Association of preoperative anemia and perioperative allogenic red blood cell transfusion with oncologic outcomes in patients with nonmetastatic colorectal cancer

Blood Transfusion and Survival of Children, Adolescent, and Young Adult Patients with Osteosarcoma: A Multicenter Retrospective Cohort Study

Background/Objectives: Prior studies suggest that blood transfusion may adversely affect the survival of patients with cancer via transfusion-related immunomodulation. The objective of our study is to investigate the association between transfusion during neoadjuvant chemotherapy and survival in children, adolescent, and young adult (CAYA, 39 years old or younger) patients with osteosarcoma. Methods: This is a multicenter retrospective cohort study of patients between 2007 and 2022. Our primary exposure was receipt of any blood product in the neoadjuvant period (i.e., neoadjuvant transfusion). The primary outcome of interest was 3-year event-free survival (EFS) calculated using the Kaplan-Meier method, while secondary outcomes of interest included 5-year EFS and 3- and 5-year overall survival (OS). Firth multivariable logistic regression models were constructed to evaluate the adjusted association between transfusion status and 3- and 5-year EFS and OS. Results: In total, 73 patients were included in the analytic sample; among them, 34 received neoadjuvant transfusion. There was no significant difference between transfused and non-transfused groups in race, ethnicity, tumor location, stage at diagnosis, histologic response to neoadjuvant chemotherapy, and receipt of ifosfamide or radiation during initial treatment. The transfusion group included more females (p = 0.02) and lower median hemoglobin at diagnosis (p = 0.002) than the non-transfusion group. EFS and OS did not significantly vary by transfusion status or type. Conclusions: We did not observe an adjusted association between neoadjuvant transfusion and survival in CAYA patients with osteosarcoma.

Predicting blood transfusion needs in colorectal surgery at a university hospital in Saudi Arabia: insights into anemia, malnutrition, and surgical factors

BACKGROUND

In Saudi Arabia, nearly a quarter of a hospital's blood supply is consumed in operating rooms. However, blood is a scarce resource, and its unavailability has led to the cancellation of many surgeries. This study aims to identify risk factors for perioperative blood transfusion in colorectal surgery, thus providing valuable insights for better blood management and transfusion planning.

METHODS

We conducted a retrospective cohort study of patients who underwent colorectal surgery at King Abdulaziz University Hospital from 2013 to 2022. Data on patient demographics, comorbidities, surgical details, and transfusion outcomes were collected and analyzed. Statistical analyses included logistic regression to identify predictors of transfusion and over-transfusion.

RESULTS

We collected data from 434 patients. Women were almost twice as likely (OR = 1.98; 95%CI = 1.35-2.90) as men to receive one or more units of RBCs. Also more likely to be transfused were patients with a higher ASA score; a lower pre-operative serum hemoglobin (Hgb) level; and malignant disease as the reason for surgery (all p < 0.001). On multivariable analysis, receiving a transfusion of packed blood cells (RBCs) was statistically linked to volume of intra-operative blood loss and Hgb level (both p < 0.001); as well as to pre-operative body mass index (BMI), with patients who were under-weight and of normal weight most at risk, and patients with a BMI between 25 and 35 less likely to be transfused. Patients whose pre-operative serum Hgb level was 12 g/dL or higher were more than twice as likely to not receive a transfusion, while those with pre-operative Hgb levels from 8.0 to 9.9 g/dL were three times more likely than not to receive blood, and those with a pre-operative Hgb under 8.0 g/dL almost five times as likely as not.

CONCLUSIONS

Key risk factors for perioperative blood transfusion in colorectal surgery are preoperative anemia, diabetes, low BMI, and significant blood loss. Addressing these through a multidisciplinary approach and the development of perioperative protocols may reduce transfusion needs. Future prospective studies are needed to validate these findings and refine transfusion risk assessments.

Reduction of red blood cell transfusion with a patient blood management protocol in urological and visceral surgery: a before-after study

BACKGROUND

Although Patient Blood Management (PBM) is recommended by international guidelines, little evidence of its effectiveness exists in abdominal surgery. The aim of this study was to evaluate the benefits of the implementation of a PBM protocol on transfusion incidence and anaemia-related outcomes in major urological and visceral surgery.

METHODS

In this before-after study, a three-pillar PBM protocol was implemented in 2020-2021 in a tertiary care centre, including preoperative correction of iron-deficiency anaemia, intraoperative tranexamic acid administration, and postoperative restrictive transfusion. A historical cohort (2019) was compared to a prospective cohort (2022) after the implementation of the PBM protocol. The primary outcome was the incidence of red blood cell transfusion intraoperatively or within 7 days after surgery.

