Leucocyte-depleted blood transfusion is an independent predictor of surgical morbidity in patients undergoing elective colon cancer surgery-a single-center analysis of 531 patients

Operative blood loss adversely affects short and long-term outcomes after colorectal cancer surgery: results of a systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery.

METHODS

A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion.

RESULTS

Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02).

CONCLUSIONS

Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject.

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.

Preoperative Walking Capacity Indirectly Relates to Decreased Postoperative Complications in Patients with Gastrointestinal Cancer

Objectives:

Postoperative complications (PCs) in patients with gastrointestinal cancer (GIC) lead to reduced lifespan and poor quality of life. The aim of this study was to investigate the correlation between preoperative exercise-related factors, together with other contributory factors, and the frequency of PCs in patients with GIC.

Methods:

This was a cross-sectional, three-institution study. We enrolled 299 patients who were scheduled for elective surgery for GIC (182 men and 117 women; age, 65.7 ± 11.0 years). PCs were graded using the Clavien–Dindo classification based on the medical records 1 month postoperatively. Exercise-related factors (the skeletal muscle index, the isometric knee extension torque, and the 6-min walk test [6 MWT] distance) were measured before surgery. Based on previous studies of factors contributing to complications, data on age, sex, clinical cancer stage, comorbidities, neoadjuvant therapy, type of surgery, surgery duration, blood loss, blood transfusion, laboratory data, respiratory function, body mass index, and visceral fat area were collected.

Results:

The frequency of PCs was positively correlated with surgery duration (β=0.427) and C-reactive protein (CRP) level on postoperative day 3 (β=0.189). The 6 MWT was negatively correlated with the frequency of PCs through CRP level on postoperative day 3 (β=–0.035). This model demonstrated an acceptable fit to the data (goodness-of-fit index, 0.979; adjusted goodness-of-fit index, 0.936; comparative fit index, 0.944; and root mean square error of approximation, 0.076).

Conclusions:

Preoperative walking capacity was correlated with PCs in patients undergoing GIC surgery. Prevention of PCs in patients with GIC requires the monitoring of both surgical parameters and postoperative inflammation.

Preoperative Improvement in Physical Function by Comprehensive Rehabilitation Leads to Decreased Postoperative Complications in Gastrointestinal Cancer Patients

Objectives:

The aim of this study was to investigate how baseline laboratory data and changes in physical function due to preoperative rehabilitation training in gastrointestinal cancer (GIC) patients can influence the frequency of postoperative complications (PCs).

Methods:

We enrolled 45 patients who were scheduled for elective surgery for GIC (27 men and 18 women, mean age 63.6±9.5 years). All patients underwent a medical examination and received general instruction from a rehabilitation physician and exercise instruction from a physical therapist from 7 to 34 days before the surgery. PCs were graded using the Clavien-Dindo classification based on the medical records 1 month postoperatively. We measured the grip strength and the isometric knee extension torque and conducted the 6-min walk test (6MWT) at baseline and just before surgery. The surgical duration, blood loss, and blood transfusion data were collected. Baseline laboratory information, including C-reactive protein levels, serum albumin levels, platelet count, white blood cell count, and the estimated glomerular filtration rate, was recorded.

Results:

The frequency of PCs was negatively correlated to the change in the 6MWT (β=−0.36) and positively correlated to the surgical duration (β=0.41). Baseline albumin was positively correlated to the change in the 6MWT distance (β=0.35). This model demonstrated an acceptable fit to the data (goodness of fit index=0.980, comparative fit index=1.000, root mean square error of approximation=0.000).

Conclusions:

The improvement of gait ability achieved with preoperative rehabilitation training in patients undergoing elective GIC surgery led to decreased PCs.

Does age of patients with gastrointestinal cancer impact postoperative physical function and quality of life? A prospective study using the new Japanese elderly standard

[Purpose] The purpose of this study was to investigate the relationship among aging factors using the new Japanese elderly standard, early postoperative physical function, and health-related quality of life (HRQOL) in patients with gastrointestinal cancer. [Participants and Methods] We studied 94 patients scheduled for elective surgery of gastrointestinal cancer: 53 males and 41 females aged 62.0 ± 12.1 years (mean ± SD). Patients were divided into three groups based on age at baseline: young (<65 years), pre-old (65–74 years), and old (≥75 years) groups. We measured body mass index, isometric knee extension force (IKEF), 6-minute walk test (6MWT), and Short-Form 36-Item Health Survey version 2 (SF-36) at baseline and 4 weeks after surgery. [Results] Patients 75 years or older had significantly lower IKEF and 6MWT compared to the other groups. Patients younger than 65 years had significantly greater scores on the mental health SF36 subscale 4 weeks after surgery compared to baseline. Comparatively, patients older than 75 years had significantly decreased mental health scores 4 weeks after surgery. [Conclusion] Based on the new Japanese elderly standard, advanced age appears to worsen the postoperative change of HRQOL in patients with gastrointestinal cancer.

