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Falsetto A, Roffey DM, Jabri H, Kingwell SP, Stratton A, Phan P, Wai EK. Allogeneic blood transfusions and infection risk in lumbar spine surgery: An American College of Surgeons National Surgery Quality Improvement Program Study. Transfusion 2022; 62:1027-1033. [PMID: 35338708 DOI: 10.1111/trf.16864] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/29/2022] [Accepted: 02/27/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Allogenic blood transfusions can lead to immunomodulation. Our purpose was to investigate whether perioperative transfusions were associated with postoperative infections and any other adverse events (AEs), after adjusting for potential confounding factors, following common elective lumbar spinal surgery procedures. STUDY DESIGN AND METHODS We performed a multivariate, propensity-score matched, regression-adjusted retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database between 2012 and 2016. All lumbar spinal surgery procedures were identified (n = 174,891). A transfusion group (perioperative transfusion within 72 h before, during, or after principal surgery; n = 1992) and a control group (no transfusion; n = 1992) were formed. Following adjustment for between-group baseline features, adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated using a multivariate logistic regression model for any surgical site infection (SSI), superficial SSI, deep SSI, wound dehiscence, pneumonia, urinary tract infection, sepsis, any infection, mortality, and any AEs. RESULTS Transfusion was associated with an increased risk of each specific infection, mortality, and any AEs. Statistically significant between-group differences were demonstrated with respect to any SSI (aOR: 1.48; 95% CI: 1.01-2.16), deep SSI (aOR: 1.66; 95% CI: 0.98-2.85), sepsis (aOR: 2.69; 95% CI: 1.43-5.03), wound dehiscence (aOR: 2.27; 95% CI: 0.86-6.01), any infection (aOR: 1.46; 95% CI: 1.13-1.88), any AEs (aOR: 1.80; 95% CI: 1.48-2.18), and mortality (aOR: 2.17; 95% CI: 0.77-6.36). CONCLUSION We showed an association between transfusion and infection in lumbar spine surgery after adjustment for various applicable covariates. Sepsis had the highest association with transfusion. Our results reinforce a growing trend toward minimizing perioperative transfusions, which may lead to reduced infections following lumbar spine surgery.
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Affiliation(s)
- Amedeo Falsetto
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Darren M Roffey
- uOttawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Hussam Jabri
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,uOttawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of Neurosurgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephen P Kingwell
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,uOttawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexandra Stratton
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,uOttawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Philippe Phan
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,uOttawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Eugene K Wai
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,uOttawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Stephens J, Tano R. Hemoglobin matters: Perioperative blood management for oncology patients. Can Oncol Nurs J 2021; 31:399-404. [PMID: 34786458 DOI: 10.5737/23688076314399404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
As the number of cancer cases rise each year in Canada, so does the number of surgical oncology cases. Surgery presents a unique and heightened stressor for the body already experiencing volatility from factors such as disease and treatments. Perioperative red blood cell (RBC) transfusions are critical to stabilize hemoglobin levels and correct anemia, as well as provide a buffer against anticipated intraoperative blood loss. Thoroughly examining and anticipating risk factors related to the potential need for perioperative blood transfusions is necessary to improve outcomes. Research evidence in recent years related to perioperative blood management of oncology patients has specifically recommended active, coordinated programs to reduce the need and amount of blood transfusions administered pre-, intra-, and post-surgery. Coordination between surgical oncologists and a local or provincial patient blood management (PBM) program is an important strategy that allows patients at risk of perioperative complications to be identified and receive early interventions and ongoing observation.
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Affiliation(s)
- Jennifer Stephens
- Assistant Professor and BN Program Director, Faculty of Health Disciplines, Athabasca University, Athabasca, AB
| | - Ruby Tano
- Patient Blood Management Coordinator, Patient Blood Management Program, Sunnybrook Health Sciences Centre, Toronto, ON
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Stephens J, Tano R. L’importance de l’hémoglobine : gestion périopératoire du sang pour les patients en oncologie. Can Oncol Nurs J 2021; 31:405-411. [PMID: 34786459 DOI: 10.5737/23688076314405411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Au Canada, le nombre de cas de cancer augmente chaque année et, par conséquent, le nombre de patients en oncologie qui subissent une opération. La chirurgie cause un stress particulièrement intense à l’organisme déjà fragilisé par la maladie et les traitements. Les transfusions périopératoires de globules rouges sont essentielles pour stabiliser le taux d’hémoglobine et soigner l’anémie, ainsi que pour gérer la perte de sang attendue pendant l’opération. Il est nécessaire d’examiner en profondeur et d’anticiper les facteurs de risque associés aux transfusions sanguines périopératoires pour améliorer le devenir des patients. Ces dernières années, la recherche sur la gestion périopératoire du sang des patients en oncologie recommande tout spécialement la création de programmes d’intervention coordonnés pour réduire la nécessité et le nombre de transfusions sanguines administrées avant, pendant et après l’opération. Pour recenser les patients à risque de complications périopératoires et leur faire bénéficier d’interventions rapides et d’une observation continue, la bonne stratégie est de mettre en lien les chirurgiens oncologues avec un programme local ou provincial de conservation du sang.
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Affiliation(s)
- Jennifer Stephens
- Professeure adjointe et Associate Dean Undergraduate Programs, Faculté des disciplines de la santé, Université d'Athabasca, Athabasca, Alberta
| | - Ruby Tano
- Coordonnatrice de la gestion du sang des patients, Programme de gestion du sang des patients, Centre des sciences de la santé Sunnybrook, Toronto, Ontario
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Kanda T, Wakiya T, Ishido K, Kimura N, Nagase H, Kubota S, Fujita H, Hagiwara Y, Hakamada K. Intraoperative Allogeneic Red Blood Cell Transfusion Negatively Influences Prognosis After Radical Surgery for Pancreatic Cancer: A Propensity Score Matching Analysis. Pancreas 2021; 50:1314-1325. [PMID: 34860818 DOI: 10.1097/mpa.0000000000001913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE We aimed to investigate the real impact of allogeneic red blood cell transfusion (ABT) on postoperative outcomes in resectable pancreatic ductal adenocarcinoma (PDAC) patients. METHODS Of 128 patients undergoing resectable PDAC surgery at our facility, 24 (18.8%) received ABT. Recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ABT. RESULTS In the entire cohort, ABT was significantly associated with decreased RFS (P = 0.002) and DSS (P = 0.014) before PSM. Cox regression analysis identified ABT (risk ratio, 1.884; 95% confidence interval, 1.015-3.497; P = 0.045) as an independent prognostic factor for RFS. Univariate and multivariate analysis identified preoperative hemoglobin value, preoperative total bilirubin value, and intraoperative blood loss as significant independent risk factors for ABT. Using these 3 variables, PSM analysis created 16 pairs of patients. After PSM, the ABT group had significantly poorer RFS rates than the non-ABT group (median, 9.8 vs 15.8 months, P = 0.022). Similar tendencies were found in DSS rates (median, 19.4 vs 40.0 months, P = 0.071). CONCLUSIONS This study revealed certain negative effects of intraoperative ABT on postoperative survival outcomes in patients with resectable PDAC.
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Affiliation(s)
- Taishu Kanda
- From the Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Nakanishi K, Kanda M, Kodera Y. Long-lasting discussion: Adverse effects of intraoperative blood loss and allogeneic transfusion on prognosis of patients with gastric cancer. World J Gastroenterol 2019; 25:2743-2751. [PMID: 31235997 PMCID: PMC6580348 DOI: 10.3748/wjg.v25.i22.2743] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 03/29/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrectomy with radical lymph node dissection is the most promising treatment avenue for patients with gastric cancer. However, this procedure sometimes induces excessive intraoperative blood loss and requires perioperative allogeneic blood transfusion. There are lasting discussions and controversies about whether intraoperative blood loss or perioperative blood transfusion has adverse effects on the prognosis in patients with gastric cancer. We reviewed laboratory and clinical evidence of these associations in patients with gastric cancer. A large amount of clinical evidence supports the correlation between excessive intraoperative blood loss and adverse effects on the prognosis. The laboratory evidence revealed three possible causes of such adverse effects: anti-tumor immunosuppression, unfavorable postoperative conditions, and peritoneal recurrence by spillage of cancer cells into the pelvis. Several systematic reviews and meta-analyses have suggested the adverse effects of perioperative blood transfusions on prognostic parameters such as all-cause mortality, recurrence, and postoperative complications. There are two possible causes of adverse effects of blood transfusions on the prognosis: Anti-tumor immunosuppression and patient-related confounding factors (e.g., preoperative anemia). These factors are associated with a worse prognosis and higher requirement for perioperative blood transfusions. Surgeons should make efforts to minimize intraoperative blood loss and transfusions during gastric cancer surgery to improve patients’ prognosis.
