluble peptides present in transfused plasma; and/or biologic mediators released into the supernatant of blood units. A recent systematic review and meta-analysis including 36 clinical observational studies (n = 174,036) concluded that perioperative ABTs not only decreased overall survival and reduced colorectal cancer-specific survival. Furthermore ABTs increased the rate of infectious, cardiac, pulmonary and anastomotic complications in colorectal cancer patients undergoing surgery. Conclusions It has been demonstrated by laboratory tests that TRIM is associated with transfusion recipient immune alterations but its influence in colorectal cancer recurrence after resection remains controversial though may exist. Surgical techniques reducing intraoperative blood loss have limited the number of ABTs perioperatively, however increase in mortality continues to be reported in literature after ABT in colorectal cancer surgery. Poor survival associated to TRIM in colorectal cancer might be due to higher number of allogeneic transfused units and/or prolonged length of blood storage.
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Affiliation(s)
| | - José Pedro Zampieri-Filho
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - José O Bordin
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil.
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4
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Rudder NJ, Borgert AJ, Kallies KJ, Smith TJ, Shapiro SB. Reduction of surgical site infections in colorectal surgery: A 10-year experience from an independent academic medical center. Am J Surg 2019; 217:1089-1093. [DOI: 10.1016/j.amjsurg.2018.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 01/18/2023]
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Patient blood management for liver resection: consensus statements using Delphi methodology. HPB (Oxford) 2019; 21:393-404. [PMID: 30446290 DOI: 10.1016/j.hpb.2018.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.
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Prescott LS, Taylor JS, Enbaya A, Marten CA, Myers KN, Meyer LA, Ramirez PT, Levenback CF, Bodurka DC, Schmeler KM. Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology. Gynecol Oncol 2019; 153:597-603. [PMID: 30872025 DOI: 10.1016/j.ygyno.2019.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery. METHODS We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost. RESULTS We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period. CONCLUSIONS Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.
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Affiliation(s)
- Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ahmed Enbaya
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Claire A Marten
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Keith N Myers
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Charles F Levenback
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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8
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Hallet J, Mahar AL, Nathens AB, Tsang ME, Beyfuss KA, Lin Y, Coburn NG, Karanicolas PJ. The impact of perioperative blood transfusions on short-term outcomes following hepatectomy. Hepatobiliary Surg Nutr 2018. [PMID: 29531938 DOI: 10.21037/hbsn.2017.05.07] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Bleeding and need for red blood cell transfusions (RBCT) remain a significant concern with hepatectomy. RBCT carry risk of transfusion-related immunomodulation that may impact post-operative recovery. This study soughs to assess the association between RBCT and post-hepatectomy morbidity. Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, we identified all adult patients undergoing elective hepatectomy over 2007-2012. Two exposure groups were created based on RBCT. Primary outcomes were 30-day major morbidity and mortality. Secondary outcomes included 30-day system-specific morbidity and length of stay (LOS). Relative risks (RR) with 95% confidence interval (95% CI) were computed using regression analyses. Sensitivity analyses were conducted to understand how missing data might have impacted the results. Results A total of 12,180 patients were identified. Of those, 11,712 met inclusion criteria, 2,951 (25.2%) of whom received RBCT. Major morbidity occurred in 14.9% of patients and was strongly associated with RBCT (25.3% vs. 11.3%; P<0.001). Transfused patients had higher rates of 30-day mortality (5.6% vs. 1.0%; P<0.0001). After adjustment for baseline and clinical characteristics, RBCT was independently associated with increased major morbidity (RR 1.80; 95% CI: 1.61-1.99), mortality (RR 3.62; 95% CI: 2.68-4.89), and 1.29 times greater LOS (RR 1.29; 95% CI: 1.25-1.32). Results were robust to a number of sensitivity analyses for missing data. Conclusions Perioperative RBCT for hepatectomy was independently associated with worse short-term outcomes and prolonged LOS. These findings further the rationale to focus on minimizing RBCT for hepatectomy, when they can be avoided.
