The impact of perioperative blood transfusion on clinical outcomes in colorectal surgery

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.

Decreasing readmissions by focusing on complications and underlying reasons

BACKGROUND

To analyze demographics and outcomes of patients focusing on 30-day readmission status and identify procedure-specific risk factors.

METHODS

Patients undergoing abdominal colorectal surgery (2011-2013) were identified Demographics and outcomes including in-hospital complications were compared based on readmission status.

RESULTS

A total of 6637 patients were identified with a mean age of 51.2(±17.1) years. Seven hundred and seventy five(11.7%) patients were readmitted at least once within 30-day. The most common index procedures related to readmission were stoma closure (n = 127/775, 16.4%) and total colectomy (n = 105/775, 13.6%). Readmitted patients had longer length of index hospital stay (LOS)(8.2 ± 5.9 vs 7.9 ± 6.9 days,p < 0.001) and operative time(167 ± 104 vs 144 ± 95 min, p < 0.001), higher intraoperative(2% vs 1%,p = 0.04) and in-hospital complication rates(36% vs 28%,p < 0.001). Main reasons for readmissions were gastrointestinal-related causes(n = 222, 29%), small bowel obstruction (n = 133,17%), wound-related complications(n = 108,14%), and dehydration(n = 93,12%). Median readmission LOS was 4(1-71)days and 54%(n = 407) of readmissions occurred within 7 days of discharge.

CONCLUSION

Increased postoperative complications may be the main preventable underlying reason for increased risk of hospital readmission after colorectal surgery. Preventive measures to decrease complications and actions to identify high risk patients for complications would help to reduce readmissions.

Impact of Blood Transfusions on Survival of Locally Advanced Cervical Cancer Patients Undergoing Neoadjuvant Chemotherapy Plus Radical Surgery

OBJECTIVE

Transfusions represent one of the main progresses of modern medicine. However, accumulating evidence supports that transfusions correlate with worse survival outcomes in patients affected by solid cancers. In the present study, we aimed to investigate the effects of perioperative blood transfusion in locally advanced cervical cancer.

METHODS

Data of consecutive patients affected by locally advanced cervical cancer scheduled to undergo neoadjuvant chemotherapy plus radical surgery were retrospectively searched to test the impact of perioperative transfusions on survival outcomes. Five-year survival outcomes were evaluated using Kaplan-Meier and Cox models.

RESULTS

The study included 275 patients. Overall, 170 (62%) patients had blood transfusion. Via univariate analysis, we observed that transfusion correlated with an increased risk of developing recurrence (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.09-4.40; P = 0.02). Other factors associated with 5-year disease-free survival were noncomplete clinical response after neoadjuvant chemotherapy (HR, 2.99; 95% CI, 0.92-9.63; P = 0.06) and pathological (P = 0.03) response at neoadjuvant chemotherapy as well as parametrial (P = 0.004), vaginal (P < 0.001), and lymph node (P = 0.002) involvements. However, via multivariate analysis, only vaginal (HR, 3.07; 95% CI, 1.20-7.85; P = 0.01) and lymph node involvements (HR, 2.4; 95% CI, 1.00-6.06; P = 0.05) correlate with worse disease-free survival. No association with worse outcomes was observed for patients undergoing blood transfusion (HR, 2.71; 95% CI, 0.91-8.03; P = 0.07). Looking at factors influencing overall survival, we observed that lymph node status (P = 0.01) and vaginal involvement (P = 0.06) were independently associated with survival.

CONCLUSIONS

The role of blood transfusions in increasing the risk of developing recurrence in LAAC patients treated by neoadjuvant chemotherapy plus radical surgery remains unclear; further prospective studies are warranted.

Impact of non-oncological factors on tumor recurrence after liver transplantation in hepatocellular carcinoma patients

Hepatocellular carcinoma (HCC) is the most common primary neoplasm of the liver and is one of the leading causes of cancer-related death worldwide. Liver transplantation (LT) has become one of the best curative therapeutic options for patients with HCC, although tumor recurrence after LT is a major and unaddressed cause of mortality. Furthermore, the factors that are associated with recurrence are not fully understood, and most previous studies have focused on the biological properties of HCC, such as the number and size of the HCC nodules, the degree of differentiation, the presence of hepatic vascular invasion, elevated serum levels of alpha-fetoprotein, and the tumor stage outside of the Milan criteria. Thus, little attention has been given to factors that are not directly related to HCC (i.e., "non-oncological factors"), which have emerged as predictors of tumor recurrence. This review was performed to assess the effects of non-oncological factors on tumor recurrence after LT. The identification of these factors may provide new research directions and clinical strategies for the prophylaxis and surveillance of tumor recurrence after LT, which can help reduce recurrence and improve patient survival.