RESULTS

Data from 488 patients in the historical cohort were compared to 499 patients in the prospective cohort. Between 2019 and 2022, screening for iron deficiency increased from 13.9% to 69.8% (p < 0.01), tranexamic acid administration increased from 9.5% to 84.6% (p < 0.01), and median haemoglobin concentration before transfusion decreased from 77 g.L-1 to 71 g.L-1 (p = 0.02). The incidence of red blood cell transfusion decreased from 11.5% in 2019 to 6.6% in 2022 (relative risk 0.58, 95% CI 0.38-0.87, p = 0.01). The incidence of haemoglobin concentration lower than 100 g.L-1 at discharge was 24.2% in 2019 and 21.8% in 2022 (p =  0.41). The incidence of medical complications was comparable between the groups.

CONCLUSION

The implementation of a PBM protocol over a two-year period was associated with a reduction of transfusion in major urological and visceral surgery.

Identification and management of preoperative anaemia in adults: A British Society for Haematology Guideline update

This updated British Society for Haematology guideline provides an up-to-date literature review and recommendations regarding the identification and management of preoperative anaemia. This includes guidance on thresholds for the diagnosis of anaemia and the diagnosis and management of iron deficiency in the preoperative context. Guidance on the appropriate use of erythropoiesis-stimulating agents and preoperative transfusion is also provided.

The association of perioperative blood transfusion with survival outcomes after major cancer surgery: a population-based cohort study in South Korea

PURPOSE

The correlation between perioperative blood transfusions and the prognosis after major cancer surgery remains controversial. We investigated the association between perioperative blood transfusion and survival outcomes following major cancer surgeries and analyzed trends in perioperative blood transfusions.

METHODS

Data for this population-based cohort study were obtained from the National Health Insurance Service of South Korea. Adult patients who underwent major cancer surgery between January 1, 2016, and December 31, 2020, were included. The primary endpoint was 90-day mortality.

RESULTS

The final analysis included 253,016 patients, of which 55,094 (21.8%) received perioperative blood transfusions. In the multivariable logistic regression model, select factors, including neoadjuvant/adjuvant chemotherapy, an increased preoperative Charlson Comorbidity Index, moderate or severe liver disease, liver cancer surgery, and small bowel cancer surgery, were associated with an increased likelihood of blood transfusion. In the multivariable Cox regression model, patients who received blood transfusion had a significantly higher risk of 90-day mortality (hazard ratio: 5.68; 95% confidence interval: 5.37, 6.00; P < 0.001) than those who did not.

CONCLUSION

We identified potential risk factors for perioperative blood transfusions. Blood transfusion is associated with an increased 90-day mortality risk after major cancer surgery.

Preoperative intravenous iron treatment - a cohort study on colorectal cancer recurrence

Background

Intravenous (i.v.) iron treatment has been speculated to increase the malignant potential of colorectal malignancies but also to enhance the immune systems potential to fight the invasive tumor. Clinical data however is very limited. We investigate if preoperative i.v. iron treatment is associated with colorectal cancer (CRC) recurrence.

Methods

Retrospective cohort study on surgical CRC patients with iron deficiency anemia (1st March 2013 - 31st December 2019). Patients were grouped based on whether they had received preoperative treatment with i.v. iron. Local data was combined with data from the National Danish Health registries to identify recurrences, death, and emigration. Survival analysis, including Kaplan-Meyer curves and multivariate competing risk analysis adjusting for sex, age, ASA-group, tumor stage, surgical radicality, and miss match repair status was performed.

Results

Of 1228 patients, 125 were available for analysis. 89 patients had received preoperative i.v. iron and 36 had not. The two groups were comparable on baseline and surgical characteristics. Median follow-up times were 4.74 in iron treated patients and 5 years in patients not receiving iron treatment. Five-year rate of non-recurrence was 85 % (0.74-0.91) in the i.v. iron treated group vs. 82 % (0.64-0.91) in the control group, non-significant difference. Multivariate survival analysis did not find iron treatment to be associated with recurrence rates (Hazard Ratio 0.88 (95 % ci; 0.31-2.51).

Conclusion

No association between preoperative i.v. iron treatment and the five-year cancer recurrence rate in iron deficient anemic CRC patients was found.

Patient Factors Affecting Inpatient Mortality Following Colorectal Cancer Resection

BACKGROUND

Our objective is to identify factors for inpatient death in patients undergoing resection for colorectal cancer (CRC).

STUDY DESIGN

Unmatched 1:3 case-control study of surgically resected CRC at a tertiary care institution between 2004 and 2018. Variables for multivariate analysis were selected using tetrachoric correlation followed by a least absolute shrinkage and selection operator (LASSO) penalized regression model.

RESULTS

A total of 140 patients were included (N = 35 patients who died inpatient, N = 105 patients who did not die). Patients who died were older, had higher Charlson Comorbidity Index (CCI), higher rates of preoperative anemia, hypoalbuminemia, emergency surgeries, blood transfusion, postoperative vasopressor requirement, anastomotic leak, and postoperative ICU admission than patients who underwent surgical resection without inpatient mortality. Anemia (aOR = 8.62, 1.44-91.58), emergency admission (aOR = 5.71, 1.46-24.36), and ICU admission (aOR 45.51, 8.31-448.4) significantly predicted inpatient mortality when controlled for CCI and hypoalbuminemia.

