Protective effect of blood transfusions on postoperative recurrence of Crohn's disease in parous women

Systematic Review and Meta-Analysis on the Role of Perioperative Blood Transfusion in Patients Undergoing Radical Cystectomy for Urothelial Carcinoma

BACKGROUND: Radical cystectomy (RC) is the standard of care in patients with muscle-invasive bladder cancer. The impact of perioperative red blood cell (RBC) transfusion on oncological outcomes after RC is not clearly established as the existing publications show conflicting results. OBJECTIVES: The aim of this systematic review and meta-analysis was to investigate the prognostic role of perioperative RBC transfusion on oncological outcomes after RC. METHODS: Systematic online search on PubMed was conducted, based on PRISMA criteria for publications reporting on RBC transfusion during RC. Publications with the following criteria were included: (I) reported data on perioperative blood transfusion; (II) Reported Hazard ratio (HR) and 95% -confidence interval (CI) for the impact of transfusion on survival outcomes. Primary outcome was the impact of perioperative RBC transfusion on recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Risk of bias assessment was performed using Newcastle-Ottawa Scale. Statistical analysis was performed using Revman 5.4 software. RESULTS: From 27 primarily identified publications, 19 eligible articles including 22897 patients were selected. Perioperative RBC transfusion showed no impact on RFS (Z = 1.34; p = 0,18) and significant negative impact on CSS (Z = 2.67; p = 0.008) and OS (Z = 3.22; p = 0.001). Intraoperative RBC transfusion showed no impact on RFS (Z = 0.58; p = 0.56) and CSS (Z = 1.06; p = 0.29) and OS (Z = 1.47; p = 0.14). Postoperative RBC transfusion showed non-significant trend towards improved RFS (Z = 1.89; p = 0.06) and no impact on CSS (Z = 1.56; p = 0.12) and OS (Z = 0.53 p = 0.60). CONCLUSION: In this meta-analysis, we found perioperative blood transfusion to be a significant predictor only for worse CSS and OS but not for RFS. This effect may be determined by differences in tumor stages and patient comorbidities for which this meta-analysis cannot control due to lack of respective raw data.

Perioperative blood transfusion is associated with post-operative infectious complications in patients with Crohn's disease

Background

We have previously demonstrated that blood transfusion (BT) was associated with post-operative complications in patients undergoing surgery for Crohn’s disease (CD), based on our institutional data registry. The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

Methods

All CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP. Variables were defined according to the ACS NSQIP guidelines. The primary outcome was infectious complications, including superficial, deep and organ/space surgical site infection, wound dehiscence, urinary tract infection, pneumonia, systemic sepsis and septic shock. Multivariate analyses were performed to assess the risk factors for post-operative infections.

Results

All 10 100 eligible patients were included and 611 (6.0%) received perioperative BT. BT patients were older, lighter in weight and more likely to be functionally dependent. BT patients were more likely to have post-operative infectious complications than those without BT, including superficial surgical site infection (SSI) (10.8% vs 7.4%, p=0.002), deep SSI (3.3% vs 1.6%, p=0.003), organ/space SSI (14.2% vs 5.4%, p<0.001), pneumonia (3.8% vs 1.3%, p<0.001), urinary tract infection (3.9% vs 2.2%, p=0.006), sepsis (11.5% vs 4.5%, p<0.001) and sepsis shock (3.1% vs 0.8%, p<0.001). Multivariate analysis showed that intra- and/or post-operative BT was an independent risk factor for post-operative infectious complications (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.8–2.7; p<0.001) and the risk increased with each administered unit of red blood cell (OR = 1.3, 95% CI: 1.2–1.5). Other independent factors were history of smoking, chronic heart disease, diabetes, hypertension and the use of corticosteroids. Pre-operative BT, however, was not found to be a risk factor to post-operative infections.

Conclusions

Intra- and/or post-operative, not pre-operative, BT was found to be associated with an increased risk for post-operative infectious complications in this CD cohort. Therefore, the timing and risks and benefits of BT should be carefully balanced.

Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era"

Crohn’s disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.

Perioperative Blood Transfusion and Postoperative Outcome in Patients with Crohn's Disease Undergoing Primary Ileocolonic Resection in the "Biological Era"

BACKGROUND

Perioperative blood transfusion has been shown to be associated with inflammatory response and immunosuppression. Patients receiving blood transfusion may have an increased risk for developing postoperative morbidities. The impact of blood transfusion on the postoperative recurrence of Crohn's disease (CD) has been controversial. The aim of this study was to assess the effect of blood transfusion on postoperative outcomes in CD in the current biological era.

METHODS

This historical cohort study involved data collection and analysis of CD patients who underwent the index ileocolonic resection in our institution between 2000 and 2012. Postoperative complications were compared between the transfused and nontransfused patients. The effects of perioperative blood transfusion on postoperative complications and disease recurrence were analyzed with both univariate and multivariate analyses.

