Perioperative transfusion, postoperative infection, and recurrence of head and neck cancer

Preoperative hemoglobin and perioperative blood transfusion in major head and neck surgery: a systematic review and meta-analysis

BACKGROUND

There is a growing concern with inappropriate, excessive perioperative blood transfusions. Understanding the influence of low preoperative hemoglobin (Hgb) on perioperative blood transfusion (PBT) in head and neck cancer (HNC) surgery with free flap reconstruction may help guide clinical practice to reduce inappropriate treatment among these patients. The objective is to synthesize evidence regarding the association between preoperative Hgb and PBT among major HNC free flap surgeries.

METHODS

Terms and synonyms for HNC surgical procedures, Hgb and PBT were used to search MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Reviews from inception to February 2020. Reference lists of included full texts and studies reporting the preoperative Hgb, anemia or hematocrit (exposure) and the PBT (outcome) in major HNC surgery with free flap reconstruction were eligible. Studies examining esophageal, thyroid and parathyroid neoplasms were excluded; as were case reports, case series (n < 20), editorials, reviews, perspectives, viewpoints and responses. Two independent, blinded reviewers screened titles, abstracts and full texts in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. A random-effects model was used to pool reported data. The primary outcome was the proportion of patients who had a PBT. Subgroup analysis examined sources of heterogeneity for perioperative predictors of PBT (age, sex, flap type, flap site and preoperative Hgb). We also examined mean preoperative Hgb in the PBT and no PBT groups.

RESULTS

Patients with low preoperative Hgb were transfused more than those with normal Hgb (47.62%, 95% CI = 41.19-54.06, I² = 0.00% and 13.92%, 95% CI = 10.19-17.65, I² = 20.69%, respectively). None of the predictor variables explained PBT. The overall pooled mean preoperative Hgb was 12.96 g/dL (95% CI = 11.33-14.59, I² = 0.00%) and was 13.58 g/dL (95% CI = 11.95-15.21, I² = 0.00%) in the no PBT group and 12.05 g/dL (95% CI = 10.01 to 14.09, I² = 0.00%) in the PBT group.

CONCLUSIONS

The heterogeneity between studies, especially around the trigger for PBT, highlights the need for additional research to guide clinical practice of preoperative Hgb related to PBT to enhance patient outcomes and improve healthcare stewardship.

Moving to a more restrictive transfusion protocol: Outcomes in head and neck free flap surgery

PURPOSE

To determine if a more restrictive transfusion protocol results in increased rates of adverse flap outcomes in patients undergoing free tissue transfer.

MATERIALS AND METHODS

Mixed retrospective and prospective cohort study. Patients who underwent surgery before the protocol change were collected retrospectively. Patients who underwent surgery after the protocol change were collected prospectively.

RESULTS

Of the 460 patients who underwent free tissue transfer, 116 patients in the pre-change cohort (N = 211) underwent transfusion (54.98%) and 78 in the post-change cohort(N = 249) (31.33%) (p < 0.001). The mean number of units transfused was 1.55 + 2.00 in the pre-change cohort, and 0.78 + 1.51 in the post-change cohort (p < 0.001). When separated temporally, the pre-change cohort received significantly more blood transfusions than the post-change cohort in the operating room (33.65% vs 18.07%) (p < 0.01), within 72 h of surgery (35.55% vs 15.66%) (p < 0.001), and after 72 h after surgery to discharge (16.59% vs 8.03%) (p = 0.018017). The rate of flap failure was 6.70% in the pre-change cohort, and 5.31% in the post-change cohort (p = 0.67). In a logistic regression model controlling for potential confounders, transfusion protocol was not significantly associated with flap failure (OR = 1.1080, 95% CI: 0.48-2.54). There were no significant differences between cohorts for medical morbidity, ICU transfer, or death.

CONCLUSION

Our data support the conclusion that patients undergoing free tissue transfer to the head and neck can be transfused following the same protocols as other patients, without increasing the rate of flap failure or other morbidities.

LEVEL OF EVIDENCE

3 (mixed retrospective, prospective cohort study).

The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review

OBJECTIVE

To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI).

METHODS

We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes.

RESULTS

A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications.