Perioperative changes in hemoglobin levels during major hepatopancreatic surgery in transfused and non-transfused patients

Background:

Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations.

Methods:

Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time.

Results:

The study included 1596 patients, of which 785 underwent pancreatoduodenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L and in partial hepatectomy patients 92.6 g/L, and these were assumed to be the trigger points for red blood cell transfusion.

Conclusions:

Despite guidelines on blood transfusion thresholds, restrictive blood transfusion policies were not observed during our study period. After major pancreatic and hepatic surgery, Hb levels recovered without transfusions. This should encourage clinicians to obey the restrictive blood transfusion policies after major hepatopancreatic surgery.

Myomectomy associated blood transfusion risk and morbidity after surgery

OBJECTIVE

To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407).

INTERVENTION(S)

Blood transfusion during or within 72 hours after myomectomy.

MAIN OUTCOME MEASURE(S)

The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy.

RESULT(S)

The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62-3.17) and other race (aOR 1.77, 95% CI 1.20-2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45-9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46-5.40); high fibroid burden (aOR 1.91, 95% CI 1.45-2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05-18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10-13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58-4.57).

CONCLUSION(S)

Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.

Perioperative Blood Transfusion and Occurrence of Surgical Site Infection: An Integrative Review

The aim of this integrative review was to locate, assess, and synthesize available evidence of the relationship between perioperative allogeneic blood transfusion and the occurrence of surgical site infection among adult patients undergoing elective surgery. After a comprehensive search of relevant databases and a review of the studies this yielded, we used a validated instrument to extract data from the 25 studies in our final sample. The clinical and surgical variables that were significantly and more frequently associated with the occurrence of surgical site infection among patients who received blood transfusions during the perioperative period were female sex, older age, and higher body mass index. Our findings indicate a lack of consensus on the hemoglobin levels that indicate a blood transfusion is necessary.

Onset factors of infective and non-infective complications in perioperative gastrointestinal cancer patients

[Purpose] This study aimed to examine the causes of post-surgical infective and non-infective complications and to examine the possibility of physical therapy for preventing postoperative complications in gastrointestinal cancer patients. [Participants and Methods] The study participants were 119 perioperative gastrointestinal cancer patients [69 males and 50 females, aged 62.2 ± 11.2 years (mean ± standard deviation)] classified into three groups according to whether they had infective complications, non-infective complications, or the absence of complications. Data on onset factors for complications, basic information, surgical information, biochemical data, respiratory function, physical function, physique, and body composition were collected from a previous study. [Results] In the group with onset factors of infective complications, blood loss, the C-reactive protein level on the third postoperative day, and the forced expiratory volume % in 1 second were found to be significant explanatory variables. In the group with onset factors of non-infective complications, surgical time was detected as a significant explanatory variable. [Conclusion] In gastrointestinal cancer patients, surgical information affected the onset of infective and non-infective complications. However, only infective complications had the onset factors of postoperative immune response and preoperative respiratory function. Preoperative physical therapy may be an option for the prevention of postoperative complications in gastrointestinal cancer patients.

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.

Perioperative blood transfusion is associated with post-operative infectious complications in patients with Crohn's disease

Background

We have previously demonstrated that blood transfusion (BT) was associated with post-operative complications in patients undergoing surgery for Crohn’s disease (CD), based on our institutional data registry. The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Methods

All CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP. Variables were defined according to the ACS NSQIP guidelines. The primary outcome was infectious complications, including superficial, deep and organ/space surgical site infection, wound dehiscence, urinary tract infection, pneumonia, systemic sepsis and septic shock. Multivariate analyses were performed to assess the risk factors for post-operative infections.

