The impact of blood transfusion on perioperative outcomes following gastric cancer resection: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database

Risk factors for pneumonia after radical gastrectomy for gastric cancer: a systematic review and meta-analysis

OBJECTIVE

The objective is to systematically gather relevant research to determine and quantify the risk factors and pooled prevalence for pneumonia after a radical gastrectomy for gastric cancer.

METHODS

The reporting procedures of this meta-analysis conformed to the PRISMA 2020. Chinese Wan Fang data, Chinese National Knowledge Infrastructure (CNKI), Chinese Periodical Full-text Database (VIP), Embase, Scopus, CINAHL, Ovid MEDLINE, PubMed, Web of Science, and Cochrane Library from inception to January 20, 2024, were systematically searched for cohort or case-control studies that reported particular risk factors for pneumonia after radical gastrectomy for gastric cancer. The pooled prevalence of pneumonia was estimated alongside risk factor analysis. The quality was assessed using the Newcastle-Ottawa Scale after the chosen studies had been screened and the data retrieved. RevMan 5.4 and R 4.4.2 were the program used to perform the meta-analysis.

RESULTS

Our study included data from 20,840 individuals across 27 trials. The pooled prevalence of postoperative pneumonia was 11.0% (95% CI = 8.0% ~ 15.0%). Fifteen risk factors were statistically significant, according to pooled analyses. Several factors were identified to be strong risk factors, including smoking history (OR 2.71, 95% CI = 2.09 ~ 3.50, I2 = 26%), prolonged postoperative nasogastric tube retention (OR 2.25, 95% CI = 1.36-3.72, I2 = 63%), intraoperative bleeding ≥ 200 ml (OR 2.21, 95% CI = 1.15-4.24, I2 = 79%), diabetes mellitus (OR 4.58, 95% CI = 1.84-11.38, I2 = 96%), male gender (OR 3.56, 95% CI = 1.50-8.42, I2 = 0%), total gastrectomy (OR 2.59, 95% CI = 1.83-3.66, I2 = 0%), COPD (OR 4.72, 95% CI = 3.80-5.86, I2 = 0%), impaired respiratory function (OR 2.72, 95% CI = 1.58-4.69, I2 = 92%), D2 lymphadenectomy (OR 4.14, 95% CI = 2.29-7.49, I2 = 0%), perioperative blood transfusion (OR 4.21, 95% CI = 2.51-7.06, I2 = 90%), and hypertension (OR 2.21, 95% CI = 1.29-3.79, I2 = 0%). Moderate risk factors included excessive surgery duration (OR 1.51, 95% CI = 1.25-1.83, I2 = 90%), advanced age (OR 1.91, 95% CI = 1.42-2.58, I2 = 94%), nutritional status (OR 2.62, 95% CI = 1.55-4.44, I2 = 71%), and history of pulmonary disease (OR 1.61, 95% CI = 1.17-2.21, I2 = 79%).

CONCLUSIONS

This study identified 15 independent risk factors significantly associated with pneumonia after radical gastrectomy for gastric cancer, with a pooled prevalence of 11.0%. These findings emphasize the importance of targeted preventive strategies, including preoperative smoking cessation, nutritional interventions, blood glucose and blood pressure control, perioperative respiratory training, minimizing nasogastric tube retention time, and optimizing perioperative blood transfusion strategies. For high-risk patients, such as the elderly, those undergoing prolonged surgeries, experiencing excessive intraoperative blood loss, undergoing total gastrectomy, or receiving open surgery, close postoperative monitoring is essential. Early recognition of pneumonia signs and timely intervention can improve patient outcomes and reduce complications.

Perioperative blood transfusions associated with reduced survival in gastroesophageal cancers - A Swedish population-based study

BACKGROUND

Blood transfusion has been associated with decreased long-term survival in cancer patients, possibly due to various immunological factors. We aimed to evaluate if perioperative transfusions decrease survival in patients who undergo resection for esophageal or gastric cancer and to identify factors associated with such events.

METHODS

A population-based cohort study was conducted based on the Swedish National Registry for Esophageal and Gastric Cancer, which prospectively collects clinical data of patients with these tumors. Almost all patients (96 %) resected for esophageal or gastric cancer in Sweden between 2017 and 2022 were included. Survival data were acquired from the Swedish Cause of Death Registry. Multivariable Cox regression was used to calculate hazard ratios (HR) with 95 % confidence intervals (CI), adjusted for age, fitness, neoadjuvant therapy, surgical access, and pathological TNM stage.

RESULTS

Of all 1365 patients, 227 (17 %) received perioperative transfusions. Transfusion was associated with an increased risk of all-cause mortality within 3 years of surgery (adjusted HR 1.50, 95 % CI 1.17-1.91). To exclude the influence of surgery-related postoperative complications, a sensitivity analysis was performed excluding patients who died within 30 days of resection and the negative impact of transfusions on 3-year mortality remained (adjusted HR 1.30, 95 % CI 1.01-1.68). Increasing age, open surgery, esophagectomy, perioperative bleeding, and nodal tumor involvement were all associated with an increased likelihood of receiving transfusions.

CONCLUSION

Perioperative blood transfusions might have a negative impact on 3-year survival in patients who undergo surgery for esophageal or gastric cancer.

Blood transfusion might not be recommended for gastric cancer patients with pretransfusion minimum hemoglobin values higher than 90 g/l: a real-world study covering 20 years of 13 470 patients

BACKGROUND

There was no consistent evidence of whether perioperative blood transfusion (PBT) affects the long-term survival of gastric cancer (GC) patients after undergoing gastrectomy. This study aimed to investigate the effects of PBT on the long-term survival of GC patients, as well as to determine the threshold of PBT and provide evidence for future surgical practice.

METHODS

We performed this real-world study of GC patients undergoing gastrectomy at China National Cancer Center from January 1, 2000 to December 30, 2019. Overall survival (OS) curves were plotted using the Kaplan-Meier method and compared statistically using the log-rank test. Univariate and multivariate Cox proportional hazard models were used to determine the risk factors for OS.

RESULTS

In total, 13 470 GC patients undergoing gastrectomy from 2000 to 2019 were included, of whom 3465 (34.6%) GC patients received PBT. PBT ratios declined from 29.1% (114/392) in 2000 to 11.2% in 2019 (149/1178), with the highest blood transfusion ratio in 2005 at 43.7% (220/504). For patients transfused with red blood cells, the median value of hemoglobin (Hb) before transfusion in the PBT group decreased from 110 g/l in 2000 to 87 g/l in 2019. Compared with patients who not receiving PBT, PBT group are more likely to be older (≥65, 39.1% vs. 30.1%, P <0.001), open operation (89.7% vs. 78.1%, P <0.001), higher American Society of Anesthesiologists score (>2, 25.3% vs. 14.9%, P <0.001) and in the later pTNM stage (pTNM stage III, 68.5% vs. 51.5%, P <0.001). Results of multivariable Cox regression analysis showed that PBT was an independent prognostic factor for worse OS in GC patients undergoing gastrectomy [HR=1.106, 95% confidence interval (CI): 1.01-1.211, P =0.03). After stratified according to tumor stage, we found that PBT group had a worse prognosis only in pTNM stage III (HR=1.197, 95% CI: 1.119-1.281, P <0.001). OS was obviously poor in the PBT group when Hb levels were higher than 90 g/l (90 g/l120 g/l: HR=1.207, 95% CI: 1.098-1.327, P <0.001), while there was no difference between the two groups when Hb levels were lower than or equal to 90 g/l (Hb≤90 g/l: HR=1.162, 95% CI: 0.985-1.370, P =0.075).