CONCLUSIONS

Surprisingly, it appears that pre-existing anemia and perioperative factors are more important in predicting inpatient mortality of patients undergoing CRC surgery than baseline comorbidity or nutritional status.

Lower need for allogeneic blood transfusion after robotic low anterior resection compared with open low anterior resection: a propensity score-matched analysis

Robotic low anterior resection (R-LAR) for rectal cancer may decrease estimated blood loss compared with open low anterior resection (O-LAR). The aim of this study was to compare estimated blood loss and blood transfusion within 30 days after O-LAR and R-LAR. This was a retrospective matched cohort study based on prospectively registered data from Västmanland Hospital, Sweden. The first 52 patients operated on using R-LAR for rectal cancer at Västmanland Hospital were propensity score-matched 1:2 with patients who underwent O-LAR for age, sex, ASA (American Society of Anesthesiology physical classification system), and tumor distance from the anal verge. In total, 52 patients in the R-LAR group and 104 patients in the O-LAR group were included. Estimated blood loss was significantly higher in the O-LAR group compared with R-LAR: 582.7 ml (SD ± 489.2) vs. 86.1 ml (SD ± 67.7); p < 0.001. Within 30 days after surgery, 43.3% of patients who received O-LAR and 11.5% who received R-LAR were treated with blood transfusion (p < 0.001). As a secondary post hoc finding, multivariable analysis identified O-LAR and lower pre-operative hemoglobin level as risk factors for the need of blood transfusion within 30 days after surgery. Patients who underwent R-LAR had significantly lower estimated blood loss and a need for peri- and post-operative blood transfusion compared with O-LAR. Open surgery was shown to be associated with an increased need for blood transfusion within 30 days after low anterior resection for rectal cancer.

A novel prognostic model to predict OS and DFS of stage II/III gastric adenocarcinoma patients in China

Background

The prognosis of advanced gastric adenocarcinoma (GAC) after radical gastrectomy varies greatly. We aimed to build and validate a novel individualized nomogram based on inflammation index and tumor markers for patients with stage II/III GAC.

Methods

A total of 755 individuals with stage II/III GAC who had undergone radical gastrectomy at the First Affiliated Hospital of Zhengzhou University between 2012 and 2017 were included in this retrospective study. The patients were randomly divided into a training cohort (n ​= ​503) and a validation cohort (n ​= ​252). Univariate and multivariate analyses were used to determine independent prognostic factors of overall survival (OS) and disease-free survival (DFS). A nomogram was developed based on these independent factors. The concordance index (C-index) and calibration curves were used to evaluate the predictive accuracy of the nomogram.

Results

Univariate and multivariate analyses demonstrated that older age, poor differentiation, advanced stage, elevated neutrophil-to-lymphocyte ratio (NLR), lower hemoglobin, and high carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were significantly associated with lower OS and DFS and were independent prognostic factors in stage II/III GAC. The nomogram developed based on these factors in the training cohort showed excellent calibration and discrimination (OS: C-index ​= ​0.739, 95% CI ​= ​0.706-0.772; DFS: C-index ​= ​0.735, 95% CI ​= ​0.702-0.769). In the internal validation cohort, the nomogram was also well-calibrated for the prediction of OS and DFS; it was superior to the 8th edition UICC/AJCC TNM staging system (for OS: C-index ​= ​0.746 vs. 0.679, respectively; for DFS: C-index ​= ​0.736 vs. 0.675, respectively; P ​< ​0.001).

Conclusion

The nomogram model could reliably predict OS and DFS in stage II/III gastric cancer patients with radical gastrectomy. It may help physicians make better treatment decisions.

Effect of a Patient Blood Management system on perioperative transfusion practice and short-term outcomes of colorectal cancer surgery

BACKGROUND

Patients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes.

MATERIALS AND METHODS

This study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015-2017) and the post-PBM (2018-2020) periods.

RESULTS

A total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation.

DISCUSSION

The PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.

The impact of perioperative red blood cell transfusion on the prognosis of colorectal cancer

Background

There is no consensus on the effect of red blood cell transfusion on colorectal cancer (CRC). This study examined the impact of perioperative red blood cell transfusion on postoperative complications, recurrence, and mortality in patients with CRC.

Methods

In this retrospective cohort study, 219 CRC patients admitted to Chongqing Emergency Medical Center, and Chongqing University Central Hospital from 2008 to 2019 were divided into transfusion (n = 75) and non-transfusion (n = 144) groups. Univariate and multivariate Logistic regression analysis were used to analyze the effects of blood transfusion on the severity of postoperative complications in patients with CRC, and univariate and multivariate Cox regression was performed to analyze the effects of blood transfusion on postoperative death and recurrence.