Results

All 10 100 eligible patients were included and 611 (6.0%) received perioperative BT. BT patients were older, lighter in weight and more likely to be functionally dependent. BT patients were more likely to have post-operative infectious complications than those without BT, including superficial surgical site infection (SSI) (10.8% vs 7.4%, p=0.002), deep SSI (3.3% vs 1.6%, p=0.003), organ/space SSI (14.2% vs 5.4%, p<0.001), pneumonia (3.8% vs 1.3%, p<0.001), urinary tract infection (3.9% vs 2.2%, p=0.006), sepsis (11.5% vs 4.5%, p<0.001) and sepsis shock (3.1% vs 0.8%, p<0.001). Multivariate analysis showed that intra- and/or post-operative BT was an independent risk factor for post-operative infectious complications (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.8–2.7; p<0.001) and the risk increased with each administered unit of red blood cell (OR = 1.3, 95% CI: 1.2–1.5). Other independent factors were history of smoking, chronic heart disease, diabetes, hypertension and the use of corticosteroids. Pre-operative BT, however, was not found to be a risk factor to post-operative infections.

Conclusions

Intra- and/or post-operative, not pre-operative, BT was found to be associated with an increased risk for post-operative infectious complications in this CD cohort. Therefore, the timing and risks and benefits of BT should be carefully balanced.

Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities

Anemia is present in more than half of cancer patients and appears to be an independent prognostic factor of short- and long-term adverse outcomes. It increases in the advanced period of cancer and perioperatively, in patients with solid tumors who undergo surgery. As a result, allogeneic red blood cell (RBC) transfusion is an indispensable treatment in cancer. However, its safety remains controversial, based on several laboratory and clinical data reporting a linkage with increased risk for cancer recurrence, infection and cancer-related mortality. Immunological, inflammatory and thrombotic reactions mediated by the residual leukocytes and platelets, the stored RBCs per se, the biological response modifiers and the plasticizer of the unit may underlie infection and tumor-promoting effects. Although the causality between transfusion and infection has been established, the effects of transfusion on cancer recurrence remain confusing; this is mainly due to the extreme biological heterogeneity that characterizes RBC donations and cancer context. In fact, the functional interplay between donation-associated factors and recipient characteristics, including tumor biology per se, inflammation, infection, coagulation and immune activation state and competence may synergistically and individually define the clinical impact of each transfusion in any given cancer patient. Our understanding of how the potential risk is mediated is important to make RBC transfusion safer and to pave the way for novel, promising and highly personalized strategies for the treatment of anemia in surgical cancer patients.

Leucoreduction of blood components: an effective way to increase blood safety?

Over the past 30 years, it has been demonstrated that removal of white blood cells from blood components is effective in preventing some adverse reactions such as febrile non-haemolytic transfusion reactions, immunisation against human leucocyte antigens and human platelet antigens, and transmission of cytomegalovirus. In this review we discuss indications for leucoreduction and classify them into three categories: evidence-based indications for which the clinical efficacy is proven, indications based on the analysis of observational clinical studies with very consistent results and indications for which the clinical efficacy is partial or unproven.

[Preoperative management of anemia in oncologic surgery]

Preoperative anemia in patients with cancer is highly prevalent, is associated with increased perioperative morbidity and is a risk factor for transfusion. There is evidence that patients who undergo transfusions have higher morbidity, increased cancer recurrence and poorer survival. The pathophysiology of anemia is multifactorial, with an inflammatory component to which chronic blood loss and nutritional deficiencies can be associated. Therefore, preoperative anemia in patients with cancer should be treated appropriately, given that there is sufficient time in the preoperative period. Of the currently available options, parenteral iron is an effective alternative, especially for those types of cancer that have an associated hemorrhagic component.

Impact of perioperative blood transfusion on immune function and prognosis in colorectal cancer patients

OBJECTIVE

To investigate the impacts of perioperative blood transfusion on the immune function and prognosis in colorectal cancer (CC) patients.

METHODS

A retrospective analysis was conducted in 1404 CC patients, including 1223 sporadic colorectal cancer (SCC) patients and 181 hereditary colorectal cancer (HCC) patients. Among them, 701 SCC and 102 HCC patients received perioperative blood transfusion. The amount of T lymphocyte subsets and natural killer (NK) cells was measured. All patients received a 10-year follow-up and relapse, metastasis and curative conditions were recorded.

