Transfusion utilization during adnexal or peritoneal cancer surgery: Effects on symptomatic venous thromboembolism and survival

A pre-operative scoring model to estimate the risk of blood transfusion over an ovarian cancer debulking surgery (BLOODS score): a Memorial Sloan Kettering Cancer Center Team Ovary study

OBJECTIVES

To develop a pre-operative tool to estimate the risk of peri-operative packed red blood cell transfusion in primary debulking surgery.

METHODS

We retrospectively reviewed an institutional database to identify patients who underwent primary debulking surgery for ovarian cancer at a single center between January 1, 2001 and May 31, 2019. Receiver operating characteristic curve and area under the receiver operating characteristic curve (AUC) were calculated. Five-fold cross-validation was applied to the multivariate model. Significant variables were assigned a 'BLOODS' (BLood transfusion Over an Ovarian cancer Debulking Surgery) score of +1 if present. A total BLOODS score was calculated for each patient, and the odds of receiving a transfusion was determined for each score.

RESULTS

Overall, 1566 patients met eligibility criteria; 800 (51%) underwent a peri-operative blood transfusion. Odds ratios (OR) were statistically significant for American Society of Anesthesiologists scores of 3 and 4 (OR 1.34, 95% confidence interval (95% CI) 1.09 to 1.63), pre-operative levels of cancer antigen 125 (CA125) (OR 2.43, 95% CI 1.98 to 2.99), platelets (OR 1.59, 95% CI 1.45 to 1.74), obesity (OR 0.76, 95% CI 0.60 to 0.96), presence of carcinomatosis (OR 2.45, 95% CI 1.93 to 3.11), bulky upper abdominal disease (OR 2.86, 95% CI 2.32 to 3.54), pre-operative serum albumin level (OR 0.31, 95% CI 0.24 to 0.40), and pre-operative hemoglobin level (OR 0.56, 95% CI 0.51 to 0.61). The corrected AUC was 0.748 (95% CI 0.693 to 0.804). BLOODS scores of 0 and 5 corresponded to 11% and 73% odds, respectively, of receiving a peri-operative blood transfusion.

CONCLUSIONS

We developed a universal pre-operative scoring system, the BLOODS score, to help identify patients with ovarian cancer who would benefit from surgical planning and blood-saving techniques. The BLOODS score was directly proportional to the American Society of Anesthesiologists score, presence of upper abdominal disease, carcinomatosis, CA125 level, and platelets level. We believe this model can help physicians with surgical planning and can benefit patient outcomes.

Association between perioperative red blood cell transfusions and postoperative venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Whether perioperative red blood cell transfusions increases the risk of postoperative venous thromboembolism is controversial and uncertain.We aims to explore the relationship between perioperative red blood cell transfusions and the risk of postoperative venous thromboembolism by conducting a meta-analysis.

OBJECTIVE

To conduct a meta-analysis to systematically evaluate the relationship between perioperative red blood cell transfusions and the risk of postoperative venous thromboembolism.

METHODS

PubMed, Embase, Cochrane, and Web of Science databases were searched to identify studies examining the relationship between perioperative red blood cell transfusions and the risk of postoperative venous thromboembolism. The databases were searched from establishment to August 2023.Two researchers independently screened literature and extracted data according to inclusion and exclusion criteria. Newcastle-ottawa Scale was used for quality assessment. Meta-analysis of data was performed using RevMan 5.4 software.

RESULTS

A total of 15 studies involving 1,880,990 patients were included in this study.Meta-analysis showed that perioperative red blood cell transfusions increased the risk of postoperative venous thromboembolism [OR = 1.61, 95%CI (1.37, 1.89), P < 0.001]. Subgroup analyses showed that the transfusion dose,transfusion timing,study population and follow-up time were closely related to the risk of postoperative venous thromboembolism.

CONCLUSIONS

In summary, this meta-analysis demonstrated a significant positive association between perioperative red blood cell transfusions and postoperative venous thromboembolism.Healthcare professionals should pay attention to the influence of blood transfusions on postoperative venous thromboembolism, strengthen management and prevention.

Predictors of Blood Transfusion in Patients Undergoing Cytoreductive Surgeries for Ovarian Malignancy

OBJECTIVES

The aims of this study were to describe the baseline estimated blood loss (EBL) in surgery and transfusion rate in patients undergoing cytoreductive surgeries for ovarian malignancy, and identify perioperative variables associated with blood loss and transfusion.

METHODS

A retrospective cohort study at a single institution was performed that included patients with known or suspected ovarian malignancy undergoing cytoreductive surgery between 2016 and 2021. t tests, χ2 tests, and multiple logistic regression analyses were used.

RESULTS

Among 44 patients meeting inclusion criteria, 61% received perioperative blood transfusion. There were significant differences in EBL and preoperative hemoglobin levels between patients who did and did not receive transfusion (EBL 442.6 vs 236.8 mL, P = 0.0008; preoperative hemoglobin 10.2 vs 11.2 g/dL, P = 0.049). After adjusting for preoperative hemoglobin, the risk of transfusion increased for each additional 200 mL of EBL (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.5-9.5). Stratified by race, the association between EBL and transfusion risk remained statistically significant only for non-Latinx White patients (OR 6.1, 95% CI 1.7-21.9), who made up 77% of the study population, but not for patients of other races and ethnicities (OR 1.0, 95% CI 0.16-6.42).

CONCLUSIONS

Perioperative blood transfusion is common in patients undergoing cytoreductive surgery. In this study, EBL and preoperative hemoglobin levels were significantly associated with transfusion receipt. Clinicians should optimize hemoglobin levels and intraoperative blood conservation strategies to reduce the need for transfusion. The results also highlight the importance of considering racial and ethnic differences when developing strategies to reduce transfusion risk.

