Allogeneic red blood cell transfusion is an independent risk factor for the development of postoperative bacterial infection

BACKGROUND AND OBJECTIVES: Allogeneic red blood cell transfusions may exert immunomodulatory effects in recipients including an increased rate of postoperative bacterial infection. It is controversial whether allogeneic transfusion is an independent predictor for the development of postoperative bacterial infection. METHODS: We analysed a prospectively collected database of 1,349 patients undergoing colorectal surgery in 11 centres across Canada. The primary outcome was the development of either a postoperative wound infection or intra-abdominal sepsis in transfused and nontransfused patients. The effect of allogeneic transfusion on postoperative infection was evaluated with adjustment for all the confounding factors in a multiple regression analysis. RESULTS: The 282 patients who received a total of 832 allogeneic units had a significantly higher frequency of wound infections and intra-abdominal sepsis than the patients who were not transfused (25. 9 vs. 14.2%, p = 0.001). A significant dose-response relationship between transfusion and infection rate was demonstrated. Multiple regression analysis identified allogeneic transfusion as a statistically significant independent predictor for postoperative bacterial infection (OR 1.18, 95% CI 1.05-1.33, p = 0.007). Other independent predictors were anastomotic leak, repeat operation, patient age and preoperative haemoglobin level. The mortality rate was also significantly higher in the transfused group. CONCLUSION: These data support the hypothesis that allogeneic red cell transfusion is an independent risk factor for the development of postoperative bacterial infection in patients undergoing colorectal surgery. This association provides further reason to minimise exposure to allogeneic transfusions in the perioperative setting.     

Impact of Blood Transfusions on Recurrence and Survival After Rectal Cancer Surgery

Purpose This study was designed to determine whether type or number of blood units transfused affected short-term and long-term outcome in patients undergoing surgery for rectal cancer. The number of perioperative blood units is associated with postoperative mortality and overall survival by some authors. In addition, allogenic perioperative blood transfusion has been postulated to produce host immunosuppression and has been reported to result in adverse outcome in patients with colorectal cancer. Autologous blood transfusion might improve results compared with allogenic transfusion. Methods Clinical outcome for 597 patients undergoing surgery for rectal cancer was analyzed according to their transfusion status. Results for type (autologous or allogenic) and number of blood units transfused were recorded. Results Blood transfusion was associated with increased postoperative mortality at 60 days. Patients who received > 3 units had a postoperative mortality of 6 percent compared with 1 percent for patients who received 1 to 3 units and 0 percent for patients who did not require transfusions. No difference was found between patients who received autologous or allogenic blood. Blood transfusions were also associated with impaired overall survival in a univariate analysis, but this finding was not confirmed in the multivariate analysis. The number or type of blood units transfused did not influence oncologic results. Local recurrence rates, distant metastases rates, and disease-free survival were not influenced by transfusion in our patients. Conclusions Increased numbers of blood units were associated with postoperative mortality. However, there is no reason, with respect to cancer recurrence or disease-free survival, to use a program of transfusion with autologous blood in patients undergoing surgery for rectal cancer. Reprints are not available.     

Perioperative blood transfusion in cancer patients undergoing laparoscopic colorectal resection: risk factors and impact on survival

Background

Perioperative blood transfusion has been associated with a poor prognosis in patients undergoing surgery for colorectal cancer. The aim of this study was to evaluate risk factors for blood transfusion and its impact on long-term outcome exclusively in patients undergoing laparoscopic surgery for curable colorectal cancer.

Methods

Data were retrieved from a prospectively collected database of patients who underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient clinic and personal contact when necessary.

Results

Two hundred and one patients underwent laparoscopic surgery for curable colorectal cancer (stage I–III). Sixty-eight (33.8 %) received blood transfusions during or after surgery. These patients were typically older, had lower preoperative hemoglobin levels, had a more advanced cancer, had a higher Charlson score, had a higher rate of complications and had a higher conversion rate. Kaplan–Meier overall survival analysis was significantly worse in patients who received blood transfusions (P = 0.004). Decreased disease-free survival was also observed in transfused patients; however, this did not reach statistical significance (P = 0.21). A multivariate analysis revealed that transfusion was not an independent risk factor for decreased overall and disease-free survival. The Charlson score was the only independent risk factor for overall survival (OR = 2.1, P = 0.002). Independent factors affecting disease-free survival were stage of disease, Charlson score and, to a lesser degree, age and body mass index.

