The association of perioperative blood transfusion with colorectal cancer recurrence

Perioperative factors associated with survival following surgery for pancreatic cancer - a nationwide analysis of 473 cases from Denmark

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal cancers worldwide, with an overall 5-year survival rate of only 5%. The effect of perioperative treatment factors including duration of surgery, blood transfusions as well as choice of anesthesia and analgesia techniques on overall survival (OS) following pancreatic resections for PDAC, is currently not well known. We hypothesized that these perioperative factors might be associated with OS after pancreatic resections for PDAC.

METHODS

This is a retrospective study from a nationwide cohort of patients who underwent surgery for PDAC in Denmark from 2011 to 2020. Kaplan-Meier 1, 2 and 5-year survival estimates were 73%, 49% and 22%, respectively. Data were obtained by joining the national Danish Pancreatic Cancer Database (DPCD) and the Danish Anaesthesia Database (DAD). Associations between the primary endpoint (OS) and perioperative factors including duration of surgery, type of anesthesia (intravenous, inhalation or mixed), use of epidural analgesia and perioperative blood transfusions were assessed using Hazard Ratios (HRs). These were calculated by Cox regression, controlling for relevant confounders identified through an assessment of the current literature. These included demographics, comorbidities, perioperative information, pre and postoperative chemotherapy, tumor staging and free resection margins.

RESULTS

Overall, data from 473 resected PDAC patients were available. Multivariate Cox regression indicated that perioperative blood transfusions were associated with shorter OS (HR 2.53, p = 0.005), with survival estimates of 8.8% in transfused vs. 28.0% in non-transfused patients at 72 months after surgery. No statistically significant associations were identified for the duration of surgery or anesthesia/analgesia techniques.

CONCLUSION

In this study, the use of perioperative blood transfusions was associated with shorter OS.

Ethical issues in solid organ transplantation: transfusion-free transplantation in Jehovah's witness patients

PURPOSE OF REVIEW

Jehovah's Witnesses do not accept transfusion of major allogeneic blood fractions. Successful solid organ transplantation is challenging for Jehovah's Witnesses when anemia, coagulation disturbances, and difficult technical aspects co-exist, and key blood bank resources cannot be utilized. Organ availability for transplantation is limited and demand exceeds supply for all organ types. Historically, the likelihood of poor outcomes in Jehovah's Witnesses patients placed ethical limitations on transplant candidacy for this population violating the precept of maximal utilization of a limited resource. The review's purpose is to describe advancements and strategies that make Jehovah's Witnesses transplant outcomes comparable to transfusion-eligible patients and allay the ethical concerns of their candidacy.

RECENT FINDINGS

Immunomodulation from allogeneic transfusion is a cause of significant postop morbidity. Blood conservation strategies have led to improved outcomes across different medical and surgical cohorts and set the stage for expanded utility in Jehovah's Witnesses with organ insufficiency.Published single-center series with descriptions of specific peri-operative strategies describe the path to major blood product avoidance.

SUMMARY

Comparable outcomes in solid organ transplantation for Jehovah's Witnesses without allogeneic transfusion are possible when inclusion-exclusion criteria are respected, and blood conservation strategies employed.

Autologous blood transfusion reduces the requirement for perioperative allogenic blood transfusion in patients undergoing major hepatopancreatobiliary surgery: a retrospective cohort study

INTRODUCTION

Major hepatopancreatobiliary surgery is associated with a risk of major blood loss. The authors aimed to assess whether autologous transfusion of blood salvaged intraoperatively reduces the requirement for postoperative allogenic transfusion in this patient cohort.

MATERIALS AND METHODS

In this single centre study, information from a prospective database of 501 patients undergoing major hepatopancreatobiliary resection (2015-2022) was analysed. Patients who received cell salvage ( n =264) were compared with those who did not ( n =237). Nonautologous (allogenic) transfusion was assessed from the time of surgery to 5 days postsurgery, and blood loss tolerance was calculated using the Lemmens-Bernstein-Brodosky formula. Multivariate analysis was used to identify factors associated with allogenic blood transfusion avoidance.

RESULTS

32% of the lost blood volume was replaced through autologous transfusion in patients receiving cell salvage. Although the cell salvage group experienced significantly higher intraoperative blood loss compared with the noncell salvage group (1360 ml vs. 971 ml, P =0.0005), they received significantly less allogenic red blood cell units (1.5 vs. 0.92 units/patient, P =0.03). Correction of blood loss tolerance in patients who underwent cell salvage was independently associated with avoidance of allogenic transfusion (Odds ratio 0.05 (0.006-0.38) P =0.005). In a subgroup analysis, cell salvage use was associated with a significant reduction in 30-day mortality in patients undergoing major hepatectomy (6 vs. 1%, P =0.04).

CONCLUSION

Cell salvage use was associated with a reduction in allogenic blood transfusion and a reduction in 30-day mortality in patients undergoing major hepatectomy. Prospective trials are warranted to understand whether the use of cell salvage should be routinely utilised for major hepatectomy.

Prognostic factors for renal function deterioration during palliative first-line chemotherapy for metastatic colorectal cancer: a retrospective study

PURPOSE

First-line choice of therapy is critical as it affects treatment decisions in later lines in patients with metastatic colorectal cancer (mCRC). We assessed changes in renal function for 1 year among patients diagnosed with mCRC who received first-line chemotherapy. We aimed to analyze the prognostic factors and effect of each chemotherapy regimen on the renal function of the patients.

METHODS

We retrospectively investigated patients with mCRC who were treated with a standard triplet regimen (FOLFOX/FOLFIRI with bevacizumab/cetuximab) in the first-line setting at Korea University Anam Hospital from 2015 to 2020. We checked renal function at 3-month intervals for 12 months. We calculated changes in eGFR (△eGFR, estimated glomerular filtration rate) and compared them with clinical factors such as age, sex, chronic disease, body mass index (BMI), disease status, baseline proteinuria, and first-line chemotherapy regimen.

RESULTS

Among 472 patients with mCRC, the median eGFR at baseline was 90.9 mL/min/1.73 m²; it was significantly lower (80.1 mL/min/1.73 m², p < 0.001) at 12 months after chemotherapy initiation. Particularly, the eGFR of patients treated with FOLFIRI + bevacizumab was 74.9 mL/min/1.73 m². The 1-year incidence rate of acute kidney injury (AKI) was 9.1%, with the lowest occurrence in patients receiving FOLFOX/cetuximab (2.1%) and the highest in those receiving FOLFIRI + bevacizumab (19.2%). Renal dysfunction was more frequent with FOLFIRI + bevacizumab as compared to the other regimens. Additionally, old age, low BMI, and proteinuria at baseline were also associated with a decreased eGFR.

