Current Status of the Use of Salvaged Blood in Metastatic Spine Tumour Surgery

Effect of intraoperative cell salvage on coagulation function outcomes in patients with massive post-Cesarean section hemorrhage

OBJECTIVE

To examine the impact of using intraoperative cell salvage (ICS) for the restoration of coagulation function in cases of massive Post-Cesarean Section Hemorrhage (PCSH).

METHODS

A retrospective analysis was conducted on 60 cases of massive PCSH meeting inclusion criteria at Suqian Maternity and Children's Hospital from January 2020 to July 2022. Patients were divided into two groups: allogeneic blood transfusion group (Group A, n = 30) and ICS group (Group B, n = 30), based on transfusion methods. Blood parameters, coagulation function, and adverse reactions were assessed before (T0) and after (T1) transfusion. Patients were categorized into good prognosis (GP) and poor prognosis (PP) groups based on adverse reaction occurrence. Clinical profiles were compared between groups, and multivariate binary logistic regression analysis was employed to evaluate the factors that may affect the prognosis in women with PCSH.

RESULTS

No significant differences in routine blood parameters were observed between groups at T0 and T1 (P>0.05). At T0, no significant differences in PT, APTT, TT, or FIB were found between groups (P>0.05). Both groups showed a reduction in PT, APTT, and TT values at T1 compared to T0, with Group B experiencing a more significant decrease than Group A (P<0.05). FIB increased in both groups at T1 compared to T0, with Group B demonstrating a higher increase than Group A (P<0.05). Both groups showed increased blood pressure at T1 compared to T0, with Group B showing a more pronounced elevation than Group A (P<0.05). The occurrence of adverse reactions was significantly lower in Group B (1/30, 3.33%) compared to Group A (7/30, 23.33%) (P<0.05). Logistic regression analysis identified FIB<1.52 g/L and HR<45.35 times/min as factors associated with increased risk of unfavorable outcome in women with PCSH.

CONCLUSION

In patients experiencing significant PCSH, ICS may lead to better postoperative recovery of blood parameters, faster restoration of coagulation function, and reduced risk of adverse events compared to ABT. Moreover, early detection of coagulation function and blood gas indexes is crucial for clinicians to implement timely prevention and treatment measures.

Impact of blood salvage therapy during oncologic liver surgeries on allogenic transfusion events, survival, and recurrence, an ambidirectional cohort study

INTRODUCTION

The use of autologous blood transfusions in oncologic surgeries is somewhat controversial due to the potential risk of disease dissemination through the salvage process. On the other hand, autologous blood transfusion can prevent the potential negative effects of allogenic blood transfusions and reduce use of valuable resources.

METHODS

This study included 106 adult patients who underwent oncologic liver surgery at our institution between December 2015 and June 2019. The patients were divided into two groups: the Cell Saver® group (operated between January 2018 and June 2019) and the control group (operated between December 2015 and December 2017). The Cell Saver® device was present in the operating room for the Cell Saver® group, and blood was re-transfused if a certain amount of blood loss occurred. Data analysis focused on outcomes such as blood transfusion requirements, overall survival, recurrence-free survival, hemoglobin levels, hospital stay, and complications. Patient records provided relevant information on demographics, surgery details, pathology, and outcomes for both groups.

RESULTS

Autologous blood transfusion was found to reduce the amount of blood units needed (4.0 units (control group) versus 0.4 units (Cell Saver® group) P=0.029. Kaplan-Meier curves showed no difference for both overall survival 471.6 days (Cell Saver® group) versus 468.3 days (control group) (P=0.219) and 488.9 days (Cell Saver® group) versus 487.2 days (control group) (P=0.993) and disease-free survival (P=0.553) and (P=0.735) for primary hepatic tumours and hepatic metastasis respectively between the Cell Saver® and control groups. Overall survival regardless of the type of tumour was similar to the control group (485.4 d vs. 481.9 d) (P=0.503). Survival was significantly lower for minor hepatectomies (516.0 d vs. 517.4 d) (P=0.050) in the Cell Saver® group, major hepatectomies showed no difference in overall survival (470.2 d vs. 466.4 d) (P=0.868). No impact on disease recurrence was found between patients who received autologous blood transfusions versus those who did not.