Utility of plasma D-dimer for diagnosis of venous thromboembolism after hepatectomy

BACKGROUND

Venous thromboembolism (VTE) is a potentially fatal complication of hepatectomy. The use of postoperative prophylactic anticoagulation in patients who have undergone hepatectomy is controversial because of the risk of postoperative bleeding. Therefore, we hypothesized that monitoring plasma D-dimer could be useful in the early diagnosis of VTE after hepatectomy.

AIM

To evaluate the utility of monitoring plasma D-dimer levels in the early diagnosis of VTE after hepatectomy.

METHODS

The medical records of patients who underwent hepatectomy at our institution between January 2017 and December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether or not they developed VTE after hepatectomy, as diagnosed by contrast-enhanced computed tomography and/or ultrasonography of the lower extremities. Clinicopathological factors, including demographic data and perioperative D-dimer values, were compared between the two groups. Receiver operating characteristic curve analysis was performed to determine the D-dimer cutoff value. Univariate and multivariate analyses were performed using logistic regression analysis to identify significant predictors.

RESULTS

In total, 234 patients who underwent hepatectomy were, of whom (5.6%) were diagnosed with VTE following hepatectomy. A comparison between the two groups showed significant differences in operative time (529 vs 403 min, P = 0.0274) and blood loss (530 vs 138 mL, P = 0.0067). The D-dimer levels on postoperative days (POD) 1, 3, 5, 7 were significantly higher in the VTE group than in the non-VTE group. In the multivariate analysis, intraoperative blood loss of > 275 mL [odds ratio (OR) = 5.32, 95% confidence interval (CI): 1.05-27.0, P = 0.044] and plasma D-dimer levels on POD 5 ≥ 21 μg/mL (OR = 10.1, 95%CI: 2.04-50.1, P = 0.0046) were independent risk factors for VTE after hepatectomy.

CONCLUSION

Monitoring of plasma D-dimer levels after hepatectomy is useful for early diagnosis of VTE and may avoid routine prophylactic anticoagulation in the postoperative period.

Transfusion use and effect on progression-free, overall survival, and quality of life in upfront treatment of advanced epithelial ovarian cancer: evaluation of the European Organization for Research and Treatment EORTC-55971 Cohort

BACKGROUND

The impact of blood transfusion on ovarian cancer survival is uncertain.

OBJECTIVE

To investigate whether peri-operative blood transfusion negatively impacted progression-free survival, overall survival, and quality of life in patients with advanced ovarian cancer.

METHODS

We performed an ancillary analysis of the European Organization for Research and Treatment (EORTC) 55971 phase III trial, in which patients were randomized to primary debulking surgery versus neoadjuvant chemotherapy. Patients included in the per-protocol analysis were categorized by receipt of a transfusion.

RESULTS

612 of 632 (97%) of patients had adequate data for analysis. Of those, 323 (53%) received a transfusion. The transfusion cohort was more likely to have had better Word Health Organization (WHO) performance status, serous histology, undergone primary debulking surgery, and received more aggressive surgery, with higher rates of no gross residual disease. Median overall survival was 34.0 vs 35.2 months in the no transfusion and transfusion cohorts (p=0.97). The adjusted HR for death was 1.18 (95% CI 0.94 to 1.48) in favor of the transfusion cohort. Median progression-free survival was 13.6 vs 12.6 months in the no transfusion and transfusion cohorts (p=0.96). The adjusted HR for progression was 1.14 (95% CI 0.91 to 1.43). There were no significant differences in global quality of life, fatigue, dyspnea, or physical functioning between the two cohorts at baseline or at any of the four assessment times. Grade 3 and 4 surgical site infections were more common in the transfusion cohort.

CONCLUSION

Transfusion did not negatively impact progression-free survival or overall survival; however, it was associated with increased peri-operative morbidity without improvements in quality of life.

Perioperative management with ferric carboxymaltose and tranexamic acid to reduce transfusion rate in gynaecological carcinoma surgery (TRANAFER-Study): study protocol for a single-blind, monocentre, randomised trial

INTRODUCTION

Radical abdominal surgery is part of the standard treatment for women with advanced gynaecological carcinoma. The surgery often leads to intraoperative blood loss frequently exceeding 1000 mL. Approximately 50% of women undergoing radical surgery require blood transfusions. Perioperative blood transfusions have been shown to increase the risk of postoperative complications, delayed wound healing, increased length of stay, increased postoperative morbidity and mortality. Previous studies have demonstrated an association between perioperative anaemia and surgical morbidity and mortality. By reducing transfusions and improving recovery from surgery, preoperative diagnostic and management of perioperative anaemia is a great opportunity to optimise postoperative patient outcome.

METHODS AND ANALYSIS

This is a single-blind, monocentre, randomised trial with four parallel groups (three therapeutic groups and one control group without treatment according to current standards of care) conducted in women undergoing radical gynaecological surgery. The primary study objective is to determine the effect of perioperative treatment with either intravenous iron, tranexamic acid or with a combination of both medicines on the reduction of intraoperative and postoperative red blood cell transfusions in gynaecological carcinoma patients. A total of N=126 women with gynaecological carcinoma will be recruited at the University Hospital Basel, Department of Gynaecology. Blood parameters will be measured at the recruitment, prior to surgery, 2 days after surgery and on the 21st-28th day after surgery. Recruitment started in August 2021.

ETHICS AND DISSEMINATION

The study will be performed according to the guidelines of the Declaration of Helsinki and is approved by the Ethics Committee for Northwest and Central Switzerland in Basel (EKNZ Protocol ID 2020-01194). The results of this study will be published and presented in various scientific forums.

TRIAL REGISTRATION NUMBER

NCT03792464.

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

Introduction

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

Materials and methods

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

Results

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

Discussion

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

Risk of venous thromboembolism for ovarian cancer patients during first-line therapy after implementation of an Enhanced Recovery After Surgery (ERAS) protocol

OBJECTIVE

To determine incidence and risk factors for VTE for patients with advanced epithelial ovarian cancer undergoing first-line therapy, including cytoreductive surgery, on an Enhanced Recovery After Surgery (ERAS) protocol.