CONCLUSIONS

These findings can serve as important factors when selecting the first-line chemotherapy regimen for patients with mCRC.

Blood transfusion has an adverse impact on the prognosis of patients receiving chemotherapy for advanced colorectal cancer: experience from a single institution with a patient blood management program

PURPOSE

Perioperative blood transfusion in early stage cancer patients had a negative effect on the prognosis of patients, but the prognostic impact of transfusion in advanced cancer patients remains unclear. To minimize and guide rational transfusion, an institutional patient blood management (PBM) program was launched, and we evaluated the new program that has changed the practice and impacted on the prognosis of advanced cancer patients.

METHODS

We investigated the medical records of colorectal cancer patients who received chemotherapy from 2015 to 2020. The amount and frequency of transfusion, iron replacement and laboratory findings, and overall survival were compared before and after implementation of PBM.

RESULTS

The rate of transfusion in colorectal cancer patients was significantly decreased from 23.5/100 person-quarter in 2015 to 1.2/100 person-quarter in 2020, but iron supplementation therapy was frequently used, and the proportion of patients who received transfusion under hemoglobin 7 g/dL significantly increased from 15.9% in 2015 to 55.3% in 2020. Multivariate analysis revealed that transfusion was a significant risk factor affecting the overall survival of patients (HR 2.70, 95% CI: 1.93-3.78, p<0.001). Kaplan-Meier analysis revealed that overall survival was significantly longer in non-transfused patients than in transfused patients (11.0 versus 22.4 months; HR 0.69, 95% CI: 0.56-0.86, p<0.001).

CONCLUSIONS

This study shows that minimized transfusion through an institutional PBM can positively affect the prognosis of patients who are receiving chemotherapy for advanced colorectal cancer.

A systematic review of the literature assessing operative blood loss and postoperative outcomes after colorectal surgery

PURPOSE

There is no consensus in the literature regarding the association between operative blood loss and postoperative outcomes in colorectal surgery, despite evidence suggesting a link. Therefore, this systematic review assesses the association between operative blood loss, perioperative and long-term outcomes after colorectal surgery.

METHODS

A literature search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane was performed to identify studies reporting on operative blood loss in colorectal surgery.

RESULTS

The review included forty-nine studies reporting on 61,312 participants, with a mean age ranging from 53.4 to 78.1 years. The included studies demonstrated that major operative blood loss was found to be a risk factor for mortality, anastomotic leak, presacral abscess, and postoperative ileus, leading to an increased duration of hospital stay. In the long term, the studies suggest that significant blood loss was an independent risk factor for future small bowel obstruction due to colorectal cancer recurrence and adhesions. Studies found that survival was significantly reduced, whilst the risk of colorectal cancer recurrence was increased. Reoperation and cancer-specific survival were not associated with major blood loss.

CONCLUSION

The results of this systematic review suggest that major operative blood loss increases the risk of perioperative adverse events and has short and long-term repercussions on postoperative outcomes. Laparoscopic and robotic surgery, vessel ligation technology and anaesthetic considerations are essential for reducing blood loss and improving outcomes. This review highlights the need for further high quality, prospective, multicentre trials with a greater number of participants, and accurate and standardised methods of measuring operative blood loss.

Joint modelling of colorectal cancer recurrence and death after resection using multi-state model with cured fraction

Curing of colorectal cancer (CRC) occurs at the time of resection but it is not immediately observable. If the cancer is not completely eliminated, the patient will not be cured of cancer and will experience recurrence as the tumor has regrown to a detectable size. The main propose of the present study was to assess the effects of different covariates on the probability of being cured as well as the time-to-recurrence, and time-to-death in CRC patients by using multi-state cure model. The information of 283 patients with CRC, who underwent resection, from 2000 to 2015 in Imam Khomeini Hospital of Hamadan, Iran, were analyzed. The results of multi-state cure model reveal that females and who experience metastasis were more likely to be apparently cured. It has been shown that sex has a significant effect on the time-to-recurrence given patient was in the not cured group. The survival time of patients of the not cured group was affected by the stage of disease. However, the survival of the apparently cured patients were affected by age at diagnosis and metastasis status. The multi-state cure model provided a flexible framework to study the effects of prognostic factors simultaneously on the transition between different states and the probability of being apparently cured of CRC.

Impact of perioperative transfusions and sepsis on long-term oncologic outcomes after curative colon cancer resection. A retrospective analysis of a prospective database

OBJECTIVE

Intra-abdominal septic complications (IASC) affect short-term outcomes after surgery for colon cancer. Blood transfusions have been associated with worse short-term results. The role of IASC and blood transfusions on long-term oncologic results is still debated. This study aims to assess the impact of these two variables on survival after curative colon cancer resection.

PATIENTS AND METHODS

Retrospective analysis of a prospectively maintained database of patients who underwent curative surgery for colon cancer at a university hospital, between 1993 and 2010. Cox regression was used to identify the role of IASC and transfusions (alone and combined) on local recurrence (LR), disease-free survival (DFS), and cancer-specific survival (CSS).

RESULTS

Out of the 1686 patients analyzed, 1277 fit in the inclusion criteria. Colorectal surgeons performed the procedure in 82.2% of the patients. Blood transfusions were administered to 25.8% of the patients. Thirty-day complication and mortality rates were 34.5% and 6.1%. IASC occurred in 9.9%. The mean follow-up was 66 months. The 5-year rates of LR, DFS, and CSS were 7%, 79.8%, and 85.1%. The year of surgery and pT (Hazard ratio 9.35, 95% CI 1.23-70.9, for T4) and pN (Hazard ratio 2.57, 95% CI 1.39-4.72, for N2) stages were independent risk factors for LR. The same variables, bowel obstruction and surgeries performed by surgeons not specialized in colorectal surgery, were also associated with worse DFS and CSS. IASC and blood transfusions were not associated with LR, DFS, and CSS, whether alone or combined.

CONCLUSIONS

IASC and transfusions were not associated with worse oncological outcomes after curative colon cancer surgery per se. Other factors were more important predictors of survival.

