Removal of EpCAM-positive tumor cells from blood collected during major oncological surgery using the Catuvab device- a pilot study

BACKGROUND

Intraoperative blood salvage (IBS) is regarded as an alternative to allogeneic blood transfusion excluding the risks associated with allogeneic blood. Currently, IBS is generally avoided in tumor surgeries due to concern for potential metastasis caused by residual tumor cells in the erythrocyte concentrate.

METHODS

The feasibility, efficacy and safety aspects of the new developed Catuvab procedure using the bispecific trifunctional antibody Catumaxomab was investigated in an ex-vivo pilot study in order to remove residual EpCAM positive tumor cells from the autologous erythrocyte concentrates (EC) from various cancer patients, generated by a IBS device.

RESULTS

Tumor cells in intraoperative blood were detected in 10 of 16 patient samples in the range of 69-2.6 × 105 but no residual malignant cells in the final erythrocyte concentrates after Catuvab procedure. IL-6 and IL-8 as pro-inflammatory cytokines released during surgery, were lowered in mean 28-fold and 52-fold during the Catuvab procedure, respectively, whereas Catumaxomab antibody was detected in 8 of 16 of the final EC products at a considerable decreased and uncritical residual amount (37 ng in mean).

CONCLUSION

The preliminary study results indicate efficacy and feasibility of the new medical device Catuvab allowing potentially the reinfusion of autologous erythrocyte concentrates (EC) produced by IBS device during oncological high blood loss surgery. An open-label, multicenter clinical study on the removal of EpCAM-positive tumor cells from blood collected during tumor surgery using the Catuvab device is initiated to validate these encouraging results.

A Novel Centrifugation Method Using a Cell Salvage Device Offers an Alternative to the Use of Leukocyte-Depleting Filters for Autologous Blood Transfusions

Autotransfusion protocols often use the use of costly filters, such as leukocyte-depleting filters (LDFs), to minimize reinfusion of activated leukocytes and inflammatory mediators associated with reperfusion injury (RI). LDFs are used extensively in hospital settings; however, they represent an additional capital expenditure for hospitals, as well as a constraint on the reinfusion rate of blood products for health-care providers. We compared a commonly used LDF to a novel centrifugation method employing a widely used cell salvage device. Complete blood counts and enzyme-linked immunosorbent assays (ELISAs) measuring tumor necrosis factor-α (TNF-α) and interleukin-2 (IL-2) were performed to compare the efficacy of these methodologies. The LDF removed, on average, 94% of all leukocytes, including 96% of neutrophils. The centrifugation method removed, on average, 89% of all leukocytes, including 91% of neutrophils and resulted in a highly concentrated red blood cell product. Our results suggest both methods offer equivalent leukocyte reduction. TNF-α was also comparably reduced following our novel centrifugation method and the LDF method and IL-2 levels were undetectable in all samples. These results indicate our novel centrifugation method may preclude the need for a LDF during select autotransfusion applications.

Blood Loss Management in Primary Hip Surgery: Is Reinfusion drain A Feasible Option in Maintaining Hemoglobin Levels?

The management of blood loss in primary hip arthroplasty is a controversial topic. Aim: To evaluate the efficacy of reinfusion drains in terms of hemoglobin levels and volume of red blood cell transfused postoperatively. Material and Methods: 295 patients who underwent primary hip arthroplasty were retrospectively assessed. After applying the exclusion criteria, 94 patients were included in the study and were divided into two groups: 45 patients received a reinfusion drain and 49 a suction drain. The following were analyzed: demographic characteristics of patients, preoperative hemoglobin level, 12-h and 24-h postoperative hemoglobin levels and their variations, number of transfused units of packed red blood cells, and postoperative complications. Results: Kruskal Wallis analysis revealed the homogeneity of the study groups (Chi-square=2.40, df=2, p=0.301). A statistically significant lower decline in mean Hb24 was found in suction drain group (p=0.001). Kruskal Wallis test revealed a significantly more frequent postoperative use of a higher number of packed red blood cell units in the suction drain group (Chi-square=28.70, df=2, p=0.001) compared to reinfusion drain group. Conclusions: We failed to demonstrate the superiority of reinfusion drains versus suction drains in maintaining hemoglobin levels.