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Affiliation(s)
- Julie Hallet
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alyson L Mahar
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Avery B Nathens
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Melanie E Tsang
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kaitlyn A Beyfuss
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yulia Lin
- Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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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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10
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Elmi M, Mahar A, Kagedan D, Law CH, Karanicolas PJ, Lin Y, Callum J, Coburn NG, Hallet J. The impact of blood transfusion on perioperative outcomes following gastric cancer resection: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Can J Surg 2016; 59:322-9. [PMID: 27668330 PMCID: PMC5042719 DOI: 10.1503/cjs.004016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Red blood cell transfusions (RBCT) carry risk of transfusion-related immunodulation that may impact postoperative recovery. This study examined the association between perioperative RBCT and short-term postoperative outcomes following gastrectomy for gastric cancer. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, we compared outcomes of patients (transfused v. nontransfused) undergoing elective gastrectomy for gastric cancer (2007-2012). Outcomes were 30-day major morbidity, mortality and length of stay. The association between perioperative RBCT and outcomes was estimated using modified Poisson, logistic, or negative binomial regression. RESULTS Of the 3243 patients in the entire cohort, we included 2884 patients with nonmissing data, of whom 535 (18.6%) received RBCT. Overall 30-day major morbidity and mortality were 20% and 3.5%, respectively. After adjustment for baseline and clinical characteristics, RBCT was independently associated with increased 30-day mortality (relative risk [RR] 3.1, 95% confidence interval [CI] 1.9-5.0), major morbidity (RR 1.4, 95% CI 1.2-1.8), length of stay (RR 1.2, 95% CI 1.1-1.2), infections (RR 1.4, 95% CI 1.1-1.6), cardiac complications (RR 1.8, 95% CI 1.0-3.2) and respiratory failure (RR 2.3, 95% CI 1.6-3.3). CONCLUSION Red blood cell transfusions are associated with worse postoperative short-term outcomes in patients with gastric cancer. Blood management strategies are needed to reduce the use of RBCT after gastrectomy for gastric cancer.
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Affiliation(s)
- Maryam Elmi
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Alyson Mahar
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Daniel Kagedan
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Calvin H.L. Law
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Paul J. Karanicolas
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Yulia Lin
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Jeannie Callum
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Natalie G. Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
| | - Julie Hallet
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Elmi, Kagedan, Law, Karanicolas, Coburn, Hallet); the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Mahar); the Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer Centre, Toronto, Ont. (Law, Karanicolas, Coburn, Hallet); the Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ont. (Lin, Callum); and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont. (Lin, Callum)
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11
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Hallet J, Kulyk I, Cheng ES, Truong J, Hanna SS, Law CH, Coburn NG, Tarshis J, Lin Y, Karanicolas PJ. The impact of red blood cell transfusions on perioperative outcomes in the contemporary era of liver resection. Surgery 2016; 159:1591-1599. [DOI: 10.1016/j.surg.2015.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 12/02/2015] [Accepted: 12/17/2015] [Indexed: 01/10/2023]
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12
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Prescott LS, Taylor JS, Lopez-Olivo MA, Munsell MF, VonVille HM, Lairson DR, Bodurka DC. How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology. Cancer Treat Rev 2016; 46:1-8. [PMID: 27046422 PMCID: PMC4884540 DOI: 10.1016/j.ctrv.2016.03.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. METHODS A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. RESULTS Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49-0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32-3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. CONCLUSION Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.