Association of preoperative anemia and perioperative allogenic red blood cell transfusion with oncologic outcomes in patients with nonmetastatic colorectal cancer

Background

We investigated whether preoperative anemia and perioperative blood transfusion (pbt) are associated with overall survival and recurrence-free survival in patients with nonmetastatic colorectal cancer.

Methods

From 1 January 2009 to 31 December 2014, 1003 patients with primary colorectal cancer were enrolled in the study. Perioperative clinical and oncologic outcomes were analyzed based on the presence of preoperative anemia and pbt.

Results

Preoperative anemia was found in 468 patients (46.7%). In the anemia and no-anemia groups, pbt was performed in 44% and 15% of patients respectively. Independent predictors for pbt were preoperative anemia, higher American Society of Anesthesiologists score, laparotomy, lengthy operative time, advanced TNM stage, T4 stage, and 30-day morbidity. The use of pbt, but not preoperative anemia, was found to be an independent adverse prognostic factor for overall survival. In terms of recurrence-free survival, the presence of preoperative anemia was similarly not a significant prognostic factor, but the use of pbt was an independent factor for an unfavourable prognosis.

Conclusions

The use of pbt, but not preoperative anemia, was independently associated with worse overall and recurrence-free survival in nonmetastatic colorectal cancer. For better oncologic outcomes, our findings indicate a need to reduce the use of blood transfusion during the perioperative period.

Prognostic impact of blood transfusion in patients with metastatic non-small cell lung cancer receiving chemotherapy

PURPOSE

To investigate the prognostic effects of Allogeneic Blood Transfusion (ABT) in patients with metastatic Non-Small Cell Lung Cancer (NSCLC) receiving Chemotherapy (CT) in the first-line treatment, comparing untransfused patients to those receiving blood transfusion during treatment period or before treatment period.

METHODS

This was a retrospective study of 433 patients with metastatic NSCLC receiving CT in the first-line treatment. Patients were categorized into 3 groups according to the transfusion strategy as follows; group-U(Untransfused patients, n = 303), group-B(patients receiving transfusion Before treatment period, n = 43), and group-D(patients receiving transfusion During treatment period, n = 87).

RESULTS

There were 433 patients in the analysis, consisting of 388 (89.6%) males, with a median age of 60 years(range, 21-92). The median Overall Survival(mOS) according to the ABT was 14 months for group-U, 9 months for group-B, and 7 months for group-D (p < 0.001). In subgroup analysis, patients with squamous cell carcinoma subtype, mOS was 11 months for group-U, 12 months for group-B, and 9 month for group-D (p = 0.074) The corresponding mOS durations for adenocarcinoma subtype were 21 months, 7 months, and 6 months (p < 0.001). Performing ABT during treatment period was found to be a negative independent factor related to OS (HR 1.50 for progression-free survival, 95% CI 1.15-1.97, HR 1.36 for OS, 95% CI 1.04-1.80).

CONCLUSION

Our results demonstrated that ABT was significantly associated with earlier progression and shorter survival in patients with metastatic NSCLC, especially in adenocarcinoma histology, hence suggesting that transfusion strategy in this group should remain limited, and its benefit should outweigh the risk of progression.

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.

LA TRASFUSIONE DI SANGUE NELLA CHIRURGIA ONCOLOGICA: RUOLO DELLA ERITROPOIETINA RICOMBINANTE UMANA (rHuEPO)

Anemia is common in cancer patients. The pathophysiology is multifactorial, however the most common cause is the anemia of chronic diseases (ACD). In 20-50% of cancer patients, anemia restricts physical activity and quality of life and requires transfusion support. The percentage of patients necessitating transfusion dramatically increases when patients require surgery.

The traditional belief that blood transfusion is an effective and safe therapy has been challenged by a heightened awareness of the infectious and immunologic risks associated with allogeneic blood administration. In cancer patients transfusion-induced immunomodulation may have the potential to significantly increase postoperative infections and cancer recurrence so that it seems reasonable to minimize allogeneic blood exposure.

Several strategies have been adopted to reduce allogeneic transfusion in surgical patients, however to properly select the appropriate blood conservation strategies the blood transfusion requirements for each patient should be defined.

Allogeneic blood transfusion in surgery can be reduced by the introduction of autologous blood (AB) programmes and by the use of rHuEPO, alone or in association with AB techniques. AB donation is currently a standard of care for elective surgical patients but its efficacy is limited by anemia that prevents the donation of the optimal number of AB units. rHuEPO has been shown to significantly increase the volume of AB that anemic patients can predeposit or, used perisurgically, to expand the circulating RBCs mass before surgery. Moreover clinical trials employed rHuEPO in anemic cancer patients with various solid tumors both on and off chemotherapy reporting a significantly increase in Hct in more than 50% of the treated patients. Recently different studies have shown the efficacy of rHuEPO in increasing the volume of AB also in patients with ACD and cancer, thus proving to be a useful addition to existing strategies of blood conservation to minimize exposure to allogeneic blood in surgical cancer patients.

The Effect of Anesthesia on the Immune System in Colorectal Cancer Patients

Colorectal cancer (CRC) is the key leading cause of high morbidity and mortality worldwide. Surgical excision is the most effective treatment for CRC. However, stress caused by surgery response can destroy the body's immunity and increase the likelihood of cancer dissemination and metastasis. Anesthesia is an effective way to control the stress response, and recent basic and clinical research has shown that anesthesia and related drugs can directly or indirectly affect the immune system of colorectal cancer patients during the perioperative period. Thus, these drugs may affect the prognosis of CRC surgery patients. This review is intended to summarize currently available data regarding the effects of anesthetics and related drugs on perioperative immune function and postoperative recurrence and metastasis in CRC patients. Determining the most suitable anesthesia for patients with CRC is of utmost importance.

Transfusion-related immunomodulation: a reappraisal

PURPOSE OF REVIEW

This review summarizes current and prior observations regarding transfusion-related immunomodulation (TRIM) and puts these ideas into a modern immunological context, incorporating concepts from innate, adaptive, and nutritional immunity. We propose that TRIM research focus on determining whether there are specific, well-defined immunosuppressive effects from transfusing 'pure' red blood cells (RBCs) themselves, along with the by-products produced by the stored RBCs as a result of the 'storage lesion.' Macrophages are a key cell type involved in physiological and pathological RBC clearance and iron recycling. The plasticity and diversity of macrophages makes these cells potential mediators of immune suppression that could constitute TRIM.