CONCLUSION

In conclusion, PBT was an independent prognostic factor for worse OS. Blood transfusion might not be recommended for GC patients with perioperative minimum Hb values higher than 90 g/l.

The Use of Bone Wax in Hemostatic Control for Total Knee and Hip Arthroplasties: A Systematic Review

Background/Objectives: Blood loss can be a serious complication in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Various methods are used by surgeons to achieve hemostatic control in these patients. Complications are associated with perioperative blood loss. In this systematic review, we examined the efficacy of using bone wax to control bleeding in patients undergoing THA and TKA. Methods: The PRISMA model was used to systematically identify and aggregate articles for this study. The PubMed and EMBASE databases were used to search individual studies that examined the use of bone wax in THA or TKA. After applying the search term "bone wax", 2478 articles were initially identified. After inclusion and exclusion criteria were applied, three articles were aggregated for this systematic review. Results: The use of bone wax in THA and TKA decreased blood loss in patients undergoing these operations. Postoperative blood loss following surgery was lower in the bone wax groups compared to the control groups as well. Patients in the bone wax groups also required fewer blood transfusions than those who did not receive bone wax. Conclusions: Bone wax appears to be another modality that can be used by physicians to maintain hemostatic control in THA or TKA patients. Reduced blood loss and transfusion rates in surgery can increase patient outcomes. More studies are needed to examine the efficacy of bone wax in comparison with other hemostatic tools.

Effect of perioperative blood transfusion on complications and prognosis after radical gastrectomy in elderly patients: a retrospective study of 1,666 cases

Background

Multiple studies have examined the effect of perioperative blood transfusion (BTF) on postoperative complications and the prognosis of gastric cancer patients, but the conclusions remain controversial, and few studies related to elderly patients are present. This study sought to examine the effect of perioperative BTF on postoperative complications and the prognosis of elderly patients who underwent radical gastrectomy.

Methods

The clinical data of 1,666 elderly patients (aged ≥60 years) at Xijing Hospital from October 2013 to October 2021 were retrospectively analyzed. The patients were stratified into the perioperative BTF group and the perioperative non-BTF group. The clinicopathological characteristics, postoperative complications, and long-term prognoses of the patients were compared.

Results

There were significant differences in terms of sex, tumor location, tumor size, gastrectomy range, tumor differentiation, T stage, N stage, tumor-node-metastasis (TNM) stage, preoperative anemia, and intraoperative blood loss between the two groups (P<0.05). The incidence of postoperative fever in the BTF group was significantly higher than that in the non-BTF group (31.6% vs. 15.4%, P<0.001), but there were no significant differences in the other complications between the two groups (P>0.05). The survival analysis showed that in stage III patients, the prognosis of the BTF group was inferior to that of the non-BTF group [the 3-year overall survival (OS) rates of the groups were 33.7% vs. 47.9% respectively, P<0.001], while there was no significant difference between the two groups among the stage I and stage II patients (P>0.05). There was no significant difference in the prognosis of patients with different transfusion times (preoperative/intraoperative/postoperative) (P>0.05). The multivariate analysis indicated that perioperative BTF was not an independent risk factor for prognosis in elderly patients with gastric cancer overall or elderly patients with gastric cancer in stage III (P>0.05).

Conclusions

Perioperative BTF may elevate the incidence of fever but has no significant effect on other complications in elderly patients after radical gastrectomy. Perioperative BTF is not an independent risk factor affecting the postoperative prognosis of elderly patients with gastric cancer.

Outcomes following perioperative red blood cell transfusion in patients undergoing elective major abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Perioperative red blood cell transfusion is a double-edged sword for surgical patients. While transfusion of red cells can increase oxygen delivery by increasing haemoglobin levels, its impact on short- and long-term postoperative outcomes, particularly in patients undergoing elective major abdominal surgery, is unclear.

METHODS

We conducted a systematic review and meta-analysis on the effect of perioperative blood transfusions on postoperative outcomes in elective major abdominal surgery. PubMed, Cochrane, and Scopus databases were searched for studies with data collected between January 1, 2000 and June 6, 2020. The primary outcome was short-term mortality, including all-cause 30-day or in-hospital mortality. Secondary outcomes included long-term all-cause mortality, any morbidity, infectious complications, overall survival, and recurrence-free survival. No randomised controlled trials were found. Thirty-nine observational studies were identified, of which 37 were included in the meta-analysis.

RESULTS

Perioperative blood transfusion was associated with short-term all-cause mortality (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.89-3.91, P<0.001), long-term all-cause mortality (hazard ratio 1.35, 95% CI 1.09-1.67, P=0.007), any morbidity (OR 2.18, 95% CI 1.81-2.64, P<0.001), and infectious complications (OR 1.90, 95% CI 1.60-2.26, P<0.001). Perioperative blood transfusion remained associated with short-term mortality in the sensitivity analysis after excluding studies that did not control for preoperative anaemia (OR 2.27, 95% CI 1.59-3.24, P<0.001).

CONCLUSIONS

Perioperative blood transfusion in patients undergoing elective major abdominal surgery is associated with poorer short- and long-term postoperative outcomes. This highlights the need to implement patient blood management strategies to manage and preserve the patient's own blood and reduce the need for red blood cell transfusion.

TRIAL REGISTRATION

PROSPERO (CRD42021254360).

Nomogram for predicting early complications after distal gastrectomy

BACKGROUND

Reducing or preventing postoperative morbidity in patients with gastric cancer (GC) is particularly important in perioperative treatment plans.

AIM

To identify risk factors for early postoperative complications of GC post-distal gastrectomy and to establish a nomogram prediction model.

METHODS

This retrospective study included 131 patients with GC who underwent distal gastrectomy at the Second Hospital of Shandong University between January 2019 and February 2023. The factors influencing the development of complications after distal gastrectomy in these patients were evaluated using univariate and multivariate logistic regression analysis. Based on the results obtained, a predictive nomogram was established. The nomogram was validated using internal and external (n = 45) datasets. Its sensitivity and specificity were established by receiver operating characteristic curve analysis. Decision curve (DCA) analysis was used to determine its clinical benefit and ten-fold overfitting was used to establish its accuracy and stability.

RESULTS

Multivariate logistic regression analysis showed that hypertension, diabetes, history of abdominal surgery, and perioperative blood transfusion were independent predictors of postoperative complications of distal gastrectomy. The modeling and validation sets showed that the area under the curve was 0.843 [95% confidence interval (CI): 0.746-0.940] and 0.877 (95%CI: 0.719-1.000), the sensitivity was 0.762 and 0.778, respectively, and the specificity was 0.809 and 0.944, respectively, indicating that the model had good sensitivity and specificity. The C-indexes of the modeling and validation datasets were 0.843 (95%CI: 0.746-0.940) and 0.877 (95%CI: 0.719-1.000), respectively. The calibration curve (Hosmer Lemeshow test: χ2 = 7.33) showed that the model had good consistency. The results of the DCA analysis indicated that this model offered good clinical benefits. The accuracy of 10-fold cross-validation was 0.878, indicating that the model had good accuracy and stability.

CONCLUSION

The nomogram prediction model based on independent risk factors related to postoperative complications of distal gastrectomy can facilitate perioperative intervention for high-risk populations and reduce the incidence of postoperative complications.

Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture

INTRODUCTION

Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance.

METHODS

The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded.

RESULTS

Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up.

