Transfusions Worsen Outcomes After Colorectal Cancer Surgery

View on the News

Concerns About Mortality and Perioperative Transfusions

The meta-analysis by Dr. Ache­son and his colleagues and an­other recent publication using the American College of Surgeons Na­tional Surgical Quality Improve­ment Program (Surgery 2012;152:344-54) highlight concerns about the increased mortality asso­ciated with perioperative blood transfusions. Intraoperative trans­fusion is associated with higher rates of 30-day operative mortality, major complications, total number of complications, and prolonged length of stay.

In general, patients requiring transfusions tend to be older, more

anemic and debilitated, have more extensive disease, and often need

larger surgical procedures with at­tendant greater blood loss. Patients

with these characteristics should be relatively evenly distributed among hospitals performing col­orectal cancer surgery, and one would expect the frequency of transfusion to be similar across in­stitutions.

However, Dr. Acheson and his associates found that the transfu­sion rate varied from 17.4% to 82.2%, suggesting that the indications for transfusion were quite

variable. Furthermore, the National Surgical Quality Improve­ment Program noted that more than 60% of patients received only one to two units of blood. This

raises concerns about whether blood transfusions are being given appropriately.

Some of the steps can be taken to decrease the use of perioperative blood transfusions and prevent transfusion-related morbidity are:

• Correcting anemia prior to

surgery by giving iron with or with­

out erythropoietin;

• Using blood conservation meth­ods when extensive surgery is


• Educating anesthesiologists and

surgeons about the indications for

transfusion (there is no rigid “trans­

fusion trigger”; each patient must be

assessed for the need to augment the

oxygen-carrying capacity of the


• Avoiding prospective donors al­loimmunized to white cell antigens

and leuko-reduce blood products

(Blood 2009;113:3406-17);

• Avoiding the use of blood that has

undergone prolonged storage (new

blood is better than old) (N. Engl. J.

Med. 2008;20:358:1229-39; Blood

2011;118:6675-82); and

• Recognizing that acute illness af­ter perioperative transfusions might be due to transfusion-transmitted infections or transfusion-associated lung injury (TRALI) (Blood 2012;119:1757-67).

Perioperative allogeneic blood transfusions can be life-saving, but must be used judiciously and with the recognition that they occasion­ally increase morbidity and mortal­ity.

DAVID GREEN, M.D., PH.D., is in the

division of hematology/oncology in

the department of medicine at

Northwestern University Feinberg

School of Medicine, Chicago. He has

no relevant disclosures.



The risks of death, postoperative infection, and other adverse clinical outcomes were significantly increased among patients undergoing colorectal cancer surgery who received perioperative allogeneic blood transfusions, according to a meta-analysis of 55 studies published in the August issue of Annals of Surgery.

Dr. Austin G. Acheson of the Nottingham (England) Digestive Disease Center at Queen’s Medical Centre and his associates reviewed 12 prospective studies and 43 retrospective cohort studies published between December 2004 and October 2010. The studies included 20,795 patients who were followed for a mean of about 5 years after undergoing surgery for colorectal cancer. Almost 60% (12,242) of these patients received a mean of three units of allogeneic red blood cells (Ann. Surg. 2012;256:235-44).

©Andrei Malov/

Patients who were transfused tended to be older, and the transfusion rate was significantly higher in women, those undergoing rectal surgery (compared with those undergoing right or left colon surgery), those with greater surgical blood loss, and those with worsening Duke's stage.

All associations between ABT and the adverse clinical outcomes described below were statistically significant.

The rates of all-cause mortality in the 29 studies that looked at this outcome were 45% among the patients who received blood transfusions vs. 35% of those who did not, a significant difference that represented a 72% increased risk. After adjusting for the duration of the observation period, the investigators found that the annual incidence of all-cause mortality was almost 9% among the transfused patients vs. 6.5% among those who were not transfused.

The rate of cancer-related mortality was 31% vs. 24% in the 17 studies that measured this outcome, a 71% increased risk. After adjusting for the length of observation, the investigators said the annual incidence of cancer-related mortality was 5.4% of those transfused and 4% of those who were not.

The rate of the combined end point of death resulting from recurrence/metastasis was 43% of those who were transfused vs. 33% of those who were not transfused – a 66% increase in risk – in the 19 studies that measured this outcome.

The risk of postoperative infections in the 12 studies that measured this outcome was 29% among those who were transfused vs. 11% of those who were not transfused, which was more than a threefold increased risk. In the two studies that measured the need for surgical reintervention, the risk was increased fourfold among those who were transfused.

In the four studies that measured the length of hospitalization, the hospital stay was a mean of almost 18 days among those who received transfusions, compared with 14 days among those who did not.

Based on evidence in this meta-analysis and other studies showing that preoperative anemia is an independent risk factor for a worse prognosis after colon surgery, and based on the association between ABTs and poorer clinical outcomes in this meta-analysis, the authors wrote that "appropriate blood management measures should, therefore, be given an important place in the care of patients with CRC [colorectal cancer] undergoing elective surgery."

The use of ABT has dropped over the past 25 years because of improvements in patient care, and the authors stated that they believe efforts should be made to further minimize ABT use. Well-designed studies are needed "to determine whether and in which patients preoperative corrective measures of anemia, other than ABTs, will contribute not only in the field of colorectal surgery but also to improve clinical outcomes," they added.

The study was supported by an unrestricted research grant from Vifor Pharma AG, a specialty pharmaceuticals company focused on the treatment of iron deficiency, according to its website. The authors disclosed receiving honoraria and/or travel support for consulting or lecturing for companies that include Vifor, Ethicon Endosurgery, Johnson & Johnson, and AstraZeneca AG; their research departments received grant support from companies that included Vifor.

Next Article:

Drug-Drug Interactions Added to Hepatitis C Drug Label

Related Articles