RECENT FINDINGS

Recent reports identified the capacity of macrophages and monocytes to exhibit 'memory.' Exposure to various stimuli, such as engulfment of apoptotic cells and interactions with ß-glucan and lipopolysaccharide, were found to induce epigenetic, metabolic, and functional changes in certain myeloid cells, particularly macrophages and monocytes.

SUMMARY

Macrophages may mediate the immunosuppressive aspects of TRIM that arise as a result of transfused RBCs and their storage lesion induced by-products.

Do packed red blood cell transfusions really worsen oncologic outcomes in colon cancer?

BACKGROUND

Data from small retrospective studies have argued that perioperative packed red blood cell transfusions may increase the risk of developing metastatic recurrence in cancer patients. This study tests this assumption in a large cohort spanning a decade of operatively treated colon cancer patients.

METHODS

All patients undergoing primary resection of a colon cancer at a tertiary care center between 2004-2014 (n = 1,423) were included in a retrospective review of a prospectively maintained data repository. Survival and disease-free survival were compared and also adjusted in multivariable Cox regression standardized for follow-up, American Society of Anesthesiologists score, age, sex, postoperative chemotherapy, baseline staging, and tumor grade.

RESULTS

Of the 1,423 patients, 305 (21.4%) received a perioperative packed red blood cell transfusion during their index admission. During follow-up, overall mortality was greater in patients who received perioperative packed red blood cell (53.1% vs 30.9%; P < .001); however, there were no appreciable differences in rates of long-term distant recurrence (in patients without baseline metastasis 11.1% vs 13.9%; P = .25), or disease-specific mortality (21.3% vs 17.3%; P = .104; without baseline metastasis: 8.6% vs 8.9%; P = .89). Similarly, multivariable Cox regression showed no statistical difference in recurrence (hazard ratio: 0.83, 95% confidence interval, 0.83-1.26; P = .38) or disease-specific mortality (hazard ratio: 1.12, 95% confidence interval, 0.83-1.51; P = .47).

CONCLUSION

Mortality rates were significantly greater in patients with perioperative packed red blood cell transfusions, a finding that is backed by a body of evidence that associates perioperative packed red blood cell transfusion with comorbidity and serious illness, but contrary to earlier evidence, findings in our cohort do not support a hypothesis that perioperative perioperative packed red blood cell transfusions have a detrimental effect on recurrence rates of operatively treated colon cancer patients.

The impact of perioperative red blood cell transfusions in patients undergoing liver resection: a systematic review

BACKGROUND

Liver resection is associated with a high proportion of red blood cell transfusions. There is a proposed association between perioperative transfusions and increased risk of complications and tumor recurrence. This study reviews the evidence of this association in the literature.

METHODS

The Medline, EMBASE, and Cochrane databases were searched for clinical trials or observational studies of patients undergoing liver resection that compared patients who did and did not receive a perioperative red blood cell transfusion. Outcomes were mortality, complications, and cancer survival.

RESULTS

Twenty-two studies involving 6832 patients were included. All studies were retrospective, with no clinical trials. No studies were scored as low risk of bias. The overall proportion of patients transfused was 38.3%. After multivariate analysis, 1 of 5 studies demonstrated an association between transfusion and increased mortality; 5 of 6 demonstrated an association between transfusion and increased complications; and 10 of 18 demonstrated an association between transfusion and decreased cancer survival.

CONCLUSION

This review supports the evidence linking perioperative blood transfusions to negative outcomes. The most convincing association was with post-operative complications, some association with long-term cancer outcomes, and no convincing association with mortality. These findings support the initiation, and further study, of restrictive transfusion protocols.

Adverse oncologic effects of intraoperative transfusion during pancreatectomy for left-sided pancreatic cancer: the need for strict transfusion policy

BACKGROUND

The aim of the present study was to investigate the prognostic impact of transfusion following distal pancreatectomy (DP) for left-sided pancreatic ductal adenocarcinoma (PDAC).

METHODS

Retrospective analysis was performed to identify prognostic factors in patients who underwent DP from July 1992 to October 2012.

RESULTS

Forty-eight patients were male, and 35 were female with a mean age of 62 ± 9 years. Twenty-three (27.7%) of the patients received intraoperative blood transfusion. In univariate analysis, combined organ resection (P = 0.046), intraoperative transfusion (P < 0.001), pathologic tumor size (≥3 cm, P = 0.051), clinical tumor size (≥3 cm, P = 0.008), lymph node metastasis (P = 0.021), lymph node ratio (LNR ≥ 0.017, P < 0.001), and tumor differentiation (P = 0.013) were analyzed to predict tumor recurrence. Multivariate analysis showed that lymph node metastasis (Exp(β) = 2.136, P = 0.016), LNR (Exp(β) = 2.003, P = 0.049), and intraoperative transfusion (Exp(β) = 2.793, P = 0.001) were independent prognostic factor predicting tumor recurrence. The amount of estimated blood loss was closely associated with intraoperative transfusion (P < 0.001).

CONCLUSION

Intraoperative transfusion should be avoided by gentle operative handling to minimize intraoperative bleeding, and the appropriate transfusion policy should be followed to increase the survival outcome.

The impact of perioperative red blood cell transfusions in patients undergoing liver resection: a systematic review protocol

BACKGROUND

Liver resection is commonly performed for malignant and benign disease and is associated with frequent use of intraoperative and postoperative blood transfusions. Blood transfusions are potentially life-saving, but they have many adverse effects; some well understood, and others less so. Some of the poorly understood side effects include increased risk of postoperative complications and possibly worse oncologic outcomes. The objective of this systematic review is to provide estimates of transfusion prevalence and the effects of perioperative blood transfusion on postoperative mortality and morbidity and long-term cancer outcomes in patients undergoing liver resection.

METHODS/DESIGN

The Cochrane, Medline, and EMBASE databases will be searched for any randomized controlled trial or observational cohort study comparing liver resection patients that received intraoperative or postoperative allogeneic red blood cell transfusions to those who did not. Outcomes include postoperative mortality, postoperative morbidity (infectious, liver failure, renal failure, cardiovascular/cerebrovascular events, and thromboembolic events), and long-term disease-free and overall survival. Only studies with adult, human patients (>18 years old) undergoing liver resection, in which the primary intervention of interest is blood transfusion will be included. Data will be extracted by two reviewers in duplicate and synthesized into a narrative review. Risk of bias will be assessed. When clinically and methodologically appropriate, meta-analysis will be performed.