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Affiliation(s)
- Koki Nakanishi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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Grasso M, Pacella G, Sangiuliano N, De Palma M, Puzziello A. Gastric cancer surgery: clinical outcomes and prognosis are influenced by perioperative blood transfusions. Updates Surg 2019; 71:439-443. [PMID: 30659478 DOI: 10.1007/s13304-019-00622-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/02/2019] [Indexed: 12/19/2022]
Abstract
Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient's clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a total or a subtotal gastrectomy accompanied by D2 lymphectomy for gastric cancer. The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87-5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87-5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70-10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73-83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.
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Affiliation(s)
- Marica Grasso
- Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84080, Baronissi, Salerno, Italy.
| | - Giulia Pacella
- Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84080, Baronissi, Salerno, Italy
| | | | | | - Alessandro Puzziello
- Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84080, Baronissi, Salerno, Italy
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Liu X, Ma M, Huang H, Wang Y. Effect of perioperative blood transfusion on prognosis of patients with gastric cancer: a retrospective analysis of a single center database. BMC Cancer 2018; 18:649. [PMID: 29890957 PMCID: PMC5996555 DOI: 10.1186/s12885-018-4574-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/01/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The association between perioperative blood transfusion and the prognosis of patients with gastric cancer is still unclear. METHODS A total of 1581 patients with gastric cancer who underwent curative gastrectomy from 2000 to 2008 were evaluated. Perioperative blood transfusion was defined as the transfusion of packed red blood cells within seven days before surgery, during surgery, or within the postoperative hospitalization period. The association between perioperative blood transfusion and prognosis was evaluated using univariate and multivariate Cox regression analyses. RESULTS Of 1581 patients, 298 patients (19%) received perioperative blood transfusion. Perioperative blood transfusion correlated with older age (P < 0.001); larger tumor size (P < 0.001); and more advanced stage (P < 0.001). Five-year survival rate was 40% in patients who had perioperative blood transfusion and 55% patients who did not have perioperative blood transfusion, and the difference was statistically significant (P < 0.001). Multivariate analysis showed that perioperative blood transfusion was defined as independent prognostic factor. Perioperative blood transfusion was associated with worse outcomes in patients with stage III (P < 0.001). CONCLUSIONS Perioperative blood transfusion independently correlated with poorer prognosis in patients with gastric cancer.
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Affiliation(s)
- Xiaowen Liu
- Department of Gastric Cancer Surgery, Fudan University Shanghai Cancer Center, 270 Dong An Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Mingze Ma
- Department of Gastric Cancer Surgery, Fudan University Shanghai Cancer Center, 270 Dong An Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Hua Huang
- Department of Gastric Cancer Surgery, Fudan University Shanghai Cancer Center, 270 Dong An Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
| | - Yanong Wang
- Department of Gastric Cancer Surgery, Fudan University Shanghai Cancer Center, 270 Dong An Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032 China
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Kerin Povšič M, Ihan A, Beovič B. Post-Operative Infection Is an Independent Risk Factor for Worse Long-Term Survival after Colorectal Cancer Surgery. Surg Infect (Larchmt) 2016; 17:700-712. [PMID: 27487109 DOI: 10.1089/sur.2015.187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Colorectal cancer surgery is associated with a high incidence of post-operative infections, the outcome of which may be improved if diagnosed and treated early enough. We compared white blood cell (WBC) count, C-reactive protein (CRP), and procalcitonin (PCT) as predictors of post-operative infections and analyzed their impact on long-term survival. METHODS This retrospective study included 186 patients undergoing colorectal surgery. Post-operative values of WBC, CRP, and PCT were analyzed by the receiver operating characteristic (ROC) analysis. We followed infections 30 d after the surgery. A five-year survival was analyzed by Kaplan-Meier method and prognostic factors by Cox regression model. RESULTS Fifty-five patients (29.5%) developed post-operative infection, the most frequent of which was surgical site infection (SSI). C-reactive protein on post-operative day three and PCT on post-operative day two demonstrated the highest diagnostic accuracy for infection (area under the curve [AUC] 0.739 and 0.735). C-reactive protein on post-operative day three was an independent predictor of infection. Five-year survival was higher in the non-infected group (70.8%), compared with the infected group (52.1%). The worst survival (40.9%) was identified in patients with organ/space SSI. Post-operative infection and tumor stage III-IV were independent predictors of a worse five-year survival. CONCLUSIONS C-reactive protein on post-operative day three and PCT on post-operative day two may be early predictors of infection after colorectal cancer surgery. Post-operative infections in particular organ/space SSI have a negative impact on long-term survival.
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Affiliation(s)
| | - Alojz Ihan
- 2 Institute of Microbiology and Immunology, Ljubljana, Slovenia
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Xue L, Chen XL, Wei-Han Z, Yang K, Chen XZ, Zhang B, Chen ZX, Chen JP, Zhou ZG, Hu JK. Impact of Perioperative Blood Transfusion on Postoperative Complications and Prognosis of Gastric Adenocarcinoma Patients with Different Preoperative Hemoglobin Value. Gastroenterol Res Pract 2015; 2016:6470857. [PMID: 26819609 PMCID: PMC4706942 DOI: 10.1155/2016/6470857] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/15/2015] [Accepted: 09/15/2015] [Indexed: 02/05/2023] Open
Abstract
Background. The impact of perioperative blood transfusion on the prognosis of gastric adenocarcinoma patients is still controversial. The aim of this study was to elucidate the impact of perioperative blood transfusion on postoperative complications and prognosis of patients who underwent gastrectomy for gastric adenocarcinoma with different levels of preoperative hemoglobin value (POHb). Method. From 2003 to 2011, 1199 patients who underwent curative gastrectomy were retrospectively enrolled and followed up to December 2014. Clinicopathological features and survival outcomes were compared between transfused and nontransfused patients. Results. In this study, transfused patients had more postoperative complications than nontransfused ones (P = 0.002). In survival analysis, the difference was not significant between transfused and nontransfused patients with POHb between 70 and 100 g/L (P = 0.191). However, in patients with POHb >100 g/L, transfused patients had significantly worse prognosis (P < 0.001), especially in TNM III stage patients (P = 0.002). And intraoperative blood transfusion predicted poor prognosis (P = 0.001). Conclusion. Perioperative blood transfusion might lead to poor survival in gastric adenocarcinoma patients with POHb >100 g/L and transfused patients had more postoperative complications; thus it is better to refrain from unnecessary perioperative blood transfusion especially intraoperative transfusion.
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Affiliation(s)
- Lian Xue
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Xiao-Long Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Zhang Wei-Han
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Kun Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Xin-Zu Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Zhi-Xin Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Jia-Ping Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Zong-Guang Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Digestive Surgery, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
| | - Jian-Kun Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
- Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, China
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Janssen SJ, Braun Y, Ready JE, Raskin KA, Ferrone ML, Hornicek FJ, Schwab JH. Are Allogeneic Blood Transfusions Associated With Decreased Survival After Surgery for Long-bone Metastatic Fractures? Clin Orthop Relat Res 2015; 473:2343-51. [PMID: 25637400 PMCID: PMC4457741 DOI: 10.1007/s11999-015-4167-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/21/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have shown that perioperative blood transfusion increases cancer recurrence and decreases patient survival after resection of primary malignancies. The question arises whether this association also exists in patients with already disseminated disease undergoing surgery for metastatic long-bone fractures. PURPOSES We sought to determine whether perioperative allogeneic blood transfusion is associated with decreased survival after operative treatment of long-bone metastatic fractures after accounting for clinical, laboratory, and treatment factors. Secondarily, we aimed to identify potential factors that are associated with decreased survival. METHODS We included 789 patients in our retrospective study who underwent surgery at two institutions for a pathologic or impending metastatic long-bone fracture. We used multivariable Cox proportional hazards regression model analysis to assess the relationship of perioperative allogeneic blood transfusion with survival, and accounted for patient age, sex, comorbidities, BMI, tumor type, fracture type and location, presence of other bone and visceral metastases, previous radiotherapy and systemic therapy, preoperative embolization, preoperative hemoglobin level, treatment type, anesthesia time, blood loss, duration of hospital admission, year of surgery, and hospital. RESULTS Considering transfusion as an "exposure," and comparing patients who received transfusions with those who did not, we found that blood transfusion was not associated with decreased survival after accounting for all explanatory variables (hazard ratio [HR] 1.06; 95% CI, 0.87-1.30; p = 0.57). Evaluating transfusion in terms of dose-response, we found that patients who received more transfusions had lower survival compared with those who had fewer transfusions after accounting for all explanatory variables (HR per unit of blood transfused, 1.07; 95% CI, 1.02-1.12; p = 0.005). We found that age (HR, 1.02; 95% CI, 1.01-1.02; p < 0.001), comorbidity status (HR, 1.06; 95% CI, 1.01-1.10; p = 0.014), duration of hospital stay (HR, 1.02; 95% CI 1.00-1.03; p = 0.021), tumor type (HR, 1.71; 95% CI, 1.44-2.03; p < 0.001), and visceral metastases (HR, 1.59; 95% CI, 1.34-1.88; p < 0.001) were independently associated with survival. CONCLUSION We found that exposure to perioperative allogeneic blood transfusion does not decrease survival, with the numbers available. However, our sample size might have been insufficient to reveal a small but potentially relevant effect. Our results do suggest a dose-response relationship; patients who received more transfusions had lower survival compared with those with fewer transfusions. Risk of death increased by 7% per unit of blood transfused. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Stein J. Janssen
| | - Yvonne Braun
| | - John E. Ready
| | - Kevin A. Raskin
| | - Marco L. Ferrone
| | - Francis J. Hornicek
| | - Joseph H. Schwab
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11
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Allogeneic blood transfusions and postoperative infections after lumbar spine surgery. Spine J 2015; 15:901-9. [PMID: 25681582 DOI: 10.1016/j.spinee.2015.02.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/24/2014] [Accepted: 02/03/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Allogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after administration of allogeneic blood transfusions. PURPOSE Our primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused. STUDY DESIGN/SETTING This is a retrospective cohort study from a tertiary care spine referral center. PATIENT SAMPLE A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine. OUTCOMES MEASURES Postoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included. METHODS Multivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery. RESULTS The adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval [CI]: 1.7-3.9, p<.001); 2.2 for urinary tract infections (95% CI: 1.3-3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96-5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3-5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis. CONCLUSIONS Conscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures.
