The impact of perioperative allogeneic blood transfusion on prognosis of hepatocellular carcinoma after radical hepatectomy: A systematic review and meta-analysis of cohort studies

Influence of intraoperative blood salvage and autotransfusion on tumor recurrence after deceased donor liver transplantation: a large nationwide cohort study

BACKGROUND AND AIMS

The practice of intraoperative blood salvage and autotransfusion (IBSA) during deceased donor liver transplantation for hepatocellular carcinoma (HCC) can potentially reduce the need for allogeneic blood transfusion. However, implementing IBSA remains debatable due to concerns about its possible detrimental effects on oncologic recurrence.

METHODS

This study retrospectively enrolled nationwide recipients of deceased donor liver transplantation for HCC between 2015 and 2020. The focus was on comparing the cumulative recurrence rate and the recurrence-free survival rate. Propensity score matching was conducted repeatedly for further subgroup comparison. Recipients were categorized based on the Milan criteria, macrovascular invasion, and pretransplant α-Fetoprotein (AFP) level to identify subgroups at risk of HCC recurrence.

RESULTS

A total of 6196 and 329 patients were enrolled in the non-IBSA and IBSA groups in this study. Multivariable competing risk regression analysis identified IBSA as independent risk factors for HCC recurrence ( P <0.05). Postmatching, the cumulative recurrence rate and recurrence-free survival rate revealed no significant difference in the IBSA group and non-IBSA group (22.4 vs. 16.5%, P =0.12; 60.3 vs. 60.9%, P =0.74). Recipients beyond Milan criteria had higher, albeit not significant, risk of HCC recurrence if receiving IBSA (33.4 vs. 22.5%, P =0.14). For recipients with macrovascular invasion, the risk of HCC recurrence has no significant difference between the two groups (32.2 vs. 21.3%, P =0.231). For recipients with an AFP level <20 ng/ml, the risk of HCC recurrence was comparable in the IBSA group and the non-IBSA group (12.8 vs. 18.7%, P =0.99). Recipients with an AFP level ≥20 ng/ml, the risk of HCC recurrence was significantly higher in the IBSA group. For those with an AFP level ≥400 ng/ml, the impact of IBSA on the cumulative recurrence rate was even more pronounced (49.8 vs. 21.9%, P =0.011).

CONCLUSIONS

IBSA does not appear to be associated with worse outcomes for recipients with HCC exceeding the Milan criteria or with macrovascular invasion. IBSA could be confidently applied for recipients with a pretransplant AFP level <20 ng/ml. For recipients with AFP levels ≥20 ng/ml, undertaking IBSA would increase the risk of HCC recurrence.

Clinical significances of several fibrotic markers for prognosis in hepatocellular carcinoma patients who underwent hepatectomy

Background

Progression of chronic liver fibrosis and related increased fibrotic markers are associated with functional liver reserves or patient prognosis as well as tumor factors in hepatocellular carcinoma (HCC) patients. The aim of this study was to newly clarify the relationship between fibrotic markers and HCC malignant behaviors or its long-term postoperative prognosis by the retrospective cohort study.

Methods

We examined the relationship between tumor-related factors or six liver fibrosis-associated parameters, including platelet count, hyaluronic acid (HA), Mac-2 binding protein glycosylation isomer (M2BPGi), type IV collagen 7S (T4C7), aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 (Fib-4) index, and clinicopathological parameters, surgical records, and postoperative prognosis in 130 HCC who underwent curative hepatectomy.

Results

Histological fibrosis stage 4 as cirrhosis was in 31%. The platelet count significantly decreased in stage 4 fibrosis and correlated with grade B liver damage (P<0.01). HA levels were significantly increased in multiple HCC, stage 4 fibrosis, and grade B liver damage (P<0.01). T4C7 was significantly increased in patients with post-hepatectomy tumor recurrence compared to those without (P<0.01). Additionally, M2BPGi was significantly higher in stage 4 fibrosis and liver damage grade B, and was significantly associated with poor prognosis (P<0.05). Fib-4 index was significantly higher in patients with liver damage B (P<0.05), and T4C7 alone did not correlate with other five fibrosis markers. Stage 4 fibrosis, higher T4C7, higher M2BPGi, and increased tumor size were significantly associated with shorter cancer-free, overall, and cancer-specific survivals. Higher T4C7, non-met Milan criteria, liver damage B, blood transfusion, and curability C were independently associated with cancer-specific survivals (P<0.05).

Conclusions

Type IV collagen 7S (T4C7) may reflect not only impaired liver function but also HCC malignant behaviors and patient survivals.

Negative Impact of Intra-Operative Blood Transfusion on Survival Outcomes of Hepatocellular Carcinoma Patients

Background

Studies have reported that blood transfusion may have an association with survival outcomes of cancer patients. This study was aimed at finding the effect of intra-operative blood transfusion on the prognosis of patients of hepatocellular carcinoma (HCC).

Methods

This was a retrospective study. HCC patients who underwent tumor resection from January 2013 to November 2018 at Harbin Medical University Cancer Hospital were included. The survival time of patients receiving or not receiving blood transfusion during the operation were compared.

Results

Of HCC patients, 21.1% (102/484) received intra-operative blood transfusion. After propensity score matching, 87 pairs of patients were included in the study. In the subset of patients with a tumor size of >4 cm, univariable analysis found that there were significant differences in recurrence-free survival (RFS; P=0.004) and overall survival (OS; P=0.028) between blood transfusion and non-blood transfusion groups. After multivariable Cox regression analysis, intra-operative blood transfusion was an independent risk factor for RFS (HR: 2.011, 95% CI: 1.146-3.529, P=0.015), but not for OS (HR: 1.862, 95% CI: 0.933-3.715, P=0.078) in the subset of patients with a tumor size of >4 cm.

Conclusion

Intra-operative blood transfusion was associated with worse RFS in HCC patients with a tumor size of >4 cm.

Stage-by-stage analysis of the effect of blood transfusion on survival after curative hepatectomy for hepatocellular carcinoma-a retrospective study

OBJECTIVE

This study is to examine the impact of perioperative (intraoperative/postoperative) blood transfusion on the outcomes of curative hepatectomy for hepatocellular carcinoma. Hepatectomy is a well-established curative treatment for hepatocellular carcinoma, and blood transfusion cannot always be avoided in treating the disease.