Effect of Perioperative Transfusion on Recurrence and Survival after Gastric Cancer Resection: A 7-Institution Analysis of 765 Patients from the US Gastric Cancer Collaborative

BACKGROUND

The prognostic effect of perioperative blood transfusion on recurrence and survival in patients undergoing resection of gastric adenocarcinoma (GAC) remains controversial.

STUDY DESIGN

All patients who underwent resection for GAC from 2000 to 2012 at the 7 institutions of the US Gastric Cancer Collaborative were identified. The effect of transfusion on recurrence-free (RFS) and overall survival (OS) in the context of adverse clinicopathologic variables was examined by univariate and multivariate regression analyses.

RESULTS

Of 965 patients, 765 underwent curative intent R0 resection. Median follow-up was 44 months; 30-day mortalities were excluded. Median estimated blood loss (EBL) was 200 mL, and 168 patients (22%) received perioperative allogeneic blood transfusions. Transfused patients were less likely to receive adjuvant therapy (44% vs 56%; p = 0.01). Transfusion was associated with significantly decreased median RFS (13.5 vs 37.2 months, p < 0.001). Median OS was similarly decreased in patients receiving transfusions (18.6 vs 49.8 months, p < 0.001). On multivariate analysis, transfusion remained an independent risk factor for decreased RFS (hazard ratio [HR] 1.63; 95% CI 1.13 to 2.37; p = 0.010) and decreased OS (HR 1.79; 95% CI 1.21 to 2.67; p = 0.004), regardless of EBL or need for splenectomy. Timing (intraoperative vs postoperative) and volume of transfusion did not alter the negative prognostic effect of transfusion on survival.

CONCLUSIONS

Perioperative allogeneic blood transfusion is associated with decreased RFS and OS after resection of gastric cancer, independent of adverse clinicopathologic factors. This supports the judicious use of perioperative transfusion during resection of gastric cancer.

Comparing survival and recurrence in curative stage I to III colorectal cancer in transfused and nontransfused patients

Evidence of the association between blood transfusions and its impact on prognostic outcomes in patients who undergo curative resection of colorectal cancer remains controversial. The aim of this study was to determine whether receiving peri-operative blood transfusions during curative colorectal cancer resection affected overall survival, cancer-related survival, and cancer recurrence. This retrospective study was undertaken at The Royal Brisbane and Women's Hospital, Australia, between 1984 and 2004. The outcomes of 1370 patients undergoing curative colorectal cancer resection for TNM stage I to III were analyzed. Four hundred twenty three patients (30.9%) required transfusion and 947 patients (69.1%) did not. Peri-operative transfusion was associated with higher rates of cancer recurrence on multivariate analysis (P = 0.024, RR, 1.257, 95% CI, 1.03-1.53); however, it was not independently associated with poorer overall or cancer-related survival. Where the aim is curative resection, this study contributes to a body of evidence that blood transfusions may be associated with poorer outcomes.

Impact of perioperative allogeneic red blood cell transfusion on recurrence and overall survival after resection of colorectal liver metastases

BACKGROUND

Perioperative allogeneic red blood cell transfusion has been conclusively shown to be associated with adverse oncologic outcomes after resection of nonmetastatic colorectal adenocarcinoma.

OBJECTIVE

The aim of the study was to identify risk factors for a perioperative transfusion and to assess the effects of transfusion on survival after curative-intended resection of hepatic metastases in patients featuring stage IV colorectal cancer.

DESIGN

This was an observational study with a retrospective analysis of a prospective data collection.

SETTING

The study was conducted at a tertiary care center.

PATIENTS

A total of 292 patients undergoing curative-intended liver resection for colorectal liver metastases were included in the study.

MAIN OUTCOME MEASURES

Univariate and multivariate analyses were performed identifying factors influencing transfusion, recurrence-free survival, and overall survival.