DISCUSSION

Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.

Risk factors for blood transfusion and its prognostic implications in curative gastrectomy for gastric cancer

BACKGROUND

Gastric cancer (GC) is still a prevalent neoplasm around the world and its main treatment modality is surgical resection. The need for perioperative blood transfusions is frequent, and there is a long-lasting debate regarding its impact on survival.

AIM

To evaluate the factors related to the risk of receiving red blood cell (RBC) transfusion and its influence on surgical and survival outcomes of patients with GC.

METHODS

Patients who underwent curative resection for primary gastric adenocarcinoma at our Institute between 2009 and 2021 were retrospectively evaluated. Clinicopathological and surgical characteristics data were collected. The patients were divided into transfusion and non-transfusion groups for analysis.

RESULTS

A total of 718 patients were included, and 189 (26.3%) patients received perioperative RBC transfusion (23 intraoperatively, 133 postoperatively, and 33 in both periods). Patients in the RBC transfusions group were older (P < 0.001), and had more comorbidities (P = 0.014), American Society of Anesthesiologists classification III/IV (P < 0.001), and lower preoperative hemoglobin (P < 0.001) and albumin levels (P < 0.001). Larger tumors (P < 0.001) and advanced tumor node metastasis stage (P < 0.001) were also associated with the RBC transfusion group. The rates of postoperative complications (POC) and 30-d and 90-d mortality were significantly higher in the RBC transfusion group than in the non-transfusion group. Lower hemoglobin and albumin levels, total gastrectomy, open surgery, and the occurrence of POC were factors associated with the RBC transfusion. Survival analysis demonstrated that the RBC transfusions group had worse disease-free survival (DFS) and overall survival (OS) compared with patients who did not receive transfusion (P < 0.001 for both). In multivariate analysis, RBC transfusion, major POC, pT3/T4 category, pN+, D1 lymphadenectomy, and total gastrectomy were independent risk factors related to worse DFS and OS.

CONCLUSION

Perioperative RBC transfusion is associated with worse clinical conditions and more advanced tumors. Further, it is an independent factor related to worse survival in the curative intent gastrectomy setting.

Effects of perioperative blood transfusion in gastric cancer patients undergoing gastrectomy: A systematic review and meta-analysis

Background

The short-term and long-term effects of perioperative blood transfusion (PBT) on patients with gastric cancer are still intriguing. This systematic review and meta-analysis aimed to investigate the effects of blood transfusion on clinical outcomes in patients with gastric cancer undergoing gastrectomy.

Methods

We searched PubMed, Web of Science, Embase, and The Cochrane Library on December 31th 2021. The main outcomes were overall survival (OS), disease-free survival (DFS), disease-specific survival (DFS), and postoperative complications. A fixed or random-effects model was used to calculate the hazard ratio (HR) with 95% confidence intervals (CIs).

Results

Fifty-one studies with a total of 41,864 patients were included for this review and meta-analysis. Compared with patients who did not receive blood transfusions (NPBT), PBT was associated with worse 5-year OS (HR = 2.39 [95%CI: 2.00, 2.84]; p < 0.001; Multivariate HR = 1.43 [95%CI: 1.24, 1.63]; p < 0. 001), worse 5-year DFS (HR = 2.26 [95%CI: 1.68, 3.05]; p < 0.001; Multivariate HR = 1.45 [95%CI: 1.16, 1.82]; p < 0. 001), and worse 5-year DSS (HR = 2. 23 [95%CI: 1.35, 3.70]; p < 0.001; Multivariate HR = 1.24 [95%CI: 0.96, 1.60]; p < 0.001). Moreover, The PBT group showed a higher incidence of postoperative complications [OR = 2.30 (95%CI:1.78, 2. 97); p < 0.001] than that in the NPBT group, especially grade III-V complications, according to the Clavien-Dindo classification. [OR = 2.50 (95%CI:1.71, 3.63); p < 0.001].

Conclusion

In patients who underwent gastrectomy, PBT was associated with negative survival effects (OS, DFS, DSS) and a higher incidence of perioperative complications. However, more research was expected to further explore the impact of PBT. Meanwhile, strict blood transfusion management should be implemented to minimize the use of PBT.

Factors Associated with Rebound Pain After Patient-controlled Epidural Analgesia in Patients Undergoing Major Abdominal Surgery: A Retrospective Study

OBJECTIVES

Although patient-controlled epidural analgesia (PCEA) is an effective form of regional analgesia for abdominal surgery, some patients experience significant rebound pain after the discontinuation of PCEA. However, risk factors for rebound pain associated with PCEA in major abdominal surgery remain unknown. This study evaluated the incidence of rebound pain related to PCEA and explored potential associated risk factors.

METHODS

We performed a retrospective review of 236 patients using PCEA following hepatobiliary and pancreas surgery between 2018 and 2020 in a tertiary hospital in South Korea. Rebound pain was defined as an increase from well-controlled pain (numeric rating scale <4) during epidural analgesia to severe pain (numeric rating scale ≥7) within 24 hours of discontinuation of PCEA. Logistic regression analysis was performed to determine the factors associated with rebound pain.

RESULTS

A total of 236 patients were included in this study. Patients were categorized into the non-rebound pain group (170 patients; 72%) and the rebound pain group (66 patients; 28%). Multivariable logistic regression analysis revealed that preoperative prognostic nutritional index (PNI) below 45 (odds ratio [OR]=2.080, 95% confidential interval [CI]=1.061-4.079, P=0.033) and intraoperative transfusion (OR=4.190, 95% CI=1.436-12.226, P=0.009) were independently associated with rebound pain after PCEA discontinuation.

DISCUSSION

Rebound pain after PCEA occurred in approximately 30% of patients who underwent major abdominal surgery, resulting in insufficient postoperative pain management. Preoperative low PNI and intraoperative transfusion may be associated with rebound pain after PCEA discontinuation.

Quality performance indicators for the surgical treatment of gastric adenocarcinoma: a systematic review

Background

A systematic review was undertaken to identify existing quality performance indicators (QPI) for the surgical treatment of gastric adenocarcinoma (GA) with the aim of defining a set of QPIs that can be used to assist in the accreditation of institutions for training, allow cross jurisdiction comparison of treatment and outcomes, as well as provide a basis to develop quality improvement programs. These QPI's capture key components of patient care that are fundamental to overall outcome.

Methods

A systematic literature review was conducted searching MEDLINE, PubMed, EMBASE, and SCOPUS with all literature available until the date of 1 August 2021 included. Search terms utilized were ‘Quality of health care OR Quality improvement or Quality control OR Quality indicators’, AND ‘Gastrectomy’ OR ‘Stomach neoplasm’ OR ‘Adenocarcinoma’ OR ‘Gastric resection’ OR ‘Gastric cancer’.

Results

Twelve articles were included in the final analysis. The selected studies included editorials (n = 2), retrospective review of institutional experience (n = 5), cohort studies (n = 2), survey methodology (n = 1), expert guidelines (n = 1) and consensus statement (n = 1). For GC QPIs, process measures included patient discussion at multi‐disciplinary meetings, access to perioperative multimodal diagnostic pathways, and specific surgical metrics (margin negative resections and adequate lymphadenectomy). Outcome measures included the RO resection rate, reoperation, readmission rate, and length of hospital stay.

Conclusions

There is a relative paucity of internationally agreed QPI for the surgical management of gastric adenocarcinoma. The data from this review will form the basis of a project to develop internationally agreed and feasible QPI for gastric cancer resections.

