Perioperative transfusion tied to worse outcomes after gastric resection

Last Updated: 2015-07-10

By Joan Stephenson PhD

NEW YORK (Reuters Health) - Perioperative allogeneic blood transfusion is associated with decreased survival in patients undergoing curative-intent resection of gastric adenocarcinoma, a large retrospective study suggests.

The adverse effect of transfusion on recurrence-free survival (RFS) and overall survival (OS) after resection was independent of estimated blood loss, the need for splenectomy, and other clinicopathologic factors, such as tumor stage.

"Based on these results, the judicious use of perioperative blood transfusions for patients undergoing gastric cancer resection is recommended," Dr. Malcolm Hart Squires III, of Emory University in Atlanta, Georgia told Reuters Health by email.

He and his colleagues also stressed the importance of meticulous surgical technique and blood-conserving strategies for limiting the need for transfusion, in a report online June 21 in the Journal of the American College of Surgeons.

The researchers analyzed survival outcomes of 765 patients who underwent complete resection of gastric adenocarcinoma from 2000 to 2012 at seven academic centers in the U. S. Gastric Cancer Collaborative.

On Kaplan Meier analysis, compared with nontransfused patients, the 168 patients (22%) who received allogeneic blood transfusions had shorter median RFS (13.5 vs 37.2 months, p<0.001) and OS (18.6 vs 49.8 months, p<0.001).

The analysis excluded patients with palliative resections, metastatic disease, or death within 30 days.

The median estimated blood loss was 200 mL.

Transfusion was associated with reduced survival regardless of timing (during or after surgery) or the volume of blood transfused.

"Of the patients who received perioperative transfusion, nearly 75% received only one or two units of RBCs, yet even small-volume transfusion in these patients was associated with significantly worse RFS and OS compared with non-transfused patients," Dr. Squires said.

The study also sought to address a debate over whether removing the spleen affects survival after transfusion in patients undergoing gastric cancer resection. Although transfusion was linked with decreased survival even in patients with an intact spleen, concurrent transfusion and splenectomy were associated with even worse survival than transfusion alone.

Previous research had similarly found perioperative allogeneic transfusion associated with reduced survival in patients undergoing resection of such malignancies as pancreatic cancer, esophageal cancer, hepatocellular cancer, and colorectal cancer. The U. S. Gastric Cancer Collaborative researchers undertook the current analysis - the largest US study to date on the issue, said Dr. Squires - because the few earlier studies exploring the prognostic effect of transfusion after gastric cancer resection had produced conflicting results.

The finding of shorter RFS and OS in transfused patients with or without splenectomy "is not entirely new or surprising," Dr. John Hunter, of Oregon Health & Science University in Portland, told Reuters Health by email. "The mechanism for this has been thought to be the immunosuppressive effects of transfusion, leading to impaired killer T cell function and impaired host defense against small-volume residual disease," an argument bolstered by the adverse effect seen with splenectomy alone.

"Nonetheless, these 'simple' explanations, especially in retrospective studies, always leave me a bit empty," Dr. Hunter said. "There are ALWAYS confounding factors that can't really be controlled for, no matter how sophisticated the multivariable regression analysis."

The authors acknowledged some of these factors, such as preoperative hemoglobin level, in their analysis.

"Other things not reported, and not controlled for, include the duration and difficulty of the operation, which may lead to planned or unplanned splenectomy," said Dr. Hunter.

Nevertheless, he said, "the evidence is pretty solid that transfusions should be used sparingly during the performance of gastrectomy for early or advanced gastric and GE junction cancer."

The study was supported in part by the Katz Foundation.

SOURCE: http://bit.ly/1CdFJ0z

J Am Coll Surg 2015.