Journal of Gastrointestinal Surgery

, Volume 18, Issue 4, pp 719–728 | Cite as

Trends and Risk Factors for Transfusion in Hepatopancreatobiliary Surgery

  • Donald J. Lucas
  • Katherine I. Schexneider
  • Matthew Weiss
  • Christopher L. Wolfgang
  • Steven M. Frank
  • Kenzo Hirose
  • Nita Ahuja
  • Martin Makary
  • John L. Cameron
  • Timothy M. Pawlik
Original Article



Patient-specific factors impacting the need for possible perioperative blood transfusions have not been examined in patients undergoing hepatopancreatobiliary (HPB) procedures. We sought to define the overall utilization of blood transfusions for HPB surgery stratified by procedure type, as well as identify patient-level risk factors for transfusion.


Hepatic and pancreatic resections were selected from the 2005–2011 American College of Surgeons National Surgical Quality Improvement Program's public use files. Transfusion utilization, risk factors, temporal trends, and outcomes were assessed using regression models. Missing data were addressed using multiple imputation.


Twenty-six thousand eight hundred twenty-seven patients met the inclusion criteria. There were 16,953 pancreas cases (distal pancreatectomy (31.2 %), pancreaticoduodenectomy (65.8 %), total pancreatectomy (3.0 %)), and 9,874 liver cases (wedge resection (60.0 %), hemi-hepatectomy (30.1 %), trisegmentectomy (9.9 %)). Overall, 25.7 % patients received a perioperative transfusion. Transfusion rates varied by operation type (hepatic wedge resection 18.7 %, lobectomy 31.3 %, trisegmentectomy 39.8 %, distal pancreatectomy 19.8 %, Whipple 28.7 %, total pancreatectomy 43.6 %, p < 0.001). On multivariate analysis, several patient-level factors were strongly associated with the risk of transfusion: preoperative hematocrit <36 % (risk ratios (RR) 1.99, 95 % CI 1.91–2.08), preoperative albumin <3.0 g/dL (RR 1.25, 95 % CI 1.19–1.31), American Society of Anesthesiologists (ASA) class IV (RR 1.24, 95 % CI 1.16–1.33), and anticoagulation/bleeding disorder (RR 1.26, 95 % CI 1.15–1.38) (all p < 0.001). Patients with any one of these high-risk factors had an over twofold increased risk of perioperative transfusion (RR 2.31, 95 % CI 2.21–2.40, p < 0.001).


There are large differences in the incidence of transfusion among patients undergoing HPB procedures. While the type of HPB procedure was associated with the risk of transfusion, patient-level factors—including preoperative hematocrit and albumin, ASA classification, and history of anticoagulation/bleeding disorder—were as important.


Transfusion HPB Surgery Pancreas Liver 



The views expressed in this paper are those of the authors and do not represent the official policy of the US Navy, Department of Defense, or US Government.