RESULTS

In SCC group, mortality, local recurrence and distant metastasis rate of transfused patients were significantly higher than non-transfused patients (all P <0.05). In HCC group, mortality was apparently higher in transfused patients than non-transfused patients (P = 0.002). SCC patients transfused with ≥3 U of blood had significantly higher mortality than patients transfused with <3 U (P = 0.006). The amount of T lymphocyte subsets and NK cells showed statistical differences before and after perioperative blood transfusion in SCC and HCC patients (all P <0.05). Also, there existed statistical differences in CD4+/CD8+ ratio among SCC patients before and after the perioperative blood transfusion (P <0.05). CC patients who received perioperative blood transfusion had markedly lower 10-year survival rates as compared with those who did not receive (both P <0.05). SCC patients transfused with ≥3 U of blood had remarkably lower survival rates compared with SCC patients transfused with <3 U (P = 0.002).

CONCLUSIONS

Perioperative blood transfusion could impact immune function, increased postoperative mortality, local recurrence rate and distant metastasis rate in CC patients; and survival rate of CC patients is negatively related to blood transfusion volume.

Risk factors and outcomes of blood transfusions in adrenalectomy

BACKGROUND

Blood transfusion has been shown to be associated with adverse long-term and short-term outcomes. We sought to evaluate the preoperative risk factors associated with blood transfusion and its effects on postoperative outcomes after adrenalectomy.

METHODS

We performed a retrospective analysis of 4735 adrenalectomies (3664 laparoscopic and 1071 open) from 2005-2012 using the National Surgical Quality Improvement Program database. Data on preoperative risk factors and postoperative morbidity and mortality were evaluated.

RESULTS

Median age and body mass index were 54 y and 29.3 kg/m(2), respectively. Most patients were female (60.0%). Of the total, 60.6% patients had American Society of Anesthesiologists score ≥3. On multivariate analysis, increasing age (odds ratio [OR] = 1.02, P < 0.001), open adrenalectomy (OR = 14.0, P < 0.001), preoperative hematocrit <38% (OR = 2.96, P < 0.001), and operative time >150 min (OR: 3.69, P < 0.001) were associated with an increased need for intraoperative blood transfusions. The need for intraoperative blood transfusions was an independent predictor of postoperative complications including mortality (OR = 12.7, P < 0.001), overall morbidity (OR = 3.2, P < 0.001), serious morbidity (OR = 3.8, P < 0.001), wound complication (OR = 2.1, P = 0.006), cardiopulmonary complication (OR = 3.6, P < 0.001), septic complication (OR = 2.5, P = 0.007), reoperation (OR = 3.6, P < 0.001), and prolonged length of stay (OR = 4.3, P < 0.001). There was an independent and incremental increase (10%-20%) in the risk of morbidity and mortality with each unit of blood transfused (P < 0.01).

CONCLUSIONS

Age, open surgery, preoperative anemia, American Society of Anesthesiologists score, and prolonged operative time are associated with an increased need for blood transfusions in laparoscopic and open adrenalectomy. Intraoperative transfusion was independently and incrementally associated with significant morbidity and mortality after laparoscopic and open adrenalectomy.

Transfusion requirements in surgical oncology patients: a prospective, randomized controlled trial

BACKGROUND

Several studies have indicated that a restrictive erythrocyte transfusion strategy is as safe as a liberal one in critically ill patients, but there is no clear evidence to support the superiority of any perioperative transfusion strategy in patients with cancer.

METHODS

In a randomized, controlled, parallel-group, double-blind (patients and outcome assessors) superiority trial in the intensive care unit of a tertiary oncology hospital, the authors evaluated whether a restrictive strategy of erythrocyte transfusion (transfusion when hemoglobin concentration <7 g/dl) was superior to a liberal one (transfusion when hemoglobin concentration <9 g/dl) for reducing mortality and severe clinical complications among patients having major cancer surgery. All adult patients with cancer having major abdominal surgery who required postoperative intensive care were included and randomly allocated to treatment with the liberal or the restrictive erythrocyte transfusion strategy. The primary outcome was a composite endpoint of mortality and morbidity.

RESULTS

A total of 198 patients were included as follows: 101 in the restrictive group and 97 in the liberal group. The primary composite endpoint occurred in 19.6% (95% CI, 12.9 to 28.6%) of patients in the liberal-strategy group and in 35.6% (27.0 to 45.4%) of patients in the restrictive-strategy group (P = 0.012). Compared with the restrictive strategy, the liberal transfusion strategy was associated with an absolute risk reduction for the composite outcome of 16% (3.8 to 28.2%) and a number needed to treat of 6.2 (3.5 to 26.5).

CONCLUSION

A liberal erythrocyte transfusion strategy with a hemoglobin trigger of 9 g/dl was associated with fewer major postoperative complications in patients having major cancer surgery compared with a restrictive strategy.