METHODS

A retrospective study of patients having curative hepatectomy for hepatocellular carcinoma from January 2010 to December 2019 at a single center was conducted. The patients were stratified by their disease stage. Patients with and without perioperative blood transfusion were matched by propensity-score matching and compared for each disease stage. Univariate and multivariate analyses were performed to identify prognostic factors for overall survival for each stage.

RESULTS

A total of 846 patients were studied. Among them, 125 received perioperative blood transfusion and 720 did not. Patients with blood transfusion had worse disease-free and overall survival. After stratification and matching, the ratios of transfusion to non-transfusion were 33:165 (stage 1), 28:140 (stage 2), and 45:90 (stage 3). Perioperative blood transfusion was associated with a higher incidence of postoperative complications in all three disease stages (p = 0.004/0.006/0.017), and hence longer hospitalization (p < 0.001 in all stages), but had no significant impact on hospital mortality (p = 0.119/0.118/0.723), 90-day mortality (p = 0.259/0.118/0.723), disease-free survival (p = 0.128/0.826/0.511), or overall survival (p = 0.869/0.122/0.122) in any disease stage. Prognostic factors for overall survival included tumor size, tumor number, alpha-fetoprotein level, and postoperative complication of grade ≥ 3A.

CONCLUSION

Perioperative blood transfusion was associated with a higher incidence of complications but had no significant impact on survival after curative hepatectomy for hepatocellular carcinoma.

Is the anterior approach recommended for liver resection of hepatocellular carcinoma? A systematic review and meta-analysis

BACKGROUND/PURPOSE

The anterior approach (AA) in liver resection has proven more effective with regard to short-term outcomes than the conventional approach (CA). However, its superiority over the CA concerning long-term outcomes remains unclear. This meta-analysis compared the short- and long-term outcomes of the AA and CA.

METHODS

Databases, including MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials, were searched to identify studies comparing the AA and CA for hepatocellular carcinoma (HCC) liver resection. The primary outcomes were the in-hospital mortality, in-hospital morbidity, disease-free survival (DFS), and overall survival (OS). Secondary outcomes were operative time, blood loss, blood transfusion, R0 rate, and length of hospital stay.

RESULTS

Ten studies involving 1369 patients were included (AA, n = 595; CA, n = 774). Despite no significant differences in the in-hospital mortality or morbidity, the AA demonstrated a superior DFS (hazard ratio [HR], 0.63; 95% confidence interval [CI]: 0.51-0.77) and OS (HR, 0.56; 95% CI: 0.48-0.65) and was associated with a longer operative time, less blood loss, and less transfusion than the CA. No marked differences in other outcomes were noted.

CONCLUSIONS

The AA for HCC liver resection helped reduce blood loss and need for transfusion, improving the DFS and OS.

Effect of RhD and RhE sample phenotypic blood transfusion on the prognosis of hepatocellular carcinoma

OBJECTIVE

This study aimed to analyze the therapeutic effects and clinical outcomes of HCC patients, who received both RhD and RhE same phenotypic blood transfusion during perioperative period.

METHODS

Microcolumn gel technology (MGT) was used to detect Rh blood group phenotyping in 98 HCC patients. Patients received RhD and RhE same phenotypic transfusion were defined experimental group, and those received only RhD same phenotypic but RhE different phenotypic transfusion were included in control group. Hemoglobin (Hb) and hematocrit (HCT) before and after perioperative transfusion were analyzed. The occurrence of adverse transfusion reactions were observed. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

After the transfusion treatment, the Hb (118.9 ± 34.8 g/L vs 99.6 ± 26.9 g/L) and HCT [(34.0 ± 7.6)% vs (29.9 ± 8.8)%] of experimental group and the Hb (104.3 ± 36.2 g/L vs 94.8 ± 25.0 g/L) of control group were significantly higher than those before blood transfusion, respectively (all P < .05). In addition, Hb and HCT in experimental group were significantly higher than those in the control group after transfusion (P < .05). For the adverse blood transfusion reactions, the incidence of backache was reduced in the patients received Rh same phenotypic transfusion compared with those in control group (1.9% vs 15.2%, P = .024). The overall survival of patients in experimental group was better than that in control group (log-rank P = .036).

CONCLUSION

Our study indicated that both RhD and RhE same phenotypic transfusion significantly increased Hb and HCT and reduced backache incidence than RhE different phenotypic transfusion in HCC patients. The overall survival of patients was improved by RhD and RhE same phenotypic transfusion.

Volumetric Remodeling of the Left Liver After Right Hepatectomy: Analysis of Factors Predicting Degree of Hypertrophy and Post-hepatectomy Liver Failure

BACKGROUND

This study investigated the volumetric remodeling of the left liver after right hepatectomy looking for factors predicting the degree of hypertrophy and severe post-hepatectomy liver failure (PHLF).

METHODS

In a cohort of 121 right hepatectomies, we performed CT volumetrics study of the future left liver remnant (FLR) preoperatively and postoperatively. Factors influencing FLR degree of hypertrophy and severe PHLF were identified by multivariate analysis.

RESULTS

After right hepatectomy, the mean degree of hypertrophy and kinetic growth rate of the left liver remnant were 25% and 3%/day respectively. The mean liver volume recovery rate was 77%. Liver remodeling volume was distributed for 79% on segments 2 and 3 and 21% on the segment 4 (p<0.001). Women showed a greater hypertrophy of segments 2 and 3 compared with men (p=0.002). The degree of hypertrophy of segment 4 was lower in case of middle hepatic vein resection (p=0.004). Left liver remnant kinetic growth rate was associated with the standardized future liver remnant (sFLR) (p<0.001) and a two-stage hepatectomy (p=0.023). Severe PHLF were predicted by intraoperative transfusion (p=0.009), biliary tumors (p=0.013), and male gender (p=0.022).

CONCLUSIONS

Volumetric remodeling of the left liver after right hepatectomy is not uniform and is mainly influenced by gender and sacrifice of middle hepatic vein. Male gender, intraoperative transfusion, and biliary tumors increase the risk of postoperative liver failure after right hepatectomy.

Does perioperative allogeneic blood transfusion worsen the prognosis of patients with hepatocellular carcinoma? A meta-analysis of propensity score-matched studies

Background

Allogeneic blood transfusion is required in a part of liver resection. The effect of allogeneic blood transfusion on the prognosis of patients with hepatocellular carcinoma (HCC) remains controversial. To investigate whether perioperative allogeneic blood transfusion (PBT) affects the long-term prognosis of patients with HCC, we conducted a meta-analysis that included only propensity score-matched (PSM) studies.