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Affiliation(s)
- Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria A Lopez-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Helena M VonVille
- The University of Texas School of Public Health, Houston, TX 77030, USA
| | - David R Lairson
- The University of Texas School of Public Health, Houston, TX 77030, USA
| | - Diane C Bodurka
- Department of Clinical Education, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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13
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Blood Transfusion Following Colorectal Resection: What Is the Real Story? Dis Colon Rectum 2016; 59:359-60. [PMID: 27050596 DOI: 10.1097/dcr.0000000000000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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14
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Hallet J, Mahar AL, Tsang ME, Lin Y, Callum J, Coburn NG, Law CHL, Karanicolas PJ. The impact of peri-operative blood transfusions on post-pancreatectomy short-term outcomes: an analysis from the American College of Surgeons National Surgical Quality Improvement Program. HPB (Oxford) 2015; 17:975-82. [PMID: 26301741 PMCID: PMC4605335 DOI: 10.1111/hpb.12473] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/11/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Peri-operative red blood cell transfusions (RBCT) may induce transfusion-related immunomodulation and impact post-operative recovery. This study examined the association between RBCT and post-pancreatectomy morbidity. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, patients undergoing an elective pancreatectomy (2007-2012) were identified. Patients with missing data on key variables were excluded. Primary outcomes were 30-day post-operative major morbidity, mortality, and length of stay (LOS). Unadjusted and adjusted relative risks (RR) with a 95% confidence interval (95%CI) were computed using modified Poisson, logistic, or negative binomial regression, to estimate the association between RBCT and outcomes. RESULTS The database included 21 132 patients who had a pancreatectomy during the study period. Seventeen thousand five hundred and twenty-three patients were included, and 4672 (26.7%) received RBCT. After adjustment for baseline and clinical characteristics, including comorbidities, malignant diagnosis, procedure and operative time, RBCT was independently associated with increased major morbidity (RR 1.49; 95% CI: 1.39-1.60), mortality (RR 2.19; 95%CI: 1.76-2.73) and LOS (RR 1.27; 95%CI 1.24-1.29). CONCLUSION Peri-operative RBCT for a pancreatectomy was independently associated with worse short-term outcomes and prolonged LOS. Future studies should focus on the impact of interventions to minimize the use of RBCT after an elective pancreatectomy.
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Affiliation(s)
- Julie Hallet
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada,Department of Surgery, University of TorontoToronto, ON, Canada
| | - Alyson L Mahar
- Department of Public Health Sciences, Queen's UniversityKingston, ON, Canada
| | - Melanie E Tsang
- Department of Surgery, University of TorontoToronto, ON, Canada
| | - Yulia Lin
- Division of Clinical Pathology, Sunnybrook Health Sciences CentreToronto, ON, Canada,Department of Laboratory Medicine and Pathobiology, University of TorontoToronto, ON, Canada
| | - Jeannie Callum
- Division of Clinical Pathology, Sunnybrook Health Sciences CentreToronto, ON, Canada,Department of Laboratory Medicine and Pathobiology, University of TorontoToronto, ON, Canada
| | - Natalie G Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada,Department of Surgery, University of TorontoToronto, ON, Canada
| | - Calvin H L Law
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada,Department of Surgery, University of TorontoToronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada,Department of Surgery, University of TorontoToronto, ON, Canada
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15
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Long-term outcomes of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer. Am J Surg 2015; 210:990-4; discussion 995. [PMID: 26455522 DOI: 10.1016/j.amjsurg.2015.06.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/18/2015] [Accepted: 06/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Perioperative blood transfusion in patients with colorectal cancer has been associated with increased cost, morbidity, mortality, and decreased survival. Five years ago, a transfusion reduction initiative (TRI) was implemented. We sought to evaluate the 5-year effectiveness and patient outcomes before and after the TRI. METHODS Patients who underwent colorectal resection for adenocarcinomas before (January 2006 to October 2009) and after the TRI (November 2009 to December 2013) were reviewed. RESULTS A total of 484 patients were included; 267 and 217 patients were in the pre- and post-TRI groups, respectively. Decreased overall transfusion rates were sustained throughout the entire post-TRI era (17% vs 28%, P = .006). Three-year colorectal cancer disease-free survival rates were similar in the pre- and post-TRI eras at 85.3% (95% confidence interval [CI]: 79.9 to 89.3) and 81.6% (95% CI: 71.9 to 88.2), respectively. Three-year disease-free survival rate was lower in those receiving BTs vs those without BTs at 78.4% (95% CI: 65.7 to 86.8) vs 85.3% (95% CI: 80.4 to 89.1), respectively. CONCLUSIONS A TRI remains a safe, effective way to reduce blood utilization in colorectal cancer surgery.