[Cell saver use during knee arthroplasty]

BACKGOUND

Gonarthrosis is a degenerative condition that importantly limits an individua's performance. Surgical treatment is used in patients with important functional limitation and severe pain. Knee arthroplasty is one of the surgeries with the best functional results in patients with this condition. However, its limitations include the risk of heavy bleeding and the resulting need for blood transfusion. The objective of this study was to assess the need for blood transfusion in patients undergoing knee arthroplasy in whom the cell saver was used postoperatively and find out the cost differences between the cell saver and standard blood transfusion.

METHODS

Retrospective, cross-sectional, retrolective trial including 300 records of patients who underwent knee arthroplasty at Hospital Angeles Querétaro that included the use of the cell saver and allogeneic blood transfusion from October 2001 to June 2013.

RESULTS

Only 3 of the 246 operated knees required allogeneic blood transfusion. There were no complications/infections resulting from the use of the cell saver. Mean age of patients was 67.1 +/- 9.78 years; females were predominant, as they were 141 (60.5%), compared to 92 (39.5%) males. The blood collected with the cell saver ranged from 150 to 1,225 ml with a mean of 318 +/- 100.6 ml and was retransfused to each patient.

CONCLUSIONS

Cell saver use in patients subjected to knee arthroplasty importantly decreases the need for allogeneic blood transfusion.

An analysis of the influence of intra-operative blood salvage and autologous transfusion on reducing the need for allogeneic transfusion in elective infrarenal abdominal aortic aneurysm repair

BACKGROUND

An intra-operative cell salvage machine, commonly known as a "cell saver", aspirates, washes, and filters patient's blood during an operation so that the blood can be returned to the patient's circulation instead of being discarded. This procedure could significantly reduce the risks related to the use of allogeneic blood and blood products in surgery. The aim of this study was to analyse the influence of intra-operative cell salvage on reducing the need for allogeneic blood in patients with asymptomatic infrarenal abdominal aortic aneurysm undergoing elective repair of the aneurysm.

MATERIAL AND METHODS

We retrospectively collected data from the clinical records of patients who underwent elective infrarenal abdominal aortic aneurysm repair. Two groups were formed: the "cell saver" group, in which intra-operative cell salvage was used, and the control group, in which a cell saver was not used.

RESULTS

Thirty patients underwent abdominal aortic aneurysm repair with the use of a cell saver, while 32 underwent the same operation without cell salvage. We found a significant association between use of the cell saver and a reduced need for allogeneic blood in these patients. Operations performed with the use of a cell saver lasted, on average, less time than those performed without it. The difference between pre-operative and post-operative haemoglobin levels was significantly greater in the group of patients who underwent repair with the use of a cell saver than in the control group.

CONCLUSION

The use of a cell saver in elective abdominal aortic aneurysm repair significantly reduces the need for intra-operative use of allogeneic blood.

Autologous re-transfusion drain compared with no drain in total knee arthroplasty: a randomised controlled trial

BACKGROUND

Post-operative anaemia following total knee arthroplasty is reported to impede functional mobility in the early period following surgery, whereas allogeneic blood transfusions, used to correct low post-operative haemoglobin levels, have concomitant disadvantages. The use of a post-operative autologous blood re-transfusion drainage system as well as no drainage system following total knee arthroplasty have been shown to reduce peri-operative blood loss and allogeneic blood transfusions, compared to the regularly used closed-suction drains. No randomised studies have been performed, to the best of our knowledge, that indicate the superiority of either method.

MATERIALS AND METHODS

An open, randomised controlled study was conducted in 115 patients undergoing total knee arthroplasty who were randomly allocated to an autotransfusion drain or no drainage system. The primary end-point was haemoglobin level on the first post-operative day.

RESULTS

In the autotransfusion group 515 mL (0-1,500 mL) of drained blood was re-transfused within the first 6 hours after surgery. Haemoglobin levels on the first (11.6 vs 11.0 g/dL), second (11.0 vs 10.3 g/dL) and third (10.5 vs 9.8 g/dL) days after surgery were significantly higher in the autotransfusion group. Total peri-operative net blood loss (1,576 mL vs 1,837 mL; -P=0.03) and allogeneic transfusion rates (10.2% vs 19.6%; P=0.15) were lower in the autotransfusion group. There were no differences in pain scores, range of motion or adverse events during hospital stay and the first 3 months after surgery.

DISCUSSION

Compared with no drainage, the use of a post-operative autologous blood re-transfusion drainage system following total knee arthroplasty results in higher post-operative haemoglobin levels and less total blood loss.