DISCUSSION

Our review will synthesize the literature pertaining to the potential beneficial and detrimental effects of red blood cell transfusion in patients undergoing liver resection. It will be an important step in the development of guidelines for the appropriate use of blood transfusions in patients undergoing liver resection.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015026132.

The relationship of blood transfusion with peri-operative and long-term outcomes after major hepatectomy for metastatic colorectal cancer: a multi-institutional study of 456 patients

BACKGROUND

Data on prognostic implications of peri-operative blood transfusion around resection of colorectal cancer liver metastases (CRLM) are conflicting. This retrospective study assesses the association of transfusion with complications and disease-specific survival (DSS).

METHODS

Major hepatectomies for CRLM from 2000 to 2010 at three institutions were included. Transfusion was analyzed based on timing and volume.

RESULTS

Of 456 patients, 140 (30.7%) received transfusions. Transfusion was associated with extended hepatectomy (28.6 vs 18.4%; p = 0.020), tumor size (5.7 vs 4.2 cm; p < 0.001), and operative blood loss (917 vs 390 mL; p < 0.001). Transfusion was independently associated with major complications (OR 2.61; 95% CI: 1.53-4.44; p < 0.001). Transfusion at any time was not associated with DSS; however, patients who specifically received blood post-operatively had reduced DSS (37.4 vs 42.7 months; p = 0.044). Increased volume of transfusion (≥3 units) was also associated with shortened DSS (Total: 37.4 vs 41.5 months, p = 0.018; Post-operative: 27.2 vs 40.3 months, p = 0.015). On multivariate analysis, however, transfusion was not independently associated with worsened DSS, regardless of timing and volume.

CONCLUSION

Transfusion with major hepatectomy for colorectal cancer metastases is independently associated with increased complications but not disease-specific survival. Judicious use of transfusion per a blood utilization protocol in the peri-operative period is warranted.

Perioperative Blood Transfusion and Postoperative Outcome in Patients with Crohn's Disease Undergoing Primary Ileocolonic Resection in the "Biological Era"

BACKGROUND

Perioperative blood transfusion has been shown to be associated with inflammatory response and immunosuppression. Patients receiving blood transfusion may have an increased risk for developing postoperative morbidities. The impact of blood transfusion on the postoperative recurrence of Crohn's disease (CD) has been controversial. The aim of this study was to assess the effect of blood transfusion on postoperative outcomes in CD in the current biological era.

METHODS

This historical cohort study involved data collection and analysis of CD patients who underwent the index ileocolonic resection in our institution between 2000 and 2012. Postoperative complications were compared between the transfused and nontransfused patients. The effects of perioperative blood transfusion on postoperative complications and disease recurrence were analyzed with both univariate and multivariate analyses.

RESULTS

A total of 318 patients were included in the study, and 52 of them (16.5 %) received perioperative blood transfusion. Blood transfusion was found to be associated with an increased risk of postoperative infectious and noninfectious complications both in univariate (P < 0.001 for each) and multivariable analyses (infectious complications: odds ratio [OR] = 8.73, 95 % confidence interval [CI] 2.85-26.78, P < 0.001; noninfectious complications: OR = 3.64, 95 % CI 1.30-10.18; P = 0.014). In addition, the Cox regression model indicated that blood transfusion was associated with both surgical (hazard ratio [HR] = 3.43, 95 % CI 1.92-6.13; P < 0.001) and endoscopic (HR = 2.08, 95 % CI 1.38-3.14; P < 0.001) CD recurrence following the index surgery.

CONCLUSION

Adverse outcomes after perioperative blood transfusion for the primary ileocolonic resection for CD resemble findings in surgery for other diseases. The presumed immunosuppressive effect of blood transfusion did not confer any protective effect on disease recurrence.

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

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.

Is estimated intra-operative blood loss a reliable predictor of surgical outcomes in laparoscopic colorectal cancer surgery?

BACKGROUND

Studies have shown that laparoscopic surgery for colorectal cancer is often associated with significantly reduced intra-operative blood loss compared to the corresponding open procedures. Increased intra-operative blood loss can be associated with increased risk of post-operative morbidity and mortality. We sought to determine whether estimated intra-operative blood loss was a reliable predictor of post-operative surgical outcomes.

METHOD

Prospective data were collected for patients undergoing elective laparoscopic colorectal cancer resections from July 2011 to November 2013. Weighing swabs and measuring blood volume in suction devices calculated the estimated intra-operative blood loss. The operative outcome data including post-operative 30 day morbidity and mortality, length of hospital stay, re-admission and re-operation within 30 days were collected. The operative blood loss was grouped into Group 1 (less than 50 ml, Group 2 (50-150 ml) and Group 3 (over 150 ml). Patients who underwent open operations and laparoscopic conversions were excluded.

RESULTS

The median age, length of hospital stay, male to female ratio and body mass index were similar in the three groups. There was no 30-day mortality in any of the groups. The number of re-admissions within 30 days was similar in all groups. The re-operation rates within 30 days were higher in Groups 2 and 3 at 11% and 8.6%, respectively. The post-operative complications were 12.5%, 16.7%, and 26% in groups 1, 2 and 3, respectively. There were no anastomotic leaks requiring re-operation noted in Group 3.

DISCUSSION

This study has shown that intra-operative blood loss was not associated with increased median length of stay nor did it increase the 30 day re-admission rate. However, increased intra-operative blood loss was associated with increased incidence of post-operative morbidity and risk of reoperation within 30 days.

Anaesthetic and pharmacological techniques to decrease blood loss in liver surgery: a systematic review

BACKGROUND

There is increasing evidence that perioperative blood loss and blood transfusions are associated with poorer short- and long-term outcomes in patients undergoing hepatectomy. The aim of this study was to systematically review the literature for non-surgical measures to decrease intraoperative blood loss during liver surgery.

METHODS

The literature search was performed using PubMed, Embase, Cochrane Library, CINAHL and Google Scholar databases. The primary outcome measures were perioperative blood loss and transfusion requirements. A secondary outcome measure was development of ischaemia-reperfusion injury.

