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Impact of Blood Transfusions and Transfusion Practices on Long-Term Outcome Following Hepatopancreaticobiliary Surgery

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The long-term impact of transfusions with packed red blood cells (PRBC) among patients undergoing hepatopancreaticobiliary (HPB) surgery remains ill-defined. We sought to determine the impact of overall blood utilization, as well as a restrictive transfusion strategy, on long-term outcomes among patients undergoing an HPB resection for a malignancy.

Methods

Data on overall blood utilization and hemoglobin (Hb) levels that triggered a transfusion were obtained for patients with cancer undergoing pancreas or liver surgery between 2009 and 2013. Risk-adjusted recurrence-free (RFS) and overall survival (OS) were assessed based on receipt of PRBC and whether the patient received a transfusion using a restrictive transfusion strategy (intraoperative: Hb <10 g/dL; postoperative: Hb <8 g/dL).

Results

Four hundred forty-two patients underwent either a pancreas (58.1 %) or liver (41.9 %) resection. Most tumors were pancreatic in origin (41.8 %), while a subset were primary (23.1 %) or secondary (18.8 %) liver tumors. One hundred seventy-five (39.6 %) patients received ≥1 PRBC transfusion either intraoperatively (16.7 %), postoperatively (12.7 %), or both (10.2 %). There was a higher incidence of PRBC transfusion among patients undergoing a pancreas resection, those with higher comorbidities, and those with lower preoperative Hb levels. Perioperative morbidity was higher among patients receiving either 1–2 units (OR 3.14) or 3 or more units of PRBC (OR 8.54). Median OS was 31.9 months. Receipt of a blood transfusion was associated with a worse OS (1–2 units: HR 1.76; 3 + units: HR 2.50; both P < 0.05), and RFS (3 + units: HR 2.91; P = 0.02). Utilization of a restrictive transfusion strategy did not impact perioperative morbidity or long-term RFS or OS.

Conclusions

Adoption of a more restrictive transfusion strategy in patients undergoing resection for cancer may preserve a limited resource, reduce costs, as well as avoid exposing oncology patients to the unnecessary risks associated with a transfusion.

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References

  1. Ejaz A, Spolverato G, Kim Y, Frank SM, Pawlik TM: Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery. The British journal of surgery 2014, 101(11):1424-1433.

    Article  CAS  PubMed  Google Scholar 

  2. Ross A, Mohammed S, Vanburen G, Silberfein EJ, Artinyan A, Hodges SE, Fisher WE: An assessment of the necessity of transfusion during pancreatoduodenectomy. Surgery 2013, 154(3):504-511.

    Article  PubMed  Google Scholar 

  3. Burrows L, Tartter P: Effect of blood transfusions on colonic malignancy recurrent rate. Lancet 1982, 2(8299):662.

    Article  CAS  PubMed  Google Scholar 

  4. Koch CG, Li L, Duncan AI, Mihaljevic T, Loop FD, Starr NJ, Blackstone EH: Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. The Annals of thoracic surgery 2006, 81(5):1650-1657.

    Article  PubMed  Google Scholar 

  5. Glance LG, Dick AW, Mukamel DB, Fleming FJ, Zollo RA, Wissler R, Salloum R, Meredith UW, Osler TM: Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011, 114(2):283-292.

    Article  PubMed  Google Scholar 

  6. Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ: Effect of blood transfusion on long-term survival after cardiac operation. The Annals of thoracic surgery 2002, 74(4):1180-1186.

    Article  PubMed  Google Scholar 

  7. Kuduvalli M, Oo AY, Newall N, Grayson AD, Jackson M, Desmond MJ, Fabri BM, Rashid A: Effect of peri-operative red blood cell transfusion on 30-day and 1-year mortality following coronary artery bypass surgery. European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 2005, 27(4):592-598.

    Article  Google Scholar 

  8. Foster RS, Jr., Costanza MC, Foster JC, Wanner MC, Foster CB: Adverse relationship between blood transfusions and survival after colectomy for colon cancer. Cancer 1985, 55(6):1195-1201.

    Article  PubMed  Google Scholar 

  9. Hyman NH, Foster RS, Jr., DeMeules JE, Costanza MC: Blood transfusions and survival after lung cancer resection. American journal of surgery 1985, 149(4):502-507.

    Article  CAS  PubMed  Google Scholar 

  10. Amato A, Pescatori M: Perioperative blood transfusions for the recurrence of colorectal cancer. The Cochrane database of systematic reviews 2006(1):CD005033.

  11. Blajchman MA, Bordin JO: Mechanisms of transfusion-associated immunosuppression. Current opinion in hematology 1994, 1(6):457-461.

    CAS  PubMed  Google Scholar 

  12. Brunson ME, Alexander JW: Mechanisms of transfusion-induced immunosuppression. Transfusion 1990, 30(7):651-658.

    Article  CAS  PubMed  Google Scholar 

  13. Corwin HL: Blood transfusion: first, do no harm! Chest 1999, 116(5):1149-1150.

    Article  CAS  PubMed  Google Scholar 

  14. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM et al: Red blood cell transfusion: a clinical practice guideline from the AABB*. Annals of internal medicine 2012, 157(1):49-58.

    Article  PubMed  Google Scholar 

  15. American College of C, American Heart Association Task Force on Practice G, American Society of E, American Society of Nuclear C, Heart Rhythm S, Society of Cardiovascular A, Society for Cardiovascular A, Interventions, Society for Vascular M, Biology et al: ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. Journal of the American College of Cardiology 2006, 47(11):2343-2355.