METHODS

Medical records were reviewed for patients with FIGO stage IIIA-IVB epithelial ovarian, fallopian tube, or primary peritoneal cancer undergoing primary or interval cytoreductive surgery from March 2017 through September 2019. All patients were enrolled on an ERAS protocol, including 28-day postoperative VTE prophylaxis. Demographic information, medical history, perioperative characteristics, and ERAS compliance were evaluated using univariate and multivariate models.

RESULTS

Of 230 patients undergoing cytoreductive surgery via laparotomy, 155 received neoadjuvant chemotherapy and 75 received primary cytoreduction. 38 patients had a VTE during the study period. 13 events (5.7%) were identified at time of diagnosis, 6 (3.9%) during neoadjuvant chemotherapy, 5 (2.2%) within 30 days after surgery, 5 (2.2%) between 30 days and 6 months after surgery, and 9 (3.9%) after the 6-month window. The cumulative incidence of VTE was 6.1% (95% CI, 4.3-8.8%) within 6 months after diagnosis and 8.5% (6.2-11.4%) within 1 year after diagnosis. Estimated blood loss (adjusted HR 1.22 [95% CI, 1.09-1.36], p = 0.001) and history of VTE (7.06 [2.34-21.29], p = 0.001) were independently associated with VTE.

CONCLUSION

With implementation of an ERAS protocol, only 1 in 46 patients experienced a VTE within 30 days after surgery. However, overall VTE occurred in 1 in 16 patients during first-line therapy. Strategies to further reduce VTE risk, especially during neoadjuvant chemotherapy and surveillance, should be investigated.

Venous Thromboembolism After Blood Transfusions in Women Undergoing Hysterectomy for Non-Malignant Indications: A Retrospective Cohort Study

OBJECTIVE

To quantify the effect of blood transfusion on the risk of venous thromboembolism (VTE) among women undergoing hysterectomy for non-malignant indications.

METHODS

A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was conducted. Women who underwent hysterectomy for non-malignant indications between 2011 and 2016 were identified using the Current Procedural Terminology and Internationally Classification of Diseases codes. The primary outcome was development of VTE. Data on patient demographics and perioperative variables were obtained. Pair-wise comparison using χ² tests were performed to compare women with and without VTE. Multivariable logistic regression was performed to adjust for potential confounders and identify independent predictors of VTE.

RESULTS

Between 2011 and 2016, 169 593 women underwent hysterectomy for non-malignant indications. The overall incidence of VTE was 0.32%. Patient characteristics associated with VTE included obesity and higher American Society of Anesthesiologists (ASA) status. Associated operative factors included abdominal surgery, blood transfusion, and prolonged operative time (P < 0.05 for all). Following adjustment for potential confounders, abdominal hysterectomy was associated with greater odds of VTE than laparoscopic or vaginal approaches (adjusted odds ratio [aOR] 1.81; 95% CI 1.48-2.21 and aOR 2.31; 95% CI 1.62-3.28, respectively). Greater odds of VTE were also observed with OR time >150 minutes (aOR 1.88; 95% CI 1.46-2.42), ASA class ≥III (aOR 1.53; 95% CI 1.05-2.26), and intra- and postoperative transfusion (aOR 2.65; 95% CI 1.78-3.95 and aOR 2.98; 95% CI 1.95-4.55, respectively).

CONCLUSION

The risk of VTE is low in women undergoing hysterectomy for non-malignant indications. Blood transfusion was associated with the highest risk of VTE.

Incidence and risk factors for postoperative venous thromboembolism in patients with ovarian cancer: Systematic review and meta-analysis

BACKGROUND

Venous Thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with ovarian malignancy. There is no meta-analysis available on this topic so far. The aim of our study was to quantitatively synthesize the data from studies with respect to the incidence and risk factors for postoperative VTE among cases with epithelial ovarian cancer (EOC).

METHODS

PubMed, Web of Science, and Embase were searched for papers containing the key words "venous thromboembolism", "postoperative", "postoperation", "ovarian neoplasm", "ovary neoplasm", "ovarian cancer", "ovary cancer", and "cancer of ovary". Studies selection, data extraction, quality assessment of eligible studies were performed independently by our different reviewers. Meta-analyses were conducted to determine postoperative VTE incidence and risk factors in women with EOC. Sensitivity analysis were used to verify the robustness of the results of meta-analyses if necessary.

RESULTS

In total, 19 studies were included in this meta-analysis. The pooled incidence for postoperative symptomatic VTE was 3% (95% CI, 0.03-0.04) and for postoperative symptomatic as well as asymptomatic VTE was 8% (95% CI, 0.07-0.09). The presence of history of VTE (OR, 2.37), advanced-stages (OR, 2.35), high complexity of surgery (OR, 2.20), clear cell carcinoma of ovary (OR, 2.53) and residual disease>1 cm (OR, 2.57) significantly increase the likelihood of having postoperative VTE. Other risk factors for postoperative VTE in EOC patients were BMI>30 (OR, 1.58), per 10-years increase in age (OR, 1.22), ASA score>2 (OR, 1.45), ascites (OR, 2.07), the diameter of residual disease is between 0 cm to 1 cm (OR, 2.06) and smoking history (OR, 1.54).

CONCLUSIONS

This study revealed that VTE, especially subclinical VTE, is a prevalent complication in postoperative patients with EOC. History of VTE, advanced FIGO stages, high complexity of surgery, obesity, older age, ascites, higher ASA score, smoking history and suboptimal debulking are associated with this increased incidence of postoperative VTE among patients with EOC. PROSPERO registration number: CRD42020209662.

