Int J Colorectal Dis DOI 10.1007/s00384-014-1854-6
ORIGINAL ARTICLE
Predictive factors for perioperative blood transfusions in laparoscopic colorectal surgery Yasmin Abu-Ghanem & Hussein Mahajna & Ronen Ghinea & Ian White & Roy Inbar & Shmuel Avital
Accepted: 31 March 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Background Allogeneic perioperative blood transfusion (PBT) has been associated with higher rates of postoperative complications in patients undergoing colorectal surgery and increased tumor recurrence in cancer patients. Our aim is to evaluate possible predictive factors for PBT, specifically, in patients undergoing laparoscopic colorectal surgery, in order to identify patients who could benefit from alternatives to allogenic PBT such as erythropoietin administration, autologous blood transfusion, and possibly preoperative blood transfusion. Methods Five hundred patients who underwent laparoscopic colorectal surgery between the years 2003 and 2011 were reviewed. Patient demographics and clinicopathologic variables were collected prospectively. Other clinical data were collected directly from the computerized records of the inhospital blood bank. PBT was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. The associations between PBT and patient variables were assessed by univariate and multivariate analyses. Results Of the 500 patients, 134 patients (26.8 %) received PBT. Multivariate analysis revealed four preoperative variables as significant risk factors for PBT: preoperative hemoglobin (P=0.001), lower rectal surgery (P=0.009), Charlson comorbidity score (P=0.001), and malignancy (P=0.024).
Yasmin Abu-Ghanem and Hussein Mahajna contributed equally to this work. Y. Abu-Ghanem (*) : H. Mahajna : R. Ghinea : I. White : R. Inbar : S. Avital Department of Surgery B, Meir Medical Center, Kfar Saba, Israel e-mail: [email protected] S. Avital Assuta Medical Center, Tel Aviv, Israel
Conclusions Preoperative Charlson score, hemoglobin level, carcinoma, and lower rectum pathologies were found to be independent risk factors for PBT in patients undergoing laparoscopic colorectal surgery. Evaluation of these risk factors prior to surgery may be helpful in selecting the patients who could benefit from possible alternatives to perioperative allogeneic blood transfusion and help constitute guidelines for a more responsible use of these alternatives. Keywords Predictive factors . Perioperative blood transfusions . Colorectal . Laparoscopy
Introduction Perioperative allogeneic red blood cell transfusions (PBT) have been shown to potentially increase peri- and postoperative morbidity and mortality [1–3]. Apart from the small risk of transfusion-transmitted viral infections and increased infectious complications [4], allogenic PBT has been postulated to increase the risk of both postoperative infectious complications and tumor recurrence after colorectal cancer surgery [5–11]. While multiple hypotheses regarding the biologic activity of PBT including host immunomodulation and growth factor delivery from red blood cells have been offered, no definitive mechanistic link has been established [9–12]. Over the past years, several attempts were made to decrease the use of allogeneic blood transfusion, including predeposited autologous blood transfusion, recombinant human erythropoietin administration, or a more recent approach, preoperative autologous blood transfusion rather than perioperative for correcting anemia [13–16]. With many reports suggesting that allogeneic blood transfusion is associated with adverse outcome, knowledge of the preoperative risk factors for PBT in colorectal surgery may be obliging in selecting the patients who could benefit from these alternative methods.
Int J Colorectal Dis
Several studies have identified some of the predictive factors for PBT in open colorectal surgery including age, body mass index, and preoperative hemoglobin [7, 8, 17, 18]. In recent years, laparoscopic colorectal surgery has become a popular approach for colorectal diseases due to its perioperative advantages. Furthermore, laparoscopic surgery has been reported to be associated with less blood loss and a reduced need for blood transfusion. Thus, in our study, risk factors for PBT were specifically evaluated in patients undergoing laparoscopic colorectal surgery.
Patients and methods Data included all patients who underwent laparoscopic colorectal surgery in Tel Aviv Medical Center and Asuta Medical Center between the years 2003 and 2011. All resections were performed by colorectal surgeons with interest in laparoscopic surgery. All operations were performed in the same surgical environment (two surgeons operating in both medical centers). Patient demographics and operative details were collected prospectively. Other clinical data was collected directly from the computerized records of the in-hospital blood bank. Clinicopathologic variables recorded included age, gender, Charlson comorbidity score, preoperative hemoglobin level, weight, receipt of PBT and number of units transfused, surgery indications, tumor stage for malignant etiology, and pathology location. Perioperative blood transfusion was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. Transfusion with other blood products was not recorded. Notably, administration of PBT was based on the discretion of the treating physicians. All patients with symptomatic anemia regardless of hemoglobin level or patients with coronary artery disease and hemoglobin levels below 10 g/dL received PBT. No other institutional standardized intraoperative or postoperative thresholds were used for transfusion. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS, Version 17.0, Chicago, IL, USA). Student’s t test was used for the analysis of continuous variables and the chi-square test was used for the analysis of categorical variables. The Cox proportional hazards regression model was used for multivariate analysis models. A P value of less than 0.05 was considered statistically significant.