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Hu Y, Ying M, Huang C, Wei H, Jiang Z, Peng X, Hu J, Du X, Wang B, Lin F, Xu J, Dong G, Mou T, Li G. Oncologic outcomes of laparoscopy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective cohort study from China. Surg Endosc 2014; 28:2048-2056. [PMID: 24651893 DOI: 10.1007/s00464-014-3426-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 12/29/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Laparoscopy-assisted gastrectomy (LAG) has been indicated to be safe, feasible, and oncologically efficacious for the treatment of early gastric cancer by both retrospective and prospective studies. Although some reports have demonstrated that LAG was also a safe and technically feasible procedure for advanced gastric cancer (AGC), its oncologic outcomes have not yet been confirmed in a multicenter, large-scale study. The aim of this study was to evaluate the oncologic outcomes of LAG for AGC on a multicenter basis in China. METHODS Data of 1,184 consecutive patients with locally AGC who underwent LAG with curative intent between February 2003 and December 2009 were collected from the Chinese Laparoscopic Gastrointestinal Surgery Study group database and retrospectively analyzed. Survival rates were estimated by the Kaplan-Meier method. Risk factors for recurrence and survival were evaluated by Cox regression models. RESULTS Postoperatively, 121 patients (10.2%) experienced complications, and 1 patient died (0.1%). Median follow-up was 12 months. Recurrence was observed in 185 patients (16.7%), including hematogenous (31 patients), peritoneal (52), locoregional (25), distant lymph node (LN) (8), mixed (63), and uncertain (6) recurrences. The cumulative 3-year overall survival and disease-free survival rates were 75.3 and 69.0%, respectively. The 3-year overall survival and disease-free survival rates were 89.7 and 88.9% for stage I tumors, 85.0 and 77.0 % for stage II, 60.5 and 59.3% for stage III. Independent risk factors for recurrence were tumor size > 40 mm, intraoperative blood transfusion, and advanced tumor stage. For survival, age > 65 years, tumor size > 40 mm, and advanced tumor stage were independent risk factors. CONCLUSIONS In addition to being safe and technically feasible, LAG for locally AGC could also yield acceptable short-term oncologic outcomes.
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Affiliation(s)
- Yanfeng Hu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Avenue, Guangzhou, 510515, Guangdong Province, China
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Das J, Kumar S, Khanna S, Mehta Y. Are we causing the recurrence-impact of perioperative period on long-term cancer prognosis: Review of current evidence and practice. J Anaesthesiol Clin Pharmacol 2014; 30:153-9. [PMID: 24803749 PMCID: PMC4009631 DOI: 10.4103/0970-9185.129996] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Newer developments in the field of chemotherapeutic drug regimes, radiotherapy, and surgical techniques have improved the prognosis of cancer patients tremendously. Today increasing numbers of patients with aggressive disease are posted for surgical resection. The advances in reconstructive flap surgery offer the patient a near normal dignified postresection life. Hence, the expectations from the patients are also on the rise. Anesthetic challenges known in oncosurgery are that of difficult airway, maintenance of hemodynamics and temperature during long surgical hours, pain management, and postoperative intensive care management. But, recently acquired data raised the possibility of the anesthetic technique and conduct of perioperative period as a possible contributory factor in the growth and possible recurrence of the primary tumor. The foundation of the concept is somewhat fragile and not supported by conclusive evidence. In fact, like any other controversial topic in medicine, contradictory reports of the favorable effects of anesthetic technique and medications are plenty in the literature. This is the basis of our article where we have analyzed the current evidence available in the literature and how these and the forthcoming large scale studies may revolutionize the practice of oncoanesthesia.
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Affiliation(s)
- Jyotirmoy Das
- Division of General Anaesthesia, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Sudhir Kumar
- Division of General Anaesthesia, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Sangeeta Khanna
- Division of General Anaesthesia, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Yatin Mehta
- Division of General Anaesthesia, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
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Reim D, Kim YW, Nam BH, Kim MJ, Yook JH, Park YK, Roh SH, Yu WS, Bae JM. FAIRY: a randomized controlled patient-blind phase III study to compare the efficacy and safety of intravenous ferric carboxymaltose (Ferinject®) to placebo in patients with acute isovolemic anemia after gastrectomy - study protocol for a randomized controlled trial. Trials 2014; 15:111. [PMID: 24708660 PMCID: PMC3992134 DOI: 10.1186/1745-6215-15-111] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/04/2014] [Indexed: 12/21/2022] Open
Abstract
Background Isovolemic anemia (decrease in hemoglobin concentration with normal or even increased blood volume) after gastric cancer surgery may negatively influence short- and long-term outcomes. Therefore correction of isovolemic postoperative anemia is supposed to be beneficial. This prospective randomized placebo-controlled multicenter trial is designed to evaluate the efficacy of ferric carboxymaltose administration with the primary end point of successful hemoglobin level increase by 2 g/dl at 12 weeks after randomization. Methods and design Gastric cancer patients after oncologic resection and postoperative hemoglobin level ≥ 7 g/dl to <10 g/dl at postoperative days 5 to 7 will be eligible for trial inclusion. After randomization, 450 patients (225 per group) are going to be subjected either to administration of ferric carboxymaltose (treatment group) or normal (0.9%) saline (placebo group). Patients will be blinded to the intervention. Patients will undergo evaluation for hemoglobin level, hematology and quality of life assessment 3 and 12 weeks after randomization. Discussion Correction of isovolemic postoperative anemia in gastric cancer patients after oncologic resection is considered to be beneficial. Administration of ferric carboxymaltose is considered to be superior to placebo for anemia correction without the possible risks of red blood cell transfusion. Further, improved quality of life for patients with quick recovery of hemoglobin levels is expected. Trial registration NCT01725789 (international: http://www.clinicaltrials.gov) and NCCCTS-12-644 (NCC, Korea).
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Affiliation(s)
| | - Young-Woo Kim
- Gastric Cancer Branch, Research Institute & Hospital, National Cancer Center, 323 Ilsan-Ro, Ilsandong-Gu, Goyang-si, Gyeonggi-do 411-769, Republic of Korea.
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Dusch N, Weiss C, Ströbel P, Kienle P, Post S, Niedergethmann M. Factors predicting long-term survival following pancreatic resection for ductal adenocarcinoma of the pancreas: 40 years of experience. J Gastrointest Surg 2014; 18:674-81. [PMID: 24241965 DOI: 10.1007/s11605-013-2408-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/29/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Long-term survival after resection for pancreas carcinoma has rarely been reported. Factors influencing long-term survival are still under debate. The aim of this study was to define predictors for long-term survival. METHODS Between 1972 and 2004, a total of 415 patients underwent resection. Data were collected in a prospective data base. Data of 360 patients were available for further analysis in 2011. All specimens of long-term survivors were histologically reviewed. RESULTS Long-term survivors (n = 69) had a median survival of 91 months. Pathological re-evaluation of all specimens re-confirmed the diagnosis. Predictive factors for long-term survival in univariate analysis were no preoperative biliary stent, low CA 19-9 level, lack of blood transfusion, R0 resection, tumour diameter, and -grading, absence of lymph node or distant metastases, lymphangiosis, and perineural infiltration. Adjuvant chemotherapy showed a significant influence on overall survival but not on long-term survival. In multivariate analysis, lymph node ratio and volume of blood transfusion were predictors of long-term survival. CONCLUSION Nearly 20% of patients with pancreas carcinoma who undergo surgical resection have a chance of long-term survival. Survival beyond 5 years is predicted by clinical and tumour-specific factors. Adjuvant chemotherapy might prolong overall survival but is, according to these results, unable to contribute to long-term survival. There is still a risk of recurrence after a 5- or even a 12-year mark. Survival beyond 5 or even 12 years, therefore, does not assure cure.