Results

Twenty-two (29.33%) patients in the transfusion group were intermediate or advanced severity of postoperative complications, 31 (41.33%) patients died in the transfusion group, and 55 (73.33%) patients occurred recurrence of the CRC, with the median follow-up time being 24.57(14.50,36.37) months. Our result showed that perioperative red blood cell transfusion was associated with an increased risk of intermediate or advanced severity of postoperative complications in CRC patients [odds ratio (OR) = 3.368, 95% CI, 1.146–9.901]. And perioperative red blood cell transfusion increased the risk of postoperative death [hazard ratio (HR) = 2.747, 95% CI, 1.048–7.205] and recurrence in patients with CRC (HR = 2.168, 95% CI, 1.192–3.943).

Conclusion

Our finding demonstrated that perioperative red blood cell transfusion was associated with severity of complications, recurrence, and death in CRC patients. However, further studies are still needed to confirm the adverse effects of red blood cell transfusions in CRC patients.

The prognostic impact of preoperative mean corpuscular volume in colorectal cancer

OBJECTIVE

The relationship between preoperative mean corpuscular volume and postoperative prognosis has been reported in some cancers recently, but no certain consensus has been reached, especially for colorectal cancer. We evaluated the usefulness of mean corpuscular volume as a prognostic factor in colorectal cancer patients.

METHODS

This study included 1003 patients with colorectal cancer who underwent curative surgery in a single institution. The relationship between mean corpuscular volume values and postoperative recurrence was evaluated by fractional polynomial model. Based on the result, patients were divided into groups according to mean corpuscular volume values. Clinicopathological factors and long-term outcomes were compared between the groups.

RESULTS

The risk of postoperative recurrence according to mean corpuscular volume value showed a J-shaped curve, suggesting that both low and high mean corpuscular volume have high risk. Low mean corpuscular volume (≤84 fl) group was oncologically advanced in terms of pathological tumor stage, histological grade and lymphatic invasion with higher inflammation markers. High mean corpuscular volume (>95 fl) group had higher frequency of drinking habit with higher values of aspartate aminotransferase, alanine aminotransferase and γ-glutamyl transpeptidase. Abnormal mean corpuscular volume group including these two groups showed significantly worse disease-free survival than the other (P < 0.001). Multivariate analysis suggested that abnormal mean corpuscular volume was an independent risk factor for postoperative recurrence (hazard ratio, 1.344; 95% confidence interval, 1.005-1.796; P = 0.046). Furthermore, its prognostic impact was more significant in pStage III than in other stages.

CONCLUSION

Preoperative low and high mean corpuscular volume is a poor prognostic factor in colorectal cancer patients. It could be a predictive marker to estimate worse survival outcome after surgery.

Preoperative intravenous iron treatment reduces postoperative complications and postoperative anemia in preoperatively anemic patients with colon carcinoma

PURPOSE

Anemia is common among patients with colorectal cancer and is associated with an increased risk of complications and poorer survival rate. The main objective of our study was to determine the effect of preoperative intravenous iron supplementation therapy on the need for red blood cell transfusions, other postoperative complications, and length of hospital stay in colon cancer patients undergoing colon resection.

METHODS

In this retrospective cohort study, data were collected from medical records of all 549 colon carcinoma patients who underwent a colon resection in Helsinki University Hospital during the years 2017 and 2018. The patients were divided into two cohorts: one with anemic patients treated with preoperative intravenous iron supplementation therapy (180 patients) and one with anemic patients without preoperative intravenous iron supplementation therapy (138 patients). Non-anemic patients and patients requiring emergency surgery were excluded (231 patients).

RESULTS

Patients treated with intravenous iron had less postoperative complications (33.9% vs. 45.9%, p = 0.045) and a lower prevalence of anemia at 1 month after surgery (38.7% vs. 65.3%, p < 0.01) when compared with patients without preoperative iv iron treatment. No difference was found in the amount of red blood cell transfusions, length of stay, or mortality between the groups.

CONCLUSION

This is the first study demonstrating a significant decrease in postoperative complications in anemic colon cancer patients receiving preoperative intravenous iron supplementation therapy. This treatment also diminishes the rate of postoperative anemia, which is often associated with a facilitated recovery.

Do Preoperative Transfusions Impact Prognosis in Moderate to Severe Anaemic Surgical Patients with Colon Cancer?

(1) Background: Anaemia is a common finding in patients with colon cancer and is commonly corrected by blood transfusion prior to surgery. However, the prognostic role of perioperative transfusions is still debated. The aim of the present study was to investigate the role of preoperative anaemia and preoperative blood transfusion in influencing the prognosis in colon cancer. (2) Patients and Methods: Patients undergoing elective surgery for colon cancer at a tertiary referral university hospital between January 2010 and December 2018 were included in a retrospective review of a prospectively collected database. Univariate and regression analyses were performed to identify the prognostic role of preoperative anaemia and preoperative transfusions in this homogeneous cohort of patients. (3) Results: A total of 780 patients were included in the final analysis. The estimated five-year overall survival rate was significantly worse in the anaemic group (83.8% in non-anaemic patients, 60.6% in mild anaemic patients, 61.3% in moderate anaemic patients and 58.4% in severe anaemic patients; log-rank < 0.001 vs. non-anaemic patients). Anaemic status was found to be an independent adverse prognostic factor (hazard ratio (HR): 1.46; 95% confidence interval (CI): 1.02–2.07) during multivariate analysis. Among moderate to severe anaemic patients, no significant association was found between preoperative transfusions and the risk of mortality or recurrence. (4) Conclusions: Preoperative anaemia, regardless of its severity, and not preoperative blood transfusion, was independently associated with a worse prognosis after surgery in patients with colonic cancer.

Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA

Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.

Does delaying curative surgery for colorectal cancer influence long-term disease-free survival? A cohort study

BACKGROUND

Surgical wait list time is a major problem in many health-care systems and its influence on survival is unclear. The aim of this study is to assess the impact of wait list time on long-term disease-free survival in patients scheduled for colorectal cancer resection.

MATERIALS AND METHODS

A prospective study was carried out in patients with colorectal cancer scheduled for surgery at a tertiary care center. Wait list time was defined as the time from completion of diagnostic workup to definitive surgery and divided into 2-week intervals from 0 to 6 weeks. The outcome variables were 2-year and 5-year disease-free survival.

RESULTS

A total of 602 patients, 364 (60.5%) male, median age 73 years (range = 71) were defined. The median wait list time was 28 days (range = 99). Two and 5-year disease-free survival rates were 521 (86.5%) and 500 (83.1%) respectively. There were no differences in 2-year or 5-year disease-free survival for the whole cohort or by tumor stage between wait list time intervals except for AJCC stage II tumors which showed a higher 5-year disease-free survival for the 2-4 and 4-6-week wait list time interval (p = 0.021).

CONCLUSIONS

Time from diagnosis to definitive surgery up to 6 weeks is not associated with a decrease in 2-year or 5-year disease-free survival (DFS) in AJCC stage I through III colorectal cancer patients. These are important findings in the light of the COVID-19 pandemic and offer a window of opportunity for preoperative optimization and prehabilitation.

Preoperative Transfusion for Anemia in Patients Undergoing Abdominal Surgery for Malignancy

BACKGROUND

Transfusion guidelines have been established for severe anemia, but limited data is available regarding the utility of preoperative transfusion. This study evaluates the predictive factors and relative value of preoperative transfusion in oncologic patients with moderate anemia undergoing abdominal surgery.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, adult patients with moderate anemia (hematocrit 21-27%) who underwent non-emergent abdominal oncologic resection from 2005 to 2017 were identified. Preoperative transfusion and non-transfused patients were propensity score matched based on baseline covariates. Outcomes were compared using univariate and Poisson regression analysis.

RESULTS

Of 6222 patients, preoperative transfused (N = 1000, 16.1%) patients were more likely to have bleeding disorders (12.1% vs 6.7%, p < 0.0001) and baseline thrombocytopenia (12% vs 7.3%, p < 0.0001) and had shorter operative length (< 180 min: 69.4% vs 59.8%, p < 0.0001). After matching (N = 987/group), preoperative transfusion was associated with higher rates of intraoperative/postoperative transfusion (odds ratio 1.24, p 0.017) and surgical site infections (odds ratio 1.67, p 0.004) and longer length of stay (incidence rate ratio 1.06, p < 0.0001).

CONCLUSIONS

Preoperative transfusion is associated with increased surgical site infections and longer hospital stay and should be carefully considered in oncologic patients given the absence of improvement in outcomes.

Impact and outcomes of postoperative anaemia in colorectal cancer patients: a systematic review

AIM

Preoperative anaemia is common in colorectal cancer patients. Little attention has been given to the prevalence and consequences of postoperative anaemia. The aim of this study was to systematically review the published literature and determine the knowledge of the prevalence and impact of postoperative anaemia in colorectal cancer patients.

METHODS

The databases Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medline, via EBSCOhost, were systematically searched to identify suitable articles published between 2004 and 2020. After an initial search, articles were screened and all eligible articles reporting on the prevalence of postoperative anaemia and clinical and long-term outcome data in colorectal cancer patients undergoing surgery were included. The Risk of Bias 2.0 tool for the assessment of randomized controlled trials and the Risk of Bias 1.0 tool for non-randomized studies were used for the assessment of bias in the studies selected in our review.

RESULTS

Six studies, one randomized control trial and five cohort studies, were included with a total population size of 1714. The prevalence of anaemia at discharge of 76.6% was reported as the primary end-point in only one study. The rate of red blood cell transfusion and length of hospital stay were found to be significantly increased in anaemic patients, while postoperative infection rate results were variable. Quality of life scores and overall survival at 5 years were significantly affected among anaemic patients as reported in two papers.

CONCLUSION

The available limited evidence on postoperative anaemia indicates its high prevalence with negative impact on clinical and long-term outcomes. Further research is required to standardize the measurement and address the true impact of correcting postoperative anaemia on functional and oncological outcomes.