CONCLUSION

The use of Cell Saver® should not be avoided in oncologic surgeries of the liver. Use of Cell Saver® for major hepatectomies might be more beneficial as OS was significantly lower for the Cell Saver® group for patients who underwent minor hepactomies. Further research is needed to explain this conflicting result. Nonetheless, the use of Cell Saver® in autologous blood transfusions can reduce the use of valuable resources and the risks associated with allogenic blood transfusions.

Reduction of EpCAM-Positive Cells from a Cell Salvage Product Is Achieved by Leucocyte Depletion Filters Alone

Intraoperative cell salvage reduces the need for allogeneic blood transfusion in complex cancer surgery, but concerns about the possibility of it re-infusing cancer cells have hindered its application in oncology. We monitored the presence of cancer cells on patient-salvaged blood by means of flow cytometry; next, we simulated cell salvage, followed by leucodepletion and irradiation on blood contaminated with a known amount of EpCAM-expressing cancer cells, assessing also residual cancer cell proliferation as well as the quality of salvaged red blood cell concentrates (RBCs). We observed a significant reduction of EpCAM-positive cells in both cancer patients and contaminated blood, which was comparable to the negative control after leucodepletion. The washing, leucodepletion and leucodepletion plus irradiation steps of cell salvage were shown to preserve the quality of RBCs in terms of haemolysis, membrane integrity and osmotic resistance. Finally, cancer cells isolated from salvaged blood lose their ability to proliferate. Our results confirm that cell salvage does not concentrate proliferating cancer cells, and that leucodepletion allows for the reduction of residual nucleated cells, making irradiation unnecessary. Our study gathers pieces of evidence on the feasibility of this procedure in complex cancer surgery. Nevertheless, it highlights the necessity of finding a definitive consensus through prospective trials.

Transfusion-free Strategies in Liver and Pancreatic Surgery: A Predictive Model of Blood Conservation for Transfusion Avoidance in Mainstream Populations

OBJECTIVE

The objective of this study is to (1) describe the techniques and prove the feasibility of performing complex hepatobiliary and pancreatic surgery on a Jehovah Witness (JW) population.  (2) Describe a strategy that offsets surgical blood loss by the manipulation of circulating blood volume to create reserve whole blood upon anesthesia induction.

BACKGROUND

Major liver and pancreatic resections often require operative transfusions. This limits surgical options for patients who do not accept major blood component transfusions. There is also growing recognition of the negative impact of allogenic blood transfusions.

METHODS

A 23-year, single-center, retrospective review of JW patients undergoing liver and pancreatic resections was performed. We describe perioperative management and patient outcomes. Acute normovolemic hemodilution (ANH) is proposed as an important strategy for offsetting blood losses and preventing the need for blood transfusion. A quantitative mathematical formula is developed to provide guidance for its use.

RESULTS

One hundred one major resections were analyzed (liver n=57, pancreas n=44). ANH was utilized in 72 patients (liver n=38, pancreas n=34) with median removal of 2 units that were returned for hemorrhage as needed or at the completion of operation. There were no perioperative mortalities. Morbidity classified as Clavien grade 3 or higher occurred in 7.0% of liver resection and 15.9% of pancreatic resection patients.

CONCLUSIONS

Deliberate perioperative management makes transfusion-free liver and pancreatic resections feasible. Intraoperative whole blood removal with ANH specifically preserves red cell mass, platelets, and coagulation factors for timely reinfusion. Application of the described JW transfusion-free strategy to a broader general population could lessen blood utilization costs and morbidities.

Blood loss in total en bloc spondylectomy for primary spinal bone tumours: a comparison of estimated blood loss versus actual blood loss in a single centre over 10 years

Background

Total en bloc spondylectomy (TES) is a widely accepted surgical technique for primary spinal bone tumours but is frequently accompanied by substantial peri-operative blood loss. Prior studies have reported estimated blood loss (EBL) can reach up to 3,200 mL. The aim of this study is to estimate the blood loss during TES procedures performed in the last ten years at our tertiary referral centre and compare EBL with actual blood loss (ABL).