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Affiliation(s)
- Niloufar Dusch
- Department of Surgery, Faculty of Medicine Mannheim, University Medical Centre Mannheim, University of Heidelberg, 68167, Mannheim, Germany
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De Oliveira GS, Schink JC, Buoy C, Ahmad S, Fitzgerald PC, McCarthy RJ. The association between allogeneic perioperative blood transfusion on tumour recurrence and survival in patients with advanced ovarian cancer. Transfus Med 2011; 22:97-103. [DOI: 10.1111/j.1365-3148.2011.01122.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Ojima T, Iwahashi M, Nakamori M, Nakamura M, Naka T, Katsuda M, Iida T, Hayata K, Yamaue H. Association of allogeneic blood transfusions and long-term survival of patients with gastric cancer after curative gastrectomy. J Gastrointest Surg 2009; 13:1821-30. [PMID: 19655208 DOI: 10.1007/s11605-009-0973-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 07/15/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The relationship between perioperative allogeneic blood transfusions and poor prognosis in patients with gastric cancer remains controversial. The aim of this study is to examine the effect of perioperative blood transfusions on long-term survival of patients undergoing curative gastric resection for gastric cancer. METHODS Eight hundred fifty-six consecutive patients with gastric cancer who underwent curative gastrectomy (R0) from January 1, 1991 through December 31, 2002 were enrolled in this retrospective study. RESULTS A multivariate overall survival analysis using Cox proportional hazard regression model revealed macroscopically infiltrative tumor, tumor infiltration of serosa, lymph node metastasis, blood transfusions (hazard ratio, 2.69), pulmonary disease, and liver dysfunction as prognostic factors for long-term survival. Blood transfusion was an independent prognostic factor at all stages of disease. Disease-specific and overall survival showed significant differences between the transfused and nontransfused groups (log-rank, P < 0.0001). Based on multivariate logistic regression analysis, the need for blood transfusion was significantly associated with advanced age (>or=65 years), long duration of operation (>or=300 min), massive blood loss (>or=1,000 ml), and anemia (Hb < 10 g/dl). CONCLUSIONS Allogeneic blood transfusion is an independent prognostic factor for long-term survival in gastric cancer patients.
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Affiliation(s)
- Toshiyasu Ojima
- Second Department of Surgery, Wakayama Medical University School of Medicine, 811-1, Kimiidera, Wakayama, 641-8510, Japan
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Oh SJ, Hyung WJ, Li C, Song J, Kang W, Rha SY, Chung HC, Choi SH, Noh SH. The effect of spleen-preserving lymphadenectomy on surgical outcomes of locally advanced proximal gastric cancer. J Surg Oncol 2009; 99:275-80. [PMID: 19152367 DOI: 10.1002/jso.21229] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to investigate the effects of D2 lymphadenectomy with spleen preservation on surgical outcomes in locally advanced proximal gastric cancer. METHODS Between January 2000 and December 2004, a total of 366 patients who underwent curative total gastrectomy were studied retrospectively from a prospectively designed database. RESULTS The spleen-preservation group experienced shorter operation times, a lower incidence of perioperative transfusion, and shorter postoperative hospital stays. Perioperative transfusion and splenectomy were independent risk factors for morbidity. There was no significant difference between the two groups in recurrence or cumulative survival rate when adjusted according to cancer stage. Multivariate analysis showed that tumor size, serosal invasion, and nodal metastasis were independent prognostic factors, while splenectomy was not. The cumulative survival rate in pN0-status patients was significantly higher in the spleen-preservation group, while there was no significant difference in the survival of pN1- or pN2-status patients between the two groups. CONCLUSIONS Splenectomy for lymph node dissection in proximal gastric cancer patients obviously showed poor short-surgical outcomes, but it did not affect long-term outcomes in terms of recurrence and overall survival rate. Therefore, spleen-preserving lymphadenectomy is a feasible method for radical surgery in locally advanced proximal gastric cancer.
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Affiliation(s)
- Sung Jin Oh
- Department of Surgery, Yonsei University College of Medicine, Seodaemun-Gu, Seoul, South Korea
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Clark E, Connor S, Taylor MA, Hendry CL, Madhavan KK, Garden OJ, Parks RW. Perioperative transfusion for pancreaticoduodenectomy and its impact on prognosis in resected pancreatic ductal adenocarcinoma. HPB (Oxford) 2007; 9:472-7. [PMID: 18345298 PMCID: PMC2215364 DOI: 10.1080/13651820701769693] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Pancreaticoduodenectomy (PD) is a major operative intervention performed most commonly for malignancy in the head of pancreas. The aim of this study was to evaluate the utilization of blood transfusion for PD and to determine whether this had prognostic significance in a subset of patients with pancreatic ductal adenocarcinoma (PDAC). MATERIAL AND METHODS Data on blood transfusion requirement were retrospectively collected for patients undergoing PD from 1998 to 2005. Standard prognostic factors and survival data were also collected in patients with PDAC. RESULTS One-hundred-and-seventy patients underwent PD. Seventy-six patients (45%) received transfusion. The median (interquartile range) number of units of red cell concentrate (RCC) transfused perioperatively (intraoperatively and within 24 h of surgery) was 1.5 (0.5-2.5). The median preoperative haemoglobin (Hb) was 126 g/dl. The median number of units of RCC transfused perioperatively in patients with Hb <126 g/dl was 2 (1-3); for those with Hb > or = 126 g/dl the median was 0 (0-1); p=0.003. Forty-nine patients who were resected for PDAC were subjected to survival analysis. Univariate and multivariate analyses showed that only posterior resection margin invasion was associated with an adverse outcome (margin positive 198 [143-470] days vs margin negative 398 [303-859] days; p=0.02). Perioperative RCC transfusion requirement was not a significant predictor of survival (transfusion 408 [214-769] days vs no transfusion 331 [217-391] days; p=0.18). Furthermore, RCC transfusion within 30 days of operation was not a significant predictor of poor survival (transfusion 331 [201-459] days vs no transfusion 317 [196-769] days; p=0.43). CONCLUSIONS PD can be performed with a moderately low requirement for RCC transfusion; however, low preoperative haemoglobin is a predictor for the requirement of RCC transfusion. Administration of RCC transfusion does not appear to be a significant adverse prognostic factor in patients with resected PDAC.
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Affiliation(s)
- E Clark
- Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK.
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Abstract
BACKGROUND The improvement of renal allograft survival by pre-transplantation transfusions alerted the medical community to the potential detrimental effect of transfusions in patients being treated for cancer. OBJECTIVES The present meta-analysis aims to evaluate the role of perioperative blood transfusions (PBT) on colorectal cancer recurrence. This is accomplished by validating the results of a previously published meta-analysis (Amato 1998); and by updating it to December 2004. SEARCH STRATEGY Published papers were retrieved using Medline, EMBASE, the Cochrane Library, controlled trials web-based registries, or the CCG Trial Database. The search strategy used was: {colon OR rectal OR colorectal} WITH {cancer OR tumor OR neoplasm} AND transfusion. The tendency not to publish negative trials was balanced by inspecting the proceedings of international congresses. SELECTION CRITERIA Patients undergoing curative resection of colorectal cancer (classified either as Dukes stages A-C, Astler-Coller stages A-C2, or TNM stages T1-3a/N0-1/M0) were included if they had received any amount of blood products within one month of surgery. Excluded were patients with distant metastases at surgery, and studies with short follow-up or with no data. DATA COLLECTION AND ANALYSIS A specific form was developed for data collection. Data extraction was cross-checked, using the most recent publication in case of repetitive ones. Papers' quality was ranked using the method by Evans and Pollock. Odds ratios (OR, with 95% confidence intervals) were computed for each study, and pooled estimates were generated by RevMan (version 4.2). When available, data were stratified for risk factors of cancer recurrence. MAIN RESULTS The findings of the 1998 meta-analysis were confirmed, with small variations in some estimates. Updating it through December 2004 led to the identification of 237 references. Two-hundred and one of them were excluded because they analyzed survival (n=22), were repetitive (n=26), letters/reviews (n=66) or had no data (n=87). Thirty-six studies on 12,127 patients were included: 23 showed a detrimental effect of PBT; 22 used also multivariable analyses, and 14 found PBT to be an independent prognostic factor. Pooled estimates of PBT effect on colorectal cancer recurrence yielded overall OR of 1.42 (95% CI, 1.20 to 1.67) against transfused patients in randomized controlled studies. Stratified meta-analyses confirmed these findings, also when stratifying patients by site and stage of disease. The PBT effect was observed regardless of timing, type, and in a dose-related fashion, although heterogeneity was detected. Data on surgical techniques was not available for further analysis. AUTHORS' CONCLUSIONS This updated meta-analysis confirms the previous findings. All analyses support the hypothesis that PBT have a detrimental effect on the recurrence of curable colorectal cancers. However, since heterogeneity was detected and conclusions on the effect of surgical technique could not be drawn, a causal relationship cannot still be claimed. Carefully restricted indications for PBT seems necessary.