[Experience in kidney transplantation without blood transfusion: kidney transplantation transfusion-free in Jehovah's Witnesses. First communication in Mexico]

BACKGROUND

Jehovah's Witness refuse blood transfusion, but they accept organ transplantation, albumin, immunoglobulin, vaccines and clotting factors.

CLINICAL CASES

We present 3 kidney transplants in Jehovah's Witness patients (two male and one female) without blood transfusion, with a mean age of 31.33 years and a mean body mass index of 20.99 kg/m(2). All patients underwent pretransplant peritoneal dialysis for an average of 52.3 months. Two transplants came from living donors and one from a deceased donor with a cold ischemia of 23 hours. The donors were two females and one male, with a mean age of 34.33 years. All patients received pretransplant erythropoietin and iron dextran and an intraoperative cell saver was used. Hemoglobin, hematocrit, red blood cells and serum creatinine levels, as well as the glomerular filtration at 24 months postransplant were stable. All patients received induction with basiliximab and initial immunosuppression with calcineurin inhibitors. One of the patients had a perirenal hematoma as a complication, which required a surgery 20 days post-transplant. At 5, 26 and 36 months postransplant the three patients are alive and with functional grafts.

CONCLUSION

It is possible to perform kidney transplantation without transfusion in Jehovah's Witness, obtaining an acceptable global survival without acute rejection.

Acute hypotension associated with intraoperative cell salvage using a leukocyte depletion filter during management of obstetric hemorrhage due to amniotic fluid embolism

Amniotic fluid embolism (AFE) is a rare but catastrophic obstetric complication that can lead to profound coagulopathy and hemorrhage. The role of cell salvage and recombinant human Factor VIIa (rFVIIa) administration in such cases remains unclear. We present a case of AFE and describe our experience with the use of cell salvage and rFVIIa administration during the resuscitation. Cell salvage and transfusion through a leukocyte depletion filter was attempted after the diagnosis of AFE was made, but the attempted transfusion was immediately followed by hypotension and a worsening of hemodynamics. rFVIIa, on the contrary, was used with clinical improvement in coagulopathy and without apparent adverse thrombotic effect.

Does single use of an autologous transfusion system in TKA reduce the need for allogenic blood?: a prospective randomized trial

BACKGROUND

Mechanical autotransfusion systems for washed shed blood (WSB) were introduced to reduce the need for postoperative allogenic blood transfusions (ABTs). Although some authors have postulated decreased requirements for ABT by using autologous retransfusion devices, other trials, mostly evaluating retransfusion devices for unwashed shed blood (USB), verified a small or no benefit in reducing the need for postoperative ABT. Because of these contradictory findings it is still unclear whether autologous retransfusion systems for WSB can reduce transfusion requirements.

QUESTIONS/PURPOSES

We therefore asked whether one such autologous transfusion system for WSB can reduce the requirements for postoperative ABT.

METHODS

In a prospective, randomized, controlled study, we enrolled 151 patients undergoing TKA. In Group A (n=76 patients), the autotransfusion system was used for a total of 6 hours (intraoperatively and postoperatively) and the WSB was retransfused after processing. In Control Group B (n=75 patients), a regular drain without suction was used. We used signs of anemia and/or a hemoglobin value less than 8 g/dL as indications for transfusion. If necessary, we administered one or two units of allogenic blood.

RESULTS

Twenty-three patients (33%) in Group A, who received an average of 283 mL (range, 160-406 mL) of salvaged blood, needed a mean of 2.1 units of allogenic blood, compared with 23 patients (33%) in Control Group B who needed a mean of 2.1 units of allogenic blood.

CONCLUSIONS

We found the use of an autotransfusion system did not reduce the rate of postoperative ABTs.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Effect of autotransfusion system on tumor recurrence and survival in hepatocellular carcinoma patients

AIM: To investigate the therapeutic efficacy and safety of continuous autotransfusion system (CATS) during liver transplantation of hepatocellular carcinoma patients.

METHODS: Eighty-three hepatocellular carcinoma (HCC) patients who underwent liver transplantation with intraoperative CATS (n = 24, CATS group) and without (n = 59, non-CATS group) between April 2006 and November 2011 at the Liver Transplant Institute of Inonu University were analyzed retrospectively. Postoperative HCC recurrence was monitored by measuring alpha-fetoprotein (AFP) levels at 3-mo intervals and performing imaging analysis by thoracoabdominal multidetector computed tomography at 6-month intervals. Inter-group differences in recurrence and correlations between demographic, clinical, and pathological data were assessed by ANOVA and χ² tests. Overall and disease-free survivals were calculated by the univariate Kaplan-Meier method.