Methods

We performed a retrospective review of all cases managed surgically with TES referred to our centre between 2005 and 2015. We recorded the oncological characteristics of each tumour and surgical management in terms of resection margins, operative duration and instrumentation. Data relating to peri-operative blood loss was also recorded including an estimation of total blood loss, the use of cell salvage where applicable and transfusion rates.

Results

A total of 21 patients were found to meet our inclusion criteria. There were 11 men and 10 women, with a median age of 40 years. The mean total ABL was 3,310 mL. Total operation time ranged from 6.53 to 19.7 h. Compared to ABL, in 59% of cases EBL had been underestimated by an average of 78% by volume. The EBL of the remaining 41% cases had been overestimated by 43%. This was not statistically significant (P=0.373). Cell salvage was used in 62% patients with a mean blood loss of 2,845 mL (884-4,939 mL) and transfusion of 3.8 units (0-12 units) versus 4,069 mL (297-8,335 mL) and 9.3 units (0-18 units) in those not managed with cell salvage. There was no significant difference in ABL between the cell salvage and non-cell salvage groups.

Conclusions

We report one of the largest case series in TES for primary bone tumours. EBL is not a reliable predictor for ABL. A large blood loss should be anticipated and use of cell salvage is recommended.

Effect of intraoperative cell rescue on bleeding related indexes after cesarean section

BACKGROUND

Obstetric hemorrhage is the leading cause of maternal mortality globally, especially in China. The key to a successful rescue is immediate and rapid blood transfusion. Autotransfusion has become an integral part of clinical blood transfusion, with intraoperative cell salvage (IOCS) being the most widely used.

AIM

To investigate the application of IOCS in cesarean section.

METHODS

A total of 87 patients who underwent cesarean section and blood transfusion in our hospital from March 2015 to June 2020 were included in this prospective controlled study. They were divided into the observation (43 cases) and control (44 cases) groups using the random number table method. The patients in both groups underwent lower-segment cesarean section. The patients in the control group were treated with traditional allogeneic blood transfusion, whereas those in the observation group were treated with IOCS. Hemorheology [Red blood cell count, platelet volume, and fibrinogen (FIB)] and coagulation function (partial prothrombin time, prothrombin time (PT), platelet count, and activated coagula-tion time) were measured before and 24 h after transfusion. In the two groups, adverse reactions, such as choking and dyspnea, within 2 h after cesarean section were observed.

RESULTS

Before and after transfusion, no significant differences in hemorheology and coagulation function indices between the two groups were observed (P > 0.05). About 24 h after transfusion, the erythrocyte count, platelet ratio, and FIB value significantly decreased in the two groups (P < 0.05); the PLT value significantly decreased in the two groups; the activated partial thromboplastin time, PT, and activated clotting time significantly increased in the two groups (P < 0.05); and no statistical differences were observed in hemorheology and coagulation function indices between the two groups (P > 0.05). Furthermore, there was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05).

CONCLUSION

In patients undergoing cesarean section, intraoperative cell salvage has a minimum effect on hemorheology and coagulation function and does not increase the risk of amniotic fluid embolism.

Cell Salvage in Oncological Surgery, Peripartum Haemorrhage and Trauma

Oncological surgery, obstetric haemorrhage and severe trauma are the most challenging conditions for establishing clinical recommendations for the use of cell salvage. When the likelihood of allogeneic transfusion is high, the intraoperative use of this blood-saving technique would be justified, but specific patient selection criteria are needed. The main concerns in the case of oncological surgery are the reinfusion of tumour cells, thereby increasing the risk of metastasis. This threat could be minimized, which may help to rationalize its indication. In severe peripartum haemorrhage, cell salvage has not proven cost-effective, damage control techniques have been developed, and, given the risk of fetomaternal alloimmunization and amniotic fluid embolism, it is increasingly out of use. In trauma, bleeding may originate from multiple sites, coagulopathy may develop, and it should be evaluated whether re-transfusion of autologous blood collected from uncontaminated organ cavities would be feasible. General safety measures include washing recovered blood and its passage through leukocyte depletion filters. To date, no well-defined indications for cell salvage have been established for these pathologies, but with accurate case selection and selective implementation, it could become safe and effective. Randomized clinical trials are urgently needed.