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Affiliation(s)
- A Amato
- Sigma Tau Research, Inc., 10101 Grosvenor Place, apartment#1415, Rockville, Maryland 20852, USA.
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Hyung WJ, Noh SH, Shin DW, Huh J, Huh BJ, Choi SH, Min JS. Adverse effects of perioperative transfusion on patients with stage III and IV gastric cancer. Ann Surg Oncol 2002; 9:5-12. [PMID: 11829431 DOI: 10.1245/aso.2002.9.1.5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The degree of immunomodulation by perioperative blood transfusion and its resultant effects on cancer surgery are a subject of controversy. We evaluated the prognostic effects of perioperative blood transfusion on gastric cancer surgery. METHODS A total of 1710 patients who underwent curative gastrectomy for gastric cancer from 1991 to 1995 were retrospectively reviewed. Uni- and multivariate analyses of the incidence, amount, and timing of perioperative blood transfusions and a comparison of the clinicopathological features were performed. RESULTS A higher incidence of blood transfusions was associated with female sex, large tumors, upper-body location, Borrmann type III or IV lesions, longer operations, total gastrectomies, splenectomies, and D3 or more extended lymphadenectomy. The tumors in the transfused group were more advanced in depth of invasion and nodal classification. More frequent tumor recurrences were found in the transfused group. A dose-response relationship between the amount of transfused blood and prognosis was evident. Subgroup analyses of prognosis according to stage showed significant differences in stages III and IV between the transfused and nontransfused groups. On multivariate analysis, transfusion was shown to be an independent risk factor for recurrence and poor prognosis. CONCLUSIONS These results suggest that perioperative transfusion is an unfavorable prognostic factor. It is thus better to refrain from unnecessary blood transfusion and to give the least amount of blood to patients with gastric cancer when transfusion is inevitable, especially for those with stage III and IV gastric cancers.
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Affiliation(s)
- Woo Jin Hyung
- Department of Surgery and the Cancer Metastasis Research Center, Yonsei University College of Medicine, Seoul, Korea
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Evaluation on factors influencing liver cancer metastasis after liver surgery by a mouse model. Chin J Cancer Res 1999. [DOI: 10.1007/bf02948447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hodge G, Lloyd JV, Hodge S, Story C, Han P. Functional lymphocyte immunophenotypes observed in thalassaemia and haemophilia patients receiving current blood product preparations. Br J Haematol 1999; 105:817-25. [PMID: 10354153 DOI: 10.1046/j.1365-2141.1999.01385.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Immune abnormalities have been reported in recipients of cellular and plasma blood products. To document the effect of current transfusion practices, we performed ex vivo lymphocyte immunophenotypic studies on patients with thalassaemia major who had received multiple (leucocyte-depleted) transfusions and patients with haemophilia A and B who had received heat viral-inactivated factor concentrates. Patients with thalassaemia major showed a significant lymphocytosis, with mainly B-cell changes consistent with ongoing B-cell stimulation associated with chronic exposure to red cell antigens. Reduced T-cell IL-2Ralpha expression would be consistent with inhibition by desferrioxamine chelation therapy. In contrast, patients with haemophilia showed predominantly T-cell changes. Patients with haemophilia A showed significantly elevated activated CD8+ cytotoxic T lymphocytes whereas those with haemophilia B showed an increase in CD8+CD11adim and CD4+CD45RA+ suppressor T cells. Several of the immune abnormalities found may be due to the presence of cytokines not removed by leucocyte filtration or destroyed by factor concentrate production (e.g. TGF-beta) causing a T-helper-2-like response. The extensive lymphocyte characterization in this study has not previously been performed and has enabled a closer examination of the functional lymphocyte immunophenotypes seen in patients treated according to current transfusion practices.
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Affiliation(s)
- G Hodge
- Department of Haematology, Women's and Children's Hospital, Adelaide; University of South Australia, Adelaide
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ten Bokkel Huinink WW, de Swart CA, van Toorn DW, Morack G, Breed WP, Hillen HF, van der Hoeven JJ, Reed NS, Fairlamb DJ, Chan SY, Godfrey KA, Kristensen GB, van Tinteren H, Ehmer B. Controlled multicentre study of the influence of subcutaneous recombinant human erythropoietin on anaemia and transfusion dependency in patients with ovarian carcinoma treated with platinum-based chemotherapy. Med Oncol 1998; 15:174-82. [PMID: 9819794 DOI: 10.1007/bf02821936] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This randomised controlled multicentre trial evaluated the effectiveness of recombinant human erythropoietin (rhEPO) in preventing anaemia and reducing the need for blood or erythrocyte transfusion in 122 ovarian cancer patients receiving platinum-based chemotherapy. The patients were randomly allocated to receive rhEPO 150 U/kg or 300 U/kg subcutaneously, three times a week, or open control. Patients also received up to 6 cycles of carboplatin or cisplatin, alone or in combination with other cytotoxic agents. Intention-to-treat analysis showed that 39.4% of patients in the control group received at least one blood transfusion, compared with 9.2% of patients treated with rhEPO. Patients treated with rhEPO experienced a significantly longer time to first erythrocyte transfusion than the control group and were less likely to experience nadir haemoglobin levels < 10 g/dl (P < 0.001 and < 0.05, respectively). A haemoglobin decrease < 1 g/dl during the first chemotherapy cycle, as well as a low baseline serum erythropoietin concentration, predicted a low transfusion need in rhEPO-treated patients but not in controls. During the study, 103 patients suffered at least one adverse event, but no serious, and only nine non-serious adverse events were considered possibly related to rhEPO therapy. These results indicate that treatment with rhEPO prevents anaemia, it reduces the need for blood or rhEPO erythrocyte transfusion in patients with ovarian cancer receiving platinum-based chemotherapy, and it is well tolerated. A starting dose of 150 U/kg of rhEPO, three times a week, may be recommended.
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Lentz SS, Shelton BJ, Toy NJ. Effects of perioperative blood transfusion on prognosis in early-stage cervical cancer. Ann Surg Oncol 1998; 5:216-9. [PMID: 9607621 DOI: 10.1007/bf02303775] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study was designed to evaluate the prognostic effects of transfusion on patients undergoing radical hysterectomy for early cervical cancer. METHODS This retrospective chart review analyzed 412 patients with stage IA-IIA disease, of whom 374 were evaluable. RESULTS Three hundred (80%) patients received transfusions and 74 (20%) did not. The clinical characteristics of the two groups were similar, with the exception that the transfused group was older. Pathologic comparisons found that microscopic parametrial disease and larger cervical lesions were more common in the transfused group. Follow-up analysis revealed no difference between the two groups in recurrence or survival. Multivariate analysis found only grade, depth of invasion, and nodal status as independent predictors of recurrence and survival. Kaplan-Meier survival analysis showed no difference in overall survival or disease-free interval between the transfused and nontransfused groups. CONCLUSIONS After correction for other prognostic factors, blood transfusion had no prognostic significance in patients with early cervical cancer undergoing radical hysterectomy.
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Affiliation(s)
- S S Lentz
- Department of Obstetrics and Gynecology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27157, USA
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Phan GQ, Yeo CJ, Cameron JL, Maher MM, Hruban RH, Udelsman R. Pancreaticoduodenectomy for selected periampullary neuroendocrine tumors: fifty patients. Surgery 1997; 122:989-96; discussion, 996-7. [PMID: 9426411 DOI: 10.1016/s0039-6060(97)90200-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Most resectable pancreatic or peripancreatic neuroendocrine tumors are treated by enucleation or distal pancreatectomy. A minority of tumors may require pancreaticoduodenectomy for complete tumor excision because of their large size, location, or lymph node involvement. METHODS This study reviews the management of 50 patients treated by pancreaticoduodenectomy for periampullary neuroendocrine tumors between 1962 and 1996 at a single institution. RESULTS There were 30 men and 20 women with a mean age of 52 +/- 2 years. Functional tumors were resected in 17 patients: insulinoma, seven tumors; gastrinoma, eight tumors; vipoma, one tumor; and glucagonoma, one tumor. Tumors were classified as malignant in 29 patients and benign in 21. The median intraoperative blood loss was 800 ml, and the median number of units of blood transfused was zero. The postoperative length of stay was 20 +/- 2 days. Postoperative morbidity included 11 patients (24%) with a pancreatic fistula and four patients (8%) with a biliary fistula. There was one in-hospital death (2%), in 1967. The actuarial survival rates at 2, 5, and 7 years are 81%, 73%, and 65%, respectively. Patients with benign tumors had a significantly improved 5-year survival rate (94%) compared with those with malignant tumors (61%; p = 0.03). CONCLUSIONS Selected patients with periampullary neuroendocrine tumors can be managed successfully by pancreaticoduodenectomy, with low mortality and acceptable morbidity rates.