CONCLUSION

Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Effect of Blood Transfusion on Short- and Long-Term Outcomes in Oral Squamous Cell Carcinoma Patients Undergoing Free Flap Reconstruction

Purpose: To analyze the short- and long-term effect of perioperative blood transfusion (PBT) in patients undergoing surgical treatment for oral squamous cell carcinoma (SCC). Methods: Patients undergoing free flap reconstruction were retrospectively enrolled and divided into two groups based on the implementation of PBT. Flap revision, surgical site infection (SSI), flap failure, overall survival (OS), and disease-specific survival (DSS) were compared between the two groups. Results: In 170 patients with PBT, 10 (5.9%) flaps required exploration revision, SSI occurred in 18 (10.6%) patients, and flap necrosis was noted in 6 (3.5%) patients. These rates were comparable to those in patients without PBT. The two groups had similar DSS rates, but the 5-year OS rates were 49 and 59% in patients with PBT and without PBT, respectively. This difference was significant. Patients with 4 units of PBT had OS rates comparable to those of patients with >4 units of PBT. A Cox model confirmed the fact that the decrease in OS was independent of PBT. Conclusion: In patients with free flap reconstruction for oral SCC, PBT did not increase the short-term complication rate or cancer-linked mortality. However, it was related to an elevated overall risk of death.

Predictive factors for perioperative blood transfusion in neck dissection

OBJECTIVES/HYPOTHESIS

There is growing interest in reducing the exposure of patients to allogeneic blood transfusions by lowering preoperative cross-matched blood ordering and adopting alternative practices, such as autologous blood donations. Our aim was to investigate the predictors for perioperative blood transfusion (PBT) in head and neck cancer patients undergoing neck dissection (ND).

STUDY DESIGN

Retrospective cohort study.

METHODS

Retrospective observational study. All patients who underwent ND between January 2011 and August 2014. The primary outcome measure was PBT. Predictors tested included: gender, age, American Society of Anesthesiologists comorbidity score, Charlson comorbidity index, preoperative hemoglobin level, head and neck primary tumor location, tumor and nodal staging, side and laterality of ND, central versus lateral ND, elective ND, preoperative chemotherapy/radiotherapy/I(131) therapy, history of previous ND, other surgical procedures in addition to the ND, bone resection, use and type of reconstruction, and the use of bony free flap reconstruction.

RESULTS

Twenty-one preoperative and operative variables were tested for an association with PBT using univariate and multivariate analyses. Multivariate analysis found only the following three predictors to be significantly associated with PBT in patients undergoing ND: low preoperative hemoglobin level, advanced N stage, and concurrent reconstructive surgery.

CONCLUSION

Evaluation of specific risk factors for predicting the need for PBT prior to neck dissection may be helpful in identifying the head and neck cancer patients in whom preoperative ordering of cross-matched blood is required or who could benefit from alternative means, such as preoperative autologous blood donation.

LEVEL OF EVIDENCE

4.

Contamination of the surgical field in head and neck oncologic surgery

BACKGROUND

The purpose of this study was to determine the timing and type of surgical field contamination in 50 consecutive resections for advanced head and neck cancer with same-stage tissue reconstruction and to analyze the relationship between contamination and the surgical site infection.

METHODS

Swabs from the surgical field and from surgical drapes close to the field were taken every 2 hours (at 0 hour, 2 hours, 4 hours, and 6 hours) and sent for a standard microbiological diagnostic procedure. Results were recorded in Microsoft Excel and analyzed with SPSS.

RESULTS

We collected 336 swabs of which 71% were contaminated. Polymicrobial contamination was observed in 153 samples (45%). Twenty-six species of pathogens were found, the most frequent was Streptococcus species. Surgical site infection with positive culture occurred in 3 patients.

CONCLUSION

In head and neck surgery for advanced cancer, standard aseptic procedures do not prevent contamination of the surgical field with physiological bacterial flora of the skin and oral cavity. Although contamination was common, surgical site infection was rare.

Identifying risk factors for allogenic blood transfusion in oral and oropharyngeal cancer surgery with free flap reconstruction

PURPOSE

Several observational studies in head and neck cancer have reported that allogenic blood transfusion is associated with increased postoperative complications, increased risk of tumor recurrence, and worse prognosis. The aim of this study was to identify preoperative and intraoperative factors predicting blood transfusion in patients undergoing surgery for oral and oropharyngeal cancer.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients undergoing tumor resection and free flap reconstruction for locally advanced oral and oropharyngeal squamous cell carcinoma between 2000 and 2008. The primary outcome variable was perioperative exposure to allogenic blood transfusion. Univariate and multivariate logistic regression models were used to determine predictors of blood transfusion.

RESULTS

A cohort of 142 participants was found eligible. In a multivariate model, Charlson score ≥ 1 (OR, 5.2; 95% CI, 1.4 to 19.3; P = .01), preoperative hemoglobin levels ≤ 12 g/dl (OR, 4.4; 95% CI, 1.2 to 16.2; P = .03), bone resection (OR, 5.1; 95% CI, 1.5 to 17.8; P = .01), and osseous free tissue transfer (OR, 8.8; 95% CI, 1.0 to 74.8; P = .046) were independently associated with an increased risk of blood transfusion.