The role of intraoperative cell salvage for musculoskeletal sarcoma surgery

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Musculoskeletal sarcoma surgery involving the lower limb is associated with significant intraoperative blood loss, with more than 500 ml in 96% of patients.

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Salvaged blood was processed and re-infused in 94% of patients.

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An estimated one-fourth of intraoperative blood loss was returned to the patient through (Intraoperative cell salvage) ICS.

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Cytological analysis of imprints from leucodepletion filters(LDF) and reinfused blood did not reveal evidence of tumour cells.

Background

The efficacy and safety of cell salvage for musculoskeletal sarcoma surgery have not been reported, and concerns over re-infusion of tumour cells remain. This study aims to i) describe the intra-operative blood loss and cell salvage reinfusion volumes for lower limb sarcoma and pelvic sarcoma procedures ii) and explore whether there is evidence of tumour cells in reinfused blood.

Methods

Retrospective analysis of 109 consecutive surgical procedures for biopsy-proven sarcoma or bone metastasis performed between 1 July 2015 and 30 October 2019. Salvaged blood was processed and reinfused when intraoperative blood loss exceeded 500 ml. Primary bone tumour (n = 86(79%)) and metastasis (n = 23(21%) constituted the study group and surgeries were classified under hemipelvectomy (n = 43(39%)), lower limb endoprosthesis replacement (LLE) (n = 50(46%)) and wide excision surgery (WE) (n = 16(15%)). Microscopic examination of imprint cytology of leuco-depletion(LD) filters, and peripheral smear examination was performed for reinfused blood.

Results

Median (IQR) intra-operative blood loss was 1750 (600–3000) ml for hemipelvectomy, 850 (600–1200) ml for LLE, and 1000 (550–2000) ml for WE. Salvaged blood was re-infused in 102 of 109 (94%) patients. The mean (SD) volume of re-infusion was 445(4 2 5) ml for hemipelvectomy, 206(1 3 1) ml for LLE, and 184(1 0 6) ml for WE. In total, 64 of 109 (59%) patients received an allogeneic red blood transfusion within 72 h of surgery. Cytology analysis of imprints taken from the filtered blood available in 95(87%) patients and peripheral smear examination of reinfused blood available in 32(29%) patients did not reveal evidence of tumour cells on microscopic examination of any samples.

Conclusion

Our study demonstrates that musculoskeletal sarcoma surgery is associated with significant blood loss, and cell salvage permits reinfusion of autologous blood in most patients. The cytological analysis did not reveal evidence of tumour cells in reinfused blood, consistent with other studies where cell salvage is used for cancer surgery.

[Safety of cell salvage in tumor surgery : Systematic review with meta-analysis]

BACKGROUND

Allogeneic blood transfusion is avoidable in many oncological interventions by the use of cell salvage or mechanical autotransfusion (MAT). As irradiation is elaborate and expensive, the safety of leucocyte depletion filters (LDF) for autologous blood from the surgical field might be a more acceptable alternative for the prevention of cancer recurrences. A previous meta-analysis could not identify an increased risk of cancer recurrence. The aim of this review article is to provide an update of a previous meta-analysis from 2012 as well as a safety analysis of cell salvage with LDF due to the improved data situation.

MATERIAL AND METHODS

This systematic review included all studies in PubMed, Cochrane, Cochrane Reviews and Web of Science on cell salvage or autotransfusion combined with outcomes, e.g. cancer recurrence, mortality, survival, blood transfusion, length of hospital stay (LOS) after the use of MAT without irradiation and with or without LDF. The grades of recommendations (GRADE) assessment of underlying evidence was applied.

RESULTS

A total of seven new observational studies and seven meta-analyses were found that compared unfiltered or filtered cell salvage with autologous predeposition, allogeneic transfusion or without any transfusion. No randomized controlled trials have been completed. A total of 27 observational and cohort studies were included in a meta-analysis. The evidence level was low. The risk of cancer recurrence in recipients of autologous salvaged blood with or without LDF was reduced (odds ratio, OR 0.71, 95% confidence interval, CI 0.58-0.86) as compared to non-transfused subjects, allogeneic or predeposited autologous transfusion. The transfusion rate could not be assessed due to the substantial selection bias and large heterogeneity. Cell salvage does not change mortality and LOS. Leucocyte depletion studies reported a removal rate of cancer cells in the range of 99.6-99.9%.

