Long-term outcomes of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer

Preoperative anemia and long-term survival in patients undergoing colorectal cancer surgery: a retrospective cohort study

BACKGROUND

The impact of preoperative anemia on a survival outcome and the importance of correcting preoperative anemia in patients with colorectal cancer (CRC) remain controversial. This study aimed to explore how preoperative anemia affects the long-term survival of patients undergoing colorectal cancer surgery.

METHODS

This was a retrospective cohort study in which adult patients underwent surgical resection for colorectal cancer between January 1, 2008, and December 31, 2014, at a large tertiary cancer center. A total of 7436 patients were enrolled in this study. Anemia was defined according to the diagnostic criteria of China (hemoglobin level < 110 g/L for women and < 120 g/L for men). The median follow-up time was 120.5 months (10.0 years). Inverse probability of treatment weighting (IPTW) using the propensity score was used to reduce selection bias. Overall survival (OS) and disease-free survival (DFS) were compared between patients with and without preoperative anemia using the Kaplan-Meier estimator and the weighted log-rank test based on IPTW. Univariate and multivariate Cox proportional hazards models were used to assess factors associated with OS and DFS. Multivariable Cox regression was also used to assess red blood cell (RBC) transfusion associations between preoperative anemia and outcomes.

RESULTS

After IPTW adjustment, clinical profiles were similar, except that tumor location and TNM stage remained imbalanced between the preoperative anemia and preoperative non-anemia groups (p < 0.001). IPTW analysis showed that the 5-year OS rate (71.3 vs. 78.6%, p < 0.001) and the 5-year DFS rate (63.9 vs. 70.9%, p < 0.001) were significantly lower in the preoperative anemia group. Multivariate analysis showed that preoperative anemia was associated with poorer OS and DFS, while RBC transfusion may improve OS (hazard ratio [HR] 0.54, p = 0.054) and DFS (HR 0.50, p = 0.020) in CRC patients with preoperative anemia.

CONCLUSIONS

Preoperative anemia is an independent risk factor for survival in patients undergoing colorectal surgery. Strategies to reduce preoperative anemia in patients with CRC should be considered.

Perioperative transfusion and the prognosis of colorectal cancer surgery: a systematic review and meta-analysis

Background

Perioperative transfusion can reduce the survival rate in colorectal cancer patients. The effects of transfusion on the short- and long-term prognoses are becoming intriguing.

Objective

This systematic review and meta-analysis aimed to define the effects of perioperative transfusion on the short- and long-term prognoses of colorectal cancer surgery.

Results

Thirty-six clinical observational studies, with a total of 174,036 patients, were included. Perioperative transfusion decreased overall survival (OS) (hazard ratio (HR), 0.33; 95% confidence interval (CI), 0.24 to 0.41; P < 0.0001) and cancer-specific survival (CSS) (HR, 0.34; 95% CI, 0.21 to 0.47; P < 0.0001), but had no effect on disease-free survival (DFS) (HR, 0.17; 95% CI, − 0.12 to 0.47; P = 0.248). Transfusion could increase postoperative infectious complications (RR, 1.89, 95% CI, 1.56 to 2.28; P < 0.0001), pulmonary complications (RR, 2.01; 95% CI, 1.54 to 2.63; P < 0.0001), cardiac complications (RR, 2.20; 95% CI, 1.75 to 2.76; P < 0.0001), anastomotic complications (RR, 1.51; 95% CI, 1.29 to 1.79; P < 0.0001), reoperation(RR, 2.88; 95% CI, 2.05 to 4.05; P < 0.0001), and general complications (RR, 1.86; 95% CI, 1.66 to 2.07; P < 0.0001).

Conclusion

Perioperative transfusion causes a dramatically negative effect on long-term prognosis and increases short-term complications after colorectal cancer surgery.