RESULTS

A total of 106 patients (36%) received allogeneic red blood cells. Female sex (p = 0.00004), preoperative anemia (p = 0.001), major intraoperative blood loss (p < 0.00001), and major postoperative complications (p = 0.02) were independently associated with the necessity of transfusion. Median recurrence-free and overall survival were 58 months. Allogeneic red blood cell transfusion was significantly associated with reduced recurrence-free survival (32 vs 72 months; p = 0.008). It was reduced further by administration of >2 units (27 months; p = 0.02). Overall survival was not significantly influenced by transfusion (48 vs 63 months; p = 0.08). When multivariately adjusted for major intraoperative blood loss and factors univariately associated, namely comorbidities, tumor load, and positive resection margins, transfusion was an independent predictor for reduced recurrence-free survival (p = 0.03).

LIMITATIONS

These include the retrospective and observational design, as well as the impossibility to prove causality of the association between transfusion and poor outcome.

CONCLUSIONS

In patients undergoing liver resection for colorectal liver metastases, perioperative transfusion is independently associated with earlier disease recurrence. This emphasizes appropriate blood management measures, including the conservative correction of preoperative anemia, the use of low transfusion triggers, and the minimization of intraoperative blood loss.

Effects of the Sangvia blood collection system on patients undergoing elective hip surgery

We have conducted a randomized controlled study where 164 patients were randomized to receive autologous salvaged blood collected by Sangvia™ Blood Salvage System or allogeneic red cell concentrates if transfusion was indicated by clinical judgement. The study was powered to detect if transfusion of autologous blood reduced the occurrence of postoperative infections. We found no statistical significant difference in postoperative infection rate between the groups, but this may be due to the fact that postoperative infections were diagnosed in only five patients. Increased C-reactive protein concentrations slightly above level of significance indicate that autologous blood transfusions stimulate the patient's immune system. However, there was no indication of increased transfusion reaction rate, including febrile reactions, in the autologous group. Transfusion of autologous blood did not reduce the use of allogeneic red cell concentrates. The mean use of allogeneic red cell concentrates was 0.93 units (both groups combined), indicating that the transfusion policy may have been too liberal. There was a highly significant inverse correlation between pre-operative haemoglobin concentration and transfusion of allogeneic blood. In a patient population with a low frequency of postoperative infection, a larger study is needed to clarify if autologous salvaged blood protects against postoperative infections.

Intraoperative blood loss during surgical treatment of low-rectal cancer by abdominosacral resection is higher than during extra-levator abdominosacral amputation of the rectum

INTRODUCTION

Abdominosacral resection (ASR) usually required blood transfusions, which are virtually no longer in use in the modified abdominosacral amputation of the rectum (ASAR). The aim of this study was to compare the intra-operative bleeding in low-rectal patients subjected to ASR or ASAR.

MATERIAL AND METHODS

The study included low-rectal cancer patients subjected to ASR (n = 114) or ASAR (n = 46) who were retrospectively compared in terms of: 1) the frequency of blood transfusions during surgery and up to 24 h thereafter; 2) the volume of intraoperative blood loss (ml of blood transfused) during surgery and up to 24 h thereafter; 3) hemoglobin concentrations (Hb) 1, 3 and 5 days after surgery; 4) the duration of hospitalization.

RESULTS

Blood transfusions were necessary in 107 ASR patients but in none of those subjected to ASAR (p < 0.001). Median blood loss in the ASR group was 800 ml (range: 100-4500 ml). The differences between the groups in median Hb determined 1, 3 and 5 days following surgery were insignificant. The proportions of patients with abnormal values of Hb, however, were significantly higher in the ASR group on postoperative days 1 and 3 (day 1: 71.9% vs. 19.6% in the ASAR group, p = 0.025; day 3: 57.% vs. 13.0%, p = 0.009). Average postoperative hospitalization in ASR patients was 13 days compared to 9 days in the ASAR group (p = 0.031).

CONCLUSIONS

Abdominosacral amputation of the rectum predominates over ASR in terms of the prevention of intra- and postoperative bleeding due to the properly defined surgical plane in low-rectal cancer patients.

Waist circumference and waist/hip ratio are better predictive risk factors for mortality and morbidity after colorectal surgery than body mass index and body surface area

OBJECTIVES

To determine whether body fat distribution, measured by waist circumference (WC) and waist/hip ratio (WHR), is a better predictor of mortality and morbidity after colorectal surgery than body mass index (BMI) or body surface area (BSA).

BACKGROUND

Obesity measured by BMI is not a consistent risk factor for postoperative mortality and morbidity after abdominal surgery. Studies in metabolic and cardiovascular diseases have shown WC and WHR to be better outcome predictors than BMI.

METHODS

A prospective multicenter international study was conducted among patients undergoing elective colorectal surgery. The WHR, BMI, and BSA were derived from body weight, height, and waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify risk factors for postoperative outcomes.