Perioperative blood transfusions do not impact overall and disease-free survival after curative rectal cancer resection: a propensity score analysis

OBJECTIVE

To assess the putative impact of perioperative blood transfusions on overall and disease-free survival in patients undergoing curative resection of stage I-III rectal cancer by applying propensity-scoring methods.

BACKGROUND

Whether perioperative blood transfusions negatively impact survival remains a matter of great debate.

METHODS

In a single-center study, 401 patients undergoing open curative resection of stage I-III rectal cancer between 1996 and 2008 were assessed. The median follow-up was 34.2 months. Patients who did and did not receive perioperative blood transfusions were compared using Cox regression and propensity score analyses.

RESULTS

Overall, 217 patients (54.1%) received blood transfusions. Patients' characteristics were highly biased concerning transfusions (propensity score 0.77±0.23 vs. 0.28±0.25; P<0.001). In unadjusted analysis, blood transfusions were associated with a 119% increased risk of mortality [hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.34-3.57, P=0.001]. In propensity score-adjusted Cox regression (HR: 1.02, 95% CI: 0.65-1.58, P=0.970), blood transfusions did not increase the risk of overall survival. Similarly, in propensity score-adjusted Cox regression (HR: 0.86, 95% CI: 0.60-1.23, P=0.672), blood transfusions were not associated with an increased risk of recurrence.

CONCLUSIONS

This is the first propensity score-based analysis providing compelling evidence that worse oncological outcomes after curative rectal cancer resection in patients receiving perioperative blood transfusions are caused by the clinical circumstances requiring transfusions, not due to the blood transfusions themselves. Therefore, concerns about overall and disease-free survival should be no issue in the decision-making regarding perioperative blood transfusions in patients undergoing curative rectal cancer resection.

Perioperative anemia management in colorectal cancer patients: A pragmatic approach

Anemia, usually due to iron deficiency, is highly prevalent among patients with colorectal cancer. Inflammatory cytokines lead to iron restricted erythropoiesis further decreasing iron availability and impairing iron utilization. Preoperative anemia predicts for decreased survival. Allogeneic blood transfusion is widely used to correct anemia and is associated with poorer surgical outcomes, increased post-operative nosocomial infections, longer hospital stays, increased rates of cancer recurrence and perioperative venous thromboembolism. Infections are more likely to occur in those with low preoperative serum ferritin level compared to those with normal levels. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management, minimizes or eliminates allogeneic blood transfusion. This includes restrictive transfusion policy, thromboprophylaxis and anemia management to improve outcomes. Normalization of preoperative hemoglobin levels is a World Health Organization recommendation. Iron repletion should be routinely ordered when indicated. Oral iron is poorly tolerated with low adherence based on published evidence. Intravenous iron is safe and effective but is frequently avoided due to misinformation and misinterpretation concerning the incidence and clinical nature of minor infusion reactions. Serious adverse events with intravenous iron are extremely rare. Newer formulations allow complete replacement dosing in 15-60 min markedly facilitating care. Erythropoiesis stimulating agents may improve response rates. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management used to minimize or eliminate allogeneic blood transfusion is indicated to improve outcomes.

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.

Impact of pre-storage and bedside filtered leukocyte-depleted blood transfusions on infective morbidity after colorectal resection: a single-center analysis of 437 patients

BACKGROUND

Leukocyte-depleted blood transfusions were introduced to reduce transfusion-associated immunomodulation, but the clinical effects of different types of leukocyte depletion have been analyzed rarely. The aim of this survey was to analyze the clinical impact of pre-storage leukocyte-depleted blood transfusions (considered as pre-storage or bedside-filtered) on post-operative complications in patients undergoing elective or urgent colorectal resection.

METHODS

Data were collected retrospectively from the medical records of 437 consecutive patients who underwent colorectal resection from 2005 to 2010. All patients requiring transfusion received pre-storage or bedside-filtered leukocyte-depleted red blood cell concentrates according to availability at the blood bank. The outcomes were measured by the analysis of post-operative morbidity in patients receiving the different types of transfusions or having other potentially predictive risk factors.

