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Fewer blood transfusions used for major oncologic abdominal surgery
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Fewer perioperative blood transfusions have occurred for oncologic abdominal surgery over the last 9 years, according to results of a retrospective review of a population-based registry.
“The relative risks and benefits of allogeneic blood transfusion are particularly complex for the oncological surgery patient,” Giorgos C. Karakousis, MD, FACS, assistant professor of surgery at the Hospital at the University of Pennsylvania and chair of the cancer committee at the Abramson Cancer Center in the Perelman School of Medicine, and colleagues wrote. “Transfusion-related immunomodulation has been recognized for more than 30 years, when it was observed that renal allograft survival was improved with preoperative blood transfusion. Whether the immunosuppressive effects of allogeneic transfusion are associated with an increased risk of cancer recurrence has not been definitely established, although associations in a variety of abdominal malignant tumors have been observed.”
Giorgos C. Karakousis
Because there has been a push for more careful use of blood transfusions due to their association with morbidity, Karakousis and colleagues sought to evaluate the trends in transfusion rates for major abdominal surgeries to assess the changes in clinical practice.
The researchers evaluated data from the American College of Surgeons National Surgical Quality Improvement Project to identify 19,680 patients aged 18 years or older (median age, 65 years; range, 57-73 years) who underwent one to three cancer operations between 2005 and 2013.
Transfusion of any quantity of packed red blood cells served as the study’s primary measure. Secondary outcomes included the rate of wound infections, renal insufficiency or myocardial infarction (MI).
A total of 5,900 (30%) patients received a blood transfusion, which included 4,074 (29.8%) of the patients who had pancreatic surgery, 378 (23.6%) of those who had a gastric resection and 1,448 (32.8%) patients who underwent a hepatic resection.
The researchers identified a significant decreasing rate of transfusion during the 9-year study period (z = –7.89; P < .001), which equated to an absolute 6.1% decrease in the transfusion rate from 2005 to 2013 (32.8% to 26.7%).
This decreased appeared primarily driven by the reduction in use of blood transfusion during a pancreatectomy (z = –7.63; P < .001), which dropped 8.9% during the study period. There also were significant decreases in the use of a blood transfusion for total gastrectomy (z = –2.5; P = .01) — which dropped 6% from 2005 to 2013 — and major hepatic resection (z = -3.6; P < .001), which decreased 11.7% between 2006 and 2012.
Researchers observed no significant change in the rate of renal insufficiency or wound infection postoperatively during the study period; however, there was an increase in perioperative MI (0.33% absolute increase; z = 3.15; P = .002).
“The precise etiology of these trends is likely multifactorial,” Karakousis and colleagues wrote. “One possibility is that changes in operative and anesthetic techniques are resulting in improved perioperative outcomes. Given that the vast majority of transfusions in this cohort occurred on the day of the procedure, we suspect that safer surgery is a strong driver of this trend.”
The researchers also suggested that this trend could be attributable to an increasing number of major surgeries being performed at high-volume hospital centers or to the growing concern among clinicians of the morbid effects of transfusion, which has led to a stricter transfusion threshold.
Researchers acknowledged the changes in transfusion rates may be indicative of changes in hospital participation in the program used for data analysis. In other words, hospitals that performed many transfusions could have dropped out of the program, and hospitals with fewer transfusions may have been added. Also, trends in the coding process have changed, which could have introduced bias in the trends.
Karl Y. Bilimoria
In an accompanying editorial, David D. Odell, MD, MMSc, assistant professor in thoracic surgery, and Karl Y. Bilimoria, MD, MS, the John Benjamin Murphy professor of surgery, both at Northwestern University in Chicago, wrote that the results from this study are encouraging, although the heterogeneity of the study population requires additional research to assess the appropriateness of blood transfusions for surgical patients.
“Understanding the precise indication for transfusion is important in developing targeted interventions,” they wrote. “Better data are needed to understand the relationship between pretransfusion hemoglobin, appropriate transfusion and the number of units transfused when considering how to best develop criteria for appropriate transfusion of blood in surgical patients.” – by Anthony SanFilippo
Disclosure: The researchers, Odell and Bilimoria report no relevant financial disclosures.
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