RESULTS

A total of 1349 patients (754 men) from 38 centers in 11 countries were included. Increasing WHR significantly increased the risk of conversion [odds ratio (OR) = 15.7, relative risk (RR) = 4.1], intraoperative complications (OR = 11.0, RR = 3.2), postoperative surgical complications (OR = 7.7, RR = 2.0), medical complications (OR = 13.2, RR = 2.5), anastomotic leak (OR = 13.7, RR = 3.3), reoperations (OR = 13.3, RR = 2.9), and death (OR = 653.1, RR = 21.8). Both BMI (OR = 39.5, RR = 1.1) and BSA (OR = 4.9, RR = 3.1) were associated with an increased risk of abdominal wound complication. In multivariate analysis, the WHR predicted intraoperative complications, conversion, medical complications, and reinterventions, whereas BMI was a risk factor only for abdominal wall complications; BSA did not reach significance for any outcome.

CONCLUSIONS

The WHR is predictive of adverse events after elective colorectal surgery. It should be used in routine clinical practice and in future risk-estimating systems.

Risk factors for postoperative mortality and morbidities in emergency surgeries

BACKGROUND

Emergency surgery itself induces high risk for postoperative mortality and morbidities; however, it remains unknown which concomitant pathological conditions of emergency surgeries are causative factors of deteriorating outcomes. This study examined the causal factors of postoperative mortality and morbidity in cases of emergency surgery.

METHODS

Patients undergoing emergency surgery from January to December 2007 were enrolled in this retrospective cohort study. Causal relationships were analyzed by stepwise multivariate logistic regression analysis between possible independent factors (sex, age, kind of surgical department, timing of surgery, duration of surgery, blood transfusion, deteriorated consciousness level, shock state, abnormal coagulate state, and history of hypertension, diabetes, ischemic heart disease, chronic obstructive pulmonary disease, renal failure, and anemia) and postoperative mortality or morbidities (failure of removal of tracheal tube after operation, tracheotomy, cerebral infarction, massive hemorrhage, severe hypotension, severe hypoxemia, and severe arrhythmia during or after surgery).

RESULTS

Shock, deteriorated consciousness level, chronic obstructive lung disease, and ischemic heart disease were significant risk factors for mortality (OR 14.2, 7.9, 6.4, and 3.8, respectively), and deteriorated consciousness level, blood transfusion, shock, chronic obstructive lung disease, diabetes, cardiovascular surgery, and operation longer than 2 h were significant risk factors for morbidity (OR 19.1, 3.3, 3.0, 2.5, 2.4, 2.4, and 1.8, respectively).

CONCLUSION

State of shock, deteriorated consciousness level, chronic obstructive lung disease, ischemic heart disease, hemorrhage requiring blood transfusion, age over 80 years, cardiovascular surgery, surgeries at night, and surgeries of duration more than 2 h cause patients to be strongly susceptible to postoperative mortality or morbidity in emergency surgeries.

Gender differences in mortality, quality of life and function after restorative procedures for rectal cancer

AIM

Studies investigating the functional outcome after restorative surgery for rectal cancer have mainly focused on the effect of different surgical techniques on bowel habit or sexual activity at a single time-point. The aim of this study was to assess, longitudinally, the effect of rectal cancer treatment on bowel function, quality of life and sexual activity.

METHOD

The study parameters were assessed using self-administered questionnaires, including the Short Form 36 (SF-36), repeatedly, over a 5-year period. Patient details were obtained from the Cleveland Clinic prospective database.

RESULTS

There were 260 (186 male) patients. The mean ages of male and female patients at the time of surgery were 60.5 and 57.5 years, respectively. There was no significant difference in comorbidity or stage between the groups. Women had a better overall survival. More women than men had postoperative radiation and perioperative blood transfusions. Men had a higher percentage of hand-sewn anastomoses (23.9%vs 10.8%, P = 0.018), but there was no overall difference in the mean level of anastomosis (2.3 cm vs 1.9 cm, P = 0.38). Men had worse nocturnal bowel function, more incontinence and a poorer mental component score on the SF-36. Pad use increased over time to a greater degree in women. Sexual activity, which was similar in men and women at baseline, had fallen at 5 years in both genders.

CONCLUSION

After restorative resection for rectal cancer, bowel function is worse in men than in women, especially night evacuation at 3 and 5 years postoperatively. Sexual function in both genders declines sharply initially within 1 year postoperatively and more gradually over 5 years.