Hemoglobin matters: Perioperative blood management for oncology patients

As the number of cancer cases rise each year in Canada, so does the number of surgical oncology cases. Surgery presents a unique and heightened stressor for the body already experiencing volatility from factors such as disease and treatments. Perioperative red blood cell (RBC) transfusions are critical to stabilize hemoglobin levels and correct anemia, as well as provide a buffer against anticipated intraoperative blood loss. Thoroughly examining and anticipating risk factors related to the potential need for perioperative blood transfusions is necessary to improve outcomes. Research evidence in recent years related to perioperative blood management of oncology patients has specifically recommended active, coordinated programs to reduce the need and amount of blood transfusions administered pre-, intra-, and post-surgery. Coordination between surgical oncologists and a local or provincial patient blood management (PBM) program is an important strategy that allows patients at risk of perioperative complications to be identified and receive early interventions and ongoing observation.

L’importance de l’hémoglobine : gestion périopératoire du sang pour les patients en oncologie

Au Canada, le nombre de cas de cancer augmente chaque année et, par conséquent, le nombre de patients en oncologie qui subissent une opération. La chirurgie cause un stress particulièrement intense à l’organisme déjà fragilisé par la maladie et les traitements. Les transfusions périopératoires de globules rouges sont essentielles pour stabiliser le taux d’hémoglobine et soigner l’anémie, ainsi que pour gérer la perte de sang attendue pendant l’opération. Il est nécessaire d’examiner en profondeur et d’anticiper les facteurs de risque associés aux transfusions sanguines périopératoires pour améliorer le devenir des patients. Ces dernières années, la recherche sur la gestion périopératoire du sang des patients en oncologie recommande tout spécialement la création de programmes d’intervention coordonnés pour réduire la nécessité et le nombre de transfusions sanguines administrées avant, pendant et après l’opération. Pour recenser les patients à risque de complications périopératoires et leur faire bénéficier d’interventions rapides et d’une observation continue, la bonne stratégie est de mettre en lien les chirurgiens oncologues avec un programme local ou provincial de conservation du sang.

The Associations between Perioperative Blood Transfusion and Long-Term Outcomes after Stomach Cancer Surgery

Simple Summary

Stomach cancer is a common malignancy and one of the leading causes of cancer death in Taiwan. Although tumor characteristics are the main determinants of oncological outcomes, modulation of the immune system may also play some role in cancer progression. Despite the hypothesis that perioperative blood transfusion may suppress the immune reactivity and promote tumor recurrence, the role of perioperative transfusion in the prognosis of stomach cancer remains controversial. To fill this gap, we designed this retrospective study using sound analytical approaches to investigate the impact of perioperative transfusion on oncologic outcomes after curative resection for stomach cancer. We demonstrated that perioperative transfusion was associated with inferior disease-free and overall survival after stomach cancer surgery and a dose-response relationship was also noted between the amount of transfusion and risk of cancer recurrence or mortality.

Abstract

Background: Whether perioperative packed red blood cell (pRBC) transfusion is associated with inferior long-term outcomes after stomach cancer surgery remains controversial. Methods: This research used a retrospective cohort study. Patients with stage I~III stomach cancer undergoing tumor resection were collected at a tertiary medical center. Patient characteristics, surgical features and pathologic findings were gathered from an electronic medical chart review. The associations of perioperative pRBC transfusion with postoperative disease-free and overall survivals were evaluated using Cox regression analysis with an inverse probability of treatment weighting (IPTW). Restricted cubic spline functions were employed to characterize dose-response relationships between the amount of transfusion and cancer outcomes after surgery. Results: Among the 569 patients, 160 (28.1%) received perioperative pRBC transfusion. Perioperative transfusion was associated with worse disease-free survival (IPTW adjusted HR: 1.42, 95% CI: 1.18–1.71, p < 0.001) and overall survival (IPTW adjusted HR: 1.27, 95% CI: 1.05–1.55, p = 0.014). A non-linear dose-response relationship was noted between the amount of transfusions and worse disease-free or overall survival. Conclusions: Perioperative pRBC transfusion was associated with worse disease-free and overall survival after stomach cancer surgery, and strategies aiming to minimize perioperative transfusion exposure should be further considered to reduce the potential risk.

Impact of Perioperative Blood Transfusions on Outcomes After Hyperthermic Intraperitoneal Chemotherapy: A Propensity-Matched Analysis

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major operation frequently necessitating red blood cell transfusion. Using multi-institutional data from the U.S. HIPEC Collaborative, this study sought to determine the association of perioperative allogenic blood transfusion (PABT) with perioperative outcomes after CRS/HIPEC.

METHODS

This retrospective cohort study analyzed patients who underwent CRS/HIPEC for peritoneal surface malignancy between 2000 and 2017. Propensity score-matching was performed to mitigate bias. Univariate analysis was used to compare demographic, preoperative, intraoperative, and postoperative variables. Factors independently associated with PABT were identified using multivariate analysis.

RESULTS

The inclusion criteria were met by 1717 patients, 510 (29.7%) of whom required PABT. The mean Peritoneal Cancer Index (PCI) of our cohort was 14.8 ± 9.3. Propensity score-matching showed an independent association between PABT and postoperative risk of pleural effusion, hemorrhage, pulmonary embolism, enteric fistula formation, Clavien-Dindo grades 3 and 4 morbidity, longer hospital stay, and reoperation (all P < 0.05 in the multivariate analysis). Compared with the patients who received 1 to 5 red blood cell (RBC) units, the patients who received more than 5 units had a greater risk of renal impairment, a longer intensive care unit (ICU) stay, and more postoperative infections. Finally, PABT was an independent predictor of worse survival for patients with appendiceal and colorectal primaries.

CONCLUSION

Even low levels of PABT for patients undergoing CRS/HIPEC are independently associated with a greater risk of infectious and non-infectious postoperative complications, and this risk is increased for patients receiving more than 5 RBC units. Worse survival was independently predicted by PABT for patients with peritoneal carcinomatosis of an appendiceal or colorectal origin.

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.

Association Among Blood Transfusion, Postoperative Infectious Complications, and Cancer-Specific Survival in Patients with Stage II/III Gastric Cancer After Radical Gastrectomy: Emphasizing Benefit from Adjuvant Chemotherapy

OBJECTIVES

This study was designed to investigate the potential additive influence of perioperative blood transfusion (BTF) and postoperative infections on cancer-specific survival (CSS) in patients with stage II/III gastric cancer (GC) after radical gastrectomy.

METHODS

The medical records of 2114 consecutive stage II/III GC patients who underwent curative resection and planned to receive adjuvant chemotherapy (AC) were retrospectively reviewed. The independent predictive factors for infections were identified using univariate and multivariate analyses. Cox regression analysis was used to assess any associations between BTF, infection and CSS.

RESULTS

A total of 507 (24.0%) received perioperative BTF and 148 (7.0%) developed infections with BTF being identified as an independent predictor for infections. Both BTF and infections independently predicted poor CSS (hazard ratio [HR]: 1.193, 95% confidence interval [CI] 1.007-1.414; HR 1.323, 95% CI 1.013-1.727) and an additive effect was confirmed as patients who had both BTF and infection had even worse CSS. Further stratified analyses showed that complete AC (≥ 6 cycles) could significantly improve CSS in patients who had BTF and/or infection, which was comparable to those without BTF and/or infection (P = 0.496).