Perioperative blood transfusion and ovarian cancer survival rates: A meta-analysis based on univariate, multivariate and propensity score matched data

The negative impact of perioperative blood transfusion on survival outcomes has been reported in several cancer types. The purpose of the present study is to summarize existing evidence in ovarian cancer patients. We searched the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases for observational and randomized trials that assessed the impact of perioperative blood transfusion on the disease-free survival (DFS) and overall survival (OS) of ovarian cancer patients that undergone debulking surgery were selected for inclusion. The methodological quality of the included studies was assessed by using the Newcastle-Ottawa Scale. Statistical meta-analysis was performed with the RevMan 5.3 software using the Der-Simonian Laird random effects model. Seven studies were identified which included 2341 ovarian cancer patients. Meta-analyses that were based on univariate and multivariate reporting revealed that perioperative blood transfusion had a significant negative impact on the patient`s OS rates (OR 1.78, 95 %CI 1.16, 2.74 and OR 1.31, 95 %CI 1.00, 1.71 respectively). Disease free survival rates were also influenced according to the results of the univariate analysis (OR 1.58, 95 %CI 1.14, 2.19), however, the effect was not significant in the multivariate analysis. The analysis that was based on propensity score matched populations did not reveal differences among transfused and non-transfused. Concluding, the findings of our meta-analysis suggest that transfusion of blood products during the perioperative period is not an independent factor that may affect survival outcomes of ovarian cancer patients. Nevertheless, it should be noted that patients that receive transfusion have several potential confounders that may affect their survival outcomes.

Intra-operative blood transfusion significantly increases the risk of post-operative pulmonary embolism

Background

Pulmonary embolism (PE) is a serious and preventable complication after surgery. Blood transfusion is a common event during surgery. The aim of the present study was to identify whether intra-operative blood product transfusions increase the risk of symptomatic post-operative PE.

Methods

A retrospective, single-center case-control study at Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University between 1 January 2013 and 31 December 2016 was performed. Adult hospitalized patients with confirmed symptomatic PE after surgery were defined as case group. Each patient was matched with two adult patients without symptomatic PE who underwent the same procedure on the same day or within one week. Perioperative data especially detailed blood transfusion was collected. Forward stepwise logistic regression analysis was performed.

Results

During the study period, altogether 188,512 procedures were included, and postoperative PE were confirmed in 40 (0.02%) patients. Twelve (30.0%) case patients and 16 (20.0%) control patients received intra-operative blood transfusion. Intra-operative blood transfusion was revealed as a significant predictor for symptomatic post-operative PE (OR 80.669, 95% CI: 3.312-1,964.641, P=0.007), along with female sex (OR 86.921, 95% CI: 4.242-1,781.124, P=0.004), older age (OR 1.078, 95% CI: 1.005-1.156, P=0.035), longer length of stay before surgery (OR 1.124, 95% CI: 1.040-1.214, P=0.003) and longer operation time (OR 1.013, 95% CI: 1.002-1.025, P=0.024).

Conclusions

Intra-operative blood transfusion was associated with an increased risk of symptomatic post-operative PE. PE prophylaxis and selective screening should be considered in patients who had received intra-operative blood transfusion, especially in female patients.

Blood transfusions increase the risk of venous thromboembolism following ventral hernia repair

BACKGROUND

Blood transfusions can affect the clotting cascade, leading to a hypercoagulable state. The association of a venous thromboembolic (VTE) event and perioperative blood transfusion has been identified previously in surgical patients, but not after ventral hernia repair (VHR). The aim of this study was to evaluate the risk of VTE in VHR patients who receive a perioperative blood transfusion.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program was queried for open (n = 34,687) and laparoscopic (n = 11,544) VHRs that occurred from 2013 to 2015. Regression analyses were used to determine factors predictive of VTE within 30-day post-operatively, the impact of bleeding requiring blood transfusion, and the influence of surgical approach on VTE.

RESULTS

Post-operative VTE occurred in 246 (0.5%) VHR patients. Among those patients, 53.0% occurred after discharge. Increased age, operative time, and comorbidities increased the risk of VTE (p < 0.05). Controlling for surgical approach, perioperative blood transfusion increased the risk of VTE 10.2-fold (p < 0.0001) in open and 12.2-fold in laparoscopic VHR (p < 0.0001).

CONCLUSION

Perioperative blood transfusions are associated with an increased rate of VTE following VHR, more than 50% of which occur after discharge. This study highlights the importance of identifying quality initiatives for at risk patients, including adequate VTE screening and potential prophylaxis for those who receive perioperative blood transfusions.

Infection, thrombosis, and oncologic outcome after interval debulking surgery: Does perioperative blood transfusion matter?

OBJECTIVES

To determine whether perioperative red blood cell transfusion (PRBCT) affects infection, thrombosis, or survival rates in epithelial ovarian cancer (EOC) patients undergoing neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS).

METHODS

Demographics, operative characteristics, and outcome data were abstracted from records of stage IIIC-IV EOC patients managed with NACT-IDS from 01/2010-07/2015. Associations of PRBCT with morbidity and oncologic outcomes were evaluated.

RESULTS

Of 270 patients, 136 (50.4%) received PRBCT. Patients with preoperative anemia and higher estimated blood loss (EBL) were more likely to undergo PRBCT (OR,95%CI 1.80, 1.02-3.17) and (OR,95%CI 1.00, 1.002-1.004), respectively. There were no significant differences in PRBCT based on patient age, Charlson Comorbidity Index, or stage. When compared to low complexity operations, patients with moderate and high complexity surgeries were more likely to receive PRBCT (OR,95%CI 1.81, 1.05-3.09) and (OR,95%CI 2.25, 1.13-4.50), respectively. On univariate analysis, PRBCT was associated with intraabdominal infection (OR,95%CI 8.31, 1.03-67.41), but not wound complications (OR,95%CI 1.57, 0.76-3.23) or venous thromboembolism/pulmonary embolism (VTE/PE) (OR,95%CI 2.02, 0.49-8.23). After adjusting for surgical complexity and preoperative anemia, PRBCT was not independently associated with intraabdominal infection (OR,95%CI 7.66, 0.92-63.66), wound complications (OR,95%CI 1.70, 0.80-3.64), or VTE/PE (OR,95%CI 2.15, 0.51-9.09). When comparing patients undergoing PRBCT versus those who did not, there were no significant differences in median progression-free survival (PFS) or median overall survival (OS) on univariate analysis after adjusting for age, stage and residual disease.