Methods

The Cochrane Library, Embase, PubMed, and Web of Science databases were systematically searched to identify PSM studies that compared the long-term outcomes of allogeneic blood transfusion in resected HCC patients. Overall survival (OS) and recurrence-free survival (RFS) rates were calculated.

Results

This meta-analysis included 9 PSM studies with 12 datasets involving 2476 patients. Lower OS and RFS in HCC patients receiving allogeneic blood transfusion were observed than those in patients not receiving blood transfusion (OS: hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.10-1.64; p < 0.01; RFS: HR, 1.29; 95% CI, 1.07-1.56; p < 0.01). Subgroup analysis revealed that among patients with BCLC A HCC, those receiving allogeneic blood transfusion had lower OS and RFS (OS: HR, 2.27; 95% CI, 1.61-3.21; RFS: HR, 2.11; 95% CI, 1.30-3.41). OS and RFS were similar in both groups of patients with BCLC B and C HCC.

Conclusion

The receipt of perioperative allogeneic blood transfusion is associated with a decrease in OS and RFS. These results seem to be reliable for patients in BCLC stage A. But more high-quality research is needed to confirm this conclusion.

Impact of liver cirrhosis and portal hypertension on minimally invasive limited liver resection for primary liver malignancies in the posterosuperior segments: An international multicenter study

INTRODUCTION

To assess the impact of cirrhosis and portal hypertension (PHT) on technical difficulty and outcomes of minimally invasive liver resection (MILR) in the posterosuperior segments.

METHODS

This is a post-hoc analysis of patients with primary malignancy who underwent laparoscopic and robotic wedge resection and segmentectomy in the posterosuperior segments between 2004 and 2019 in 60 centers. Surrogates of difficulty (i.e, open conversion rate, operation time, blood loss, blood transfusion, and use of the Pringle maneuver) and outcomes were compared before and after propensity-score matching (PSM) and coarsened exact matching (CEM).

RESULTS

Of the 1954 patients studied, 1290 (66%) had cirrhosis. Among the cirrhotic patients, 310 (24%) had PHT. After PSM, patients with cirrhosis had higher intraoperative blood transfusion (14% vs. 9.3%; p = 0.027) and overall morbidity rates (20% vs. 14.5%; p = 0.023) than those without cirrhosis. After coarsened exact matching (CEM), patients with cirrhosis tended to have higher intraoperative blood transfusion rate (12.1% vs. 6.7%; p = 0.059) and have higher overall morbidity rate (22.8% vs. 12.5%; p = 0.007) than those without cirrhosis. After PSM, Pringle maneuver was more frequently applied in cirrhotic patients with PHT (62.2% vs. 52.4%; p = 0.045) than those without PHT.

CONCLUSION

MILR in the posterosuperior segments in cirrhotic patients is associated with higher intraoperative blood transfusion and postoperative morbidity. This parameter should be utilized in the difficulty assessment of MILR.

Incidence and predictors of hypophosphataemia after ferric carboxymaltose use-A 3-year experience from a single institution in Singapore

Ferric carboxymaltose (FCM) administration helps reduce transfusion requirements in the perioperative situation, which improves patient outcomes and reduces healthcare costs. However, there is increasing evidence of hypophosphataemia after FCM use. We aim to determine the incidence of hypophosphataemia after FCM administration and elucidate potential biochemical factors associated with the development of subsequent hypophosphataemia. A retrospective review of anonymised data of all FCM administrations in a single institution was conducted from August 2018 to August 2021. Each unique FCM dose administered was examined to assess its effect on Hb and serum phosphate levels within the subsequent 28 days from each FCM administration. Phosphate levels were repeatedly measured within the 28-day interval and the lowest phosphate level within that period was determined. Patients' serum phosphate levels within 28 days of FCM administration were compared against normal serum phosphate levels within 2 weeks before FCM administration. The odds ratios of various pre-FCM serum markers were calculated to elucidate potential biochemical predictors of post-FCM hypophosphataemia. In 3 years, a total of 1296 doses of FCM were administered to 1069 patients. The mean improvement in Hb was 2.45 g/dL (SD = 1.94) within 28 days of FCM administration, with the mean time taken to peak Hb levels being 6.3 days (SD = 8.63), which is earlier than expected, but was observed in this study and hence reported. The incidence of hypophosphataemia <0.8 mmol/L was 22.7% (n = 186), and <0.4 mmol/L was 1.6% (n = 9). This figure is lower than the numbers reported in previously published meta-analyses given that routine checks of serum phosphate levels were not conducted initially and hence could possibly be higher. The odds of developing hypophosphataemia (<0.8 mmol/L) were 27.7 (CI: 17.3-44.2, p < 0.0001) if baseline serum phosphate was less than 1 mmol/L. The odds of developing hypophosphataemia (<0.8 mmol/L) were 1.3 (CI: 1.08-1.59, p < 0.01) if the change in Hb levels observed after FCM administration were more than 4 g/dL. Hypophosphataemia after FCM administration is significant and FCM should be used by clinicians with caution.

Effect of blood product transfusion on the prognosis of patients undergoing hepatectomy for hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

Hepatectomy, the most common treatment for hepatocellular carcinoma, is associated with greater intraoperative blood loss than is resection of other malignancies. The effect of blood product transfusion (red blood cell [RBC], platelet, fresh frozen plasma [FFP], 5 and 25% albumin) on prognosis remains unclear. This study examined effects of blood product transfusion on prognoses of patients who underwent hepatectomy for hepatocellular carcinoma.

METHODS

We included 2015 patients with pathologically confirmed hepatocellular carcinoma who underwent hepatectomy at our institution during 1990-2019. Patients (n = 534) who underwent repeat hepatectomy, non-curative hepatectomy, those with synchronous cancer in other organs, those who died within 1 month of surgery, and those with missing data were excluded. Finally, 1481 patients (1142 males, 339 females; median age: 68 years) with curability A or B were included.