Patient optimization for gastrointestinal cancer surgery

BACKGROUND

Although surgical resection remains the central element in curative treatment of gastrointestinal cancer, increasing emphasis and resource has been focused on neoadjuvant or adjuvant therapy. Developments in these modalities have improved outcomes, but far less attention has been paid to improving oncological outcomes through optimization of perioperative care.

METHODS

A narrative review is presented based on available and updated literature in English and the authors' experience with enhanced recovery research.

RESULTS

A range of perioperative factors (such as lifestyle, co-morbidity, anaemia, sarcopenia, medications, regional analgesia and minimal access surgery) are modifiable, and can be optimized to reduce short- and long-term morbidity and mortality, improve functional capacity and quality of life, and possibly improve oncological outcome. The effect on cancer-free and overall survival may be of equal magnitude to that achieved by many adjuvant oncological regimens. Modulation of core factors, such as nutritional status, systemic inflammation, and surgical and disease-mediated stress, probably influences the host's immune surveillance and defence status both directly and through reduced postoperative morbidity.

CONCLUSION

A wider view on long-term effects of expanded or targeted enhanced recovery protocols is warranted.

Impact of blood transfusions on survival and recurrence in colorectal cancer surgery

The aim of our study was to evaluate the prognostic significance of blood transfusion on recurrence and survival in patients undergoing curative resections for colorectal cancer. Retrospective analysis of prospectively collected data of patients after elective resections for colorectal cancer between January 2001 and December 2009 was undertaken. The main endpoint was overall survival, disease-free survival, and recurrence rate. These data were evaluated in relation to blood transfusion (group A, no blood transfusion; group B, one to two blood transfusions; group C, three and more blood transfusions). A total of 583 patients met the criteria for inclusion in the study. Of these, 132 (22.6 %) patients received blood transfusion in the perioperative period. There were 83 (14.2 %) patients who received one or two blood transfusions and 49 (8.4 %) patients who required three or more transfusions. Patients with three or more transfusions had a significantly worse 5-year overall survival, disease-free survival, and increased incidence of distant recurrences in comparison with the group without transfusion or the group with one or two transfusions. Multivariate analysis showed that the application of three or more blood transfusions is an independent risk factor for overall survival (P = 0.001; HR 2.158; 95 % CI 1.370-3.398), disease-free survival (P < 0.001; HR 2.514; 95 % CI 1.648-3.836), and the incidence of distant recurrence (P < 0.001; HR 2.902; 95 % CI 1.616-5.212). Application of three or more blood transfusions in patients operated for colorectal carcinoma is an adverse prognostic factor. Indications for blood transfusion should be carefully considered not only with regard to the risk of early complications, but also because of the possibility of compromising long-term results.

Blood storage duration and biochemical recurrence of cancer after radical prostatectomy

OBJECTIVE

To test the hypothesis that perioperative transfusion of allogeneic and autologous red blood cells (RBCs) stored for a prolonged period speeds biochemical recurrence of prostate cancer after prostatectomy.

PATIENTS AND METHODS

We evaluated biochemical prostate cancer recurrence in men who had undergone radical prostatectomy and perioperative blood transfusions from July 6, 1998, through December 27, 2007. Those who received allogeneic blood transfusions were assigned to nonoverlapping "younger," "middle," and "older" RBC storage duration groups. Those who received autologous RBC transfusions were analyzed using the maximum storage duration as the primary exposure. We evaluated the association between RBC storage duration and biochemical recurrence using multivariable Cox proportional hazards regression.

RESULTS

A total of 405 patients received allogeneic transfusions. At 5 years, the biochemical recurrence-free survival rate was 74%, 71%, and 76% for patients who received younger, middle, and older RBCs, respectively; our Cox model indicated no significant differences in biochemical recurrence rates between the groups (P=.82; Wald test). Among patients who received autologous transfusions (n=350), maximum RBC age was not significantly associated with biochemical cancer recurrence (P=.95). At 5 years, the biochemical recurrence-free survival rate was 85% and 81% for patients who received younger and older than 21-day-old RBCs, respectively.

CONCLUSION

In patients undergoing radical prostatectomy who require RBC transfusion, recurrence risk does not appear to be independently associated with blood storage duration.

Effects of perioperative red blood cell transfusion on disease recurrence and survival after pancreaticoduodenectomy for ductal adenocarcinoma

BACKGROUND

The premise that allogeneic red blood cell transfusion (RBCT) contributes to adverse oncologic outcomes after surgery remains controversial. We examined the effects of RBCT during and after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) on disease recurrence and survival.