CONCLUSIONS

Among patients undergoing NACT-IDS, intraabdominal infection, wound complication and VTE/PE rates are similar, regardless of PRBCT. PRBCT does not impact PFS or OS.

Neoadjuvant chemotherapy is associated with a high rate of perioperative blood transfusion at the time of interval cytoreductive surgery

Background

The oncologic safety of allogeneic blood transfusion in ovarian cancer patients is unknow. We sought to determine the prevalence and oncologic safety of perioperative allogeneic blood transfusion during interval cytoreduction surgery among women receiving neoadjuvant chemotherapy for ovarian cancer.

Methods

We utilized retrospective chart review to identify a cohort of patients undergoing interval cytoreduction at a large academic tertiary referral center. We compared outcomes in patients who were exposed to perioperative blood transfusion compared with patients who were not exposed. Our primary endpoint was progression free survival; our secondary endpoint was overall survival. Baseline clinical characteristics were collected for patients in each group.

Results

Sixty-six women were included in the final cohort of women undergoing interval cytoreductive surgery after NACT. A total of 51 women (77%) were exposed to allogeneic perioperative pRBC transfusion. Fifteen women (23%) were not exposed to transfusion. The baseline characteristics were generally well matched. Women who were not exposed to a perioperative blood transfusion were more likely to have a normalized CA125 prior to undergoing cytoreductive surgery. Preoperative hemoglobin concentration was lower in the transfusion group (10.5 g/dLvs 11.5 g/dL, p < 0.009). Perioperative transfusion was not associated with a significant difference in progression free survival (PFS = 7.6 months for transfused, 9.4 months for not transfused; log-rank test p = 0.4617). Similarly, there was no observed difference between groups for overall survival (OS = 23.6 months for transfused, 22.5 months for not transfused; log-rank test p = 0.1723).

Conclusions

Women undergoing neoadjuvant chemotherapy for ovarian cancer are at high risk of exposure to blood transfusion at the time of interval cytoreductive surgery. Future studies will continue to evaluate the safety and impact of transfusion on ovarian cancer survival in this at risk population.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4882-8) contains supplementary material, which is available to authorized users.

Transfusion of autologous extracellular vesicles from stored red blood cells does not affect coagulation in a model of human endotoxemia

BACKGROUND

Red blood cell (RBC) transfusion has been related to thromboembolic events. Microvesicles in the RBC product may support coagulation because they have procoagulant effects in vitro. We investigated whether transfusion of RBCs containing extracellular vesicles promotes coagulation in human recipients. As transfusion is mostly administered to ill patients, we used a model of endotoxemia.

STUDY DESIGN AND METHODS

Eighteen healthy volunteers were randomized to receive either saline or fresh (2 days stored) or stored autologous (35 days stored) RBC transfusion (Dutch Trial Register: NTR4455). Two hours after infusion of lipopolysaccharide (LPS, from Escherichia coli, 2 ng/kg body weight), subjects received either saline or fresh or stored RBCs. Blood was sampled every 2 hours up to 8 hours after LPS infusion. Vesicles were measured with a flow cytometer (A50-Micro, Apogee Flow Systems).

RESULTS

LPS resulted in increased thrombin generation compared to baseline. During storage, the total number of extracellular vesicles increased from 1.4 × 10⁸ /mL (interquartile range [IQR], 8.3 × 10⁷ -1.9 × 10⁸ /mL) in the fresh product to 1.7 × 10¹⁰ /mL (IQR, 7.9 × 10⁹ -2.3 × 10¹⁰ /mL; p < 0.01) in the stored product (p < 0.001). Vesicles appeared to be mostly RBC derived.

CONCLUSION

After transfusion, extracellular vesicles from stored RBC products, but not from fresh products, could be detected in the circulation of healthy volunteers. However, infusion of stored RBC extracellular vesicles did not augment thrombin generation compared to endotoxemic controls. Also, levels of d-dimer and thrombin-antithrombin complex were unaffected. In conclusion, transfusion of autologous RBCs containing high levels of extracellular vesicles does not enhance coagulation in human volunteers with endotoxemia.

Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery

BACKGROUND

Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion.

RESULTS

The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9-7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05).

CONCLUSIONS

Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.

Indications for and complications of transfusion and the management of gynecologic malignancies

Anemia, which is highly prevalent in oncology patients, is one of the most established negative prognostic factors for several gynecologic malignancies. Multiple factors can cause or contribute to the development of anemia in patients with gynecologic cancers; these factors include blood loss (during surgery or directly from the tumor), renal impairment (caused by platinum-based chemotherapy), and marrow dysfunction (from metastases, chemotherapy, and/or radiation therapy). Several peri- and intra-operative strategies can be used to optimize patient management and minimize blood loss related to surgery. Blood transfusions are routinely employed as corrective measures against anemia; however, blood transfusions are one of the most overused healthcare interventions. There are safe and effective evidence-based blood transfusion strategies used in other patient populations that warrant further investigation in the surgical oncology setting. Blood is a valuable healthcare resource, and clinicians can learn to use it more judiciously through knowledge of the potential risks and complications of blood interventions, as well as the ability to properly identify the patients most likely to benefit from such interventions.

Application of a clot-based assay to measure the procoagulant activity of stored allogeneic red blood cell concentrates

BACKGROUND

Thrombotic effects are possible complications of red blood cell transfusion. The generation and accumulation of procoagulant red blood cell extracellular vesicles during storage may play an important role in these thrombotic effects. The objective of this study was to assess the value of a simple phospholipid-dependent clot-based assay (STA^®-Procoag-PPL) to estimate the procoagulant activity of stored red blood cells and changes in this activity during storage of the blood component.