RESULTS

Intraoperative blood loss (> 500 mL) was an independent predictor of RBC transfusion (odds ratio, 8.482; P < 0.001). All transfusion groups had poorer recurrence-free survival (RFS) and overall survival (OS) than non-transfusion groups. After propensity score matching, the 5 year RFS rate was 13.4 and 16.3% in the RBC and no-RBC groups, respectively (P = 0.020). The RBC group had a significantly lower 5 year OS rate than the no-RBC group (42.1 vs. 48.8%, respectively; P = 0.035) and the FFP group (57.0%) than the no-FFP group (63.9%) (p = 0.047). No significant between-subgroup differences were found for other blood transfusion types.

CONCLUSIONS

RBC transfusion promotes hepatocellular carcinoma recurrence and RBC/FFP transfusions reduced long-term survival and RFS and OS in patients who underwent radical liver resection of HCC.

Short- and Long-Term Outcomes in Laparoscopic Versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Systematic Review and Meta-Analysis

Background: Laparoscopic hepatectomy (LH) is considered a safe and feasible treatment for patients with hepatocellular carcinoma (HCC) in recent studies. However, in elderly patients, application of LH still remains controversial, and the outcomes of LH versus open hepatectomy (OH) have not been fully evaluated. Our objective is to compare the short- and long-term outcomes of LH with OH in elderly patients with HCC. Materials and Methods: All studies comparing LH and OH in elderly patients with HCC were systematically searched in the databases of PubMed, EmBase, and Web of Science. Statistical analysis was conducted using Review Manager 5.3 (Cochrane Collaboration, 2014). The last search was performed on March 20, 2022. Short-term outcomes include blood loss, operation time, blood transfusion, overall and major postoperative complications, mortality, hospital stay, tumor size, and surgical margin. Long-term outcomes include 1-, 3-, and 5-year overall survival (OS); 1-, 3-, and 5-year disease-free survival (DFS); and 1-, 3-, and 5-year recurrence-free survival (RFS). Results: Fourteen studies involving 1596 patients were included in this meta-analysis. The short-term outcomes of LH were a shorter postoperative hospital stay and fewer overall and major postoperative complications (all P < .00001). However, there were no significant differences in operation time, blood loss, blood transfusion rate, surgical margin, tumor size, and mortality. For the long-term outcomes, LH is comparable with OH in terms of 1-, 3-, and 5-year OS; 1-, 3-, and 5-year DFS; and 1-, 3-, and 5-year RFS. Conclusions: Compared with OH, LH is a safe and feasible treatment for elderly patients with HCC.

Effects of perioperative blood transfusion in gastric cancer patients undergoing gastrectomy: A systematic review and meta-analysis

Background

The short-term and long-term effects of perioperative blood transfusion (PBT) on patients with gastric cancer are still intriguing. This systematic review and meta-analysis aimed to investigate the effects of blood transfusion on clinical outcomes in patients with gastric cancer undergoing gastrectomy.

Methods

We searched PubMed, Web of Science, Embase, and The Cochrane Library on December 31th 2021. The main outcomes were overall survival (OS), disease-free survival (DFS), disease-specific survival (DFS), and postoperative complications. A fixed or random-effects model was used to calculate the hazard ratio (HR) with 95% confidence intervals (CIs).

Results

Fifty-one studies with a total of 41,864 patients were included for this review and meta-analysis. Compared with patients who did not receive blood transfusions (NPBT), PBT was associated with worse 5-year OS (HR = 2.39 [95%CI: 2.00, 2.84]; p < 0.001; Multivariate HR = 1.43 [95%CI: 1.24, 1.63]; p < 0. 001), worse 5-year DFS (HR = 2.26 [95%CI: 1.68, 3.05]; p < 0.001; Multivariate HR = 1.45 [95%CI: 1.16, 1.82]; p < 0. 001), and worse 5-year DSS (HR = 2. 23 [95%CI: 1.35, 3.70]; p < 0.001; Multivariate HR = 1.24 [95%CI: 0.96, 1.60]; p < 0.001). Moreover, The PBT group showed a higher incidence of postoperative complications [OR = 2.30 (95%CI:1.78, 2. 97); p < 0.001] than that in the NPBT group, especially grade III-V complications, according to the Clavien-Dindo classification. [OR = 2.50 (95%CI:1.71, 3.63); p < 0.001].

Conclusion

In patients who underwent gastrectomy, PBT was associated with negative survival effects (OS, DFS, DSS) and a higher incidence of perioperative complications. However, more research was expected to further explore the impact of PBT. Meanwhile, strict blood transfusion management should be implemented to minimize the use of PBT.

General Anesthetics in CAncer REsection Surgery (GA-CARES) randomized multicenter trial of propofol vs volatile inhalational anesthesia: protocol description

BACKGROUND

Studies indicate that patients can be "seeded" with their own cancer cells during oncologic surgery and that the immune response to these circulating cancer cells might influence the risk of cancer recurrence. Preliminary data from animal studies and some retrospective analyses suggest that anesthetic technique might affect the immune response during surgery and hence the risk of cancer recurrence. In 2015, experts called for prospective scientific inquiry into whether anesthetic technique used in cancer resection surgeries affects cancer-related outcomes such as recurrence and mortality. Therefore, we designed a pragmatic phase 3 multicenter randomized controlled trial (RCT) called General Anesthetics in Cancer Resection (GA-CARES).

METHODS

After clinical trial registration and institutional review board approval, patients providing written informed consent were enrolled at five sites in New York (NY) State. Eligible patients were adults with known or suspected cancer undergoing one of eight oncologic surgeries having a high risk of cancer recurrence. Exclusion criteria included known or suspected history of malignant hyperthermia or hypersensitivity to either propofol or volatile anesthetic agents. Patients were randomized (1:1) stratified by center and surgery type using REDCap to receive either propofol or volatile agent for maintenance of general anesthesia (GA). This pragmatic trial, which seeks to assess the potential impact of anesthetic type in "real world practice", did not standardize any aspect of patient care. However, potential confounders, e.g., use of neuroaxial anesthesia, were recorded to confirm the balance between study arms. Assuming a 5% absolute difference in 2-year overall survival rates (85% vs 90%) between study arms (primary endpoint, minimum 2-year follow-up), power using a two-sided log-rank test with type I error of 0.05 (no planned interim analyses) was calculated to be 97.4% based on a target enrollment of 1800 subjects. Data sources include the National Death Index (gold standard for vital status in the USA), NY Cancer Registry, and electronic harvesting of data from electronic medical records (EMR), with minimal manual data abstraction/data entry.