METHODS

A prospective database of 220 patients undergoing PD for PDAC from 2000 to 2008 was reviewed and transfusion data collected. Univariate and multivariate analyses were performed for factors influencing RBCT, recurrence-free survival (RFS), and overall survival (OS). The effect of amount and timing (intraoperative vs. postoperative) of RBCT was analyzed.

RESULTS

One hundred forty-seven patients (67%) received RBCT: 70 (32%) received 1 to 2 units, and 77 (35%) received >2 units. Median RFS and OS for the entire cohort was 12 and 16 months, respectively. RBCT of >2 units was associated with reduced RFS (9 vs. 15 months; P = 0.033) and OS (14 vs. 20 months; P = 0.003). Stratified by timing of transfusion, postoperative RBCT was associated with shortened RFS and OS. Controlling for age, body mass index, comorbidities, tumor factors, and major complications, each incremental unit of postoperative RBCT was associated with reduced RFS (hazard ratio 1.10, 95% confidence interval 1.02-1.18) and OS (hazard ratio 1.08, 95% confidence interval 1.03-1.12). Low hemoglobin and presence of comorbidities were the only preoperative factors independently associated with RBCT.

CONCLUSIONS

Allogeneic red blood cell transfusion after PD for PDAC is independently associated with earlier cancer recurrence and reduced survival, in particular when administered postoperatively and in larger quantities. Blood-conservation methods are especially indicated for patients with preoperative anemia and medical comorbidities.

The plasma fraction of stored erythrocytes augments pancreatic cancer metastasis in male versus female mice

BACKGROUND

Males with pancreatic cancer have decreased survival compared with females. Interestingly, perioperative blood transfusions have been shown to reduce survival in patients with pancreatic adenocarcinoma. Recent evidence incriminates blood transfusions from female donors as a causative factor in acute lung injury. We therefore hypothesize that male mice with pancreatic cancer will have greater tumor progression than female mice in response to transfusion.

METHODS

Mice previously inoculated with pancreatic cancer cells received an intravenous injection of acellular plasma collected from single donor erythrocytes from either male or female donors. Control mice received an equal volume of intravenous saline. Necropsy to determine metastasis was performed in female mice at 4 wk status post-transfusion. The male group necessitated sacrifice at 3 wk post-transfusion due to clinical deterioration.

RESULTS

Male mice developed more metastatic events than female mice, and this was accentuated when receiving blood from female donors. Male mice experienced weight loss within 2 wk of tail vein injection, and three mice in the male transfused groups died secondary to malignancy. Female mice did not manifest substantial weight loss, and did not die in the study time period.

CONCLUSION

Male mice, compared with female, had significantly more metastatic events following transfusion of plasma from stored erythrocytes in an immunocompetent murine model of pancreatic adenocarcinoma. Moreover, the adverse effect of transfusion was augmented with female donor blood. These data are consistent with clinical outcomes from centers of excellence in treating pancreatic cancer and warrant further investigation.

Intravenous delivery of the plasma fraction of stored packed erythrocytes promotes pancreatic cancer growth in immunocompetent mice

BACKGROUND

Perioperative blood transfusion in pancreatic cancer patients has been linked to decreased survival; however, a causal mechanism has not been determined. During the processing and storage of packed erythrocytes, biologically active molecules accumulated in the acellular plasma fraction; therefore, the authors hypothesized that the plasma fraction of stored packed erythrocytes promoted tumor progression.

METHODS

Proliferation and migration of murine pancreatic cancer and control cells were determined in vitro in response to the plasma fraction from leukocyte and nonleukocyte-reduced fresh versus stored packed erythrocytes. Last, an immunocompetent murine model was used to assess the effect of the plasma fraction of stored and processed packed erythrocytes on pancreatic cancer progression.

RESULTS

Incubation of pancreatic cancer cells with the plasma fraction of packed erythrocytes increased proliferation and migration. Intravenous delivery of the acellular plasma fraction to mice with pancreatic cancer significantly increased the tumor weight in both leukocyte-reduced and nonleukocyte-reduced packed-erythrocyte groups (P<.01), although tumor growth and morbidity were greatest in the nonleukocyte-reduced group.

CONCLUSIONS

The plasma fraction of stored packed erythrocytes promoted murine pancreatic cancer proliferation and migration in vitro and when administered intravenously, significantly augmented pancreatic cancer growth in immunocompetent mice.