CONCLUSION

Our study identified patient- and surgery-related factors predicting a higher risk of exposure to allogenic blood transfusion. This readily available preoperative information could be used to better stratify patients according to their transfusion risk and may thereby guide blood conservation strategies in high-risk patients.

An evaluation of the preoperative hemoglobin level as a prognostic factor for oral squamous cell carcinoma

Background

Hypoxia seems to be an influencing factor for oral squamous cell carcinomas (SCC), and several immunohistochemical markers have been discussed in this regard. The aim of the present study was to evaluate preoperative hemoglobin levels as a prognostic factor for oral SCC.

Materials and methods

The files of 287 patients who had been treated for oral SCC between 1999 and 2008 were studied retrospectively. Hemoglobin levels between 1 and 5 days prior to surgical treatment were compared to Tumor (T)- and Nodal (N)- status, local recurrence, and lymph node metastases rate. The minimum follow-up period was 12 months.

Results

From a total of 287 patients with oral SCC, 205 (71.4%) were in the normal hemoglobin (Hb) group (female Hb≥12.0 g/dl; male Hb≥13.0 g/dl), 53 (18.5%) in the mild anemia (female Hb = 11.0-11.9 g/dl; male Hb = 11.0-12.9 g/dl), and 29 (10.1%) in the severe anemia group (female & male Hb<11.0 g/dl). Anemia was significant for the development of lymph node metastasis (p = 0.005) as well as for local recurrence (p = 0.001). No significant correlation was found to the initial T status (p = 0.183).

Conclusion

Our data suggests that an Hb of below 11 g/dl contributes to and is an indicator for a poor prognosis. Consequently, pre-treatment Hb corrections may significantly improve outcome, but further investigations, including blood transfusion/application of erythropoietin due to tumor anemia, independent of intraoperative blood-loss are necessary to ascertain their role in an improved survival.

The influence of allogenic blood transfusion in patients having free-flap primary surgery for oral and oropharyngeal squamous cell carcinoma

The influence of perioperative blood transfusion in oral and oropharyngeal squamous cell carcinoma remains uncertain. It is believed that blood transfusion downregulates the immune system and may have an influence on cancer recurrence and survival. In all, 559 consecutive patients undergoing primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and 2002 were included in this study. Known prognostic variables along with transfusion details were obtained from head and neck cancer and blood transfusion service databases, respectively. Adjusting for relevant prognostic factors in Cox regression, the hazard ratio for patients having 3 or more transfused units relative to those not transfused was 1.52 (95% confidence interval (CI) 0.93–2.47) for disease-specific and 1.52 (95% CI 1.05–2.22) for overall mortality. Blood transfusion of 3 or more units might confer a worse prognosis in patients undergoing primary surgery for oral and oropharyngeal squamous cell carcinoma. Therefore, every effort should be made to limit the amount of blood transfused to the minimum requirement.

Improved Survival Associated With Postoperative Wound Infection in Dogs Treated With Limb-Salvage Surgery for Osteosarcoma

BACKGROUND

Limb-salvage surgery and adjuvant chemotherapy are performed as a treatment of appendicular osteosarcoma in dogs. Approximately 50% of dogs that undergo limb-salvage surgery develop postoperative surgical wound infections. Postoperative surgical infections may affect survival in cancer patients. The purposes of this study were to examine the effect of surgical wound infection on survival, local recurrence, and metastasis in relation to other prognostic factors for dogs with spontaneous osteosarcoma treated with limb-salvage surgery.

METHODS

Forty-seven client-owned dogs with osteosarcoma of the distal radius were treated with limb-salvage surgery and adjuvant chemotherapy--either carboplatin or carboplatin and doxorubicin. Hazard ratios were estimated by using the Cox proportional hazard model, and survival functions were estimated by using the Kaplan-Meier product-limit life-table method.

RESULTS

Of the 47 dogs in this study, 32 (68%) developed a postoperative wound infection. Infection, dog weight, and extent of the primary tumor (percentage of length) significantly affected survival, and infection and percentage of length significantly affected time to metastasis. None of the variables considered in this study affected local recurrence. Dogs that were diagnosed with an infection were less likely to die (hazard ratio, .446), and dogs with greater body weight and greater percentage length involvement were more likely to die (hazard ratios of 3.37 and 3.66, respectively).

CONCLUSIONS

In dogs with osteosarcoma treated with limb-salvage surgery, infection has a positive influence on survival, as does a smaller initial length of radius involved and lower body weight.

[Necessity for blood transfusion in head and neck surgery]

INTRODUCTION

Sometimes, use of blood products is necessary in head and neck surgery, but blood transfusion also entails risks for the patients and causes high costs for the department. Therefore, we examined the surgical procedures in our department and analysed how often transfusion of blood was necessary and which expenses were incurred.