DISCUSSION

Enrollment has been completed (n = 1804) and the study is in the follow-up phase. This unfunded, pragmatic trial, uses a novel approach for data collection focusing on electronic sources.

TRIAL REGISTRATION

Registered (NCT03034096) on January 27, 2017, prior to consent of the first patient on January 31, 2017.

Sustained Systemic Inflammatory Response Predicts Survival in Patients with Hepatocellular Carcinoma After Hepatic Resection

BACKGROUND

Preoperative systematic inflammatory response, represented by neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), and C-reactive protein-albumin ratio (CAR), has been associated with long-term outcomes in patients with hepatocellular carcinoma (HCC). However, the impact of sustained systematic inflammatory response after resection remains unclear.

METHODS

This study comprised 210 patients who had undergone primary hepatic resection for HCC between 2008 and 2018. Preoperative and postoperative NLR, LMR, and CAR were evaluated, and patients were then classified into three groups according to the status of each marker: persistently high inflammatory state (elevated group), preoperatively low inflammatory state (normal group), and preoperatively high but postoperatively low inflammatory state (normalized group). Multivariate Cox proportional hazard models were conducted to assess disease-free and overall survival, adjusting for potential confounders.

RESULTS

In multivariate analysis, sex (p = 0.002), hepatitis B surface antigen (HBsAg) positivity (p = 0.002), serum α-fetoprotein (AFP) level ≥ 20 ng/mL (p < 0.001), multiple tumors (p < 0.001), microvascular invasion (p = 0.003), type of resection (p = 0.007), and elevated CAR (hazard ratio [HR] 2.40, 95% confidence interval [CI] 1.55-3.73; p < 0.001) were independent and significant predictors of cancer recurrence, while sex (p = 0.05), HBsAg positivity (p = 0.03), serum AFP level ≥20 ng/mL (p = 0.009), multiple tumors (p = 0.03), microvascular invasion (p = 0.006), and elevated CAR (HR 2.10, 95% CI 1.13-3.91; p = 0.02) were independent predictors of overall survival.

CONCLUSIONS

Sustained elevated CAR may be an independent and significant indicator of poor long-term outcomes in patients with HCC after hepatic resection, suggesting the interplay of the host's inflammatory state and tumor recurrence and progression in HCC.

Survival Impact of Perioperative Red Blood Cell Transfusion During Pancreatectomy in Patients With Pancreatic Ductal Adenocarcinoma: A Propensity Score Matching Analysis

OBJECTIVES

The aim of this study was to show the real impact of perioperative red blood cell transfusion (PBT) on prognosis in patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma.

METHODS

Patients who underwent pancreatectomy between 2004 and 2018 were enrolled. Short- and long-term outcomes in patients who received PBT (PBT group) were compared with those who did not (non-PBT group).

RESULTS

From a total of 197 patients, 55 (27.9%) received PBT, and 142 (72.1%) did not. The PBT group displayed a higher level of carbohydrate antigen 19-9 (P = 0.02), larger tumor size (P < 0.001), and a higher rate of lymph node metastasis (P = 0.02), and underwent more frequent pancreaticoduodenectomy (P < 0.001) and portal vein resection (P < 0.001). Before matching, recurrence-free survival (RFS) and overall survival (OS) in the PBT group were significantly worse than the non-PBT group (RFS: hazard ratio [HR], 1.73 [P = 0.002]; OS: HR, 2.06 [P < 0.001]). After matching, RFS and OS in the PBT group were not significantly different from the non-PBT group (RFS: HR, 1.44 [P = 0.15]; OS: HR, 1.53 [P = 0.11]).

CONCLUSIONS

Our results show that PBT has no survival impact in patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma.

Hepatectomy outcomes in patients with hepatitis C virus-related hepatocellular carcinoma with or without cirrhosis

Purpose

Hepatocellular carcinoma (HCC) is rare in HCV patients without cirrhosis, and little is known about the postoperative results of these patients. The present study compares the outcomes of cirrhotic and non-cirrhotic groups after liver resection (LR) in solitary HCV-related HCC patients and identifies risk factors for prognosis according to the presence or absence of cirrhosis in these patients.

Methods

Two hundred and 7 adult hepatectomy patients with treatment-naïve solitary HCV-related HCC were identified prospectively at our institution between July 2005 and May 2019.

Results

The non-cirrhotic group had better liver function than the cirrhotic group based on platelet count, liver function tests, liver stiffness measurement, and indocyanine green retention rate at 15 minutes but were older than the cirrhotic group. Consistently, noninvasive markers in the cirrhotic group were significantly higher than in the non-cirrhotic group. The cumulative disease-free survival and overall survival in the non-cirrhotic group were significantly higher than in the cirrhotic group. HCC recurrence was related to major LR and α-FP of >40 ng/mL and death was related to long hospitalization and α-FP of >40 ng/mL in multivariate analysis. Noninvasive markers and the presence of cirrhosis were not related to HCC recurrence or death in multivariate analyses.

Conclusion

The cirrhotic group showed poor prognosis due to poor liver function after LR compared to the non-cirrhotic group, but this was not sustained in multivariate analysis. The factors influencing HCC recurrence and death were different in the cirrhotic and non-cirrhotic groups.

Realization of improved outcomes following liver resection in hepatocellular carcinoma patients aged 75 years and older

Purpose

Little is known about liver resection (LR) in hepatocellular carcinoma (HCC) patients older than 75 years of age. This study aimed to compare the postoperative and long-term outcomes of hepatectomy in this patient population according to operation period.

Methods

This study included 130 elderly patients who underwent LR for solitary treatment-naïve HCC between November 1998 and March 2020. Group 1 included patients who underwent LR before 2016 (n = 68) and group 2 included those who underwent LR during or after 2016 (n = 62).

Results

The proportion of major LR, anatomical LR, and laparoscopic LR (LLR) in group 1 was significantly lower than those in group 2. Also, the median operation time, amount of blood loss, hospitalization length, rates of intraoperative blood transfusion, and complications in group 2 were less than those in group 1. In the subgroup analysis of group 1, high proteins induced by vitamin K absence or antagonist-II, long hospitalization, and LLR were closely associated with mortality. In the subgroup analysis of group 2, however, none of the factors increased mortality. Nevertheless, the presence of tumor grade 3 or 4 and the incidence of microvascular invasion were higher in group 1 than in group 2, and the disease-free survival and overall survival were better in group 2 than in group 1 because of minimized blood loss and quicker recovery period by increased surgical techniques and anatomical approach, and LLR.