Perioperative blood transfusions promote pancreas cancer progression

Complex abdominal procedures to extirpate malignancies are often associated with blood transfusion. In particular, perioperative transfusion rates for pancreaticoduodenectomy can be as high as 75%. In the early 1970s it was shown that blood transfusions likely had immunomodulating effects as renal allografts were found to have longer survival in patients who received multiple transfusions. Subsequently, it has been suggested that blood transfusions may promote cancer progression. Many retrospective series have supported this hypothesis, and recent studies examining long-term survival in patients undergoing "Whipple" procedures suggests that transfusion is a negative prognostic factor. Despite these studies, the claim that transfusion is a simple surrogate for patient health, tumor size, location, and biology are difficult to refute. The use of syngeneic murine models has allowed many confounding variables to be controlled, and suggest that transfusion does indeed promote pancreas cancer progression. Based on these findings, as well as the continued need for blood transfusion, alternate strategies in transfusion management are warranted.

Allogeneic blood transfusion in patients in Dukes B stage of colorectal cancer

The aim of this study is to evaluate influence of allogeneic blood transfusion on prognosis in patients in Dukes B stage of colorectal cancer. All patients with colorectal cancer who were admitted at our Department of Surgery between January 2000 and December 2004 were analyzed. One hundred fifty-one patients who fulfilled inclusion criteria were enrolled in further evaluation. B stage according to Dukes classification and curative resection were inclusion criteria. Exclusion criteria were polyposis syndromes, nonpolyposis syndromes, inflammatory bowel disease, autoimmune disease and previous blood transfusion. Patients were divided into two groups: Group 1 received ≤ 3 units of allogeneic blood transfusion and group 2 received >3 units of allogeneic blood transfusion. "Cutoff" value of 3 units of blood was defined according to our results and literature data. Follow-up was 5 year. There was no statistical difference between these groups in local recurrence (χ(2) = 0.009, P > 0.05) and distant metastasis (χ(2) = 0.44, P > 0.05). Also, the Kaplan-Meier survival curves were calculated, and long-rank test did not show a survival difference between these two groups (log rank = 0.075, P > 0.05). Postoperative complications are significantly more frequent in Group 2 (χ(2) = 4.67, P < 0.05). Multivariate logistic regression analysis confirmed that intraoperative blood transfusion more than three units had independent influence on local recurrence. Postoperative transfusion more than 3 units was statistically independent prognostic factor for metastasis and mortality. Overall transfusion less than 3 units of allogeneic blood does not influence the outcome of patients in Dukes B stage of colorectal cancer.

Predictors of blood transfusion requirement in elective liver resection

BACKGROUND

Liver resection remains major surgery frequently requiring intra-operative blood transfusion. Patients are typically over cross-matched, and with blood donor numbers falling, cross-matching and transfusion policies need rationalizing.

AIM

To identify predictors of peri-operative blood transfusion.

METHODS

A retrospective review of elective hepatic resections over a 4-year period was performed. Twenty-six variables including clinicopathological variables and intra-operative data were collated, together with the number of units of blood cross-matched and transfused in the immediate peri-operative period (48 h). Multivariate regression analysis was performed to identify independent predictors of blood transfusion, and a Risk Score for transfusion constructed.

RESULTS

Five hundred and eighty-nine patients were included in the study, and were cross-matched with a median 10 units of blood. Seventeen per cent of patients received a blood transfusion; median transfusion when required was 2 units. Regression analysis identified seven factors predictive of transfusion: haemoglobin <12.5 g/dL, pre-operative biliary drainage, coronary artery disease, largest tumour >3.5 cm, cholangiocarcinoma, redo resection and extended resection (5+ segments). Patients were stratified into high or low risk of transfusion based on Risk Score with a sensitivity of 73% [receiver-operating characteristic (ROC) 0.77].

CONCLUSIONS

Patients undergoing elective liver resection are over-cross-matched. Patients can be classified into high and low risk of transfusion using a Risk Score, and cross-matched accordingly.

Early readmission after ileoanal pouch surgery

PURPOSE

This study was designed to evaluate factors that might be predictive of readmission and early and long-term outcomes for patients readmitted after ileal pouch-anal anastomosis.

METHODS

Data for patients readmitted within 30 days after ileal pouch-anal anastomosis were identified from a prospectively maintained database and compared with the remaining patients. Early and delayed outcomes for readmitted patients, including long-term functional outcomes and quality of life, were evaluated. Potential predictors of readmission were assessed using a multivariate analysis of factors.