  1. 1.
    Schneider EB, Hyder O, Wolfgang CL, et al. Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies. J Am Coll Surg. 2012, Nov;215(5):607–15.PubMedCrossRefGoogle Scholar
  2. 2.
    Crist DW, Sitzmann JV, and Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg. 1987, Sep;206(3):358–65.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Aloia TA, Fahy BN, Fischer CP, et al. Predicting poor outcome following hepatectomy: analysis of 2313 hepatectomies in the NSQIP database. HPB (Oxford). 2009, Sep;11(6):510–5.PubMedCentralCrossRefGoogle Scholar
  4. 4.
    Kneuertz PJ, Pitt HA, Bilimoria KY, et al. Risk of morbidity and mortality following hepato-pancreato-biliary surgery. J Gastrointest Surg. 2012, Sep;16(9):1727–35.PubMedCrossRefGoogle Scholar
  5. 5.
    Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol. 2011, Aug;18(8):2126–35.PubMedCrossRefGoogle Scholar
  6. 6.
    Compatibility testing. In: Rudmann SV. Textbook of blood banking and transfusion medicine. Saunders; 2005.Google Scholar
  7. 7.
    Nuttall A, Santrach J, Oliver C, et al. A prospective randomized trial of the surgical blood order equation for ordering red cells for total hip arthroplasty patients. Transfusion. 1998, Sep;38(9):828–833.PubMedCrossRefGoogle Scholar
  8. 8.
    Becker J and Shaz B. Guidelines for patient blood management and blood utilization. American Association of Blood Banks, 2011.Google Scholar
  9. 9.
    Friedman BA. An analysis of surgical blood use in United States hospitals with application to the maximum surgical blood order schedule. Transfusion. 1979;19(3):268–78.PubMedCrossRefGoogle Scholar
  10. 10.
    Frank SM, Rothschild JA, Masear CG, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013; 118:1286–1297.PubMedCrossRefGoogle Scholar
  11. 11.
    Palmer T, Wahr JA, O’Reilly M, and Greenfield ML. Reducing unnecessary crossmatching: a patient-specific blood ordering system is more accurate in predicting who will receive a blood transfusion than the maximum blood ordering system. Anesth Analg. 2003, Feb;96(2):369–75.PubMedGoogle Scholar
  12. 12.
    Henderson WG, Daley J. Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg 2009;198:S19-27.PubMedCrossRefGoogle Scholar
  13. 13.
    Cohen ME, Ko CY, Bilimoria KY, et al. Optimizing ACS NSQIP Modeling for evaluation of surgical quality and risk: Patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg. 2013 Apr;26. In press.Google Scholar
  14. 14.
    User Guide for the 2011 Participant Use Data File. American College of Surgeons National Surgical Quality Improvement Program. Chicago, IL: American College of Surgeons; October 2012.Google Scholar
  15. 15.
    Zou G. A modified Poisson regression approach to prospective studies with binary data. American Journal of Epidemiology. 2004, Apr 1;159(7):702–706.PubMedCrossRefGoogle Scholar
  16. 16.
    Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747–51.PubMedCrossRefGoogle Scholar
  17. 17.
    Ho CK, Kleeff J, Friess H, and Büchler MW. Complications of pancreatic surgery. HPB (Oxford). 2005;7(2):99–108.PubMedCentralCrossRefGoogle Scholar
  18. 18.
    Ball CG, Pitt HA, Kilbane ME, Dixon E, Sutherland FR, and Lillemoe KD. Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy. HPB (Oxford). 2010, Sep;12(7):465–71.CrossRefGoogle Scholar
  19. 19.
    Sakurai Y, and Okada C. Comparison by simulation of the efficiency of surgical blood order equation (SBOE) with that of maximum surgical blood order schedule (MSBOS). Masui. 2001, Jan;50(1):69–75.PubMedGoogle Scholar
  20. 20.
    Sun RC, Button AM, Smith BJ, Leblond RF, Howe JR, and Mezhir JJ. A comprehensive assessment of transfusion in elective pancreatectomy: risk factors and complications. J Gastrointest Surgery 2013. Apr 17;(4):627–35CrossRefGoogle Scholar
  21. 21.
    Kooby DA, Stockman J, Ben-Porat L, et al. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg. 2003, Jun;237(6):860–9; discussion 869–70.PubMedCentralPubMedGoogle Scholar
  22. 22.
    Burrows L, and Tartter P. Effect of blood transfusions on colonic malignancy recurrent rate. Lancet. 1982, Sep 18;2(8299):662.PubMedCrossRefGoogle Scholar
  23. 23.
    Weiden PL, Bean MA, and Schultz P. Perioperative blood transfusion does not increase the risk of colorectal cancer recurrence. Cancer. 1987, Aug 15;60(4):870–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Foster RS, Foster JC, and Costanza MC. Blood transfusions and survival after surgery for breast cancer. Arch Surg. 1984, Oct;119(10):1138–40.PubMedCrossRefGoogle Scholar
  25. 25.
    Kampschöer GH, Maruyama K, Sasako M, Kinoshita T, and van de Velde CJ. The effects of blood transfusion on the prognosis of patients with gastric cancer. World J Surg. 1989;13(5):637–43.PubMedCrossRefGoogle Scholar
  26. 26.
    McAlister FA, Clark HD, Wells PS, and Laupacis A. Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies. Br J Surg. 1998, Feb;85(2):171–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999, Feb 11;340(6):409–17.PubMedCrossRefGoogle Scholar
  28. 28.
    Shander A, Fink A, Javidroozi M, et al. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Trans Med Rev 2011;25(3):232–46.CrossRefGoogle Scholar
  29. 29.
    Participant list, American College of Surgeons National Surgical Quality Improvement Program. American College of Surgeons; 2013. Accessed May 28, 2013.
  30. 30.
    Gammon HM, Waters JH, Watt A, Loeb JM, and Donini-Lenhoff A. Developing performance measures for patient blood management. Transfusion. 2011, Nov;51(11):2500–9.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Donald J. Lucas
    • 1
  • Katherine I. Schexneider
    • 2
  • Matthew Weiss
    • 3
  • Christopher L. Wolfgang
    • 3
  • Steven M. Frank
    • 4
  • Kenzo Hirose
    • 3
  • Nita Ahuja
    • 3
  • Martin Makary
    • 3
  • John L. Cameron
    • 3
    • 5
  • Timothy M. Pawlik
    • 3
    • 5
  1. 1.Department of SurgeryWalter Reed National Military Medical CenterBethesdaUSA
  2. 2.Department of PathologyUniformed Services University of the Health SciencesBethesdaUSA
  3. 3.Department of SurgeryThe Johns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Department of Anesthesiology/Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreUSA
  5. 5.Division of Surgical OncologyJohn Hopkins HospitalBaltimoreUSA

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