Iron deficiency in colorectal cancer patients: a cohort study on prevalence and associations

AIM

The aim of this work was to estimate the prevalence of iron deficiency in patients diagnosed with colorectal cancer (CRC) and to clarify its association with patient- and tumour-related characteristics.

METHOD

This was a single-centre registry-based cohort study. Iron status was routinely evaluated upon diagnosis of CRC, and these data were coupled with patient- and tumour-specific data from the Danish CRC Group Registry (2013-2018). Data were analysed using multivariate logistic regression.

RESULTS

Out of 846 patients, 543 (64%) were iron deficient. There was an association between increasing depth of invasion and iron deficiency, with odds ratios (ORs) of iron deficiency being 2.8 (p = 0.001, CI 1.5-5.1), 4.22 (p < 0.001, CI 2.48-7.18) and 4.63 (p < 0.001, CI 2.30-9.34) for T-stages 2, 3 and 4, respectively. Right-sided tumours had an OR of 3.54 (p < 0.001, CI 2.22-5.67) of iron deficiency compared with left-sided tumours. Tumours diagnosed through the national CRC screening programme were less likely to be associated with iron deficiency (OR 0.34, CI 0.22-0.52), while female gender was associated with an increase in the odds for iron deficiency (OR 1.91, CI 1.33-2.76). Iron deficiency was prevalent in 88% of anaemic patients and 43% of nonanaemic patients.

CONCLUSION

Iron deficiency was highly prevalent in patients diagnosed with CRC. Increased depth of tumour invasion, right-sided location and female gender were all associated with higher odds for iron deficiency, while patients diagnosed through the national screening programme were associated with lower odds for iron deficiency. A large proportion of patients with a normal haemoglobin were also iron deficient.

Is there an optimal trade-off between anaemia and red blood cell transfusion in surgical critically ill patients after oncologic surgery?

BACKGROUND AND OBJECTIVES

Equipoise remains on the optimal transfusion strategy in surgical oncologic patients. The primary objective of our study was to determine the impact of anaemia and red blood cells (RBCs) transfusion on severe postoperative complications in surgical oncologic critically ill patients.

MATERIALS AND METHODS

Retrospective single-centre study. Adults admitted to intensive care unit after major oncologic surgery were eligible. Analyses to determine the independent risk factors, including anaemia or RBC transfusion, for postoperative complications and/or hospital mortality were performed.

RESULTS

Of the 283 patients included, 246 patients (86.9%) had anaemia. Fifty-five patients (19·4%) were transfused. Patients exposed to moderate-to-severe anaemia or RBC transfusion had more often severe complications, especially acute kidney injury and infectious complications. Multivariate analysis found an independent association between moderate and severe anaemia and severe postoperative complications (moderate anaemia: OR 14·02 [2·52-264]; severe anaemia: OR 16·25 [2·62-318·5]; P < 0·05). Elderly, obese patients and patients operated from abdominal surgery appeared to be more vulnerable to anaemia than other patients. Transfusion was also an independent risk factor for postoperative complications (OR 4·19 [2·12-8·39]; P < 0·001). When considering moderate-to-severe anaemic patients, RBC transfusion was no longer associated with postoperative complications.

CONCLUSIONS

Anaemia was associated with severe postoperative complications, and this association was stronger in elderly, obese patients and after abdominal surgery. RBC transfusion also negatively impacts on patients' prognosis. However, this association was not found in case of moderate-to-severe anaemia exposure (haemoglobin < 10 g/dl).

Perioperative blood transfusion is not an independent predictor for worse outcomes in retroperitoneal sarcoma surgery

BACKGROUND

Surgery for retroperitoneal soft tissue sarcoma (RPS) is technically challenging, often requiring perioperative red blood cell transfusion (PBT). In other cancers, controversy exists regarding the association of PBT and oncologic outcomes. No study has assessed this association in primary RPS, or identified factors associated with PBT.

METHODS

Data was collected on all resected primary RPS between 2006 and 2020 at The Ottawa Hospital (Canada) and University Hospital Birmingham (United Kingdom). 'PBT' denotes transfusion given one week before surgery until discharge. Multivariable regression (MVA) identified clinicopathologic factors associated with PBT and assessed PBT association with oncologic outcomes. Surgical complexity was measured using resected organ score (ROS) and patterns of resection.

RESULTS

192 patients were included with 98 (50.8%) receiving PBT. Median follow-up was 38.2 months. High tumour grade (OR 2.20, P = 0.048), preoperative anemia (OR 2.78, P = 0.020), blood loss >1000 mL (OR 4.89, P = 0.004) and ROS >2 (OR 2.29, P = 0.026) were associated with PBT on MVA. A direct linear relationship was observed between higher ROS and increasing units of PBT (β = 0.586, P = 0.038). Increasingly complex patterns of resection were associated with increasing odds of PBT. PBT was associated with severe post-operative complications (P = 0.008) on MVA. Univariable association between PBT and 5-year disease-free or overall survival was lost upon MVA.