Conclusion

LR in elderly HCC patients has been frequently performed recently, and the outcomes have improved significantly compared to the past.

The difference in prolonged continuous and intermittent Pringle maneuver during complex hepatectomy for hepatocellular carcinoma patients with chronic liver disease: A retrospective cohort study

Purpose

To explore the differences between prolonged continuous Pringle maneuver (CPM) and prolonged intermittent Pringle maneuver (IPM) in patients with hepatocellular carcinoma (HCC), who underwent complex hepatectomy.

Methods

This retrospective cohort study performed between June 2014 and May 2016 included 142 patients who underwent complex hepatectomy for HCC and concomitant chronic liver disease but with good liver function. Patients were categorized into CPM (n = 69) and IPM groups (n = 73). The differences in these aspects were compared between the two groups which include operation time, intraoperative bleeding, perioperative transfusion, postoperative complications, liver function injury, postoperative overall survival (OS), and tumor recurrence.

Results

The cumulative clamping time, operation time, intraoperative bleeding, and perioperative transfusion rates were 38.0, 132 min, 300 ml, and 17.4% in CPM and 40.0, 145 min, 400 ml, and 32.9% in IPM, respectively. There were significant intergroup differences in operation time (p = 0.018), intraoperative bleeding (p < 0.001), and perioperative transfusion rates (p = 0.034). Besides, the postoperative complications and postoperative liver function injury of the CPM group were better than those of IPM. There was no significant intergroup difference in OS (p = 0.908) and tumor recurrence (p = 0.671) between two groups.

Conclusion

Compared with IPM, CPM with a cumulative clamping time between 30 and 50 min can shorten operation time, reduce intraoperative bleeding and perioperative transfusion, and reduce postoperative complications and postoperative liver function injury in patients who underwent complex hepatectomy for HCC and concomitant liver disease but with good liver function. There was no significant difference in OS and tumor recurrence between two groups.

Risk factors and clinical outcomes of extrahepatic recurrence in patients with post-hepatectomy recurrent hepatocellular carcinoma

BACKGROUND

Extrahepatic recurrence remains a major obstacle to an improved prognosis in patients with hepatocellular carcinoma (HCC) undergoing hepatectomy.

METHODS

From January 2001 to December 2014, we screened 1330 consecutive patients who underwent curative hepatectomy for HCC. Patients who experienced recurrence were enrolled in this study and divided into an extrahepatic recurrence (EHR) group and a pure intrahepatic recurrence (IHR) group. Clinical data and follow-up results were retrospectively collected and analysed.

RESULTS

A total of 556 patients were enrolled (EHR, 52; IHR, 504). In the EHR group, the lung was the most common site of extrahepatic recurrence (53.8%), among which 67.3% had associated intrahepatic lesions. Background Hepatitis B (HR 0.282; 95% CI 0.106-0.752; P = 0.011), tumour size ≥10 cm at initial diagnosis (HR 2.679; 95% CI 1.283-5.596; P = 0.009) and blood transfusion during initial surgery (HR 2.218; 95% CI 1.132-4.346; P = 0.020) were predictive of EHR. A multidisciplinary team treated recurrent HCC. After a median follow-up period of 46 months (range, 24-192 months), the 1-, 3- and 5-year overall survival rates in the EHR group were 60.7%, 8.9% and 0%, respectively, after recurrence, and 78.8%, 30.2% and 8.9%, respectively, after initial surgery, which were much lower than those in the IHR group.

CONCLUSION

Tumour size ≥10 cm and blood transfusion during initial surgery were predictive of extrahepatic recurrence in patients with post-hepatectomy recurrent HCC. Treatment options were limited, and long-term survival was unsatisfactory.

Anaesthesia as an influence in tumour progression

Purpose

Tumour growth and the formation of metastases are essential elements in the progression of cancer. The centre of treatment is the surgical resection of primary solid tumours. But even if the tumour can be removed without microscopic residual cells, local recurrences and distant metastases occur and determine the patient’s fate. During the operation, tumour cells are shed from the primary tumour and released into the circulation. These circulating tumour cells might play an important role in the formation of new tumour sites. Therefore, a functional innate and adaptive immune system is essential, especially in this perioperative period. Anaesthesia influences consciousness and pain perception and interacts directly with the immune system and tumour cells.

Methods

Review of the current literature concerning intra- and postoperative anaesthetic decisions and tumour progression.

Results

There are beneficial aspects for patient survival associated with total intravenous anaesthesia, the use of regional anaesthetics and the avoidance of allogeneic red blood cell transfusions. Alternatives such as irradiated intraoperative blood salvage and preoperative iron supplementation may be advantageous in cases where transfusions are limited or not wanted. The immunosuppressive properties of opioids are theoretical, but strong evidence to avoid them does not exist. The application of nonsteroidal anti-inflammatory drugs and postoperative nausea and vomiting prophylaxis do not impair the patient’s survival and may even have a positive effect on tumour regression.

Conclusion

Anaesthesia does play an important part in the perioperative period in order to improve the cancer-related outcome. Further research is necessary to make more concrete recommendations.

Development and Validation of a Machine Learning Prognostic Model for Hepatocellular Carcinoma Recurrence After Surgical Resection

Surgical resection remains primary curative treatment for patients with hepatocellular carcinoma (HCC) while over 50% of patients experience recurrence, which calls for individualized recurrence prediction and early surveillance. This study aimed to develop a machine learning prognostic model to identify high-risk patients after surgical resection and to review importance of variables in different time intervals. The patients in this study were from two centers including Eastern Hepatobiliary Surgery Hospital (EHSH) and Mengchao Hepatobiliary Hospital (MHH). The best-performed model was determined, validated, and applied to each time interval (0-1 year, 1-2 years, 2-3 years, and 3-5 years). Importance scores were used to illustrate feature importance in different time intervals. In addition, a risk heat map was constructed which visually depicted the risk of recurrence in different years. A total of 7,919 patients from two centers were included, of which 3,359 and 230 patients experienced recurrence, metastasis or died during the follow-up time in the EHSH and MHH datasets, respectively. The XGBoost model achieved the best discrimination with a c-index of 0.713 in internal validation cohort. Kaplan-Meier curves succeed to stratify external validation cohort into different risk groups (p < 0.05 in all comparisons). Tumor characteristics contribute more to HCC relapse in 0 to 1 year while HBV infection and smoking affect patients' outcome largely in 3 to 5 years. Based on machine learning prediction model, the peak of recurrence can be predicted for individual HCC patients. Therefore, clinicians can apply it to personalize the management of postoperative survival.