RESULTS

Seventeen studies met the inclusion criteria and included 1573 patients. All were randomized controlled studies. In eight studies (n = 894), pharmacological methods, and in another nine studies (n = 679), anaesthetic methods to decrease blood loss were investigated. Anti-fibrinolytic drugs, acute normovolaemic haemodilution, autologous blood donation and use of inhalational anaesthetic agent may affect blood loss and post-operative hepatic function.

CONCLUSIONS

There is potential for use of non-surgical techniques to decrease perioperative bleeding. However, on the basis of this review alone, due to heterogeneity of randomized trials conducted, no particular strategy can be recommended. Future studies should be conducted looking at pathways to decrease bleeding in liver surgery.

Comparing survival and recurrence in curative stage I to III colorectal cancer in transfused and nontransfused patients

Evidence of the association between blood transfusions and its impact on prognostic outcomes in patients who undergo curative resection of colorectal cancer remains controversial. The aim of this study was to determine whether receiving peri-operative blood transfusions during curative colorectal cancer resection affected overall survival, cancer-related survival, and cancer recurrence. This retrospective study was undertaken at The Royal Brisbane and Women's Hospital, Australia, between 1984 and 2004. The outcomes of 1370 patients undergoing curative colorectal cancer resection for TNM stage I to III were analyzed. Four hundred twenty three patients (30.9%) required transfusion and 947 patients (69.1%) did not. Peri-operative transfusion was associated with higher rates of cancer recurrence on multivariate analysis (P = 0.024, RR, 1.257, 95% CI, 1.03-1.53); however, it was not independently associated with poorer overall or cancer-related survival. Where the aim is curative resection, this study contributes to a body of evidence that blood transfusions may be associated with poorer outcomes.

Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation

There has been recent interest in enhanced-recovery after surgery (ERAS®) or "fast-track" perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.

Blood Density Is Nearly Equal to Water Density: A Validation Study of the Gravimetric Method of Measuring Intraoperative Blood Loss

Purpose. The gravimetric method of weighing surgical sponges is used to quantify intraoperative blood loss. The dry mass minus the wet mass of the gauze equals the volume of blood lost. This method assumes that the density of blood is equivalent to water (1 gm/mL). This study's purpose was to validate the assumption that the density of blood is equivalent to water and to correlate density with hematocrit. Methods. 50 µL of whole blood was weighed from eighteen rats. A distilled water control was weighed for each blood sample. The averages of the blood and water were compared utilizing a Student's unpaired, one-tailed t-test. The masses of the blood samples and the hematocrits were compared using a linear regression. Results. The average mass of the eighteen blood samples was 0.0489 g and that of the distilled water controls was 0.0492 g. The t-test showed P = 0.2269 and R² = 0.03154. The hematocrit values ranged from 24% to 48%. The linear regression R² value was 0.1767. Conclusions. The R² value comparing the blood and distilled water masses suggests high correlation between the two populations. Linear regression showed the hematocrit was not proportional to the mass of the blood. The study confirmed that the measured density of blood is similar to water.

Perioperative blood transfusion as a poor prognostic factor after aggressive surgical resection for hilar cholangiocarcinoma

BACKGROUND

Blood transfusion is linked to a negative outcome for malignant tumors. The aim of this study was to evaluate aggressive surgical resection for hilar cholangiocarcinoma (HCCA) and assess the impact of perioperative blood transfusion on long-term survival.

METHODS

Sixty-six consecutive major hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for HCCA were performed using macroscopically curative resection at our institute from 2002 to 2012. Clinicopathologic factors for recurrence and survival were retrospectively assessed.

RESULTS

Overall survival rates at 1, 3, and 5 years were 86.7, 47.3, and 35.7 %, respectively. In univariate analysis, perioperative blood transfusion and a histological positive margin were two of several variables found to be significant prognostic factors for recurrence or survival (P<0.05). In multivariate analysis, only perioperative blood transfusion was independently associated with recurrence (hazard ratio (HR)=2.839 (95 % confidence interval (CI), 1.370-5.884), P=0.005), while perioperative blood transfusion (HR=3.383 (95 % CI, 1.499-7.637), P=0.003) and R1 resection (HR=3.125 (95 % CI, 1.025-9.530), P=0.045) were independent risk factors for poor survival.

CONCLUSIONS

Perioperative blood transfusion is a strong predictor of poor survival after radical hepatectomy for HCCA. We suggest that circumvention of perioperative blood transfusion can play an important role in long-term survival for patients with HCCA.

Peri-operative blood transfusion in gastric cancer surgery: prognostic or confounding factor?

BACKGROUND AND PURPOSE

The relationship between peri-operative blood transfusions (PBTs) and poor prognosis in gastric cancer (GC) patients is still debated. The aim of this study is to examine the real prognostic impact of PBTs in comparison to well-known prognostic factors.

METHODS

We retrospectively analyzed a series of 224 patients who underwent surgery with curative intent for GC from January 1995 to December 2011. Among 224 patients, 46 (20%) required PBTs.

RESULTS

The overall 5-year survival was 77% in non-transfused patients and 65% in patients who received PBTs (p = 0.03). PBTs did not further stratify any recognized prognostic category (such as pT or pN according to the 7th edition of the TNM staging system). Multivariate analysis including all known prognostic variables (both cancer- and non-cancer-related) did not select PBTs as an independent prognostic factor. Only preoperative hemoglobin and albumin level, pT and operative time were significantly associated with the requirement for PBTs.

CONCLUSIONS

The study showed a worse prognosis for transfused patients, but PBTs seem a confounding factor more than a prognostic indicator, as they are obviously affected by other variables.

Intraoperative blood loss during surgical treatment of low-rectal cancer by abdominosacral resection is higher than during extra-levator abdominosacral amputation of the rectum

INTRODUCTION

Abdominosacral resection (ASR) usually required blood transfusions, which are virtually no longer in use in the modified abdominosacral amputation of the rectum (ASAR). The aim of this study was to compare the intra-operative bleeding in low-rectal patients subjected to ASR or ASAR.

MATERIAL AND METHODS

The study included low-rectal cancer patients subjected to ASR (n = 114) or ASAR (n = 46) who were retrospectively compared in terms of: 1) the frequency of blood transfusions during surgery and up to 24 h thereafter; 2) the volume of intraoperative blood loss (ml of blood transfused) during surgery and up to 24 h thereafter; 3) hemoglobin concentrations (Hb) 1, 3 and 5 days after surgery; 4) the duration of hospitalization.