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Affiliation(s)
- G Q Phan
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md., USA
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Eaves-Pyles T, Alexander JW. The effect of blood transfusion on susceptibility to bacterial infection in genetically defined mouse models. THE JOURNAL OF TRAUMA 1997; 43:894-8. [PMID: 9420101 DOI: 10.1097/00005373-199712000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Blood transfusions suppress immune function and increase susceptibility to infection, but the effects are not consistent. STUDY DESIGN AND METHODS Genetically defined mouse strains with the same or different haplotypes were used as blood transfusion recipients and donors. Transfused animals were subjected to cecal ligation and puncture (CLP) and followed for survival or were injected intravenously with Candida albicans to follow clearance of the Candida from the kidneys. RESULTS BALB/c (H-2d) mice transfused with C3H/HeJ (H-2k) or DBA/2 (H-2d) blood followed by CLP showed significantly lower survival (7 and 10%) than mice transfused with syngeneic blood (61%) or saline controls (56%). Lower survival was also observed in C3H/HeJ (H-2k) mice transfused with BALB/c (H-2d) blood and subjected to CLP (25%) compared with syngeneic transfusion (80%) or saline controls (70%). C57BL/6J (H-2b) mice showed minimal increases in mortality after CLP after transfusion with blood from C3H/HeJ (H-2k) (60% survival), DBA/2 (H-2d) (70% survival), or BALB/c (H-2d) mice (90% survival). When C. albicans was infused intravenously into transfused mice, a similar pattern of altered resistance to infection was found. CONCLUSION The ability of blood transfusions to increase susceptibility to bacterial infection appears to be dependent on genetic factors unrelated to the major haplotype.
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Affiliation(s)
- T Eaves-Pyles
- University of Cincinnati, College of Medicine, Department of Surgery, and the Shriners Burns Institute, Cincinnati Unit, Ohio 45267-0558, USA
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Farrell TJ, Barbot DJ, Rosato FE. Pancreatic resection combined with intraoperative radiation therapy for pancreatic cancer. Ann Surg 1997; 226:66-9. [PMID: 9242339 PMCID: PMC1190908 DOI: 10.1097/00000658-199707000-00009] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of the study was to analyze a single center's experience in the treatment of pancreatic carcinoma with a combination of pancreatic resection and intraoperative radiation therapy (IORT). SUMMARY BACKGROUND DATA Pancreatic cancer is the most lethal form of gastrointestinal malignancy. Historically, it carries a 20% 1-year survival and a 5-year survival of 3% to 5%. Since 1987, patients at Thomas Jefferson University Hospital have been offered IORT in an attempt to improve their survival. METHODS The authors reviewed all patients treated at Thomas Jefferson University Hospital with pancreatic adenocarcinoma from 1987 to 1994. From this population, 14 patients were identified who received IORT in conjunction with curative surgery. Duration of hospital stay, perioperative complications, duration of postoperative ileus, and survival were assessed by retrospective review. RESULTS Of the 14 patients, 6 were male and 8 were female. Patient median age was 61. Six patients had stage I disease, 2 had stage II, 6 had stage III. Two patients had total pancreatectomy, 2 had distal pancreatectomy, and the remaining had pancreaticoduodenectomy (Whipple resection). Median survival was 16 months with a 15.5% 5-year survival. Postoperative complications, duration of hospital stay, and duration of postoperative ileus were not adversely affected by the addition of IORT when compared to in-house control subjects. CONCLUSIONS Intraoperative radiation therapy is a useful adjunct to surgical resection as treatment of pancreatic cancer. The authors' data suggested it can prolong median survival and long-term survival without adding significant morbidity.
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Affiliation(s)
- T J Farrell
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Abstract
BACKGROUND Survival for adenocarcinoma of the pancreatic remains unchanged over the last two decades. The majority of patients (85%) are diagnosed with an inoperable tumor. Patterns of failure reveal that pancreatic cancer involves three compartments: the pancreatic bed and regional lymph nodes, the liver and the peritoneal surfaces. Twelve patients with advanced, unresectable pancreatic cancer, Stage II/III, were treated with regional intra-arterial chemotherapy and extracorporeal hemofiltration directed towards the pancreatic tumor-bearing area and the liver. METHODS Five patients had an arterial catheter/port system placed within the celiac axis; the rest had an angiographically placed arterial catheter. All patients had a 16 Fr PFM filtration catheter inserted in the vena cava positioning the tip at the level of the diaphragm and then connected to a hemofiltration unit. Mitomycin C was infused over 25 minutes followed by 5-FU over 10 minutes. The hemofiltration was begun before the drug infusion and continued for 70 minutes. The twelve patients underwent 33 cycles of regional chemotherapy plus hemofiltration. RESULTS Five patients had a partial response (45.5%), five had stable disease (45.5%), and one had progression (9%). Four patients were re-explored with one patient undergoing a curative resection. The average survival for patients with unresectable pancreatic adenocarcinoma is 13 months. Tumor implantation and progression on the peritoneal surfaces remains the major site of treatment failure. CONCLUSIONS Regional chemotherapy plus hemofiltration with MMC and 5-FU appears to improve the response of Stage II/III inoperable pancreatic cancer and can convert some patients to resectability without significant complications and with no mortality.
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Affiliation(s)
- J H Muchmore
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Abstract
Cancer patients frequently develop anemia, due either to the cancer itself or to the effects of cancer-related therapy. Recent years have brought insights into both the pathogenesis of the anemia of cancer and the extent to which erythropoietin regulation participates in this process. Although transfusion therapy was the mainstay of therapy for symptomatic anemia in the past, clinical trials have demonstrated that recombinant human erythropoietin can alleviate both anemia and transfusion requirements in many cancer patients and may prove to have an important role in the treatment of cancer-related anemia in the future.
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Affiliation(s)
- A R Moliterno
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Parente MBMCS. Anemia e cancro do pulmão**Tema Apresentado na Mesa Redonda “Terapêutica de Suporte e Sintomática” (Coordenador: Dr. Agostinho Costa): XI Congresso de Pneumologia. Coimbra 5-8 de Novembro de 1995). REVISTA PORTUGUESA DE PNEUMOLOGIA 1996. [DOI: 10.1016/s0873-2159(15)31149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Conlon KC, Klimstra DS, Brennan MF. Long-term survival after curative resection for pancreatic ductal adenocarcinoma. Clinicopathologic analysis of 5-year survivors. Ann Surg 1996; 223:273-9. [PMID: 8604907 PMCID: PMC1235115 DOI: 10.1097/00000658-199603000-00007] [Citation(s) in RCA: 540] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The authors reviewed the clinicopathologic characteristics of patients who underwent resection with curative intent for ductal adenocarcinoma of the pancreas between 1983 and 1989. SUMMARY BACKGROUND DATA Recent studies have demonstrated a reduction in the morbidity and mortality of pancreatic resection and improvement in the actuarial 5-year survival for patients with resected ductal adenocarcinoma. METHODS Resection with curative intent was performed on 118 of 684 patients (17%) with pancreatic cancer admitted to the authors' institution. Clinical, demographic, treatment, and pathologic variables were analyzed. The original material for all cases was reviewed; nonductal cancers were excluded. RESULTS The head of the gland was the predominant tumor site (n = 102), followed by the body (n = 9), and tail (n = 7). Seventy-two percent of the patients underwent pancreaticoduodenectomies, 15% underwent total pancreatectomies, 10% underwent distal pancreatectomies, and 3% underwent distal subtotal pancreatectomies. Operative mortality was 3.4%. Median survival was 14.3 months after resection compared with 4.9 months if patients did not undergo resection (p < 0.0001). Twelve patients survived 5 years after surgery (10.2% overall actual 5-year survival rate). Three of the tumors were well differentiated, five were moderately differentiated, and four were poorly differentiated. Extrapancreatic invasion occurred in nine cases (75%), and perineural invasion was present in ten cases (83%). Five tumors exhibited invasion of duodenum, ampulla of Vater, and/or common bile duct, and an additional tumor invaded the portal vein. Lymph node involvement by carcinoma was noted in five cases (42%). Six patients remain alive without evidence of disease at a median follow-up of 101 months (range, 82-133 months). Five patients died of recurrent or metastatic pancreatic cancer at 60, 61, 62, 64, and 64 months, respectively. One patient died at 84 months of metastatic lung cancer without evidence of recurrent pancreatic disease. CONCLUSIONS This paper emphasizes the grim prognosis of pancreatic ductal adenocarcinoma. Five-year survival cannot be equated to cure. Although pancreatectomy offers the only chance for long-term survival, it should be considered as the best palliative procedure currently available for the majority of patients. This emphasizes the need for the development of novel and effective adjuvant therapies for this disease.