Impact of perioperative allogeneic blood transfusion on the long-term prognosis of patients with different stage tumors after radical resection for hepatocellular carcinoma

BACKGROUND

We previously reported that perioperative allogeneic blood transfusion (PABT) did not affect long-term survival after radical resection for hepatocellular carcinoma (HCC). This study aimed to investigate the effects of PABT on the prognosis of HCC patients with different stage tumors.

METHODS

Patients with primary HCC who underwent curative liver resection between 2003 and 2012 were retrospectively enrolled and divided into the early-stage (stage I) and non-early-stage (stages II, III and IV) groups. The impacts of PABT on the long-term prognosis of patients in different groups after resection were investigated using propensity score matching (PSM) and multivariable Cox regression analyses.

RESULTS

We enrolled 426 HCC patients, including 53 matched pairs of patients with early-stage tumors and 51 matched pairs of patients with non-early-stage tumors. Survival analyses of the patients with early-stage tumors showed that the recurrence-free survival (RFS) and overall survival (OS) rates of the transfusion group were significantly worse than those of the nontransfusion group both before and after PSM. Multivariable Cox analyses identified that PABT was an independent predictor of RFS and OS of the patients with early-stage tumors. However, survival analyses of the propensity-matched patients with non-early-stage tumors showed no significant differences in RFS and OS rates between the transfusion and nontransfusion groups (p = 0.296; p = 0.472).

CONCLUSIONS

This study demonstrates that PABT has negative impacts on the long-term prognosis of patients with early-stage tumors after radical resection of HCC but has no impact on the long-term prognosis of patients with non-early-stage tumors.

The Effects of Allogeneic Blood Transfusion in Hepatic Resection

BACKGROUND

Hepatectomy has a high risk of perioperative bleeding due to the underlying disease. Here, we investigated the postoperative impact of allogeneic blood transfusion during hepatectomy.

METHODS

The surgical outcomes in 385 patients who underwent hepatic resection for hepatocellular carcinoma were retrospectively reviewed. The association of allogeneic blood transfusion with surgical outcomes and remnant liver regeneration data was analyzed.

RESULTS

Eighty-six patients (24.0%) received an allogeneic blood transfusion and 272 patients (76.0%) did not. After propensity score matching, the incidence rates of postoperative complication (Clavien-Dindo grade >IIIA), posthepatectomy liver failure, and massive ascites were significantly higher for the group that received a blood transfusion than for the group that did not receive blood transfusion (P < .001, P = .001, and <.001, respectively). Postoperative measures of total bilirubin, albumin, platelet count, prothrombin time, aspartate aminotransferase, and alanine aminotransferase were significantly more favorable in patients without blood transfusion until day 7 after surgery. There were no correlations in the remnant liver regeneration at 7 days, and 1, 2, 5, and 12 months postoperatively between the 2 groups (P = .585, .383, .507, .261, and .430, respectively). Regarding prognosis, there was no significant difference in overall and recurrence-free survival between the 2 groups (P = .065 and .166, respectively).

CONCLUSION

Allogeneic transfusion during hepatectomy strongly affected remnant liver function in the early postoperative period; however, this was not related to the remnant liver regeneration volume. Despite that the allogeneic transfusion resulted in poorer postoperative laboratory test results and increased postoperative complication and mortality rates, it had no effect on the long-term prognosis.

Perioperative Allogeneic Blood Transfusion Does not Influence Patient Survival After Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis

BACKGROUND

Whether perioperative allogeneic blood transfusion (PABT) negatively influences patient survival after hepatectomy (HR) for hepatocellular carcinoma (HCC) remains controversial.

METHODS

Five hundred two patients who underwent HR for initial HCC between 1994 and 2015 were enrolled in this study. All patients were divided into two groups: the PABT group and the non-PABT group. Differences of clinicopathological factors, overall survival (OS), recurrence-free survival (RFS), and the recurrence pattern between the two groups were evaluated. Using propensity score matching for tumor-related factors, liver functions, and surgical factors (total 11 factors), the survival impact of PABT was also analyzed.

RESULTS

In the entire cohort, 78 patients (15.5%) received PABT such as red cell concentrate, fresh-frozen plasma, or platelets. OS (5-year OS: 55% vs. 76%; p = 0.0005) and RFS (2-year RFS: 47% vs. 56%; p = 0.0131) were significantly worse in the PABT group. The extrahepatic recurrence happened more frequently in the PABT group (15% vs. 5.4%; p = 0.0039). There were many significant clinicopathological differences between the two groups: more advanced tumor stage (tumor diameter, stage III or IV, microvascular invasion), worse liver functions (albumin, indocyanine green retention rate at 15 min), and more surgical stress (blood loss, operation time) in the PABT group. After propensity score matching, 43 pairs of patients were extracted. In this matched cohort, the survival curves of the PABT and non-PABT groups almost completely overlapped both in OS (5-year OS: 62% vs. 62%; p = 0.4384) and in RFS (2-year RFS: 49% vs. 47%; p = 0.8195). The significant difference of the extrahepatic recurrence rate disappeared in the matched cohort (p = 0.5789).

CONCLUSION

Using propensity score matching, we found that PABT does not influence patient survival after HR for HCC.

Pringle Maneuver in Extended Liver Resection: A propensity score analysis

Despite the ongoing decades-long controversy, Pringle maneuver (PM) is still frequently used by hepatobiliary surgeons during hepatectomy. The aim of this study was to investigate the effect of PM on intraoperative blood loss, morbidity, and posthepatectomy hemorrhage (PHH). A series of 209 consecutive patients underwent extended hepatectomy (EH) (≥5 segment resection). The association of PM with perioperative outcomes was evaluated using multivariate analysis with a propensity score method to control for confounding. Fifty patients underwent PM with a median duration of 19 minutes. Multivariate analysis revealed that risk of excessive intraoperative bleeding (≥1500 ml; odds ratio [OR] 0.27, 95%-confidence interval [CI] 0.10–0.70, p = 0.007), major morbidity (OR 0.41, 95%-CI 0.18–0.97, p = 0.041), and PHH (OR 0.22, 95%-CI 0.06–0.79, p = 0.021) were significantly lower in PM group after EH. Furthermore, there was no significant difference in 3-year recurrence-free-survival between groups. PM is associated with lower intraoperative bleeding, PHH, and major morbidity risk after EH. Performing PM does not increase posthepatectomy liver failure and does not affect recurrence rate. Therefore, PM seems to be justified in EH.