MATERIALS AND METHODS

Extracellular vesicles from 12 red blood cell concentrates were isolated at 13 storage time-points and characterised by quantitative and functional methods: the degree of haemolysis (direct spectrophotometry), the quantification and determination of cellular origin (flow cytometry) and the procoagulant activity (thrombin generation and STA^®-Procoag-PPL assays) were assessed.

RESULTS

The mean clotting time of extracellular vesicles isolated from red blood cell concentrates decreased from 117.2±3.6 sec on the day of collection to 33.8±1.3 sec at the end of the storage period. This illustrates the phospholipid-dependent procoagulant activity of these extracellular vesicles, as confirmed by thrombin generation. Results of the peak of thrombin and the STA^®-Procoag-PPL were well correlated (partial r=-0.41. p<0.001). In parallel, an exponential increase of the number of red blood cell-derived extracellular vesicles from 1,779/μL to 218,451/μL was observed.

DISCUSSION

The STA^®-Procoag-PPL is a potentially useful technique for assessing the procoagulant activity of a red blood cell concentrate.

Platelet-derived microparticles trigger THP-1 monocytic cell aggregation and release of pro-coagulant tissue factor-expressing microparticles in vitro

Microparticles (MPs) released by blood or endothelial cells are present in plasma for transfusion. They originate from the collected donor blood or are triggered by the variable steps taking place during collection and production/storage processes of blood components. While MPs may contribute to hemostasis, their presence in transfused plasma may lead to uncontrolled thrombin generation when transfused to susceptible cancer or hypercoagulable patients. Understanding the biochemical and cellular triggers of MP-mediated thrombogenesis is therefore crucial. We isolated platelet MPs (PMPs) present in platelet concentrate supernatant plasma (N-PMPs) or prepared by activation of isolated platelets using 0.1 IU/mL thrombin (T-PMPs). N-PMPs and T-PMPs were characterized by dynamic light scattering and counted by tunable resistive pulse sensing to determine population size and number. T-MPMs, but not N-PMPs, induced immediate, long-lasting, strong aggregation of THP-1 monocytic cells in vitro. In addition, co-cultures of THP-1 cells with both N-PMPs and T-PMPs triggered the generation of pro-coagulant tissue factor (TF)-bearing MPs from THP-1 cells. Therefore, some PMPs may induce THP-1 monocytic cell aggregation in vitro and trigger immune cell-mediated thrombogenicity linked to the release of pro-coagulant tissue factor-bearing MPs. Controlling the impact of the presence of PMPs in transfused blood components in certain patient population or critically ill patients deserves in-depth consideration.

Perioperative blood transfusion in gynecologic oncology surgery: analysis of the National Surgical Quality Improvement Program Database

OBJECTIVE

To use a large-scale multi-institutional dataset to quantify the prevalence of packed red blood cell transfusions and examine the associations between transfusion and perioperative outcomes in gynecologic cancer surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use file was queried for all gynecologic cancer cases between 2010 and 2012. Demographic, preoperative and intraoperative variables were compared between transfusion and non-transfusion groups using chi-squared, Fisher's exact and Wilcoxon rank-sum tests. The primary endpoint was 30-day composite morbidity. Secondary endpoints included composite surgical site infections, mortality and length of stay.

RESULTS

A total of 8519 patients were analyzed, and 13.8% received a packed red blood cell transfusion. In the multivariate analysis, after adjusting for key clinical and perioperative factors, including preoperative anemia and case magnitude, transfusion was associated with higher composite morbidity (OR = 1.85, 95% CI 1.5-2.24), surgical site infections (OR 1.80, 95% CI 1.39-2.35), mortality (OR 3.38, 95% CI 1.80-6.36) and length of hospital stay (3.02 days v. 7.17 days, P < 0.001).

CONCLUSIONS

Blood transfusions are associated with increased surgical wound infections, composite morbidity and mortality. Based on our analysis of the NSQIP database, transfusion practices in gynecologic cancer should be scrutinized. Examination of institutional practices and creation of transfusion guidelines for gynecologic malignancies could potentially result in better utilization of blood bank resources and clinical outcomes among patients.

The central role of extracellular vesicles in the mechanisms of thrombosis in paroxysmal nocturnal haemoglobinuria: a review

Paroxysmal nocturnal haemoglobinuria (PNH) is an acquired disorder of the haematopoietic stem cell that makes blood cells more sensitive to the action of complement. PNH patients experience an increased risk of arterial and venous thrombosis – major causes of death due to this disease. Though many potential interlaced mechanisms are suspected, extracellular vesicles (EVs) of various origins may play a central role. The processes possibly involved are haemolysis, platelet activation, injured endothelial cells and monocyte activation. The impact of transfusion should be evaluated. A better understanding of the mechanisms involved may help to propose guidelines for the prophylaxis and treatment of thrombosis in PNH. In this paper, we propose an updated review of the pathophysiology of the underlying mechanisms of thrombosis associated with PNH, with specific focus on the prominent role of EVs.

Single-dose tranexamic acid in advanced ovarian cancer surgery reduces blood loss and transfusions: double-blind placebo-controlled randomized multicenter study

OBJECTIVE

To determine whether single-dose tranexamic acid given intravenously immediately before surgery for presumed advanced ovarian cancer reduces perioperative blood loss and blood transfusions.

DESIGN

A randomized double-blind, placebo-controlled multicenter study.

SETTING

Two university hospitals and two central hospitals in the southeast health region of Sweden.

POPULATION

One hundred women with presumed advanced ovarian cancer scheduled for radical debulking surgery between March 2008 and May 2012 who complied with inclusion/exclusion criteria were randomized; 50 were allocated to receive tranexamic acid and 50 to receive placebo. Analysis was performed according to intention-to-treat principles.