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Affiliation(s)
- K C Conlon
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Abstract
In this review, the pathophysiology and treatment of the anemia of multiple myeloma will be examined. While the anemia of cancer has multiple causes, an important component is labeled the "anemia of chronic disease" which is characterized by the combination of a shortened erythrocyte survival with failure of the bone marrow to increase red cell production in compensation. Depressed erythropoiesis is itself related to a combination of factors, including impaired availability of storage iron, inadequate erythropoietin response to anemia, and overproduction of cytokines which are capable of inhibiting erythropoiesis. These cytokines are involved in the retention of iron in the reticuloendothelial system, gastrointestinal tract and hepatocytes, may interfere with erythropoietin production by the kidney, and may exert direct inhibitory effects on erythroid precursors. While overproduction of several such cytokines, including IL-6, IL-1 and TNF-alpha, has been definitely demonstrated in multiple myeloma patients, it is still unclear whether they are directly involved in the pathogenesis of the anemia which develops. Although several mechanisms, such as hemodilution, bleeding, and decreased red cell survival operate, the anemia is mostly caused by defective erythropoietic activity. This in turn is partly explained by inadequate erythropoietin (Epo) production even in some patients without renal impairment. Based on measurements of serum erythropoietin and transferrin receptor, the distinction between marrow unresponsiveness to normal Epo stimulation and deficient Epo production is important for the treatment of the anemia of multiple myeloma with recombinant human Epo. Higher doses would probably be necessary if adequate Epo production is present, whereas only replacement therapy with lower doses may be sufficient when Epo production has been shown to be inappropriate.
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Affiliation(s)
- Y Beguin
- Department of Medicine, University of Liège, Belgium
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Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN, Dooley WC, Coleman J, Pitt HA. Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg 1995; 221:721-733. [PMID: 7794076 PMCID: PMC1234702 DOI: 10.1097/00000658-199506000-00011] [Citation(s) in RCA: 694] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas. SUMMARY OF BACKGROUND DATA In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%. METHODS Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date. RESULTS The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection. CONCLUSIONS The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.
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Affiliation(s)
- C J Yeo
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Ozaki H. Modern surgical treatment of pancreatic cancer. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1994; 16:121-9. [PMID: 7868938 DOI: 10.1007/bf02944322] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- H Ozaki
- Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
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Dusenbery KE, McGuire WA, Holt PJ, Carson LF, Fowler JM, Twiggs LB, Potish RA. Erythropoietin increases hemoglobin during radiation therapy for cervical cancer. Int J Radiat Oncol Biol Phys 1994; 29:1079-84. [PMID: 8083076 DOI: 10.1016/0360-3016(94)90403-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE Anemia during radiation therapy independently predicts poor outcome in patients with cervical cancer. Despite a randomized trial demonstrating red cell transfusions improve local control and survival, many patients are not transfused due to toxicity concerns. This study evaluates the efficacy of recombinant human erythropoietin (r-HuEPO) in reversing anemia in patients undergoing radiation therapy. METHODS AND MATERIALS Twenty patients with criteria of anemia (Hgb < 12.5 g/dL) and surgically staged cervical cancer FIGO stages IB (n = 7), IIA (n = 1), IIB (n = 9), and IIIB (n = 3), ranging in ages from 23-75 years (median 43), were included in this Phase I/II study. Fifteen were treated with r-HuEPO (200 U/kg/day) and ferrous sulfate 5-10 days prior to initiation of external beam radiation therapy, continuing until Hgb was < or = 14 g/dL or completion of radiation therapy. Five patients were treated with ferrous sulfate alone. An additional 61 historical controls meeting eligibility criteria were analyzed. All received external beam radiation therapy and two intracavitary cesium applications. Cisplatinum chemotherapy (20 mg/m2/week) was given as a radiosensitizer in 14 r-HuEPO patients, 4 concurrent controls, and 17 historical controls. RESULTS A marked reticulocytosis was seen in the r-HuEPO group, but not the study controls. In the r-HuEPO group, the mean +/- SD serum Hgb rose + 30% over the course of radiation therapy from a baseline of 10.3 +/- 1.04 g/dL to 13.2 +/- 1.7 g/dL. Average increase in Hgb was 0.5 g/dL per week. Average Hgb during RT was 13.4 g/dL. In study and historical controls, mean initial Hgb levels were 10.7 +/- 1.04 g/dL and 11.1 +/- 1.3g/dL, respectively, remaining unchanged over the course of radiation therapy. Average Hgb levels during radiation therapy were 11.1 g/dL in study controls and 11.4 g/dL in historical controls, significantly lower than r-HuEPO patients (p = 0.0001). Erythropoietin was well tolerated. There were no significant differences in white blood counts (p = 0.6) or platelet counts (p = 0.4) between r-HuEPO patients and both control groups. No patients had blood pressure changes during r-HuEPO therapy. The only possible side effect was deep venous thrombosis, occurring in two patients who were withdrawn from r-HuEPO therapy. Two additional patients developed deep venous thrombosis 9 and 10 days after radiation therapy and r-HuEPO were completed. CONCLUSION Erythropoietin appears to be both safe and effective at raising Hgb levels in anemic cervical cancer patients receiving radiation therapy and chemotherapy.
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Affiliation(s)
- K E Dusenbery
- University of Minnesota Hospital and Clinic, Department of Radiation Oncology 55455
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Yamawaki T, Tanaka H, Takeuchi S, Yanase H, Taniguchi H, Toyoda N. Autologous blood transfusion using recombinant human erythropoietin in radical hysterectomy. ASIA-OCEANIA JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1994; 20:147-53. [PMID: 8092959 DOI: 10.1111/j.1447-0756.1994.tb00441.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The possibility of serious complications of infection and GVHD and adverse prognosis in cancer patients resulting from homologous blood transfusions has been reported. We used recombinant human erythropoietin (rHuEPO) in autologous blood transfusions for radical hysterectomies to avoid the risks associated with transfusions. rHuEPO efficacy, stability and influence on hemodynamics were investigated. All patients were able to donate 1,200 ml of autologous blood prior to surgery, and anemia did not result despite phlebotomy three times each week. Elevation in Hb concentration was calculated at 0.78 +/- 0.37 g/dl over the first 7 days, and 2.12 +/- 0.35 g/dl over the first 14 days. No adverse side effects were observed in any patient. The serum EPO level was measured by RIA, and compared to the homologous blood transfusion group. rHuEPO did not influence postoperative EPO secretion. Autologous blood transfusion with rHuEPO in radical hysterectomy was extremely effective in mitigating the risks associated with homologous blood transfusions.
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Affiliation(s)
- T Yamawaki
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Japan
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Fong Y, Karpeh M, Mayer K, Brennan MF. Association of perioperative transfusions with poor outcome in resection of gastric adenocarcinoma. Am J Surg 1994; 167:256-60. [PMID: 8135315 DOI: 10.1016/0002-9610(94)90087-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The clinical records of patients identified by a prospective database as having undergone curative gastric resections for adenocarcinoma not involving the gastroesophageal junction were reviewed in order to examine transfusional practices and to determine if perioperative transfusion had an adverse effect on outcome. Between January 1985 and January 1992, 232 patients received such curative resections. The median follow-up for these patients was 19.0 months, whereas median survival for nonsurvivors was 12.3 months. Fifty-eight percent of the patients received transfusion of blood products. Fifty-four percent of these transfusions amounted to less than 2 units of blood products. By chi 2 analysis, advanced stage of disease (p = .03), advanced T-stage of primary tumor (p = .004), and total gastrectomy (p = .04) were associated with greater likelihood of transfusion. By univariate analysis, male sex (p = .004), total gastrectomy (p = .01), advanced stage of disease (p = .000006), high histologic grade of tumor (p = .03), and blood transfusion (p = .006) were predictors of poor outcome. By multivariate analysis using the proportional hazards model with stage, tumor grade, gender, extent of resection, and transfusion as covariates, blood transfusion was an independent predictor of poor outcome (p = .029, hazard 1.74). These results encourage prospective studies of transfusion on cancer recurrence and studies of alternatives to allogeneic blood transfusions in restoration of oxygen-carrying capacity during surgery in patients with gastric cancer.
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Affiliation(s)
- Y Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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Terris DJ, Minchinton AI. Computerized histographic characterization of changes in tissue pO2 induced by erythropoietin. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1994; 361:613-8. [PMID: 7597990 DOI: 10.1007/978-1-4615-1875-4_113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Anemia associated with malignancy is a common clinical problem, and has a negative effect on oxygen delivery and, therefore, response of tumors to radiotherapy. Erythropoietin (EPO) has been shown to increase the hematocrit of rodents when administered subcutaneously. The objectives of this study were to measure tumor and normal tissue pO2 with computerized pO2 histography, to characterize the change in rodent hematocrit with EPO administration, and to assess the capacity of pO2 histography to measure changes in tumor pO2 during growth, with or without EPO administration. Ten C3H mice were implanted with SCCVII tumors and after three weeks of tumor growth, EPO (1500 IU/kg/day) was administered for two weeks. Tumor and subcutaneous (SQ) measurements were made weekly with an Eppendorf pO2 histograph and hematocrits were obtained concomitantly. Eight C3H/SCCVII mice, which received no EPO and underwent similar measurements, served as controls. The hematocrits of the control mice dropped progressively from 42.0 to 23.0% during the two week period. There was a corresponding fall in both the SQ and tumor mean pO2 (55.6 to 40.3 mm Hg, and 19.9 to 10.0 mm Hg, respectively). In the treated group, the hematocrits remained stable (38.0 to 43.1%) as did the mean pO2 of the SQ (46.1 to 54.3 mm Hg) and the tumor (11.1 to 11.3 mm Hg). These data lend support to the value of EPO in reversing the anemia associated with malignancy and suggest a role of pO2 histography in monitoring the beneficial effects of EPO therapy.