CONCLUSIONS

Infection was the most common complication after gastrectomy and BTF was identified as an independent risk factor. BTF was associated with shorter CSS in stages II/III GC, independent of infections, and receiving BTF and developing infections had an additive effect that was associated with even worse CSS. However, complete AC could significantly improve CSS in these patients. Thus, strategies designed to ensure the completion of AC, such as neoadjuvant chemotherapy, should be further investigated.

Association of perioperative red blood cell transfusions with all-cause and cancer-specific death in patients undergoing surgery for gastrointestinal cancer: Long-term outcomes from a population-based cohort

BACKGROUND

Red blood cell transfusions are common in patients undergoing gastrointestinal cancer surgery. Yet, to adequately balance their risks and benefits, clinicians must understand how transfusions may affect long-term outcomes. We aimed to determine if perioperative red blood cell transfusions are associated with a higher risk of all-cause and cancer-specific death among patients who underwent gastrointestinal cancer resection.

METHOD

We identified a population-based cohort of patients who underwent gastrointestinal cancer resection in Ontario, Canada (2007-2019). All-cause death was compared between transfused and nontransfused patients using Cox proportional hazards regression, while cancer-specific death was compared with competing risk regression.

RESULT

A total of 74,962 patients (mean age, 67.7 years; 55.4% male; 79.7% colorectal cancer) had gastrointestinal cancer surgery during the study period; 20.8% received perioperative red blood cell transfusions. Patients who received red blood cell transfusions had increased hazards of all-cause and cancer-specific death relative to patients who did not (hazard ratio: 1.39, 95% confidence interval 1.34-1.44; cause-specific hazard ratio: 1.36, 1.30-1.43). The adjusted risk of all-cause death was higher in early follow-up intervals (3-6 months postoperatively) but remained elevated in each interval over 5 years. The association persisted after restricting to patients without postoperative complications or bleeding and was robust to unmeasured confounding.

CONCLUSION

Red blood cell transfusion among patients with gastrointestinal cancer is associated with increased all-cause death. This was observed long beyond the immediate postoperative period and independent of short-term postoperative morbidity and mortality. These findings should help clinicians balance the risks and benefits of transfusion before well-designed trials are conducted in this patient population.

Are Type and Screen Samples Routinely Necessary Before Laparoscopic Cholecystectomy?

AIMS

Type and screen (T&S) samples are routinely requested before all laparoscopic cholecystectomies (LCs) at our centre despite the low reported risk of major vascular injury and peri-operative transfusion. Our retrospective case series aimed to identify local transfusion need to inform policy.

METHODS

Emergency and elective LC performed at a single tertiary centre between March 2014 and October 2016 (30 months) were analysed. This included all patients aged ≥ 16, and procedures converted to open where LC was the primary procedure. Peri-operative complications and transfusion data were obtained from electronic records.

RESULTS

In total, 1002 consecutive patients met inclusion criteria; 12 patients were transfused during index admission (1.20%). No patients required emergency transfusion or had major vascular injuries. Despite local policy, 106 patients (10.6%) did not have a valid T&S sample prior to their procedure. Transfused patients were more likely to be emergency admissions (n = 10/12). The most common indications for transfusion were pre-operative anaemia (n = 7/12) and septic coagulopathy (n = 2/12).

CONCLUSIONS

Peri-operative transfusions at our centre were low. No patients required intra-operative blood transfusions dependent on a pre-operative T&S sample. Patients requiring transfusion were predictable from their pre-operative clinical status. We propose that a highly selective T&S policy is safe and can reduce costs.

Fluid management: An update for perioperative practitioners

An interprofessional team approach is required to achieve optimum fluid balance for patients during the perioperative period. Incorrect management of fluid assessment and monitoring is associated with adverse outcomes. The scientific understanding of perioperative fluid balance has improved over recent years leading to changes in clinical practice with regard to volume and choice of intravenous fluid. It is important that perioperative practitioners have an understanding of intravenous fluid, fluid compartmentalisation, fluid mechanics and intravascular fluid control mechanisms. Optimum fluid status not only shortens hospital stay but also reduces the incidence of postoperative nausea and vomiting and complication profiles. This article aims to provide perioperative practitioners with a comprehensive overview of fluid management. It will cover important issues surrounding physiological control of fluid balance, choice of intravenous fluid therapy, methods to monitor intravascular volume and factors which influence delivery.

Improved postoperative outcomes and reduced transfusion rates after implementation of a Patient Blood Management program in gastric cancer surgery

INTRODUCTION

Gastric cancer patients are often transfused with red blood cells, with negative impact on postoperative course. This multicenter prospective interventional cohort study aimed to determine whether implementation of a Patient Blood Management (PBM) program, was associated with a decrease in transfusion rate and improvements in clinical outcomes in gastric cancer surgery.

METHODS

We compared transfusion practices and clinical outcomes in patients undergoing elective gastric cancer resection before and after implementing a PBM program, including strategies to detect and treat anemia and restrictive transfusion practice (2014-2018). Primary outcome was transfusion rate (TR). Secondary outcomes were complications, reoperations, length of stay, readmissions, 90-day mortality and failure-to-rescue. Differences were adjusted by confounding factors.

RESULTS

Some 789 patients were included (496 pre- and 293 post-PBM). TR decreased from 39.1% to 27.0% (adjusted difference -9.1, 95% CI -15.2 to -2.9), being reduction particularly significant in patients with anemia, ASA score 3-4, locally advanced tumors, undergoing open surgery and total gastrectomy. Infectious complications diminished from 25% to 16.4% (-6.1, 95%CI -11.5 to -0.7), reoperations from 8.1% to 6.1% (-2.2, 95%CI -5.1 to +0.6), median length of stay from 11 [IQR 8-18] to 8 [7-12] days (p < 0.001), hospital readmission from 14.1% to 8.9% (-5.4, 95%CI -9.6 to -1.1), mortality from 7.9% to 4.8% (-2.4, 95%CI -4.7 to -0.01), and failure-to rescue from 62.7% to 32.7% (-23.1, 95%CI -37.7 to -8.5).

CONCLUSION

Implementation of a PBM program was associated with a reduction in transfusion rate and improvement in postoperative outcomes in gastric cancer patients undergoing curative resection.

Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

BACKGROUND

Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published over the past 10 years supports restrictive transfusion practices and blood conservation programs. Whether transfusion practices have changed remains unclear. We describe temporal RBC transfusion trends in a large North American population who underwent gastrointestinal cancer surgery.

METHODS

We conducted a population-based retrospective cohort study of patients who underwent gastrointestinal cancer resection between 2007 and 2018 using health administrative datasets. The outcome was RBC transfusion during hospitalization. Temporal transfusion trends were analyzed with Cochran-Armitage tests. Multivariable regression assessed the association between year of diagnosis and likelihood of RBC transfusion while controlling for confounding.

RESULTS

Of 79,764 patients undergoing gastrointestinal cancer resection, the median age was 69 years old (interquartile range (IQR) 60-78 years) and 55.5% were male. The most frequent procedures were colectomy (52.8%) and proctectomy (23.0%). A total of 18,175 patients (23%) received RBC transfusion. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p < 0.001). After adjusting for patient, procedure, and hospital factors, the most recent time period (2015-2018) was associated with a reduced likelihood of receiving RBC transfusion [relative risk 0.86 (95% confidence interval: 0.83-0.89)] relative to the intermediate time period (2011-2014).

CONCLUSION

Over 11 years, we observed decreased RBC transfusion use and reduced likelihood of transfusion in patients undergoing gastrointestinal cancer resection. This information provides a foundation to further examine transfusion appropriateness or explore if additional transfusion minimization in surgical patients can be achieved.