The Impact of Blood Transfusion on Recurrence and Mortality Following Colorectal Cancer Resection: A Propensity Score Analysis of 4,030 Patients

Whether blood transfusion exacerbates cancer outcomes after surgery in humans remains inconclusive. We utilized a large cohort to investigate the effect of perioperative blood transfusion on cancer prognosis following colorectal cancer (CRC) resection. Patients with stage I through III CRC undergoing tumour resection at a tertiary medical center between 2005 and 2014 were identified and evaluated through August 2016. Propensity score matching was used to cancel out imbalances in patient characteristics. Postoperative disease-free survival (DFS) and overall survival (OS) were analysed using Cox regression model. A total of 4,030 and 972 patients were analysed before and after propensity score matching. Cox regression analyses demonstrated blood transfusion associated with shorter DFS and OS before and after matching (hazard ratio: 1.41, 95% CI: 1.2–1.66 for DFS; 1.97, 95% CI: 1.6–2.43 for OS). Larger transfusion volume was linked to higher overall mortality (≤4 units vs. nil, HR = 1.58; >4 units vs. nil, HR = 2.32) but not more cancer recurrence. Preoperative anemia was not associated with decreased survival after adjusting covariates. Perioperative blood transfusion was associated with worse cancer prognosis after curative colorectal resection, independently of anemia status. Strategies aimed at minimizing transfusion requirements should be further developed.

The effect of epidural analgesia on cancer progression in patients with stage IV colorectal cancer after primary tumor resection: A retrospective cohort study

Retrospective clinical studies showed perioperative epidural analgesia (EA) was associated with better postoperative oncologic outcomes in patients with specific types of non-metastatic cancers. This study aimed to investigate the effects of EA on cancer prognosis after surgical intervention for stage IV colorectal cancer. In this retrospective study, patients with stage IV colorectal cancer undergoing primary tumor resection and metastasectomy between January 2005 and December 2014 were classified into two groups based on their use of perioperative EA or not and evaluated through August 2016. Primary and secondary endpoints were postoperative progression-free survival (PFS) and overall survival (OS), respectively. A total of 999 patients were included and 165 (16.5%) of them received EA. The median follow-up interval was 17.5 months and no significant difference in PFS or OS was noted between the EA and non-EA groups in the univariate analysis. Multivariable Cox proportional hazards model identified four independent risk factors both for disease progression and mortality, including American Society of Anesthesiologists (ASA) physical status ≥ 3, higher pretreatment carcinoembryonic antigen (CEA), multiple distant metastases, and pathologic lymphovascular invasion. After adjustment for the selected risk factors, the effects of EA on PFS and OS remained non-significant (hazard ratio: 1.06, 95% CI: 0.87 to 1.29, for PFS and 0.90, 95% CI: 0.68 to 1.20 for OS). Similar findings were demonstrated by propensity score analysis. Our results did not support the association between perioperative epidural analgesia and better progression-free or overall survival in patients following stage IV colorectal cancer surgery.

Perioperative fasting time among cancer patients submitted to gastrointestinal surgeries

OBJECTIVE

To identify the length of perioperative fasting among patients submitted to gastrointestinal cancer surgeries.

METHOD

Retrospective cohort study, developed by consulting the medical records of 128 patients submitted to gastrointestinal cancer surgeries.

RESULTS

The mean of total length of fasting was 107.6 hours. The total length of fasting was significantly associated with the number of symptoms presented before (p=0.000) and after the surgery (p=0.007), the length of hospital stay (p=0.000), blood transfusion (p=0.013), nasogastric tube (p=0.001) and nasojejunal tube (p=0,003), postoperative admission at ICU (p=0.002), postoperative death (p=0.000) and length of preoperative fasting (p=0.000).

CONCLUSION

The length of fasting is associated with complications that affect the quality of the patients' postoperative recovery and nurses' work. The nursing team should be alert to this aspect and being responsible for overseeing the patients' interest, should not permit the unnecessary extension of fasting.

OBJETIVO

Identificar la duración del ayuno perioperatorio entre los pacientes sometidos a cirugías de cáncer gastrointestinal.

MÉTODO

Estudio de cohorte retrospectivo, por consulta de los registros médicos de 128 pacientes sometidos a cirugías de cáncer gastrointestinal.

RESULTADOS

La media de la duración total del ayuno fue de 107,6 horas. La duración total del ayuno se asoció significativamente con el número de síntomas presentados antes (p=0,000) y después de la cirugía (p=0,007), la duración de la estancia hospitalaria (p=0,000), transfusión de sangre (p=0,013),tubo nasogástrico (P=0,003), ingreso postoperatorio en la UCI (p=0,002), muerte postoperatoria (p=0,000) y duración del ayuno preoperatorio (p=0,000).

CONCLUSIÓN

La duración del ayuno se asocia con complicaciones que afectan la calidad de la recuperación postoperatoria de los pacientes y el trabajo de enfermería. El equipo de enfermería debe estar alerta en relación a este aspecto y ser responsable de supervisar el interés de los pacientes, no permitiendo la extensión innecesaria del ayuno.