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Affiliation(s)
- D J Terris
- Division of Otolaryngology/Head & Neck Surgery, Stanford University Medical Center, California, USA
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Abstract
The "10/30" (hemoglobin/hematocrit) rule has long been recognized and accepted in the medical community as the threshold for transfusion in the perioperative setting. However, an increasing number of publications suggest there is no absolute threshold for transfusion, and that this decision should be based on an assessment of the overall clinical picture presented by the patient. This article reviews the risks associated with blood transfusions, and the data in humans and animals that describe the benefits of transfusion. Recommendations on the trigger for red cell transfusion are provided.
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Affiliation(s)
- J L Carson
- Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick
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Abstract
Immunocompromised patients are increasingly common in modern surgical practice. Challenges related to their care include identifying the determinants of increased risk and selecting the appropriate therapy for individual patients. There are multiple and overlapping causes of immunosuppression in surgical patients that make the interpretation of clinical trials difficult. A clear understanding of these mechanisms guides the physician to choose the immunomodulatory agents that can be used for improving current rates of complication and mortality. The best practical approach to immunocompromised patients involves determining who is at risk, aggressive diagnosis, early therapy, and a high index of suspicion for infectious complications.
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Affiliation(s)
- J Yee
- Department of Surgery, McGill University, Royal Victoria Hospital, Montreal, Quebec, Canada
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Spahn DR, Smith LR, McRae RL, Leone BJ. Effects of acute isovolemic hemodilution and anesthesia on regional function in left ventricular myocardium with compromised coronary blood flow. Acta Anaesthesiol Scand 1992; 36:628-36. [PMID: 1279924 DOI: 10.1111/j.1399-6576.1992.tb03533.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The effects of progressive, isovolemic hemodilution using Dextran 70 and the effect of halothane (0.7, 0.9, 1.1, and 1.3% end-tidal, administered randomly at each level of hemodilution) on global cardiovascular and regional LV contractile functions were investigated in 24 dogs with induced critical constriction of the left anterior descending coronary artery (LAD). Two additional groups of six dogs each (with and without LAD stenosis) not undergoing hemodilution served as time controls. Regional LV contractile function was assessed by sonomicrometry in the flow-compromised apical LAD territory, as well as in three non-compromised LV areas supplied by the left circumflex coronary artery. Regional myocardial function was found to be stable throughout the study period of 4-5 h in both time control groups. Mean arterial and coronary perfusion pressures as well as LV dP/dtmin decreased (P < 0.01) during hemodilution. LV dP/dtmax remained unchanged, and heart rate and LVEDP increased slightly (P < 0.05). Systolic shortening (SS) in the LAD territory was unchanged at a hematocrit (HCT) of 33.5 +/- 0.3% (mean +/- s.e. mean), and decreased marginally at an HCT of 24.2 +/- 0.1% (SS of 17.4 +/- 1.0% as compared to 20.2 +/- 1.6% at critical constriction (CC), P < 0.05). No increase in post-systolic shortening (PSS) occurred in the compromised area. Severe LAD dysfunction was observed in the LAD territory at an HCT of 14.9 +/- 0.1%, as systolic shortening decreased (11.8 +/- 1.1%, P < 0.01 vs CC) and PSS increased (31.2 +/- 3.4%, P < 0.01 vs CC). The effects of hemodilution on global cardiovascular and regional myocardial functions were unaffected by halothane.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D R Spahn
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710
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Miller DS, Spirtos NM, Ballon SC, Cox RS, Soriero OM, Teng NN. Critical reassessment of second-look exploratory laparotomy for epithelial ovarian carcinoma. Minimal diagnostic and therapeutic value in patients with persistent cancer. Cancer 1992; 69:502-10. [PMID: 1728381 DOI: 10.1002/1097-0142(19920115)69:2<502::aid-cncr2820690238>3.0.co;2-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
From 1979 to 1984, 88 women with epithelial ovarian cancer were treated with surgery and chemotherapy, achieved a clinical complete response, and then had "second-look" exploratory laparotomy to assess the pathologic status of their disease. Persistent cancer was found in 50 (57%) patients: 34 of 50 (68%) had gross tumor, which was larger than 2 cm in 12 (24%) and smaller than 2 cm in 22 (44%), and 16 (32%) had microscopic disease. Salvage therapy was as follows for these patients: whole abdominal irradiation, 29 (58%); chemotherapy, 17 (34%); intraperitoneal chromic phosphate, 1 (2%); and no further therapy, 3 (6%). With a follow-up time of 4 to 8 years, 7 (14%) patients are alive without evidence of cancer, 7 (14%) are alive with disease, 35 (70%) are dead of disease, and 1 (2%) has died of treatment complications. At 5 years, the relapse-free rate was 18% and the survival rate was 25%. Seventy-two parameters of suspected prognostic significance and 64 potential sites of tumor involvement were correlated with survival in a univariate analysis. The factors favorably affecting survival included the following: lower grade; microscopic tumor versus gross disease at second-look laparotomy; removal of the uterus; removal of the omentum; pelvic and paraaortic lymph node biopsy; negative results of a right diaphragm biopsy; and radiation therapy at Stanford University Medical Center, Stanford, California. There was no survival advantage for whole abdomen irradiation compared with chemotherapy or for the patients who had their disease successfully debulked at second-look laparotomy. The above factors and others were evaluated by multivariate regression. The best model (P = 0.000004) for predicting survival included largest tumor mass (P = 0.0002), operative blood loss (P = 0.002), perioperative blood transfusion (P = 0.003), and grade (P = 0.004). The detection of persistent ovarian cancer by second-look exploratory laparotomy should identify a subgroup of patients whose conditions can be salvaged by a second-line therapy. Unfortunately, that subgroup is small (8%) and an effective salvage therapy remains to be identified.
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Affiliation(s)
- D S Miller
- Department of Gynecology and Obstetrics, Stanford University Medical Center, California
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48
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Affiliation(s)
- A J Erslev
- Cardeza Foundation for Hematologic Research, Department of Medicine, Jefferson Medical College, Philadelphia, PA 19107
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49
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Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer. Am J Surg 1991; 161:120-4; discussion 124-5. [PMID: 1987845 DOI: 10.1016/0002-9610(91)90371-j] [Citation(s) in RCA: 403] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Eighty-nine patients with carcinoma of the head of the pancreas underwent pancreaticoduodenectomies. The actuarial 5-year survival for all 89 patients was 19%, with a median survival of 11.9 months. The 81 hospital survivors were analyzed in an effort to determine factors influencing long-term survival. Negative lymph nodes and the absence of blood vessel invasion both favored long-term survival. The strongest predictive factor was negative lymph node status with a median survival of 55.8 months, compared with 11 months with lymph nodes involved with tumor (p less than 0.05). Blood transfusions were also predictive, with patients receiving two or fewer units having a median survival of 24.7 months, compared with 10.2 months for those receiving three or more units (p less than 0.05). The most important determinant of long-term survival after pancreaticoduodenectomy for pancreatic cancer is biology of the tumor (lymph node status, blood vessel invasion). However, performance of the resection (units of blood transfused) also appears to be an important factor influencing survival.
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50
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Little AG, Wu HS, Ferguson MK, Ho CH, Bowers VD, Segalin A, Staszek VM. Perioperative blood transfusion adversely affects prognosis of patients with stage I non-small-cell lung cancer. Am J Surg 1990; 160:630-2; discussion 633. [PMID: 2174651 DOI: 10.1016/s0002-9610(05)80762-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
It has been speculated that blood transfusion might adversely affect prognosis in cancer patients by immunosuppression. To avoid the confounding affect of advanced disease, we tested this hypothesis in 117 patients with stage I non-small-cell lung cancer. Mean and median follow-up were 49.7 months and 47 months, respectively. Patients who died during the postoperative period were not included. Perioperative transfusion was defined as administration of whole blood or packed cells within 30 days of operation. The overall cumulative 5-year disease-free survival rate was 67%. In patients with transfusion, it was 53% and in patients without transfusion it was 81% (p = 0.0055). A multivariate analysis was performed that included patient age, race, sex, cell type, extent of operation (pneumonectomy versus lobectomy/segmentectomy), operative blood loss, admission hematocrit, discharge hematocrit, and the presence or absence of perioperative transfusion. The only variable that significantly correlated with 5-year disease-free survival was the presence or absence of perioperative transfusion (p = 0.0278), and this effect was not related to the number of transfusions. Retrospective analysis of long-term results of patients surviving curative operation for stage I lung cancer shows that any perioperative transfusion significantly worsens the patient's prognosis and suggests very strongly that this association is due to an adverse effect of the transfusion rather than the transfusion serving as a marker for another risk factor.
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Affiliation(s)
- A G Little
- Department of Surgery, University of Nevada School of Medicine, Las Vegas 89102
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