CONCLUSIONS

Surgical complexity and high tumour grade are potentially related to PBT. Oncologic outcomes are not predicted by PBT but are better explained by tumour grade which subsequently may increase surgical complexity. Strategies to reduce PBT should be considered in primary RPS patients.

Postoperative Morbidity After Resection of Recurrent Retroperitoneal Sarcoma: A Report from the Transatlantic Australasian RPS Working Group (TARPSWG)

BACKGROUND

This study aimed to evaluate perioperative morbidity after surgery for first locally recurrent (LR1) retroperitoneal sarcoma (RPS). Data concerning the safety of resecting recurrent RPS are lacking.

METHODS

Data were collected on all patients undergoing resection of RPS-LR1 at 22 Trans-Atlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG) centers from 2002 to 2011. Uni- and multivariable logistic models were fitted to study the association between major (Clavien-Dindo grade ≥ 3) complications and patient/surgery characteristics as well as outcome. The resected organ score, a method of standardizing the number of organs resected, as previously described by the TARPSWG, was used.

RESULTS

The 681 patients in this study had a median age of 59 years, and 51.8% were female. The most common histologic subtype was de-differentiated liposarcoma (43%), the median resected organ score was 1, and 83.3% of the patients achieved an R0 or R1 resection. Major complications occurred for 16% of the patients, and the 90-day mortality rate was 0.4%. In the multivariable analysis, a transfusion requirement was found to be a significant predictor of major complications (p < 0.001) and worse overall survival (OS) (p = 0.010). However, having a major complication was not associated with a worse OS or a higher incidence of local recurrence or distant metastasis.

CONCLUSIONS

A surgical approach to recurrent RPS is relatively safe and comparable with primary RPS in terms of complications and postoperative mortality when performed at specialized sarcoma centers. Because alternative effective therapies still are lacking, when indicated, resection of a recurrent RPS is a reasonable option. Every effort should be made to minimize the need for blood transfusions.

Preoperative rectal tumor embolization as an adjunctive tool for bloodless abdominoperineal excision: A case report

BACKGROUND

Abdominoperineal excision (APE)-related hemorrhage can be challenging due to difficult access to pelvic organs and the risk of massive blood loss. The objective of the present study was to demonstrate the use of preoperative embolization (PE) as a strategy for blood preservation in a patient with a large low rectal tumor with a high risk of bleeding, scheduled for APE.

CASE SUMMARY

A 56-year-old man presented to our institution with a one-year history of anal bleeding and rectal tenesmus. The patient was diagnosed with bulky adenocarcinoma limited to the rectum. As the patient refused any clinical treatment, surgery without previous neoadjuvant chemoradiation was indicated. The patient underwent a tumor embolization procedure, two days before surgery performed via the right common femoral artery. The tumor was successfully devascularized and no major bleeding was noted during APE. Postoperative recovery was uneventful and a one-year follow-up showed no signs of recurrence.

CONCLUSION

Therapeutic tumor embolization may play a role in bloodless surgeries and increase surgical and oncologic prognoses. We describe a patient with a bulky low rectal tumor who successfully underwent preoperative embolization and bloodless abdominoperineal resection.

Correlation between hematological parameters and outcome in patients with locally advanced cervical cancer treated by concomitant chemoradiotherapy

Background

Hemoglobin (Hb), white blood cell (WBC), and polymorphonuclear neutrophil (PMN) blood counts may be correlated with outcomes in patients with locally advanced cervical cancer.

Methods

Hb, WBC, and PMN counts were measured at diagnosis and during concomitant cisplatin‐based chemoradiotherapy (CCRT) in a retrospective sample of 103 patients between 2010 and 2017. Red blood cell (RBC) transfusions were also recorded. The associations between hematological variables and patient overall survival (OS) and recurrence‐free survival (RFS) were assessed by Cox regression models.

Results

The 3‐year OS and RFS rates were 81.4% and 76.8%, respectively. In addition to tumor size and smoking, OS and RFS were found to be significantly associated with changes in WBC and PMN counts from the first to the last cisplatin cycle. Hb count throughout the treatment and RBC transfusions were not predictive of outcome.

Conclusions

This study found no association between Hb count or RBC transfusions and outcome. The daily practice of maintaining the Hb count above 12 g/dL during CCRT should be weighed against the potential risks of transfusions. Drops in WBC and PMN counts during treatment positively impacted OS and RFS and could, therefore, serve as biomarkers during CCRT to adapt the follow‐up and consider the need for adjuvant systemic treatments.

Intravenous Iron in a Prehabilitation Program for Older Surgical Patients: Prospective Cohort Study

BACKGROUND

Older patients often have iron deficiency anemia before surgery, which can be effectively treated with intravenous iron supplementation (IVIS). Anemia and blood transfusions are associated with an increased risk of delirium. The aim of this research was to assess the effectiveness and safety of using IVIS in a prehabilitation program.