RESULTS: Of the 83 liver transplanted HCC patients, 89.2% were male and the overall mean age was 51.3 ± 8.9 years (range: 18-69 years). The CATS and non-CATS groups showed no statistically significant differences in age, sex ratio, body mass index, underlying disease, donor type, graft-to-recipient weight ratio, Child-Pugh and Model for End-Stage Liver Disease scores, number of tumors, tumor size, AFP level, Milan and University of California San Francisco selection criteria, tumor differentiation, macrovascular invasion, median hospital stay, recurrence rate, recurrence site, or mortality rate. The mean follow-up time of the non-CATS group was 17.9 ± 12.8 mo, during which systemic metastasis and/or locoregional recurrence developed in 25.4% of the patients. The mean follow-up time for the CATS group was 25.8 ± 15.1 mo, during which systemic metastasis and/or locoregional recurrence was detected in 29.2% of the patients. There was no significant difference between the CATS and non-CATS groups in recurrence rate or site. Additionally, no significant differences existed between the groups in overall or disease-free survival.

CONCLUSION: CATS is a safe procedure and may decrease the risk of tumor recurrence in HCC patients.

[Post-operative retransfusion and intra-operative autotransfusion systems in total knee arthroplasty. A comparison of their efficacy]

PURPOSE OF THE STUDY

The aim of the study was to compare the effect of post-operative retransfusion with that of intra-operative autotransfusion in non-anaemic patients undergoing total knee arthroplasty (TKA).

MATERIAL AND METHODS

Between February 2004 and June 2006, a total of 129 patients free of anaemia who underwent elective primary unilateral cemented TKA for primary arthritis received blood retransfusion by means of the post-operative retransfusion system. Intra-operative transfusion was not administered. Patients with coagulation disorders, thrombocytopaenia or other haematological diseases were not included. The results were compared with those of the group of 142 patients undergoing the same surgery, but with use of the intra-operative autotransfusion system, in the period from February 2009 to December 2010. The following patient data were reviewed: patient's age at the time of surgery; value of haemoglobin before and two days after surgery; allergic and febrile reactions associated with retransfusion, renal failure after retransfusion, number of postoperative allogeneic transfusions, early TKA infection and thrombo-embolic complications.

RESULTS

Of the 129 patients with post-operative retransfusion, 25 received one or more allogeneic blood transfusions due to the haemoglobin level below 90g/l and symptoms of anaemia. The average haemoglobin level was 136 g/l (range, 111 to 159 g/l) one day before surgery and 107 g/l (range, 81 to 143 g/l) on the 2nd post-operative day. A single allogeneic blood transfusion was administered to 12 patients and two were necessary in 13 patients. The average blood volume returned to the patient through the post-operative retransfusion system was 725.3 ml (range, 250 to 1 300 ml). Of the 142 patients with intra-operative autotransfusion, 11 patients required blood transfusion in the post-operative period, with seven receiving one and four receiving two transfusions. The average haemoglobin level was 135 g/l (range, 110 to 161 g/l ) one day before surgery and 107 g/l (range, 85 to 130 g/l ) two days after it. The average volume of erythrocyte mass returned to the patient through the intra-operative autotransfusion system was 330.7 ml (range, 0 to 850 ml). No allergic, pyretic or other reaction or complication was recorded in either group. No early TKA infection occurred.

DISCUSSION

No reports comparing the efficacies of post-operative retransfusion and intra-operative auto-transfusion systems in patients undergoing total knee replacement have been found in the literature. Therefore, the only possible comparison can be made with the studies that involve patients receiving blood recuperation and control groups with no blood recuperation. In our study, 19.3% of the patients with post-operative retransfusion required allogeneic blood transfusion while this was necessary in only 7.7% of the patients with intra-operative autotransfusion. This difference was caused by a better efficiency of the intra-operative autotransfusion system which can treat up to 2 litres of harvested blood per hour and return it to the patient in the form of erythrocyte mass, while the post-operative retransfusion system can salvage only 1500 ml of blood.

