[Perioperative autotransfusion with salvage blood in 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.

Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy: a propensity-score-matched case-control analysis

BACKGROUND

Liver resection may be associated with substantial blood loss, and cell saver use has been recommended for patients at high risk. We performed a study to compare the allogenic erythrocyte transfusion rate after liver resection between patients who had intraoperative cell salvage with a cell saver device versus patients who did not. Our hypothesis was that cell salvage with autologous transfusion would reduce the allogenic blood transfusion rate.

METHODS

Cell salvage was used selectively in patients at high risk for intraoperative blood loss based on preoperatively known predictors: right and repeat hepatectomy. Patients who underwent elective right or repeat hepatectomy between Nov. 9, 2007, and Jan. 27, 2016 were considered for the study. Data were retrieved from a liver resection database and were analyzed retrospectively. Patients with cell saver use (since January 2013) constituted the experimental group, and those without cell salvage (2007-2012), the control group. To reduce selection bias, we matched propensity scores. The primary outcome was the allogenic blood transfusion rate within 90 days postoperatively. Secondary outcomes were the number of transfused erythrocyte units, and rates of overall and infectious complications.

RESULTS

Ninety-six patients were included in the study, 41 in the cell saver group and 55 in the control group. Of the 96, 64 (67%) could be matched, 32 in either group. The 2 groups were balanced for demographic and clinical variables. The allogenic blood transfusion rate was 28% (95% confidence interval [CI] 12.5%-43.7%) in the cell saver group versus 72% (95% CI 56.3%-87.5%) in the control group (p < 0.001). The overall and infectious complication rates were not significantly different between the 2 groups.

CONCLUSION

Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy reduced the allogenic blood transfusion rate.

Does autologous blood transfusion during liver transplantation for hepatocellular carcinoma increase risk of recurrence?

AIM: To analyze outcomes in patients who underwent liver transplantation (LT) for hepatocellular carcinoma (HCC) and received autologous intraoperative blood salvage (IBS).

METHODS: Consecutive HCC patients who underwent LT were studied retrospectively and analyzed according to the use of IBS or not. Demographic and surgical data were collected from a departmental prospective maintained database. Statistical analyses were performed using the Fisher’s exact test and the Wilcoxon rank sum test to examine covariate differences between patients who underwent IBS and those who did not. Univariate and multivariate Cox regression models were developed to evaluate recurrence and death, and survival probabilities were estimated using the Kaplan-Meier method and compared by the log-rank test.

RESULTS: Between 2002 and 2012, 158 consecutive patients who underwent LT in the same medical center and by the same surgical team were identified. Among these patients, 122 (77.2%) were in the IBS group and 36 (22.8%) in the non-IBS group. The overall survival (OS) and recurrence free survival (RFS) at 5 years were 59.7% and 83.3%, respectively. No differences in OS (P = 0.51) or RFS (P = 0.953) were detected between the IBS and non-IBS groups. On multivariate analysis for OS, degree of tumor differentiation remained as the only independent predictor. Regarding patients who received IBS, no differences were detected in OS or RFS (P = 0.055 and P = 0.512, respectively) according to the volume infused, even when outcomes at 90 d or longer were analyzed separately (P = 0.518 for both outcomes).

CONCLUSION: No differences in RFS or OS were detected according to IBS use. Trials addressing this question are justified and should be designed to detect small differences in long-term outcomes.

Responses of advanced directives by Jehovah's Witnesses on a gynecologic oncology service

Objectives

To review the responses of advance directives signed by Jehovah’s Witness patients prior to undergoing surgery at a gynecologic oncology service.

Study design

A retrospective chart review of gynecologic oncology patients undergoing surgery at a bloodless surgery center from 1998–2007 was conducted. Demographic, pathologic, and clinical data were recorded. The proportion of patients who accepted and refused various blood-derived products was determined and was compared to previously published results from a similar study of labor and delivery unit patients.

Results

No gynecologic oncology patients agreed to accept transfusions of whole blood, red cells, white cells, platelets, or plasma under any circumstance, whereas 9.8% of pregnant patients accepted transfusion (P=0.0385). However, 98% of gynecologic oncology patients agreed to accept some blood products, including fractions such as albumin, immunoglobulins, and clotting factors, while only 39% of pregnant patients agreed (P<0.0001). In addition, all gynecologic oncology patients (100%) accepted intraoperative hemodilution, compared to 55% of pregnant patients (P<0.0001).