RESULTS

Blood transfusions were necessary in 107 ASR patients but in none of those subjected to ASAR (p < 0.001). Median blood loss in the ASR group was 800 ml (range: 100-4500 ml). The differences between the groups in median Hb determined 1, 3 and 5 days following surgery were insignificant. The proportions of patients with abnormal values of Hb, however, were significantly higher in the ASR group on postoperative days 1 and 3 (day 1: 71.9% vs. 19.6% in the ASAR group, p = 0.025; day 3: 57.% vs. 13.0%, p = 0.009). Average postoperative hospitalization in ASR patients was 13 days compared to 9 days in the ASAR group (p = 0.031).

CONCLUSIONS

Abdominosacral amputation of the rectum predominates over ASR in terms of the prevention of intra- and postoperative bleeding due to the properly defined surgical plane in low-rectal cancer patients.

Factors predicting long-term survival following pancreatic resection for ductal adenocarcinoma of the pancreas: 40 years of experience

BACKGROUND

Long-term survival after resection for pancreas carcinoma has rarely been reported. Factors influencing long-term survival are still under debate. The aim of this study was to define predictors for long-term survival.

METHODS

Between 1972 and 2004, a total of 415 patients underwent resection. Data were collected in a prospective data base. Data of 360 patients were available for further analysis in 2011. All specimens of long-term survivors were histologically reviewed.

RESULTS

Long-term survivors (n = 69) had a median survival of 91 months. Pathological re-evaluation of all specimens re-confirmed the diagnosis. Predictive factors for long-term survival in univariate analysis were no preoperative biliary stent, low CA 19-9 level, lack of blood transfusion, R0 resection, tumour diameter, and -grading, absence of lymph node or distant metastases, lymphangiosis, and perineural infiltration. Adjuvant chemotherapy showed a significant influence on overall survival but not on long-term survival. In multivariate analysis, lymph node ratio and volume of blood transfusion were predictors of long-term survival.

CONCLUSION

Nearly 20% of patients with pancreas carcinoma who undergo surgical resection have a chance of long-term survival. Survival beyond 5 years is predicted by clinical and tumour-specific factors. Adjuvant chemotherapy might prolong overall survival but is, according to these results, unable to contribute to long-term survival. There is still a risk of recurrence after a 5- or even a 12-year mark. Survival beyond 5 or even 12 years, therefore, does not assure cure.

Impact of intraoperative blood loss on long-term survival after lung cancer resection

PURPOSE

The purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients.

METHODS

We retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL.

RESULTS

Volume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival.

CONCLUSION

Since degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.

Blood transfusions in colorectal cancer surgery: incidence, outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis

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.

Intraoperative blood loss independently predicts survival and recurrence after resection of colorectal cancer liver metastasis

Background

Although numerous prognostic factors have been reported for colorectal cancer liver metastasis (CRLM), few studies have reported intraoperative blood loss (IBL) effects on clinical outcome after CRLM resection.

Methods

We retrospectively evaluated the clinical and histopathological characteristics of 139 patients who underwent liver resection for CRLM. The IBL cutoff volume was calculated using receiver operating characteristic curves. Overall survival (OS) and recurrence free survival (RFS) were assessed using the Kaplan–Meier and Cox regression methods.

Results

All patients underwent curative resection. The median follow up period was 25.0 months (range, 2.1–88.8). Body mass index (BMI) and CRLM number and tumor size were associated with increased IBL. BMI (P=0.01; 95% CI = 1.3–8.5) and IBL (P<0.01; 95% CI = 1.6–12.5) were independent OSOs predictors. Five factors, including IBL (P=0.02; 95% CI = 1.1–4.1), were significantly related to RFS via multivariate Cox regression analysis. In addition, OSOs and RFS significantly decreased with increasing IBL volumes. The 5-year OSOs of patients with IBL≤250, 250–500, and >500mL were 71%, 33%, and 0%, respectively (P<0.01). RFS of patients within three IBL volumes at the end of the first year were 67%, 38%, and 18%, respectively (P<0.01).

Conclusions

IBL during CRLM resection is an independent predictor of long term survival and tumor recurrence, and its prognostic value was confirmed by a dose–response relationship.

Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions

Debate on appropriate triggers for transfusion of allogeneic blood products and their effects on short- and long-term survival in surgical and critically ill patients continue with no definitive evidence or decisive resolution. Although transfusion-related immune modulation (TRIM) is well established, its influence on immune competence in the recipient and its effects on cancer recurrence after a curative resection remains controversial. An association between perioperative transfusion of allogeneic blood products and risk for recurrence has been shown in colorectal cancer in randomized trials; whether the same is true for other types of cancer remains to be determined. This article focuses on the laboratory, animal, and clinical evidence to date on the mechanistic understanding of inflammatory and immune-modulatory effects of blood products and their significance for recurrence in the cancer surgical patient.

Blood transfusions and prognosis in colorectal cancer: long-term results of a randomized controlled trial

OBJECTIVE

Perioperative blood transfusions may adversely affect survival in patients with colorectal malignancy, although definite proof of a causal relationship has never been reported.

BACKGROUND

We report the long-term outcomes of a randomized controlled trial performed between 1986 and 1991 to compare the effects of allogeneic blood transfusions and an autologous blood transfusion program in colorectal cancer patients.

METHODS

All 475 randomized patients operated upon for colorectal cancer were tracked via a national computerized record-linkage system to investigate survival and cause of death. Kaplan-Meier survival curves were constructed and multivariate Cox regression analysis was performed to study 20 years' overall survival. Colorectal cancer-specific survival was analyzed over the 10-year time period after surgery.

RESULTS

The overall survival percentage at 20 years after surgery was worse in the autologous group (21%) compared to the allogeneic group (28%) (P = 0.041; log-rank test). Cox regression, allowing for tumor stage, age, and sex, resulted in a hazard ratio (autologous vs allogeneic group) for overall mortality of 1.24 (95% confidence interval 1.00-1.54; P = 0.051). Colorectal cancer-specific survival at 10 years for the whole study group was 48% and 60% for the autologous and allogeneic group, respectively (P = 0.020; log-rank test). The adjusted hazard ratio was 1.39 (95 confidence interval 1.05-1.83; P = 0.045).