CONCLUSION

Randomized controlled trials on a comparison of MAT and allogeneic blood transfusion as well as LDF and irradiation would be desirable but are not available. From observational trials and more than 6300 subjects and various tumors, cell salvage in cancer surgery with or without LDF appears to be sufficiently safe. The efficacy of leucocyte depletion of autologous salvaged blood is equivalent to irradiation. Unavailability of radiation is not a contraindication for cell salvage use in cancer surgery. By usage of leucocyte depleted salvaged autologous blood, the risks of allogeneic transfusion can be avoided.

Is the Spinal Instability Neoplastic Score Accurate and Reliable in Predicting Vertebral Compression Fractures for Spinal Metastasis? A Systematic Review and Qualitative Analysis

Spinal metastases can present with varying degrees of mechanical instability. The Spinal Instability Neoplastic Score (SINS) was developed as a tool to assess spinal neoplastic-related instability while helping to guide referrals among oncology specialists. Some previous papers suggested that the SINS was accurate and reliable, while others disagreed with this opinion. We performed a systematic review regarding the SINS to evaluate its accuracy and precision in predicting vertebral compression fractures (VCFs). The 21 included studies investigated a total of 2118 patients. Thirteen studies dealt with the accuracy of SINS to predict post-radiotherapy VCFs, and eight dealt with the precision. Among 13 studies, 11 agreed that the SINS categories showed statistically significant accuracy in predicting VCF. Among eight studies, body collapse was effective for predicting VCFs in six studies, and alignment and bone lesion in two studies. Location has no statistical significance in predicting VCFs in any of the eight studies. The precision of SINS categories was substantial to excellent in six of eight studies. Among the six components of the SINS, the majority of the included studies reported that location showed near perfect agreement; body collapse, alignment, and posterolateral involvement showed moderate agreement; and bone lesion showed fair agreement. Bone lesion showed significant accuracy in predicting VCFs in half of eight studies, but displayed fair reliability in five of seven studies. Although location was indicated as having near perfect reliability, the component showed no accuracy for predicting VCFs in any of the studies and deleting or modifying the item needs to be considered. The SINS system may be accurate and reliable in predicting the occurrence of post-radiotherapy VCFs for spinal metastasis. Some components seem to be substantially weak and need to be revised.

Intraoperative cell salvage is associated with reduced allogeneic blood requirements and has no significant impairment on coagulation function in patients undergoing cesarean delivery: a retrospective study

OBJECTIVE

The aim of the study is to examine the association between Intraoperative cell salvage (ICS), allogeneic blood transfusion (ABT) and coagulation function in obstetrics.

METHODS

A total of 486 pregnant women undergoing cesarean delivery, of whom 157 were enrolled in this retrospective study. Patients were divided into ICS group (n = 101, ICS used during operation) and control group (n = 56, ICS not used during operation). Clinical data, including plasma prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib) and thrombin time (TT) levels, were collected from all patients preoperatively (within 12-24 h) and postoperatively (within 6-12 h) and analyzed by t test, two-way repeated-measures ANOVA and Spearman's correlation.

RESULTS

The use of ICS is associated with lower requirement rate for ABT (P < .001), while the blood loss was similar between the two groups (P = .990). Mean volume of ICS transfusion was 432.65 mL. Compared to preoperative values, the postoperative PT and APTT levels were significantly increased, while Fib was decreased in the two groups (all P < .01). No significant difference in coagulation function was observed between groups in preoperative and postoperative phase (P > .05). Furthermore, PT, APTT and TT after surgery were not correlated with the transfused volume of salvaged blood (P > .05) while the levels of Fib were negatively correlated with the volume (P < .01). In addition, there were no transfusion reactions in both two groups.

CONCLUSIONS

Intraoperative cell salvage is correlated with reduced allogeneic blood requirements but did not impair blood coagulation significantly in patients undergoing cesarean delivery.