CONCLUSIONS

The use of either of these systems has proved to be a simple and safe method of reducing the need of allogeneic blood transfusion in the TKA procedure. While the post-operative retransfusion system facilitates the return of drained blood only, the more efficient "cell-saver" technology collects blood shed during both intra- and post-operative periods and allows for erythrocyte mass retransfusion during and after surgery. Since the administration of allogeneic blood was required in less than 10% of the patients receiving intra-operative autotransfusion, this system was adopted as a more efficient method in routine TKA procedures.

Autologous transfusion of drain contents in elective primary knee arthroplasty: its value and relevance

BACKGROUND

Total knee arthroplasty is associated with significant post-operative blood loss often necessitating blood transfusions. Blood transfusions may be associated with transfusion reactions and may transmit human immunodeficiency virus, hepatitis C virus and hepatitis B virus, with devastating consequences. After total knee arthroplasty, transfusion of the contents of an autologous drain is becoming common practice. The aim of our study was to look at the effectiveness of these drains in elective primary total knee arthroplasty.

MATERIALS AND METHODS

A prospective study was conducted including 70 non-randomised patients. A normal suction drain was used in 35 patients (group A), whereas in the other 35 patients, a CellTrans™ drain was used (group B). All the operations were performed by four surgeons using a tourniquet with a medial parapatellar approach. Pre- and post-operative haemoglobin concentrations were recorded in both groups. A Student's t-test was applied to determine the statistical significance of the data collected.

RESULTS

The average fall in post-operative haemoglobin was 3.66 g/dL (SD 1.46; range, 0.6-7.0) among patients in whom the simple drain was used (group A) and 2.29 g/dL (SD 0.92; range, 0.6-5.9) among those in whom the CellTrans™ drain was used (group B) (p<0.0001). Twenty-five units of allogeneic blood were required in group A compared to four units in group B. The rate of transfusion was 5.7% (2 patients) in the group in which CellTrans™ drain was used and 25.7% (9 patients) in the group in which a simple suction drain was used.

DISCUSSION

Total knee arthroplasty is associated with significant post-operative blood loss despite best operative technique. Autologous reinfusion of the contents of a CellTrans™ drain significantly reduces the rate of post-operative blood transfusion. This study indicates that the use of an autologous drain could be recommended as routine practice in primary total knee arthroplasty.

Is use of a Continuous Autotransfusion System beneficial in emergency abdominal aortic aneursym (AAA) surgery?

BACKGROUND

Allogeneic blood products have become a limited and expensive resource. The Continuous Autotransfusion System (CATS) has been promoted as a method for reducing the need for allogeneic blood transfusion. This study was undertaken to ascertain whether the use of CATS in emergency open AAA surgery has any benefits.

METHODS

This is a retrospective study of all patients undergoing emergency open AAA surgery in our center during a 5-year period (between July 2004 and July 2009). Patients were identified from a prospectively maintained vascular database, and data were obtained from patient records.

RESULTS

CATS was used in 69 emergency open AAA repairs. The median total blood loss was 3,500 mL (range: 751-13,796 mL) but the median volume of packed red blood cells produced by CATS was only 493 mL (~ 2 U). An average of 7 U (range: 0-19 U) of bank blood was still used despite the availability of CATS. The mean hemoglobin 24 hours postoperatively was 10.3 g/dL (6.4-14.1) with a hematocrit of 0.30.

CONCLUSION

The use of CATS in emergency AAA surgery does not seem to reduce the use of allogeneic blood transfusion. This may be because of over transfusion, as reflected by relatively high postoperative hemoglobin levels.

No drain, autologous transfusion drain or suction drain? A randomised prospective study in total hip replacement surgery of 168 patients

We performed a prospective, randomised controlled trial to assess the differences in the use of a conventional suction drain, an Autologous Blood Transfusion (ABT) drain and no drain, in 168 patients. There was no significant difference between the drainage from ABT drains ( mean : 345 ml) and the suction drain (314 ml). Forty percent of patients receiving a suction drain had a haemoglobin level less than 10 g/dL at 24 hours, compared to 35% with no drain and 28% with an ABT drain. Patients that had no drains had wounds that were dry significantly sooner, mean 3.0 days compared to a mean of 3.9 days with an ABT drain and a mean of 4 days with a suction drain. Patients that did not have a drain inserted stayed in hospital a significantly shorter period of time, compared with drains. We feel the benefits of quicker drying wounds, shorter hospital stays and the economic savings justify the conclusion that no drain is required after hip replacement.