Rates, Risk Factors, and Complications of Red Blood Cell Transfusion in Metastatic Spinal Tumor Surgery: An Analysis of a Prospective Multicenter Surgical Database

OBJECTIVE

To identify rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery.

METHODS

The multicenter prospective American College of Surgeons National Quality Improvement Program database was queried for the years 2012-2016. Adult patients with disseminated cancer who underwent metastatic spinal tumor surgery were identified. Transfusion was defined as having received at least 1 intraoperative/postoperative RBC transfusion within the first 72 hours of surgery start time. A stepwise multiple logistic regression model with backward elimination was used.

RESULTS

Of 1601 patients identified, 623 patients (38.9%) received a RBC transfusion. Independent predictors of RBC transfusion included higher American Society of Anesthesiologists class (odds ratio [OR] = 1.54), preoperative anemia (OR = 3.10), instrumentation (OR = 1.63), and longer operative time (OR = 1.52). The overall complication rate was significantly higher in patients who received a transfusion compared with patients who did not receive a transfusion (22.3% vs. 15.0%, P < 0.001). Individual complications that were more common in patients who received a transfusion were sepsis (3.5% vs. 1.9%, P = 0.050), deep vein thrombosis (6.1% vs. 3.3%, P = 0.007), and prolonged ventilation (3.9% vs. 1.3%, P = 0.001). RBC transfusion (OR = 1.65), hypoalbuminemia (OR = 1.53), and anterior/anterolateral approaches for corpectomy (OR = 2.11) were independent risk factors for developing a postoperative complication.

CONCLUSIONS

RBC transfusion after metastatic spinal tumor surgery may increase the risk of early postoperative complications. Future research into preoperative patient optimization and decreasing intraoperative blood loss is needed.

Restrictive allogeneic blood transfusion strategy in patients with extremity bone sarcomas

Allogeneic blood transfusions (ABTs) are common in patients with cancer. The present study investigated the safety of a restrictive ABT strategy in patients with extremity sarcomas.Patients who underwent operations for extremity bone sarcomas between May 2008 and November 2018 were retrospectively reviewed. Clinical outcomes based on hemoglobin concentrations, postoperative infections, and hospital stay were compared between 20 patients who received liberal ABT (control group) and 19 patients who received restrictive ABT (restrictive group). The rates of distant metastasis and death were compared between the groups.The mean number of ABTs was 3.6 ± 3.8 units in the control group and 0.33 ± 0.74 units in the restrictive group (P < .001). Only 3 of 19 patients received transfusions (2 red cell packs each). The hemoglobin levels tended to fall during the first 3 postoperative days but seemed to stabilize within the first postoperative week in both groups. Postoperative surgical site infections only occurred in the patients who received ABTs regardless of the group. The rates of distant metastasis and death were higher in the control group than in the restrictive group (25.0% vs 15.7% and 10.0% vs 0%, respectively), but the differences were not significant.A restrictive ABT strategy may be safely performed in patients with extremity bone sarcomas depending on the intraoperative status and specific characteristics of each patient.

Risk Factors for Blood Transfusion with Neck Dissection

OBJECTIVES

To identify risk factors of perioperative blood transfusions (PBTs) for neck dissection and identify the association of PBTs with other postoperative outcomes.

METHODS

This is a retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The database was queried for neck dissection procedures performed by otolaryngologists from 2006 to 2014. Multivariable logistic regression was used to determine associations between demographic and preoperative factors, mortality, unplanned reoperation, and unplanned readmission with PBTs.

RESULTS

Of the 3090 patients included in our study, 346 (11.2%) received a PBT, 249 patients (72.0%) received blood intraoperatively or on postoperative day (POD) 0, and 97 patients (28.0%) received blood within 5 PODs. American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.2), preoperative weight loss (OR, 2.2; 95% CI, 1.5-3.2), and anemia (OR, 5.5; 95% CI, 4.1-7.6) were independently associated with PBTs. Free flaps were also significantly associated with PBTs. PBTs were significantly associated with unplanned return to the operating room within 30 days (OR, 4.31; 95% CI, 3.01-6.18) but not with 30-day unplanned readmission or 30-day mortality.

DISCUSSION

Eleven percent of patients undergoing neck dissection receive a PBT. Identifying associated risk factors may reduce PBT among patients with cancer. Comorbid data, such as weight loss, anemia, and ASA class, may be useful in determining risk for transfusion during these procedures.

IMPLICATIONS FOR PRACTICE

Awareness of preoperative risk factors for PBT may lead surgeons to reduce the risk of PBT, anticipate the need for transfusion, and manage these patients carefully to prevent unplanned reoperation.

Is surgical volume still the most accurate indicator of blood usage in the United States?

BACKGROUND

Estimates of blood collection and use in the United States derived from the National Blood Collection and Utilization Survey (NBCUS) call for application of robust statistical methods in the analysis of survey data. Since 1993, annual inpatient surgical volume has been used as the main stratification variable for sampling and estimation. However, recent NBCUS results have shown a decrease in blood use in surgical settings, raising the possibility that inpatient surgical volume may no longer be the optimal stratification variable. The objective of this study is to explore factors affecting hospital blood utilization.

STUDY DESIGN AND METHODS

A multivariate generalized linear regression with a negative binomial distribution was used to determine which hospital characteristics best explained allogeneic red blood cell (RBC) use, using data from the 2015 NBCUS to determine hospital blood use and the 2013 annual American Hospital Association database to identify hospital characteristics.

RESULTS

Annual inpatient surgical volume explained the most variation in allogeneic RBC use among hospitals (pseudo-R² of 70.8%). Additional variables, such as presence of an oncology service, were also statistically significant in the models but explained little additional variability in blood use.

CONCLUSION

These findings suggest that annual inpatient surgical volume is an appropriate indicator for estimating blood utilization in the United States. As trends in blood utilization continue to evolve, ongoing analytic efforts to understand indicators of blood use are necessary.

Gastric cancer surgery: clinical outcomes and prognosis are influenced by perioperative blood transfusions

Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient's clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a total or a subtotal gastrectomy accompanied by D2 lymphectomy for gastric cancer. The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87-5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87-5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70-10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73-83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.

Outcomes of Non-curative Gastrectomy for Gastric Cancer: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)

BACKGROUND

The surgical care of patients with metastatic gastric cancer (GC) remains debated. Despite level 1 evidence showing lack of survival benefit, surgery may be used for symptoms prevention or palliation. This study examined short-term postoperative outcomes of non-curative gastrectomy performed for metastatic GC.

METHODS

A multi-institutional retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, including gastrectomies for GC (2007-2015). The primary outcome was 30-day major morbidity. Multivariable analysis examined the association between metastatic status and outcomes adjusted for relevant demographic and clinical covariates.

RESULTS

Of 5341 patients, 377 (7.1%) had metastases. Major morbidity was more common with metastases (29.4 vs. 19.6%; p < 0.001), driven by a higher rate of respiratory events. Prolonged hospital length of stay (beyond the 75th percentile: 11 days) was more likely with metastases than with no metastases (41.9 vs. 28.3%; p < 0.001). After adjustment, metastatic status was associated with major morbidity (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.16-1.90). This association remained for respiratory events (OR, 1.58; 95% CI, 1.07-2.33), 30-day mortality (OR, 2.19; 95% CI, 1.38-3.48), and prolonged hospital stay (OR, 1.65; 95% CI, 1.31-2.07).

