Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey

BACKGROUND

This study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes.

METHODS

A survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations.

RESULTS

The 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89-14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion.

CONCLUSION

Practices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.

Evaluating variation in perioperative red blood cell transfusion for patients undergoing elective gastrointestinal cancer surgery

BACKGROUND

Patients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients.

METHODS

We identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with R² measures, variance partition coefficients, and median odds ratios.

RESULTS

Of 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30-1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23-1.42). We observed comparable effects across procedure-type subgroups.

CONCLUSION

Transfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.

Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings

BACKGROUND

Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided.

METHODS

We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients.

RESULTS

Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively.

CONCLUSION

Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.

Failure to Thrive Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy: Causes and Consequences

BACKGROUND

Failure to thrive (FTT) is a complex syndrome of nutritional failure and functional decline. Readmission for FTT following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS HIPEC) is common but underexamined. This study aims to determine features, risk factors, and prognostic significance of FTT following CRS HIPEC.

PATIENTS AND METHODS

We reviewed patients who underwent CRS HIPEC from 2010 to 2018 at our institution. Patients were categorized into no readmission, FTT readmission, and other readmission. FTT was determined by coding and chart review. We compared baseline characteristics, oncologic data, perioperative outcomes, and survival among the three cohorts.

RESULTS

Of 1068 discharges examined, 379 patients (36%) were readmitted within 90 days, of which 134 (12.5%) were labeled as FTT. Patients with FTT readmission had worse preoperative functional status, higher rates of malnutrition, more complex resections, longer hospital stays, and more postoperative complications (all p < 0.001). Ostomy creation [relative risk ratio (RRR) 4.06], in-hospital venous thromboembolism (VTE), discharge to nursing home (RRR 2.48), pre-CRS HIPEC chemotherapy (RRR 1.98), older age (RRR 1.84), and female gender (RRR 1.69) were all independent predictors for FTT readmission on multinomial regression (all p < 0.01). FTT readmission was associated with worse median overall survival on multivariate analysis [hazard ratio (HR) 1.60, p < 0.001] after controlling for oncologic, perioperative, and baseline factors.

CONCLUSIONS

FTT is common following CRS HIPEC and appears to be associated with baseline patient characteristics, operative burden, and postoperative complications. Perioperative strategies for improving nutrition and activity, along with early recognition and intervention in FTT may improve patient outcomes.