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16
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Venkat R, Guerrero MA. Risk factors and outcomes of blood transfusions in adrenalectomy. J Surg Res 2015; 199:505-11. [PMID: 26188958 DOI: 10.1016/j.jss.2015.06.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/31/2015] [Accepted: 06/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Blood transfusion has been shown to be associated with adverse long-term and short-term outcomes. We sought to evaluate the preoperative risk factors associated with blood transfusion and its effects on postoperative outcomes after adrenalectomy. METHODS We performed a retrospective analysis of 4735 adrenalectomies (3664 laparoscopic and 1071 open) from 2005-2012 using the National Surgical Quality Improvement Program database. Data on preoperative risk factors and postoperative morbidity and mortality were evaluated. RESULTS Median age and body mass index were 54 y and 29.3 kg/m(2), respectively. Most patients were female (60.0%). Of the total, 60.6% patients had American Society of Anesthesiologists score ≥3. On multivariate analysis, increasing age (odds ratio [OR] = 1.02, P < 0.001), open adrenalectomy (OR = 14.0, P < 0.001), preoperative hematocrit <38% (OR = 2.96, P < 0.001), and operative time >150 min (OR: 3.69, P < 0.001) were associated with an increased need for intraoperative blood transfusions. The need for intraoperative blood transfusions was an independent predictor of postoperative complications including mortality (OR = 12.7, P < 0.001), overall morbidity (OR = 3.2, P < 0.001), serious morbidity (OR = 3.8, P < 0.001), wound complication (OR = 2.1, P = 0.006), cardiopulmonary complication (OR = 3.6, P < 0.001), septic complication (OR = 2.5, P = 0.007), reoperation (OR = 3.6, P < 0.001), and prolonged length of stay (OR = 4.3, P < 0.001). There was an independent and incremental increase (10%-20%) in the risk of morbidity and mortality with each unit of blood transfused (P < 0.01). CONCLUSIONS Age, open surgery, preoperative anemia, American Society of Anesthesiologists score, and prolonged operative time are associated with an increased need for blood transfusions in laparoscopic and open adrenalectomy. Intraoperative transfusion was independently and incrementally associated with significant morbidity and mortality after laparoscopic and open adrenalectomy.
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Affiliation(s)
- Raghunandan Venkat
- Division of Surgical Oncology, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Marlon A Guerrero
- Division of Surgical Oncology, Department of Surgery, University of Arizona, Tucson, Arizona; Arizona Cancer Center, Banner University Medical Center, Tucson, Arizona.
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17
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Hallet J, Tsang M, Cheng ESW, Habashi R, Kulyk I, Hanna SS, Coburn NG, Lin Y, Law CHL, Karanicolas PJ. The Impact of Perioperative Red Blood Cell Transfusions on Long-Term Outcomes after Hepatectomy for Colorectal Liver Metastases. Ann Surg Oncol 2015; 22:4038-45. [PMID: 25752895 DOI: 10.1245/s10434-015-4477-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Red blood cell transfusions (RBCTs) are associated with cancer recurrence following resection of colorectal cancer. Their impact after colorectal liver metastases (CRLM) resection remains debated. We sought to explore the association between perioperative RBCT and oncologic outcomes following resection of CRLM. METHODS We reviewed patients undergoing partial hepatectomy for CRLM from 2003 to 2012 at a single institution. Date of death was abstracted from a validated population-based cancer registry. Primary outcome was overall survival (OS). Secondary outcome was recurrence-free survival (RFS). Survivals were estimated using Kaplan-Meier methods and compared with log-rank test based on transfusion status. Cox regression analysis examined the association of RBCT with OS and RFS, while adjusting for age, preoperative chemotherapy, Clinical Risk Score, and period of treatment (2003-2007 vs. 2008-2012). RESULTS Among 483 patients, 27.5 % received RBCT. Ninety-day postoperative mortality was 4.8 %. At median follow-up of 33 (interquartile range 20.1-54.8) months, 5-year OS was inferior in transfused patients (45.9 vs. 61.0 %; p < 0.0001). Five-year RFS was decreased with RBCT (15.5 vs. 31.6 %; p < 0.0001). The difference persisted when considering only 90-day survivors for 5-year OS (53.1 vs. 61.9 %, p = 0.023) and RFS (15.6 vs. 31.6 %; p < 0.0001). After adjustment for prognostic factors, RBCT was independently associated with decreased OS (hazard ratio 2.24; 95 % confidence interval 1.60-3.15) and RFS (hazard ratio 1.71; 95 % confidence interval 1.28-2.28). CONCLUSIONS Perioperative RBCT is independently associated with decreased OS and RFS following hepatectomy for CRLM. Interventions to minimize and rationalize the use of RBCT for hepatectomy are warranted to mitigate this detrimental effect on long-term outcomes.