CONCLUSION

Non-curative gastrectomy for metastatic GC was associated with significant major morbidity and mortality as well as a prolonged hospital stay, longer than expected for gastrectomy for non-metastatic GC. These data can inform decision making regarding non-curative gastrectomy, helping surgeons to weigh the risks of morbidity against the potential benefits and alternative therapeutic options.

The impact of advanced age on short-term outcomes following gastric cancer resection: an ACS-NSQIP analysis

BACKGROUND

Evidence on short-term outcomes for GC resection in elderly patients is limited by small samples from single-institutions. This study sought to examine the association between advanced age and short-term outcomes of gastrectomy for gastric cancer (GC).

METHODS

Using ACS-NSQIP data, patients undergoing gastrectomy for GC (2007-2013) were identified. Primary outcome was 30-day major morbidity. Outcomes were compared across age categories (<65, 65-70, 71-75, 76-80, >80 years old). Univariable and multivariable regression was used to estimate the morbidity risk associated with age.

RESULTS

Of 3637 patients, 60.6% were ≥65 years old. Major morbidity increased with age, from 16.3% (<65 years old) to 21.5% (76-80 years old), and 24.1% (>80 years old) (p < 0.001), driven by higher respiratory and infectious events. Perioperative 30-day mortality increased from 1.2% (<65years old) to 6.5% (>80 years old) (p < 0.0001). After adjustments, age was independently associated with morbidity for 76-80 years of age (RR 1.31, 95% CI, 1.08-1.60) and >80 years old (RR 1.49, 95% CI, 1.23-1.81). Predicted morbidity increased by 18.6% in those 75-80 years old and 27.5% in those >80 years old (compared to <65 years old) for total gastrectomy, and by 11.6% and 17.2% for subtotal gastrectomy, for worst case scenario. Morbidity increased by 5.1% in those 75-80 years old and 7.6% in those >80 years old for total gastrectomy, and by 3.1% and 4.7% for subtotal gastrectomy, for best case scenario.

CONCLUSIONS

Advanced age, defined as more than 75 years, was independently associated with increased morbidity after GC resection. The magnitude of this impact is further modulated by clinical scenarios. Increased risk in elderly GC patient should be recognized and considered in indications for resection.

The Era of the Large Databases: Outcomes After Gastroesophageal Surgery According to NSQIP, NIS, and NCDB Databases. Systematic Literature Review

BACKGROUND

The term big data refers to databases that include large amounts of information used in various areas of knowledge. Currently, there are large databases that allow the evaluation of postoperative evolution, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the National Cancer Database (NCDB). The aim of this review was to evaluate the clinical impact of information obtained from these registries regarding gastroesophageal surgery.

METHODS

A systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines was performed. The research was carried out using the PubMed database identifying 251 articles. All outcomes related to gastroesophageal surgery were analyzed.

RESULTS

A total of 34 articles published between January 2007 and July 2017 were included, for a total of 345 697 patients. Studies were analyzed and divided according to the type of surgery and main theme in (1) esophageal surgery and (2) gastric surgery.

CONCLUSIONS

The information provided by these databases is an effective way to obtain levels of evidence not obtainable by conventional methods. Furthermore, this information is useful for the external validation of previous studies, to establish benchmarks that allow comparisons between centers and have a positive impact on the quality of care.

HLA-DQB1*03 genotype and perioperative blood transfusion are not conducive to the prognosis of patients with gastric cancer

BACKGROUND

Gastric cancer (GC) is a disease associated with a higher incidence and mortality, and some host genetic polymorphisms have been reported as potential factors contributing to the development of GC. In view of this, the study was conducted to investigate the effects of HLA-DQB1 gene polymorphisms and perioperative blood transfusion on prognosis of patients with gastric cancer (GC).

METHODS

A total of 142 patients with GC (case group) and 150 healthy controls (control group) were enrolled. Relationship between HLA-DQB1 gene polymorphisms, perioperative blood transfusion, and clinical pathological parameters of patients with GC after operation was analyzed. Kaplan-Meier curve was applied for analyzing survival rate of patients with GC, and Cox multivariate regression analysis for prognostic factors of patients with GC.

RESULTS

The frequency of HLA-DQB1*03 gene was increased in patients with GC. Patients with GC with HLA-DQB1*03 genotype had higher number of tumor size >6 cm, deeper depth of infiltration, higher LNM rate, and later stage of disease. Patients with HLA-DQB1*03 genotype had lower survival rate compared with other genotypes. Anemia before operation, depth of infiltration in T3 stage and T4 stage, LNM in N1 stage and N2 stage, and HLA-DQB1*03 genotype were regarded as independent risk factors for patients with GC.

CONCLUSION

These results demonstrate that HLA-DQB1*03 genotype and perioperative blood transfusion are not conducive to the prognosis of patients with GC, which could provide a reference for the treatment of GC.

Total iron-binding capacity is a novel prognostic marker after curative gastrectomy for gastric cancer

BACKGROUND

Patients with gastric cancer (GC) are affected by changes in iron status. Before surgery, GC patients are likely to have iron-deficiency anemia; and after gastrectomy, patients suffer from low nutritional status and low iron. This study investigated preoperative iron status associated with prognosis after curative gastrectomy for gastric cancer.

METHODS

We evaluated preoperative serum hemoglobin (Hgb), Fe and total iron-binding capacity (TIBC) in 298 patients who underwent curative gastrectomy for GC without preoperative chemotherapy, and analyzed these factors' associations with prognosis after surgery.

RESULTS

Of the 298 patients, 129 (43.2%) had low Hgb levels, and 33 (11.1%) had low TIBC (< 260 µg/dl) that was not associated with Hgb or Fe level. Patients with low TIBC were significantly associated with older age (≥ 65 years old; P = 0.0085), low albumin (< 3.9 g/dl; P = 0.0388) and high CRP (≥ 0.15 mg/dl; P = 0.0018) in multivariate analysis. Low Fe (< 60 µg/dl) was not associated with disease-free survival (DFS) or overall survival (OS); however, low Fe was associated with longer cancer-specific survival in Stage III GC patients (P = 0.0333). Both low Hgb and low TIBC were significantly associated with shorter DFS (Hgb: P = 0.0433; TIBC: P < 0.0001) and shorter OS (Hgb: P = 0.0352; TIBC: P < 0.0001). Low TIBC were significantly associated with shorter DFS (HR 2.167, 95% CI 1.231-3.639, P = 0.0086) and shorter OS (HR 2.065, 95% CI 1.144-3.570, P = 0.0173) in multivariate Cox hazard regression analysis.

CONCLUSIONS

Preoperative serum TIBC level of GC patients who undergo curative gastrectomy is a novel prognostic marker in univariate and multivariate analyses.

Impact of peri-operative blood transfusion on post-operative infections after radical gastrectomy for gastric cancer: a propensity score matching analysis focusing on the timing, amount of transfusion and role of leukocyte depletion

Purpose

Allogeneic blood transfusions (BTF) are sometimes inevitable during radical gastrectomy with lymphadenectomy for advanced gastric cancer. The aim of this retrospective study was to investigate the association between BTF and post-operative infections, focusing on the impact of timing, amount of transfusion and the role of leukocyte depletion.

Methods

The study cohort was 2064 patients who underwent gastrectomy for gastric cancer from November 2010 to August 2017. The association between BTF and post-operative infections was estimated by univariate and multivariate analyses after propensity score matching. Subgroup analysis was performed according to the timing and amount of transfusion, and leukocyte depletion or not.