Conclusion

Our results confirm the commonly held belief that the majority of Jehovah’s Witness patients refuse to accept major blood components. However, Jehovah’s Witness patients at a gynecologic oncology service will accept a variety of blood-derived products (minor fractions) and interventions designed to optimize outcomes when undergoing transfusion-free surgery. Patients presenting to a gynecologic oncology service respond differently to advanced directives related to bloodless surgery, as compared to patients from an obstetrical service.

Liver transplantation for hepatocellular carcinoma--is there a risk of recurrence caused by intraoperative blood salvage autotransfusion?

BACKGROUND/AIMS

The use of intraoperative blood salvage autotransfusion (IBSA) during surgical approaches may contribute to tumour cell dissemination. Therefore, IBSA should be avoided in cases of malignancy. However, the risks of IBSA might be acceptable in liver transplantation (LT) for selected small hepatocellular carcinoma (HCC).

METHODS

In total, 136 recipients of LT with histologically proven HCC in the explanted liver were included in this analysis. With regard to tumour recurrence, 40 patients receiving IBSA despite HCC (IBSA group) were compared to 96 patients without IBSA (non-IBSA group).

RESULTS

Milan criteria as assessed in the explanted liver were fulfilled in 24 of 40 IBSA patients and 58 of 96 non-IBSA patients (p = 0.85). Five of 40 patients in the IBSA group and 18 of 96 patients in the non-IBSA group experienced tumour recurrence (p = 0.29). In spite the theoretical risk of tumour cell dissemination, the recurrence rate was not increased in the IBSA group.

CONCLUSION

Our results indicate that IBSA does not modify the risk of HCC recurrence. Therefore, in highly selected HCC patients undergoing LT, the use of IBSA appears to be justified.

Intraoperative blood salvage during liver transplantation in patients with hepatocellular carcinoma: efficiency of leukocyte depletion filters in the removal of tumor cells

BACKGROUND

Intraoperative blood salvage (IBS) reduces homologous transfusion in orthotopic liver transplantation (OLT), but may carry with it the risk of reinfusing tumor cells in patients with hepatocellular carcinoma (HCC). The use of leukocyte depletion filters (LDFs) for the removal of tumor cells is rarely reported in clinical OLT. The aims of this study were to evaluate the frequency of tumor cell contamination in surgical field during OLT for HCC recipients and to investigate the efficiency of additional LDFs for eliminating tumor cells from IBS.

METHODS

Thirty-two HCC patients with preoperatively elevated serum alpha-fetoprotein (AFP) underwent OLT. The blood from the surgical field was collected and processed by an autotransfusion device (Cell Saver 5), followed by 2 consecutive LDF filtrations. The HCC cells in IBS samples and filtered samples were determined using a nested RT-PCR technique to detect the AFP mRNA.

RESULTS

The shed blood samples from 20 (62.5%) of the 32 HCC patients were contaminated with HCC cells and 15 of them remained positive after Cell Saver processing. Patients within the Milan or UCSF criteria were less likely to have HCC cell contamination and the contaminated HCC cells were more likely to be removed by the Cell Saver in these patients as compared to other patients (P<0.01). After filtration through an additional LDF, most cases (13/15) became negative except for those with ruptured tumors (P<0.05).

CONCLUSIONS

Our results suggest that blood filtration with the LDF can efficiently remove tumor cells and the use of an additional LDF after use of the Cell Saver could markedly reduce the risk of tumor cell reintroduction during the OLT in HCC recipients with nonruptured tumors.

Blood salvage autotransfusion during transplantation for hepatocarcinoma: does it increase the risk of neoplastic recurrence?

Impact of intraoperative blood salvage autotransfusion (IBSA) on neoplastic recurrence. during liver transplantations for hepatocellular carcinoma (LT-HCC). Between January 1989 and February 2003, 16 patients received a LT-HCC without IBSA. This group was compared with 31 patients who received the same surgical procedure during the same period, but with IBSA. Data were prospectively collected. All patients had at least a 1-year postoperative follow up. Pairing was made according to the size of the largest nodule. The percentage of recurrence observed in the two groups was similar: 6.4% in the IBSA group vs. 6.3% in the group without IBSA. The median amount of transfused salvage blood was 1558 ml. The differences observed between the two groups concerned the Child score which was A in 58% patients of the IBSA group vs. 80% in the other group; the percentage of severe portal hypertension was 55% in the IBSA group vs. 31%; the median number of packed red blood cell units transfused intraoperatively was 7 in the IBSA group vs. 0, and the median number of frozen fresh plasma units transfused intraoperatively was 11 in the IBSA group vs. 4.5. It appears that IBSA, essentially used during the most haemorrhagic transplantations, could be used in the case of HCC because it does not modify the risk of neoplastic recurrence.