METHODS

Of 3989 operations performed in 1989, 187 patients were found to be at an increased risk for blood loss. The costs for blood group analysis (euro 23.16), cross-testing (euro 13.91) and the transfusion itself (euro 70.35) were estimated in each patient.

RESULTS

In 1998 more than 60% of the 187 patients had undergone extensive head and neck surgery for advanced squamous cell carcinoma. Only 17 patients (<15%) received nearly 45% of all units of stored blood transfused that year. In patients who had undergone skull base surgery, the probability of receiving blood was 30%. The transfusion-related costs were estimated to be euro 20,000 during the observation period. Potential savings could have been achieved in cross-testing.

CONCLUSION

Preparations should be done on an individual basis. Such preparations are sometimes unnecessary even in patients undergoing surgical procedures with a high risk for blood loss.

Factors influencing the development of wound infection following free-flap reconstruction for intra-oral cancer

Wound infection following tissue transfer in head and neck oncology is common. Factors known to be associated with infective complications include blood transfusion, pre-operative radiotherapy, duration of surgery, duration of pre-operative stay and a history of smoking. The present study specifically examined 100 consecutive patients on a standard antibiotic protocol undergoing free flap reconstruction following resection of cancers of the oral cavity or oropharynx. Despite prophylactic antibiotics, 21 patients developed a head and neck wound infection. No statistically significant association was found between infective wound complications and a history of smoking, pre-operative radiotherapy or chemotherapy, length of pre-operative hospital stay, duration of surgery, or number of units of blood transfused. We conclude that, in this group of patients, wound infection is a common and difficult problem, but with no statistically significant association with any of the variables studied.

Significado prognóstico da deiscência e infecção da ferida operatória no carcinoma epidermóide das vias aerodigestivas superiores

OBJETIVO: Avaliar o efeito da infecção e da deiscência da ferida operatória sobre o controle local do carcinoma epidermóide das vias aerodigestivas superiores, identificando fatores associados à ocorrência destas complicações. MÉTODO: Estudo retrospectivo de 239 pacientes com carcinoma epidermóide de boca, orofaringe e hipofaringe tratados cirurgicamente no Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia do Hospital Heliópolis entre 1990 e 1996, onde foram avaliados o hemograma e o proteinograma pré-operatório em relação ao risco de desenvolvimento de deiscência e infecção da ferida operatória e comparadas as taxas de recidiva local entre os pacientes com e sem deiscência/infecção da ferida operatória. RESULTADOS: A doença em estádio avançado (estádio IV) e a relação albumina/globulina inferior a 1,2 foram mais freqüentes entre os pacientes que desenvolveram deiscência/infecção (DI) da ferida operatória. A taxa de recidiva local foi de 49% nos pacientes que apresentaram DI e 42% naqueles sem DI. CONCLUSÃO: os pacientes com doença em estádio avançado e aqueles com relação albumina/globulina inferior a 1,2 apresentam maior risco de deiscência/infecção da ferida operatória. A presença de deiscência/infecção não apresentou relação com as taxas de recidiva local.

Immune response to autologous transfusion in healthy volunteers: WB versus packed RBCs and FFP

BACKGROUND

Storage of blood as packed RBCs and FFP is standard practice in allogeneic transfusion. Separation into components has been proposed for autologous transfusion, as well, but beneficial effects have not yet been shown.

STUDY DESIGN AND METHODS

Twenty-four healthy male volunteers were randomly assigned to receive 1 unit of either autologous RBCs and FFP (RCP group) or WB (WB group) after 49 or 35 days of storage, respectively. The immune response was analyzed by ELISA for IL-6, C3a, terminal complement complex SC5b-9, TNF-alpha, and neopterin. Differential WBC counts and the phagocytosis of neutrophils and monocytes were measured by flow cytometry.

RESULTS

Cell counts of monocytes (0.85 x 10(3) ng/microL) [corrected] and neutrophils (6.9 x 10(3) ng/microL) [corrected] increased 30 minutes after WB transfusion and then returned to close to the baseline values seen in the RCP group (0.47 and 2.9 x 10(3) ng/microL [corrected], respectively) throughout the monitored period (p<0.05). C3a (169 vs. 116 ng/microL) [corrected] and IL-6 (29 vs. 6 pg/mL) reached higher plasma concentrations in the WB group (n = 11) than in the RCP group (n = 10). Phagocytosis of opsonized Escherichia coli was increased in neutrophils and monocytes and lasted up to 7 days after the transfusion of whole blood.

CONCLUSION

Autologous WB induces a modest immunomodulation, but this effect is not observed upon transfusion of autologous blood components.

Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group

BACKGROUND

The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis.

METHODS

Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications.

RESULTS

Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors.

CONCLUSION

Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.