MATERIAL AND METHODS

Patients ≥70 y who underwent abdominal surgery between November 2015 and June 2018 were included in this single-center prospective cohort study. All patients were prehabilitated; however, only anemic patients received a single dose of 1000 mg intravenous iron (ferric carboxymaltose) to increase preoperative hemoglobin levels (IVIS group). Nonanemic patients received standard care (SC). The hemoglobin levels (primary outcome) were assessed at the outpatient clinic visit, at admission, and at discharge. Secondary outcomes were postoperative delirium, postoperative anemia, blood transfusion, complications other than delirium, and length of hospital stay. All outcomes were compared between the IVIS group and SC group.

RESULTS

Of all patients (n = 248), 97 anemic patients received IVIS (39%). Of the anemic patients, 50 patients (52%) had iron deficiency. Initial differences in hemoglobin concentrations between the IVIS group and SC group at T1 and T2 (7.2 versus 8.8; P < 0.001 and 7.4 versus 8.6; P = 0.023, respectively) were no longer present at discharge (6.6 versus 7.2; P = 0.35). No statistically significant differences were observed for all secondary outcomes between the IVIS group and the SC group. No infusion-related adverse events occurred.

CONCLUSIONS

Adding IVIS to prehabilitation programs is safe and diminishes differences in these concentrations between preoperatively anemic and nonanemic patients. IVIS may be worthwhile as an additional component of prehabilitation programs. Results merit further investigation.

Prognostic evaluation of colorectal cancer using three new comprehensive indexes related to infection, anemia and coagulation derived from peripheral blood

Background: Many indicators of peripheral blood in routine blood test (BRT) results of colorectal cancer (CRC) patients are related to prognosis. Currently, indexes such as NLR (Neutrophil-to- Lymphocyte Ratio), PLR (Platelet-to-Lymphocyte Ratio) and LMR (Lymphocyte-to-Monocyte ratio) evaluate the survival risk of patients by assessing the inflammatory - immune status of CRCs. These indexes are more comprehensive and accurate than independent estimates. We hope to design more effective indexes through fully considering the correlation and significance between BRT indicators and prognosis, so as to play a guiding role in clinical malignant estimation of CRCs.

Methods: 701 CRCs in training set and 256 CRCs in test set were included in the study samples, and their clinical data, tumor pathology results and peripheral blood routine results were collected. The prognosis, progression, and survival status of all patients were determined after follow-up. Above data were used for statistical analysis and designing new indexes.

Results: It was found that high NE, MONO, RDW-CV/SD and PLT in peripheral blood indicated poor prognosis of DFS and OS. Conversely, CRCs with postoperative tumor progression or death had lower LY, EO, RBC, HGB, HCT, MCV, MCH, MCHC, PDW, and P-LCR. IRR, ARR and CRR related to infection, anemia and coagulation were designed respectively using the largest AUC indicators (P<0.05) selected by ROC curve. The formula: IRR= (NE*MONO)/(LY*EO); ARR= (HGB*MCHC)/RDW-CV; CRR=PLT/PDW. Results of Kaplan‑Meier survival analysis and multivariate COX proportional hazard analysis adjusted for age, gender, TNM stage, infiltration, adhesion showed IRR, ARR, CRR were all able to be used as the evaluation standard of survival of CRC. The result was also authenticated in the test set.

Conclusion: We designed three different prognostic indexes of colorectal cancer, IRR, ARR and CRR, which could be used as risk indicators of CRC prognosis, tumor progression and survival.

Use of intravenous iron therapy in colorectal cancer patient with iron deficiency anemia: a propensity-score matched study

PURPOSE

Iron deficiency anemia is common in colorectal cancer patients and is related to poor surgical outcome. Increasing evidence supports preoperative use of intravenous iron (IVI) to correct anemia. Our study investigates effect of preoperative IVI on hemoglobin level.

METHODS

From August 2017 to March 2019, colorectal cancer patients with iron deficiency anemia received intravenous iron at least 2 weeks before their scheduled operations (IVI group). These patients' prospectively collected data were compared to a historic cohort of anemic patients who received elective colorectal surgery within 3 years before the study period (non-IVI).

RESULTS

Forty-six patients were included after receiving intravenous iron. After propensity score matching on 1:2 ratio, 38 patients in IVI group were matched with 62 patients from non-IVI group. There was no statistical difference for preoperative mean hemoglobin level between the two groups (8.43 g/dL in IVI, 8.79 g/dL in non-IVI, p = 0.117), but IVI group has significantly higher mean hemoglobin level on admission (10.63 g/dL in IVI, 9.46 g/dL in non-IVI, p = < 0.001). IVI group had higher median hemoglobin rise (1.9 in IVI, 0.6 in non-IVI, p = <0.001) and significantly less red cell transfusion (8 patients in IVI, 30 in non-IVI, p = 0.006). Subgroup analysis showed that less patients in IVI group required transfusions in preoperative period (1 in IVI group, 20 in non-IVI, p < 0.001).

CONCLUSION

Our data suggested that IVI can significantly increase hemoglobin level in iron deficiency anemic patients before colorectal surgery, with reduction in red cell transfusions.