METHODS

The volume of tranexamic acid (15 mg/kg body weight, 100 mg/mL tranexamic acid) or the same volume of placebo (0.9% NaCl) was added to a 100-mL saline solution plastic bag. The study medication was given immediately before the start of surgery. Data were analyzed by means of non-parametric statistics and multivariate models adjusted for confounding factors.

MAIN OUTCOME MEASURES

Blood loss and red blood cell transfusions.

RESULTS

The total blood loss volume and transfusion rate were significantly lower in the tranexamic acid group compared with the placebo group. Median total blood loss was 520 and 730 mL, respectively (p = 0.03). Fifteen (30%) and 22 (44%), respectively received transfusions (odds ratio 0.44; upper 95% CI 0.97; p = 0.02).

CONCLUSION

A single dose of tranexamic acid given immediately before surgery reduces blood loss and transfusion rates significantly in advanced ovarian cancer surgery. Tranexamic acid may be recommended as standard prophylactic treatment in advanced ovarian cancer surgery.

Evaluation of Risk Factors for Venous Thromboembolism in Chinese Women With Epithelial Ovarian Cancer

Objective

Venous thromboembolism (VTE) is a life-threatening complication that often occurs in ovarian tumors. However, the risk factors for VTE are still undetermined.

Methods

We retrospectively analyzed VTE occurrence and its potential risk factors in 254 Chinese patients with ovarian tumor at Fudan University Cancer Hospital from July 2007 to June 2011.

Results

The VTE incidence was 7.1% (13/183) in epithelial ovarian cancer (EOC), and no VTE was found in ovarian borderline or benign tumor. D-dimer levels were significantly higher in EOC than in ovarian benign and borderline tumors. Furthermore, D-dimer levels increased with the advancement of EOC stages. Correlation analysis suggested that D-dimer levels were well correlated with platelet counting (PLT), prothrombin time (PT), white blood cell counting (WBC), cancer antigen (CA) 125, and CA153. Univariate logistic regression analysis found that D-dimer levels greater than 788 μg/L, PLT levels greater than 261 × 109/L, PT greater than 11.7 seconds, CA125 greater than 760 U/mL, and ascites greater than 1500 mL are risk factors for VTE in EOC. Moreover, multivariate analysis grouped primary EOC, low differentiated grade, D-dimer greater than 788 μg/L, PT greater than 11.7 seconds, and CA125 greater than 760 U/mL as prediction factors for VTE.

Conclusions

In addition to D-dimer and ascites, high levels of PLT, PT, and CA125, which are highly correlated with D-dimer, are independent risk factors for VTE

Association of blood transfusion and venous thromboembolism after colorectal cancer resection

INTRODUCTION

Red blood cell (RBC) transfusion is a common event in the perioperative course of patients undergoing surgery. Transfused blood can disrupt the balance of coagulation factors and modulates the inflammatory cascade. Since inflammation and coagulation are tightly coupled, we postulated that RBC transfusion may be associated with the development of venous thromboembolic phenomena. We queried the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database to examine the relationship between intraoperative blood transfusion and development of venous thromboembolism (VTE) in patients undergoing colorectal resection for cancer.

MATERIALS AND METHODS

We analyzed the data from 2005 to 2009 for patients undergoing colorectal resections for cancer based on the primary procedure CPT-4 code and operative ICD-9 diagnosis code. The primary outcome was 30-day deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Intraoperative transfusion of RBC's was categorized as: none, 1-2 units, 3-5 units and 6 units or more. DVT/PE occurrences were analyzed by multivariable forward stepwise regression (p for entry<.05, for exit>.10) to identify independent predictors of DVT.

RESULTS

The database contained 21943 colorectal cancer resections. The DVT rate was 1.4% (306/21943) and the PE rate was 0.8% (180/21943). Patients were diagnosed with both only 40 times and the combined DVT or PE rate (VTE) was 2.0% (446/21943). After adjusting for age, gender, race, ASA (American Society of Anesthesiologists) class, emergency procedure, operative duration and complexity of the procedure (based on Relative Value Units, RVU's), along with six clinical risk factors, intraoperative blood transfusion was a significant risk factor for the development of VTE and the risk increased with increasing number of units transfused. Preoperative hematocrit did not enter the multivariable model as an independent predictor of VTE, nor did open versus laparoscopic resection or wound class.

CONCLUSION

In this study of 21943 patients undergoing colorectal resection for cancer, blood transfusion is associated with increased risk of VTE. Malignancy and surgery are known prothrombotic stimuli, the subset of patients receiving intraoperative RBC transfusion are even more at risk for VTE, emphasizing the need for sensible use of transfusions and rigorous thromboprophylaxis regimens.

Blood transfusions, thrombosis, and mortality in hospitalized patients with cancer

BACKGROUND

Anemia is frequent in patients with cancer, but there are concerns regarding treatment with erythropoiesis-stimulating agents. Blood transfusions are commonly used as an alternative, but with little data regarding outcomes.

METHODS

In a retrospective cohort study, we investigated the associations between transfusions and venous thromboembolism, arterial thromboembolism, and mortality in hospitalized patients with cancer using the discharge database of the University HealthSystem Consortium, which included 504 208 hospitalizations of patients with cancer between 1995 and 2003 at 60 US medical centers.

RESULTS

Of the patients included, 70 542 (14.0%) received at least 1 red blood cell (RBC) transfusion and 15 237 (3.0%) received at least 1 platelet transfusion. Of patients receiving RBC transfusions, 7.2% developed venous thromboembolism and 5.2% developed arterial thromboembolism, and this was significantly greater than the rates of 3.8% and 3.1%, respectively, for the remaining study population (P < .001). In multivariate analysis, RBC transfusion (odds ratio [OR], 1.60; 95% confidence interval [CI], 1.53-1.67) and platelet transfusion (1.20; 1.11-1.29) were independently associated with an increased risk of venous thromboembolism. Both RBC transfusion (OR, 1.53; 95% CI, 1.46-1.61) and platelet transfusion (1.55; 1.40-1.71) were also associated with arterial thromboembolism (P < .001 for each). Transfusions were also associated with an increased risk of in-hospital mortality (RBCs: OR, 1.34; 95% CI, 1.29-1.38; platelets: 2.40; 2.27-2.52; P < .001).