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Affiliation(s)
- Julie Hallet
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Melanie Tsang
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Eva S W Cheng
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada
| | - Rogeh Habashi
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada
| | - Iryna Kulyk
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada
| | - Sherif S Hanna
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Yulia Lin
- Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Calvin H L Law
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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18
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Restrictive blood transfusion protocol in liver resection patients reduces blood transfusions with no increase in patient morbidity. Am J Surg 2014; 209:280-8. [PMID: 25305797 DOI: 10.1016/j.amjsurg.2014.06.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 06/17/2014] [Accepted: 06/20/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Management of anemia in surgical oncology patients remains one of the key quality components in overall care and cost. Continued reports demonstrate the effects of hospital transfusion, which has been demonstrated to lead to a longer length of stay, more complications, and possibly worse overall oncologic outcomes. The hypothesis for this study was that a dedicated restrictive transfusion protocol in patients undergoing hepatectomy would lead to less overall blood transfusion with no increase in overall morbidity. METHODS A cohort study was performed using our prospective database from January 2000 to June 2013. September 2011 served as the separation point for the date of operation criteria because this marked the implementation of more restrictive blood transfusion guidelines. RESULTS A total of 186 patients undergoing liver resection were reviewed. The restrictive blood transfusion guidelines reduced the percentage of patients that received blood from 31.0% before January 9, 2011 to 23.3% after this date (P = .03). The liver procedure that was most consistently associated with higher levels of transfusion was a right lobectomy (16%). Prior surgery and endoscopic stent were the 2 preoperative interventions associated with receiving blood. Patients who received blood before and after the restrictive period had similar predictive factors: major hepatectomies, higher intraoperative blood loss, lower preoperative hemoglobin level, older age, prior systemic chemotherapy, and lower preoperative nutritional parameters (all P < .05). Patients who received blood did not have worse overall progression-free survival or overall survival. CONCLUSIONS A restrictive blood transfusion protocol reduces the incidence of blood transfusions and the number of packed red blood cells transfused. Patients who require blood have similar preoperative and intraoperative factors that cannot be mitigated in oncology patients. Restrictive use of blood transfusions can reduce cost and does adversely affect patients undergoing liver resection.
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19
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Hicks CW, Frank SM, Wasey JO, Efron J, Gearhart S, Fang S, Safar B, Makary MA, Wick EC. A Novel Means of Assessing Institutional Adherence to Blood Transfusion Guidelines. Am J Med Qual 2014; 30:584-90. [DOI: 10.1177/1062860614542972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Sabate A. Nuevos paradigmas en el manejo de la transfusión perioperatoria en cirugía electiva. Cir Esp 2014; 92:1-3. [DOI: 10.1016/j.ciresp.2013.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
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21
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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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22
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Farid SG, Gechev Z, Couch D, Morris-Stiff G. Re. Mroczkowski et al.: Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009. Colorectal Dis 2013; 15:760-1. [PMID: 23517092 DOI: 10.1111/codi.12217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 12/21/2012] [Indexed: 02/08/2023]
Affiliation(s)
- S. G. Farid
- Northampton General Hospital; Cliftonville; Northampton; NN5 5NQ; UK
| | - Z. Gechev
- Northampton General Hospital; Cliftonville; Northampton; NN5 5NQ; UK
| | - D. Couch
- Northampton General Hospital; Cliftonville; Northampton; NN5 5NQ; UK
| | - G. Morris-Stiff
- Northampton General Hospital; Cliftonville; Northampton; NN5 5NQ; UK
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