RESULTS

A total of 318 patients were included in the study, and 52 of them (16.5 %) received perioperative blood transfusion. Blood transfusion was found to be associated with an increased risk of postoperative infectious and noninfectious complications both in univariate (P < 0.001 for each) and multivariable analyses (infectious complications: odds ratio [OR] = 8.73, 95 % confidence interval [CI] 2.85-26.78, P < 0.001; noninfectious complications: OR = 3.64, 95 % CI 1.30-10.18; P = 0.014). In addition, the Cox regression model indicated that blood transfusion was associated with both surgical (hazard ratio [HR] = 3.43, 95 % CI 1.92-6.13; P < 0.001) and endoscopic (HR = 2.08, 95 % CI 1.38-3.14; P < 0.001) CD recurrence following the index surgery.

CONCLUSION

Adverse outcomes after perioperative blood transfusion for the primary ileocolonic resection for CD resemble findings in surgery for other diseases. The presumed immunosuppressive effect of blood transfusion did not confer any protective effect on disease recurrence.

Postoperative Crohn's disease

More than three quarters of patients with Crohn's disease (CD) will require surgery. After resection, disease recurs postoperatively with a median time to second resection of about 10 years. Despite its importance, the postoperative period remains one of the most poorly understood clinical settings in the field. Postoperatively, CD may exhibit unique pathophysiologic features, but the current state of knowledge does not allow for identification of patients at risk for relapse, and leaves clinicians without guidance on optimal maintenance treatment. Therapies used as maintenance for CD in other settings may have different efficacies when used after surgery, and clinical research in patients requiring surgery is limited by the subset of patients available for study. Despite the many limitations in current knowledge of postoperative CD, it is an exciting field because new developments have improved patient care, and ongoing research has the potential for further gains.

Microchimerism in immune competent patients related to the leukocyte content of transfused red blood cell concentrates

BACKGROUND

Microchimerism may play a part in transfusion complications. The aim of this study was to examine whether establishment of post-transfusion microchimerism was related to leukocyte content.

METHODS

Twenty non-pregnant female patients, without known malignant or immunological diseases, mean age 68 years, receiving 2-4 units of red blood cell concentrates during elective surgery, were included. One or two of the units were from male donors. Ten patients received buffy-coat depleted red blood cell concentrates, leukocyte count 108-109 per unit, and 10 patients received red blood cells leukoreduced by prestorage leukocyte filtration, with a leukocyte count of <106 per unit. EDTA samples were collected in vacuum tubes before and after 1 week and 6 months after transfusion. The tubes were frozen and stored at -400 degrees C. Genomic DNA was isolated and PCR performed using four primer sets amplifying markers on the Y-chromosome.

RESULTS

Microchimerism was detected in a total of eight out of the 20 patients. In three patients microchimerism was detected only before transfusion. These patients had given birth to one or two boys each, and had no history of previous transfusion. Two patients receiving buffy-coat depleted red blood cell concentrates and two patients receiving leukoreduced red blood cell concentrates had detectable microchimerism 1 week after transfusion. The age of the transfused red blood cell concentrates was 6, 24, 8 and 7 days, respectively. One patient receiving leukoreduced red blood cell concentrates had detectable microchimerism after 6 months. The age of this concentrate was 22 days.

DISCUSSION

This study demonstrates that microchimerism after transfusion does not seem to be dose dependent, and can be induced even by a >3 week old leukoreduced red blood cell concentrate with a very low leukocyte content.

[Perioperative transfusion in colorectal surgery]

Several studies have evaluated the role and effect of blood transfusion in colorectal surgery. To date, no recommendation concerning its use in colorectal surgery has been yet published. However, blood transfusion is often required in colorectal surgery, especially in anaemic patients who suffer from malignant disease. The aim of this review is to define the effect of blood transfusion on oncologic and operative results, and to evaluate the clinical potential of alternative to allogeneic blood transfusion in order to promote the development of transfusion policy in colorectal surgery.

Prognostic parameters of Crohn's disease recurrence

Patients with Crohn's disease are haunted by the likelihood of recurrence following resection of their disease. In an effort to better counsel patients about their relative risk, many centres have evaluated a myriad of factors thought to be harbingers of recurrence. Insightful review of the numerous studies requires consideration of the definition of recurrence, length and manner of follow-up, and statistical tools used for analysis of the data. Factors that may possibly influence recurrence include: age of disease onset; gender; tobacco use; anatomical pattern of disease; clinical pattern of disease; extra-intestinal manifestations; duration of pre-operative symptoms; previous resections; operative indication; blood transfusion; extent of resection; faecal diversion; pathological features of resected bowel; and chemotherapy following resection. Unfortunately, the role that these factors play in disease recurrence remains poorly understood.

Transfusion-associated graft-versus-host disease: current concepts and future trends

Since the initial reports, in the early 1960s, of Transfusion-Associated Graft-versus-Host Disease (TA-GVHD) in infants with congenital immunodeficiency and individuals with various haematological malignancies, our knowledge of this rare but uniformly fatal consequence of transfusion has improved. Today, it is possible to define with greater certainty patients who are most at risk; the blood components capable of causing TA-GVHD; and the methods for preventing TA-GVHD. In the absence of effective treatment for TA-GVHD, attention is currently focused on potential preventative measures, in particular using u.v.- or gamma-irradiated blood components. This overview deals with some general aspects of the current concepts and future trends in treatment of TA-GVHD.