RESULTS

The overall morbidity rate, infective morbidity rate, and non-infective morbidity rate were, respectively, 35.6%, 28.1%, and 21.0%. Two hundred five patients (46.9%) received peri-operative transfusions. On multivariable analysis, leukocyte-depleted transfusion (odds ratio [OR] 3.33; 95% confidence interval [CI] 2.14-5.20; p<0.001) and both pre-storage (OR 2.82; 95% CI 1.73-4.59; p<0.001) and bedside-filtered (OR 4.69; 95% CI 2.54-8.67; p<0.001) transfusions were independent factors for post-operative morbidity. Prolonged operation (p=0.035), American Society of Anesthesiologists score≥3 points (p=0.023), diagnosis of cancer rather than benign disease (p=0.022), and urgent operation (p=0.020) were other independent predictors of post-operative complications. Patients transfused with bedside-filtered blood showed significantly higher rates of infective complications (51.4% vs. 31.8%; p=0.006), but not non-infectious complications (35.7% vs. 32.6; p=0.654) than patients who received pre-storage transfusions.

CONCLUSIONS

Leukocyte-depleted blood transfusions and, in particular, bedside-filtered blood have a significant negative effect on infectious complications after colorectal resection.

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.

Transfusion immunomodulation--the case for leukoreduced and (perhaps) washed transfusions

During the last three decades, a growing body of clinical, basic science and animal model data has demonstrated that blood transfusions have important effects on the immune system. These effects include: dysregulation of inflammation and innate immunity leading to susceptibility to microbial infection, down-regulation of cellular (T and NK cell) host defenses against tumors, and enhanced B cell function that leads to alloimmunization to blood group, histocompatibility and other transfused antigens. Furthermore, transfusions alter the balance between hemostasis and thrombosis through inflammation, nitric oxide scavenging, altered rheologic properties of the blood, immune complex formation and, no doubt, several mechanisms not yet elucidated. The net effects are rarely beneficial to patients, unless they are in imminent danger of death due to exsanguination or life threatening anemia. These findings have led to appeals for more conservative transfusion practice, buttressed by randomized trials showing that patients do not benefit from aggressive transfusion practices. At the risk of hyperbole, one might suggest that if the 18th and 19th centuries were characterized by physicians unwittingly harming patients through venesection and bleeding, the 20th century was characterized by physicians unwittingly harming patients through current transfusion practices. In addition to the movement to more parsimonious use of blood transfusions, an effort has been made to reduce the toxic effects of blood transfusions through modifications such as leukoreduction and saline washing. More recently, there is early evidence that reducing the storage period of red cells transfused might be a strategy for minimizing adverse outcomes such as infection, thrombosis, organ failure and mortality in critically ill patients particularly at risk for these hypothesized effects. The present review will focus on two approaches, leukoreduction and saline washing, as means to reduce adverse transfusion outcomes.

[Perioperative tumour dissemination. 1. Influence of perioperative factors]

There has been growing concern in the last few years on the effect of anaesthetic drugs used during oncological surgery could have on tumour progression in the long-term, as well as the influence of other perioperative factors. Although much of the available data has weak evidence, the role of the surgery itself, pain, transfusion of blood derivatives, etc., have been assessed in several studies. How some substances used during the anaesthetic process can influence tumour immune surveillance, cell proliferation or tumour angiogenesis processes have been observed in laboratory studies. The possible relevance of the anaesthetic technique used as regards the long-term tumour progression and survival is still to be determined. However, based on retrospective studies, it seems that those anaesthetic techniques combined with the use of regional anaesthesia and analgesia could be beneficial compared to those that are maintained on opioid use. Further research should help to elucidate the long-term clinical relevance of the perioperative procedures, including the anaesthetic, during oncological surgery.

Perioperative Red Blood Cell Transfusion: Harmful or Beneficial to the Patient?

Although the transfusion of red blood cells (RBCs) is safer than ever regarding infections, it is still associated with several adverse reactions and therefore should only be used on the basis of evidence-based triggers. However, prevention of RBC transfusion and subsequent substitution of blood losses with acellular solutions will inevitably result in dilutional anemia. Acute dilutional anemia can be compensated by the body over a wide range of hemoglobin concentrations without a critical restriction of tissue oxygenation. On the other hand, chronic anemia is known to be a potent cause of morbidity and mortality. As a consequence, the impact of perioperative anemia on mortality is difficult to describe, because anemia, as well as the transfusion of RBCs, can influence the clinical outcome. The resulting 'Gordian knot' cannot be cut easily, and this circumstance forces clinical physicians to make a daily trade-off between transfusion-associated and anemia-associated risks. This review focuses on the physiology of oxygen transport, the hazards of acute anemia, the hazards of RBC transfusion, and the literature putting these problems into perspective.