    Article  Google Scholar 

  16. Society of Thoracic Surgeons Blood Conservation Guideline Task F, Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Society of Cardiovascular Anesthesiologists Special Task Force on Blood T et al: 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. The Annals of thoracic surgery 2011, 91(3):944-982.

    Article  Google Scholar 

  17. Napolitano LM, Kurek S, Luchette FA, Corwin HL, Barie PS, Tisherman SA, Hebert PC, Anderson GL, Bard MR, Bromberg W et al: Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Critical care medicine 2009, 37(12):3124-3157.

    Article  PubMed  Google Scholar 

  18. Frank SM, Resar LM, Rothschild JA, Dackiw EA, Savage WJ, Ness PM: A novel method of data analysis for utilization of red blood cell transfusion. Transfusion 2013.

  19. Frank SM, Savage WJ, Rothschild JA, Rivers RJ, Ness PM, Paul SL, Ulatowski JA: Variability in blood and blood component utilization as assessed by an anesthesia information management system. Anesthesiology 2012, 117(1):99-106.

    Article  PubMed  Google Scholar 

  20. Ejaz A, Spolverato G, Kim Y, Frank SM, Pawlik TM: Identifying variations in blood use based on hemoglobin transfusion trigger and target among hepatopancreaticobiliary surgeons. Journal of the American College of Surgeons 2014, 219(2):217-228.

    Article  PubMed  Google Scholar 

  21. Mayo SC, Shore AD, Nathan H, Edil BH, Hirose K, Anders RA, Wolfgang CL, Schulick RD, Choti MA, Pawlik TM: Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion. HPB: the official journal of the International Hepato Pancreato Biliary Association 2011, 13(7):473-482.

    Article  Google Scholar 

  22. Choosing wisely - AABB. http://www.choosingwisely.org/doctor-patient-lists/american-association-of-blood-banks/

  23. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K et al: Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011, 365(26):2453-2462.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  24. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH et al: Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA: the journal of the American Medical Association 2010, 304(14):1559-1567.

    Article  CAS  Google Scholar 

  25. Ejaz A FS, Spolverato G, Kim Y, Pawlik TM: Potential Economic Impact of using a Restrictive Transfusion Trigger Among Patients Undergoing Major Abdominal Surgery. JAMA Surg In press.

  26. Wang T, Luo L, Huang H, Yu J, Pan C, Cai X, Hu B, Yin X: Perioperative blood transfusion is associated with worse clinical outcomes in resected lung cancer. The Annals of thoracic surgery 2014, 97(5):1827-1837.

    Article  PubMed  Google Scholar 

  27. Busch OR, Hop WC, Hoynck van Papendrecht MA, Marquet RL, Jeekel J: Blood transfusions and prognosis in colorectal cancer. The New England journal of medicine 1993, 328(19):1372-1376.

    Article  CAS  PubMed  Google Scholar 

  28. Busch OR, Hop WC, Marquet RL, Jeekel J: Prognostic impact of blood transfusions on disease-free survival in colorectal carcinoma. Scandinavian journal of gastroenterology Supplement 1993, 200:21-23.

    Article  CAS  PubMed  Google Scholar 

  29. Al-Refaie WB, Parsons HM, Markin A, Abrams J, Habermann EB: Blood transfusion and cancer surgery outcomes: a continued reason for concern. Surgery 2012, 152(3):344-354.

    Article  PubMed  Google Scholar 

  30. Dejam A, Malley BE, Feng M, Cismondi F, Park S, Samani S, Samani Z, Pinto DS, Celi LA: The effect of age and clinical circumstances on the outcome of red blood cell transfusion in the critically ill patients. Critical care 2014, 18(4):487.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Carson JL, Carless PA, Hebert PC: Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. The Cochrane database of systematic reviews 2012, 4:CD002042.

  32. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. The New England journal of medicine 1999, 340(6):409-417.

    Article  CAS  PubMed  Google Scholar 

  33. Hebert PC, Wells G, Marshall J, Martin C, Tweeddale M, Pagliarello G, Blajchman M: Transfusion requirements in critical care. A pilot study. Canadian Critical Care Trials Group. JAMA: the journal of the American Medical Association 1995, 273(18):1439-1444.

    Article  CAS  Google Scholar 

  34. Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, Johansson PI, Aneman A, Vang ML, Winding R et al: Lower versus higher hemoglobin threshold for transfusion in septic shock. The New England journal of medicine 2014, 371(15):1381-1391.

    Article  PubMed  Google Scholar 

  35. Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J et al: Transfusion strategies for acute upper gastrointestinal bleeding. The New England journal of medicine 2013, 368(1):11-21.

    Article  CAS  PubMed  Google Scholar 

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Author notes

    Authors and Affiliations

    1. Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA

      Aslam Ejaz

    2. Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, 21287, USA

      Gaya Spolverato, Yuhree Kim, Georgios A. Margonis, Rohan Gupta, Neda Amini & Timothy M. Pawlik

    3. Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

      Steven M. Frank

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    1. Aslam Ejaz
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    2. Gaya Spolverato
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    Correspondence to Timothy M. Pawlik.

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    Aslam Ejaz and Gaya Spolverato contributed equally to this work.

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    Ejaz, A., Spolverato, G., Kim, Y. et al. Impact of Blood Transfusions and Transfusion Practices on Long-Term Outcome Following Hepatopancreaticobiliary Surgery. J Gastrointest Surg 19, 887–896 (2015). https://doi.org/10.1007/s11605-015-2776-5

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