CONCLUSIONS

At long-term follow-up colorectal cancer patients did not benefit from autologous transfusion compared with standard allogeneic transfusion. On the contrary, the overall and colorectal cancer-specific survival rates were worse in the patients in the autologous transfusion group.

The impact of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer

BACKGROUND

Perioperative blood transfusions in patients with colorectal cancer are associated with increased cost, morbidity, mortality and decreased survival. In 2009, a 3-part transfusion reduction initiative (TRI) was introduced. The hypothesis was that this would decrease transfusions without increasing complications in patients undergoing elective resection for colorectal cancer.

METHODS

After institutional review board approval was obtained, the medical records of patients who underwent colon resection before (January 2006 to October 2009) and after (November 2009 to March 2011) the TRI were reviewed.

RESULTS

Three hundred sixty-eight patients were included, 272 and 96 in the pre-TRI and post-TRI groups, respectively. Transfusion rates decreased in the post-TRI group compared with the pre-TRI group (15% vs 28%, P = .011). Median postoperative hemoglobin levels among transfused patients were 8.4 and 7.3 g/dL in the pre-TRI and post-TRI groups, respectively (P = .009). There was no difference in complications or 30-day mortality. Transfused patients with stages I to III adenocarcinoma had worse 4-year survival (P < .05).

CONCLUSIONS

Perioperative transfusions in colorectal cancer surgery decreased after the implementation of a TRI. Complication rates did not change. Perioperative transfusions were associated with worse survival in patients with stages I to III cancer.

Intraoperative blood transfusion contributes to decreased long-term survival of patients with esophageal cancer

BACKGROUND

Several prognostic factors for patients who have undergone esophagectomy owing to esophageal squamous cell carcinoma have been suggested, including intraoperative blood loss. There are few data, however, suggesting such an association with the prognosis following radical esophagectomy.

METHODS

Patients with esophageal squamous cell carcinoma who underwent radical esophagectomy were divided into two groups based on the median value of the intraoperative blood loss (510 g). A multivariate Cox proportional-hazard regression analysis was performed to determine if intraoperative blood loss could be an independent prognostic factor for long-term survival following radical esophagectomy. Kaplan-Meier survival analysis with a log-rank test was performed between the groups.

RESULTS

From April 2005 to May 2009, a total of 37 patients underwent radical esophagectomy for the treatment of esophageal squamous cell carcinoma at the Juntendo Shizuoka Hospital and were assigned either to one of two groups: those with ≥510 g blood loss [bleeding group (BG), n = 19] or of those with <510 g blood loss [less bleeding group (LBG), n = 18]. The distribution of the stage of disease, the number of positive lymph nodes, and the presence of lymphatic and vascular invasion was comparable between the groups, but the Kaplan-Meier survival analysis demonstrated that survival was significantly worse in the BG group than in the LBG group (p = 0.00295). This was supported by the multivariate analysis, which indicated that intraoperative blood loss was independently associated with long-term survival after radical esophagectomy.

CONCLUSIONS

Intraoperative blood loss could be a useful prognostic factor following radical esophagectomy in patients with esophageal squamous cell carcinoma.

Intraoperative blood transfusion contributes to decreased long-term survival of patients with esophageal cancer

BACKGROUND

Several prognostic factors for patients who have undergone esophagectomy owing to esophageal squamous cell carcinoma have been suggested, including intraoperative blood loss. There are few data, however, suggesting such an association with the prognosis following radical esophagectomy.

METHODS

Patients with esophageal squamous cell carcinoma who underwent radical esophagectomy were divided into two groups based on the median value of the intraoperative blood loss (510 g). A multivariate Cox proportional-hazard regression analysis was performed to determine if intraoperative blood loss could be an independent prognostic factor for long-term survival following radical esophagectomy. Kaplan-Meier survival analysis with a log-rank test was performed between the groups.

RESULTS

From April 2005 to May 2009, a total of 37 patients underwent radical esophagectomy for the treatment of esophageal squamous cell carcinoma at the Juntendo Shizuoka Hospital and were assigned either to one of two groups: those with ≥510 g blood loss [bleeding group (BG), n = 19] or of those with <510 g blood loss [less bleeding group (LBG), n = 18]. The distribution of the stage of disease, the number of positive lymph nodes, and the presence of lymphatic and vascular invasion was comparable between the groups, but the Kaplan-Meier survival analysis demonstrated that survival was significantly worse in the BG group than in the LBG group (p = 0.00295). This was supported by the multivariate analysis, which indicated that intraoperative blood loss was independently associated with long-term survival after radical esophagectomy.

CONCLUSIONS

Intraoperative blood loss could be a useful prognostic factor following radical esophagectomy in patients with esophageal squamous cell carcinoma.

Fresh frozen plasma transfusion does not affect outcomes following hepatic resection for hepatocellular carcinoma

AIM: To investigate whether fresh frozen plasma (FFP) transfusion affects outcomes following hepatic resection for hepatocellular carcinoma (HCC) in terms of liver function, postoperative complications and cancer prognosis.

METHODS: We retrospectively compared the incidence of postoperative complications between 204 patients who underwent hepatectomy for HCC with routine FFP transfusion in an early period (1983-1993, Group A) and 293 with necessity for FFP transfusion during a later period (1998-2006, Group B), and also between two subgroups of Group B [22 patients with FFP transfusion (Group B1) and 275 patients without FFP transfusion (Group B2)]. Additionally, only in limited patients in Group B1 and Group B2 with intraoperative blood loss ≥ 2000 mL (Group B1_{≥ 2000 mL} and Group B2_{≥ 2000 mL}), postoperative complications, liver function tests, and cancer prognosis were compared.

RESULTS: No mortality was registered in Group B, compared to 8 patients (3.9%) of Group A. The incidence of morbidity in Group B2 [23.2% (64/275)] was not significantly different from Group B1 [40.9% (9/22)] and Group A [27.0% (55/204)]. The incidence of complications and postoperative liver function tests were comparable between Group B1_{≥ 2000 mL}vs Group B2_{≥ 2000 mL}. Postoperative prognosis did not correlate with administration of FFP, but with tumor-related factors.

CONCLUSION: The outcome of hepatectomy for HCC is not influenced by FFP transfusion. We suggest FFP transfusion be abandoned in patients who undergo hepatectomy for HCC.