CONCLUSIONS

Both RBC and platelet transfusions are associated with increased risks of venous and arterial thrombotic events and mortality in hospitalized patients with cancer. Further investigation is necessary to determine whether this relationship is causal.

Multivariable Predictors of Postoperative Venous Thromboembolic Events after General and Vascular Surgery: Results from the Patient Safety in Surgery Study

BACKGROUND

Venous thromboembolism (VTE) is a potentially preventable postoperative complication. Accurate risk prediction is an essential first step toward limiting serious, and sometimes fatal, postoperative VTE. We sought to develop and test a model to predict patients at high risk for postoperative VTE.

STUDY DESIGN

Data from the Patient Safety in Surgery (PSS) Study were used to develop and test a predictive model of VTE using multiple logistic regression analyses.

RESULTS

VTE occurred in 1,162 of 183,069 (0.63%) patients undergoing vascular and general surgical procedures. The 30-day mortality in patients who suffered a VTE was 11.19%. Fifteen variables independently associated with increased risk of VTE included patient factors (female gender, higher American Society of Anesthesiologists class, ventilator dependence, preoperative dyspnea, disseminated cancer, chemotherapy within 30 days, and > 4 U packed red blood cell transfusion in the 72 hours before operation), preoperative laboratory values (albumin < 3.5 mg/dL, bilirubin > 1.0 mg/dL, sodium > 145 mmol/L, and hematocrit < 38%), and operative characteristics (type of surgical procedure, emergency operation, work relative value units, and infected/contaminated wounds). These variables were used to develop a predictive model for postoperative VTE (c-index = 0.7647) and a risk score that can be used in the preoperative assessment of patients undergoing major operations.

CONCLUSIONS

Venous thromboembolic events after noncardiac operations are relatively infrequent but highly lethal. Important multivariable risk factors for VTE in this setting were identified in the large PSS database. The risk-prediction scoring system, developed by using the logistic regression odds ratios, helps to identify patients at risk for postoperative VTE and to institute appropriate perioperative prophylactic measures.

Determination of the necessary total protein substitution requirements in patients with advanced stage ovarian cancer and ascites, undergoing debulking surgery. Correlation with plasma proteins

BACKGROUND

Ascites is common in patients with advanced ovarian carcinoma (AOC). Its drainage during surgery affects plasma proteins. We sought to correlate the volume of ascites with the oncological parameters of the disease, calculate its drainage effect on plasma proteins, and determine the necessary substitution requirements and a clinical way of achieving that.

PATIENTS AND METHODS

We evaluated 138 patients with AOC and ascites who underwent primary cytoreductive surgery. Intraoperatively found ascites and its postoperative production were evaluated. Its drainage effect on plasma proteins and the substitution requirements were determined using a mathematic formula. Human albumin(HA) and fresh frozen plasma (FFP) were used to cover these requirements.

RESULTS

The intraoperative ascites was found to correlate only with the stage of the disease, while its postoperative production correlated with the residual disease. Optimally debulked patients had a mean ascites production of 128 mL on postoperative day 1 compared with 668 mL of the suboptimally debulked. This production required 3 and 5-7 days, respectively, to drop <50 mL. Plasma proteins fell on their minimum level (88.9 versus 80.8%) on the second postoperative day. The protein deficit was calculated to be 379 and 691 g/day, respectively. This deficit was substituted by administering 2 HA and 2 FFP for 3-6 days.

CONCLUSIONS

Ascites drainage affects the postoperative homeostasis of plasma proteins. A mean acute drop of 12-20% is monitored on postoperative day 2. This deficit can be managed with HA and FFP for a minimum of 3 days.

Venous Thromboembolism in Obstetrics and Gynecology

The diagnosis of venous thromboembolism can present a clinical challenge. Using D-dimer testing and spiral or helical computed tomography scans has simplified the diagnosis of venous thromboembolism. In addition, the use of low molecular weight heparin has become widely accepted in the prevention and treatment of venous thromboembolism. However, further studies are needed to determine optimal prevention and treatment strategies, particularly in the obstetric population.

Perioperative clinical thromboembolic events after radical or partial nephrectomy

OBJECTIVES

To evaluate the incidence of, and identify the risk factors for, clinical thromboembolic events after radical/partial nephrectomy. Cancer is an established risk factor for deep vein thrombosis (DVT) and pulmonary embolism (PE); however, their incidence after nephrectomy for renal tumors has been poorly studied.

METHODS

We reviewed our prospective institutional renal database and identified 2208 patients who underwent renal tumor surgery from January 1989 to July 2005. The clinical parameters evaluated were age, sex, race, body mass index, smoking history, medical comorbidities, American Society of Anesthesia grade, procedure type, estimated blood loss, and length of hospitalization. Hospital records, discharge "International Classification of Diseases, Ninth Revision" codes, and 30-day postoperative morbidity and mortality data were reviewed to identify patients diagnosed with perioperative DVT or PE.

RESULTS

A total of 34 (1.5%, 95% confidence interval 1.1% to 2.1%) thromboembolic events (20 PEs and 14 DVTs) were identified in 33 patients. Patients with a preoperative history of arrhythmia (P = 0.02) or prior DVT (P = 0.053) were more likely to experience PE. The estimated blood loss was directly associated with an increased risk of PE (P = 0.001). Patients with coronary artery disease (P = 0.050) or of advanced age (P = 0.02) were more likely to experience DVT (P = 0.02).

CONCLUSIONS

To our knowledge, this is the first study on the incidence of thromboembolic events after nephrectomy. Thromboembolic events are rare but are more likely to occur in patients with coronary artery disease, cardiac arrhythmia, prior DVT, Stage 3 or 4 tumors, or a large estimated blood loss.