RESULTS

Of 3,410 patients who underwent ileal pouch-anal anastomosis from 1984 to 2008, 410 (12%) were readmitted. Reasons for readmission included ileus, obstruction or dyselectrolytemia (54.9%), surgical site infection (19.8%), anastomotic problems (9.8%), and thrombotic (3.4%), hemorrhagic (3.2%), infectious (2.9%), cardiac (1.2%), and miscellaneous (4.3%) complications. Thirty-two (7.8%) patients underwent reoperation; 74 (18%) required invasive nonoperative interventions. Median hospital stay for readmission was four (range, 1-52) days. Readmitted patients had worse long-term functional results (P = 0.015) and social (P = 0.024), work (P = 0.008), and sexual (P = 0.046) restriction as compared with patients who were not readmitted. The Cleveland Global Quality of Life (P = 0.018) and physical SF-36 (P = 0.008) scores were also significantly lower for readmitted patients. On multivariate analysis, comorbid conditions (P = 0.014, odds ratio = 1.36), laparoscopic technique (P = 0.008, odds ratio = 1.8), proctocolectomy (rather than initial subtotal colectomy) at ileal pouch-anal anastomosis (P < 0.001, odds ratio = 1.55), and postoperative blood transfusion (P = 0.02, odds ratio = 1.54) were independently associated with readmission.

CONCLUSION

Early readmission after ileal pouch-anal anastomosis is common. Associated comorbidity, laparoscopic approach, reconstruction of the ileal pouch-anal anastomosis at the index surgery, and postoperative blood transfusion are associated with readmission.

Perioperative blood transfusions for the recurrence of colorectal cancer

BACKGROUND

The improvement of renal allograft survival by pre-transplantation transfusions alerted the medical community to the potential detrimental effect of transfusions in patients being treated for cancer.

OBJECTIVES

The present meta-analysis aims to evaluate the role of perioperative blood transfusions (PBT) on colorectal cancer recurrence. This is accomplished by validating the results of a previously published meta-analysis (Amato 1998); and by updating it to December 2004.

SEARCH STRATEGY

Published papers were retrieved using Medline, EMBASE, the Cochrane Library, controlled trials web-based registries, or the CCG Trial Database. The search strategy used was: {colon OR rectal OR colorectal} WITH {cancer OR tumor OR neoplasm} AND transfusion. The tendency not to publish negative trials was balanced by inspecting the proceedings of international congresses.

SELECTION CRITERIA

Patients undergoing curative resection of colorectal cancer (classified either as Dukes stages A-C, Astler-Coller stages A-C2, or TNM stages T1-3a/N0-1/M0) were included if they had received any amount of blood products within one month of surgery. Excluded were patients with distant metastases at surgery, and studies with short follow-up or with no data.

DATA COLLECTION AND ANALYSIS

A specific form was developed for data collection. Data extraction was cross-checked, using the most recent publication in case of repetitive ones. Papers' quality was ranked using the method by Evans and Pollock. Odds ratios (OR, with 95% confidence intervals) were computed for each study, and pooled estimates were generated by RevMan (version 4.2). When available, data were stratified for risk factors of cancer recurrence.

MAIN RESULTS

The findings of the 1998 meta-analysis were confirmed, with small variations in some estimates. Updating it through December 2004 led to the identification of 237 references. Two-hundred and one of them were excluded because they analyzed survival (n=22), were repetitive (n=26), letters/reviews (n=66) or had no data (n=87). Thirty-six studies on 12,127 patients were included: 23 showed a detrimental effect of PBT; 22 used also multivariable analyses, and 14 found PBT to be an independent prognostic factor. Pooled estimates of PBT effect on colorectal cancer recurrence yielded overall OR of 1.42 (95% CI, 1.20 to 1.67) against transfused patients in randomized controlled studies. Stratified meta-analyses confirmed these findings, also when stratifying patients by site and stage of disease. The PBT effect was observed regardless of timing, type, and in a dose-related fashion, although heterogeneity was detected. Data on surgical techniques was not available for further analysis.

AUTHORS' CONCLUSIONS

This updated meta-analysis confirms the previous findings. All analyses support the hypothesis that PBT have a detrimental effect on the recurrence of curable colorectal cancers. However, since heterogeneity was detected and conclusions on the effect of surgical technique could not be drawn, a causal relationship cannot still be claimed. Carefully restricted indications for PBT seems necessary.