malignant etiology (stages I–IV). One hundred and four (20.8 %) were operated for polyps, 46 (9.2 %) for diverticulosis, 27 (5.4 %) for Crohn’s disease, and the remaining 8.2 % for other indications. One hundred and thirty-four of the 500 patients (26.8 %) received PBT. The average number of blood units given to patients who received blood transfusions was 2.3 (range 1 to 8 U, Table 1). Univariate analysis revealed five variables to be associated with an increased risk of PBT (Table 2). As can be seen, patients receiving blood transfusion were significantly older (P
ORIGINAL ARTICLE
Predictive factors for perioperative blood transfusions in laparoscopic colorectal surgery Yasmin Abu-Ghanem & Hussein Mahajna & Ronen Ghinea & Ian White & Roy Inbar & Shmuel Avital
Accepted: 31 March 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Background Allogeneic perioperative blood transfusion (PBT) has been associated with higher rates of postoperative complications in patients undergoing colorectal surgery and increased tumor recurrence in cancer patients. Our aim is to evaluate possible predictive factors for PBT, specifically, in patients undergoing laparoscopic colorectal surgery, in order to identify patients who could benefit from alternatives to allogenic PBT such as erythropoietin administration, autologous blood transfusion, and possibly preoperative blood transfusion. Methods Five hundred patients who underwent laparoscopic colorectal surgery between the years 2003 and 2011 were reviewed. Patient demographics and clinicopathologic variables were collected prospectively. Other clinical data were collected directly from the computerized records of the inhospital blood bank. PBT was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. The associations between PBT and patient variables were assessed by univariate and multivariate analyses. Results Of the 500 patients, 134 patients (26.8 %) received PBT. Multivariate analysis revealed four preoperative variables as significant risk factors for PBT: preoperative hemoglobin (P=0.001), lower rectal surgery (P=0.009), Charlson comorbidity score (P=0.001), and malignancy (P=0.024).
Yasmin Abu-Ghanem and Hussein Mahajna contributed equally to this work. Y. Abu-Ghanem (*) : H. Mahajna : R. Ghinea : I. White : R. Inbar : S. Avital Department of Surgery B, Meir Medical Center, Kfar Saba, Israel e-mail: [email protected] S. Avital Assuta Medical Center, Tel Aviv, Israel
Conclusions Preoperative Charlson score, hemoglobin level, carcinoma, and lower rectum pathologies were found to be independent risk factors for PBT in patients undergoing laparoscopic colorectal surgery. Evaluation of these risk factors prior to surgery may be helpful in selecting the patients who could benefit from possible alternatives to perioperative allogeneic blood transfusion and help constitute guidelines for a more responsible use of these alternatives. Keywords Predictive factors . Perioperative blood transfusions . Colorectal . Laparoscopy
Introduction Perioperative allogeneic red blood cell transfusions (PBT) have been shown to potentially increase peri- and postoperative morbidity and mortality [1–3]. Apart from the small risk of transfusion-transmitted viral infections and increased infectious complications [4], allogenic PBT has been postulated to increase the risk of both postoperative infectious complications and tumor recurrence after colorectal cancer surgery [5–11]. While multiple hypotheses regarding the biologic activity of PBT including host immunomodulation and growth factor delivery from red blood cells have been offered, no definitive mechanistic link has been established [9–12]. Over the past years, several attempts were made to decrease the use of allogeneic blood transfusion, including predeposited autologous blood transfusion, recombinant human erythropoietin administration, or a more recent approach, preoperative autologous blood transfusion rather than perioperative for correcting anemia [13–16]. With many reports suggesting that allogeneic blood transfusion is associated with adverse outcome, knowledge of the preoperative risk factors for PBT in colorectal surgery may be obliging in selecting the patients who could benefit from these alternative methods.
Int J Colorectal Dis
Several studies have identified some of the predictive factors for PBT in open colorectal surgery including age, body mass index, and preoperative hemoglobin [7, 8, 17, 18]. In recent years, laparoscopic colorectal surgery has become a popular approach for colorectal diseases due to its perioperative advantages. Furthermore, laparoscopic surgery has been reported to be associated with less blood loss and a reduced need for blood transfusion. Thus, in our study, risk factors for PBT were specifically evaluated in patients undergoing laparoscopic colorectal surgery.
Patients and methods Data included all patients who underwent laparoscopic colorectal surgery in Tel Aviv Medical Center and Asuta Medical Center between the years 2003 and 2011. All resections were performed by colorectal surgeons with interest in laparoscopic surgery. All operations were performed in the same surgical environment (two surgeons operating in both medical centers). Patient demographics and operative details were collected prospectively. Other clinical data was collected directly from the computerized records of the in-hospital blood bank. Clinicopathologic variables recorded included age, gender, Charlson comorbidity score, preoperative hemoglobin level, weight, receipt of PBT and number of units transfused, surgery indications, tumor stage for malignant etiology, and pathology location. Perioperative blood transfusion was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. Transfusion with other blood products was not recorded. Notably, administration of PBT was based on the discretion of the treating physicians. All patients with symptomatic anemia regardless of hemoglobin level or patients with coronary artery disease and hemoglobin levels below 10 g/dL received PBT. No other institutional standardized intraoperative or postoperative thresholds were used for transfusion. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS, Version 17.0, Chicago, IL, USA). Student’s t test was used for the analysis of continuous variables and the chi-square test was used for the analysis of categorical variables. The Cox proportional hazards regression model was used for multivariate analysis models. A P value of less than 0.05 was considered statistically significant.
malignant etiology (stages I–IV). One hundred and four (20.8 %) were operated for polyps, 46 (9.2 %) for diverticulosis, 27 (5.4 %) for Crohn’s disease, and the remaining 8.2 % for other indications. One hundred and thirty-four of the 500 patients (26.8 %) received PBT. The average number of blood units given to patients who received blood transfusions was 2.3 (range 1 to 8 U, Table 1). Univariate analysis revealed five variables to be associated with an increased risk of PBT (Table 2). As can be seen, patients receiving blood transfusion were significantly older (P