Perioperative adverse events following surgery for primary bone tumors of the spine and en bloc resection for metastases

OBJECTIVE

Surgical treatment of primary bone tumors of the spine and en bloc resection for isolated metastases are complex and challenging. Operative care is fraught with complications, though the true incidence and predictors of adverse events (AEs), length of stay (LOS), and mortality in this population remain poorly understood. The primary objective of this study was to describe the incidence and predictors of perioperative AEs in these patients. Secondary objectives included the determination of the incidence and predictors of admission to the intensive care unit (ICU), unanticipated reoperation during the same admission, hospital LOS, and mortality.

METHODS

In this retrospective analysis of prospectively collected data, the authors included consecutive patients at a single quaternary care referral center (January 1, 2009, to September 30, 2018) who underwent either surgery for a primary bone tumor of the spine or an en bloc resection for an isolated spinal metastasis. Information on perioperative AEs, demographic data, primary tumor histology, neurological status, surgical variables, pathological margins, Enneking appropriateness, LOS, ICU stay, reoperation during the same admission period, and in-hospital mortality was collected prospectively in the institutional database. The modified frailty score was extracted retrospectively.

RESULTS

One hundred thirteen patients met the inclusion criteria: 98 with primary bone tumors and 15 with isolated metastases. The cohort was 59% male, and the mean age was 49 years (SD 19 years). Overall, 79% of the patients experienced at least 1 AE. The median number of AEs per patient was 2 (IQR 0-4 AEs), and the median LOS was 16 days (IQR 9-32 days). No in-hospital deaths occurred in the cohort. Thirty-two patients (28%) required an ICU stay and 19% underwent an unanticipated second surgery during their admission. A longer surgical duration was associated with a higher likelihood of AEs (OR 1.21/hour, 95% CI 1.06-1.37, p = 0.005), longer ICU stay (OR 1.35/hour, 95% CI 1 1.20-1.52, p < 0.001), and reoperation (OR 1.001/hour, 95% CI 1.0003-1.003, p = 0.012). Longer hospital LOS was independently predicted by older age, female sex, upper cervical and sacral location of the tumor, surgical duration, preoperative neurological deficit, presence of AEs, and higher modified frailty index score.

CONCLUSIONS

Surgeries for primary bone tumors and en bloc resection for metastatic tumors are associated with a high incidence of perioperative AEs. Surgical duration predicts complications, reoperation, LOS, and ICU stay.

Clinical presentation, management and outcomes of sacral metastases: a multicenter, retrospective cohort study

Background

Sacral metastases are rare and literature regarding their management is sparse. This multicenter, prospective, observational study aimed to determine health related-quality of life (HRQOL) and pain in patients treated for sacral metastases with surgery and/or radiation therapy (RT). The secondary objectives were to describe the adverse event (AE) profile and change in neurologic function in this population.

Methods

Twenty-three patients presenting with symptomatic sacral metastases were identified from the Epidemiology, Process and Outcomes of Spine Oncology (EPOSO) dataset, a prospective multicenter study on spinal metastases. Patients requiring surgery and/or RT between August 2013 and February 2017 were prospectively enrolled. HRQOL, assessed by the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQv2.0), the Short Form-36 version 2 (SF-36v2), and the EuroQol-5Dimension (EQ-5D) was documented at baseline, 6 weeks, 3 and 6 months post-treatment. Pain numeric rating scale (NRS), AEs, lower extremities motor score (ASIA), and bowel and bladder function were also recorded.

Results

Eight patients underwent surgery ± RT and 15 patients underwent RT alone. Mean age was 59.3 (SD 11.7) years and 13 patients were female. At 6 months, 3 (37.5%) surgical patients and 2 (13.3%) RT patients were deceased. There was a trend showing that surgical patients had worse baseline HRQOL and pain. Pain NRS, EQ-5D, SOSGOQv2.0, and the mental component of the SF-36v2 showed improvement, irrespective of treatment (P>0.05). Ten AEs occurred in the surgical cohort, dominated by wound complications (n=3). Bowel and bladder function improved at 6 weeks in both groups.

Conclusions

Surgical treatment and RT are both valid treatment options for symptomatic sacral metastases. Improvement in HRQOL can be expected with an acceptable AE rate.