Results

Out of a total 2064 patients, 426 (20.6%) received peri-operative BTF. After one-to-one matching, 361 pairs of patients were included for further analysis, of who 68 (9.4%) developed infections. Multivariate analysis identified that an operation time ≥ 240 min, combined multi-organ resection, BTF and BMI ≥ 25 kg/m² were independent risk factors for post-operative infection. Patients given a high-volume (> 7.5 U), intra-operatively of leukocyte-non-depleted BTF had the highest risk of developing infections clarified by subgroup analysis.

Conclusion

Infection was the most common complication following gastrectomy for gastric cancer and BTF was identified as an independent risk factor by propensity score matching and multivariate analyses. The timing, amount of transfusion and leukocyte depletion had an impact on the incidence of infection. To decrease infection, BTF should be avoided where possible, particularly during operation, with a large amount and leukocyte-not-depleted blood.

Prognostic Significance of Blood Transfusion in Elderly Patients with Primary Diffuse Large B-Cell Lymphoma

The current study sought to evaluate whether blood transfusions affect survival of elderly patients with primary diffuse large B-cell lymphoma (DLBCL). A total of 104 patients aged 60 years and over were enrolled and divided into two groups: 24 patients who received transfusions and 80 patients who did not. Statistical analyses showed significant differences in LDH levels, platelet (Plt) counts, and hemoglobin (Hb) and albumin (Alb) levels between the two groups. Univariate analyses showed that LDH level ≥ 245 IU/L, cell of origin (germinal center/nongerminal center), and blood transfusion were associated with both overall survival (OS) and progression-free survival (PFS). Higher IPI (3–5), Alb level < 35 g/L, and rituximab usage were associated with OS. Appearance of B symptoms was associated with PFS. Multivariate analyses showed that cell of origin and rituximab usage were independent factors for OS and LDH level was an independent factor for PFS. Blood transfusion was an independent factor for PFS, but not for OS. Our preliminary results suggested that elderly patients with primary DLBCL may benefit from a restrictive blood transfusion strategy.

The negative effect of perioperative red blood cell transfusion on morbidity and mortality after major abdominal operations

BACKGROUND

This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations.

METHODS

The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality.

RESULTS

Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p < 0.001), pancreatectomy (OR = 1.88/3.01, p < 0.001), hepatectomy (OR = 2.82/5.78, p < 0.001), colectomy (OR = 2.15/3.17, p < 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p < 0.001).

CONCLUSIONS

Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations.

Peri-Operative Blood Transfusion Does Not Influence Overall and Disease-Free Survival After Radical Gastrectomy for Stage II/III Gastric Cancer: a Propensity Score Matching Analysis

OBJECTIVE

Whether peri-operative blood transfusions (BTF) negatively impact long-term survival after gastrectomy for gastric cancer (GC) remains controversial. The aim of this retrospective study was to investigate independent predictive factors of BTF and the potential impact of BTF on overall survival (OS) and disease-free survival (DFS) in patients who underwent radical gastrectomy for stage II/III GC.

METHODS

Of 1020 patients who underwent gastrectomy for stage II/III GC from November 2010 to December 2015, 231 (22.6%) patients received BTF. The independent predictive factors of BTF were identified using univariate and multivariate analyses. Cox regression and propensity score matching (PSM) analyses of OS and DFS in patients who received BTF or not were compared.

RESULTS

Multivariate analysis revealed that age, pre-operative hemoglobin levels, tumor size, operation time, combined multi-organ resection, and intra-operative blood loss were independent predictive factors for BTF. PSM analysis created 205 pairs of patients. BTF was significantly associated with decreased OS (P = 0.025) and DFS (P = 0.034) in the entire cohort before PSM. After PSM, there was no longer a significant association between BTF and OS (P = 0.850) or DFS (P = 0.880). BTF was not identified as an independent risk factor for OS or DFS by multivariate Cox regression analysis.

CONCLUSIONS

The present study revealed that BTF did not influence OS and DFS after radical gastrectomy for stage II/III GC. Worse oncological outcomes were caused by clinical circumstances requiring blood transfusions, including longer operation time and advanced tumor stage, not due to BTF itself.

The Effect of Blood Transfusion on Outcomes in Aortic Surgery

The use of blood transfusion in cardiac surgery varies widely. The beneficial effects of blood products are offset by an increase in morbidity and mortality. Despite multiple studies showing an association between blood product exposure and adverse short- and long-term events, it is difficult to determine causality. Nevertheless, the implication is sufficient to warrant the search for alternative strategies to reduce the use of blood products while providing a standard of care that optimizes postoperative outcomes. Aortic surgery, in particular, is associated with an increased risk of bleeding requiring a blood transfusion. There is a paucity of evidence within aortic surgery regarding the deleterious effects of blood products. Here, we review the current evidence regarding patient outcomes after blood transfusion in cardiac surgery, with special emphasis on aortic surgery.

Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities

Anemia is present in more than half of cancer patients and appears to be an independent prognostic factor of short- and long-term adverse outcomes. It increases in the advanced period of cancer and perioperatively, in patients with solid tumors who undergo surgery. As a result, allogeneic red blood cell (RBC) transfusion is an indispensable treatment in cancer. However, its safety remains controversial, based on several laboratory and clinical data reporting a linkage with increased risk for cancer recurrence, infection and cancer-related mortality. Immunological, inflammatory and thrombotic reactions mediated by the residual leukocytes and platelets, the stored RBCs per se, the biological response modifiers and the plasticizer of the unit may underlie infection and tumor-promoting effects. Although the causality between transfusion and infection has been established, the effects of transfusion on cancer recurrence remain confusing; this is mainly due to the extreme biological heterogeneity that characterizes RBC donations and cancer context. In fact, the functional interplay between donation-associated factors and recipient characteristics, including tumor biology per se, inflammation, infection, coagulation and immune activation state and competence may synergistically and individually define the clinical impact of each transfusion in any given cancer patient. Our understanding of how the potential risk is mediated is important to make RBC transfusion safer and to pave the way for novel, promising and highly personalized strategies for the treatment of anemia in surgical cancer patients.

Prognostic Significance of Blood Transfusion in Newly Diagnosed Multiple Myeloma Patients without Autologous Hematopoietic Stem Cell Transplantation

The aim of this study was to evaluate whether blood transfusions affect overall survival (OS) and progression-free survival (PFS) in newly diagnosed multiple myeloma (MM) patients without hematopoietic stem cell transplantation. A total of 181 patients were enrolled and divided into two groups: 68 patients in the transfused group and 113 patients in the nontransfused group. Statistical analyses showed that there were significant differences in ECOG scoring, Ig isotype, platelet (Plt) counts, hemoglobin (Hb) level, serum creatinine (Scr) level, and β₂-microglobulin (β₂-MG) level between the two groups. Univariate analyses showed that higher International Staging System staging, Plt counts < 100 × 10⁹/L, Scr level ≥ 177 μmol/L, serum β₂-MG ≥ 5.5 μmol/L, serum calcium (Ca) ≥ 2.75 mmol/L, and thalidomide use were associated with both OS and PFS in MM patients. Age ≥ 60 was associated with OS and Ig isotype was associated with PFS in MM patients. Moreover, blood transfusion was associated with PFS but not OS in MM patients. Multivariate analyses showed that blood transfusion was not an independent factor for PFS in MM patients. Our preliminary results suggested that newly diagnosed MM patients may benefit from a liberal blood transfusion strategy, since blood transfusion is not an independent impact factor for survival.