Predictors of post-operative complications after surgical resection of hepatocellular carcinoma and their prognostic effects on outcome and survival: A propensity-score matched and structural equation modelling study

INTRODUCTION

Although hepatectomy is the mainstay of curative therapy for hepatocellular carcinoma (HCC), post-operative complications remain high. Presently there is conflicting data on the impact of morbidity on oncologic outcomes. We sought to identify predictors for the occurrence of post-hepatectomy complications, as well as to analyse the impact on overall survival (OS) and recurrence-free survival (RFS).

MATERIALS AND METHODS

We performed a retrospective review of 888 patients who underwent resection for HCC from 2001 to 2016 in our institution.

RESULTS

A total of 237 patients (26.7%) developed 254 complications of Clavien-Dindo Grade ≥2. Hepatitis B (p = 0.0397), elevated ASA score (p = 0.0002), higher platelet counts (p = 0.0277), raised pre-operative APRI scores (p = 0.0105) and bloodloss (p < 0.0001) were independently associated with the development of complications. After propensity-score matching, 458 patients were compared in a 1:1 ratio (229 with complications versus 229 without). Patients with complications had significantly longer median length of stay (9 days [IQR 7-15] versus 6 days [IQR 5-8], p < 0.0001), higher 90-day mortality rates as well as inferior OS (p = 0.0139), but there was no difference in RFS (p = 0.4577). Age (p = 0.0006), elevated Child Pugh points (p < 0.0001), microvascular invasion (p = 0.0002), multifocal tumours (p = 0.0002), R1 resection (p = 0.0443) and development of complications (p = 0.0091) were independent predictors of inferior OS.

CONCLUSION

Post-operative morbidity affected both short-term and OS outcomes after hepatectomy for HCC. Hepatitis B, higher ASA scores, elevated preoperative APRI and increased blood loss were found to predict a higher likelihood of developing complications. This may potentially be mitigated by careful patient selection and adopting strict measures to minimise intraoperative bleeding.

Impact of perioperative blood transfusion on oncologic outcomes in patients with nonmetastatic renal cell carcinoma treated with curative nephrectomy: A retrospective analysis of a large, single-institutional cohort

Purpose

To evaluate the impact of perioperative blood transfusion (PBT) on oncologic outcomes after surgery in patients with nonmetastatic renal cell carcinoma (RCC).

Materials and Methods

This retrospective review included 2,329 patients who underwent partial or radical nephrectomy for localized RCC in a single institution from 2000 to 2014. PBT was defined as transfusion of allogeneic packed red blood cells (pRBCs) during nephrectomy or within the preoperative or postoperative hospitalization period. Oncologic outcomes of interest were recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS).

Results

PBT was performed in 275 patients (11.8%). In the multivariable logistic regression analysis, symptomatic presentation, advanced age at surgery, higher preoperative serum creatinine, and lower preoperative hemoglobin were independent preoperative risk factors for PBT (all p<0.05). Kaplan–Meier plots revealed that transfused patients showed poorer 5-year RFS (65.1% vs. 91.2%, p<0.001), OS (71.4% vs. 92.8%, p<0.001), and CSS (74.0% vs. 95.5%, p<0.001) than nontransfused patients. However, in the multivariable Cox regression analyses, PBT was not significantly associated with RFS, OS, or CSS. In multivariable analyses involving transfused patients only (n=275), an higher number of pRBC units was an independent predictor of worse OS (hazard ratio [HR], 1.043; 95% confidence interval [CI], 1.008–1.078; p=0.016) and CSS (HR, 1.066; 95% CI, 1.033–1.100; p<0.001).

Conclusions

The results of this study are inconclusive in that the influence of PBT on survival outcomes could not be determined in the multivariate analysis. However, increasing pRBC units in transfused patients might be a concern in light of worse OS and CSS. Therefore, efforts to limit PBT overuse seem necessary to improve postoperative survival in patients with RCC.

Endoscopic hepatic resection and endoscopic radiofrequency ablation as initial treatments for hepatocellular carcinoma within the Milan criteria

PURPOSES

The indication of endoscopic (laparoscopic and thoracoscopic) hepatic resection (HR) has been expanded in the past decade because of its low invasiveness. However, the indications of endoscopic HR and radiofrequency ablation (RFA) have not yet been determined.

METHODS

Among the 906 patients hospitalized for the initial treatment of hepatocellular carcinoma (HCC) between 2000 and 2017, 77 underwent endoscopic partial HR (E-pHR), and 94 underwent endoscopic RFA (E-RFA). We compared the short- and long-term outcomes between the E-pHR and E-RFA groups.

RESULTS

The patients in the E-RFA group were characterized primarily by an impaired liver function. Among the patients with liver damage B or C, the overall survival (OS) in the E-pHR group was significantly worse than in the E-RFA group (3-year OS: 36% vs. 82%, p = 0.003).

CONCLUSION

E-RFA may be recommended for the initial treatment of HCC in patients with a severely impaired liver function. However, E-pHR should be avoided as the initial treatment of HCC in such patients.

Guidelines on the intraoperative transfusion of red blood cells: a protocol for systematic review

INTRODUCTION

A significant proportion of red blood cell (RBC) transfusions are administered intraoperatively; yet there is limited evidence to guide transfusion decisions in this setting. The objective of this systematic review is to explore the availability, quality and content of clinical practice guidelines (CPGs) reporting on the indication for allogenic RBC transfusion during surgery.

METHODS

Major electronic databases (MEDLINE, EMBASE and CINAHL), guideline clearinghouses and Google Scholar, will be systematically searched from inception to January 2019 for CPGs pertaining to indications for intraoperative allogenic RBC transfusion. Characteristics of eligible guidelines will be reported in a summary table. The AGREE II instrument will be used to appraise the quality of identified guidelines. Recommendations advising on indications for intraoperative RBC transfusion will be manually extracted and presented to allow for comparison of similarities and/or discrepancies in the literature.

ETHICS AND DISSEMINATION

The results of this systematic review will be disseminated through relevant conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

CRD42018111487.