Conclusions

Perioperative blood transfusion is associated with decreased long-term survival in patients undergoing laparoscopic resection for colorectal cancer. However, this association apparently reflects the poorer medical condition of patients requiring surgery and not a causative relationship.     

Surgical outcomes for colorectal cancer patients including the elderly

BACKGROUND/AIMS: The aim of this study was to compare the short- and long-term outcome of older and younger colorectal cancer patients resected for cure. METHODOLOGY: Three hundred and forty-six consecutive colorectal cancer patients who underwent some form of surgery were analyzed. One hundred and forty-four patients were < 65 years old (group 1), 151 patients were 65-79 years old (group 2), and 51 patients were 80 years or more (group 3). RESULTS: The overall perioperative mortality rate was 1.7% (n = 6). The median length of hospital stay was 19 days (range: 3-86 days). By univariate analysis, intraoperative bleeding (500 mL or more) (P = 0.009), duration of operations (240 min or more) (P = 0.03), and the presence of rectal cancer (P = 0.001), were strongly associated with higher incidence of postoperative complications. In multiple logistic regression analysis, only rectal cancer (P = 0.02) was significantly associated with serious postoperative complications. No age-related difference was noted concerning 5-year cancer-specific survival rates for patients with < 65, 65-79, and > or = 80 years who underwent surgery for cure (85%, 76%, and 69%, respectively) (P = 0.3). Using logistic regression analysis, tumor stage (P = 0.0001) and perioperative blood transfusions (500 mL or more) (P = 0.05) were strongly associated with outcome. CONCLUSIONS: Colorectal curative surgery for malignancy can be performed safely in the elderly with acceptable morbidity and mortality rates and long-term survival.     

Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation

BACKGROUND Jehovah's Witness patients (Witnesses) who undergo cardiac surgery provide a unique natural experiment in severe blood conservation because anemia, transfusion, erythropoietin, and antifibrinolytics have attendant risks. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions. METHODS A total of 322 Witnesses and 87?453 non-Witnesses underwent cardiac surgery at our center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38?467 did not receive blood transfusions and 48?986 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival. RESULTS Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% vs 2.8% (P?=?. 01); additional operation for bleeding, 3.7% vs 7.1% (P?=?. 03); prolonged ventilation, 6% vs 16% (P?<?. 001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 vs 24, 48, and 162 hours (P?<?. 001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 vs 6, 8, and 16 days (P?<?. 001). Witnesses had better 1-year survival (95%; 95% CI, 93%-96%; vs 89%; 95% CI, 87%-90%; P?=?. 007) but similar 20-year survival (34%; 95% CI, 31%-38%; vs 32% 95% CI, 28%-35%; P?=?. 90). CONCLUSIONS Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.     

Correlation between perioperative blood transfusion and prognosis of patients subjected to surgery for stage I lung cancer

BACKGROUND: It has been reported, but not proven, that perioperative blood transfusions have a detrimental effect on the survival of patients undergoing surgery for lung cancer. STUDY DESIGN: and methods: A prospective study was carried out on the patients undergoing lobectomy for stage I lung cancer at our department from 1995 to 2000. The criteria for exclusion included previous cases of malignancy, autoimmune diseases, and any other relevant comorbidity. RESULTS: Two hundred eighty-one patients were observed, 24.6% of whom received transfusions. The only significant difference between the transfused and nontransfused patients was their preoperative hemoglobin (Hb) concentration (12.5 +/- 1.20 g/dL vs 13.3 +/- 1.22 g/dL, p < 0.001). The disease-free interval of the transfused patients was significantly lower than that of the nontransfused patients (53% vs 78% at 73 months, p < 0.005), as was also the case for actuarial survival (52% vs 71% at 73 months, p < 0.02). Blood transfusion was significantly predictive of tumor relapse according to the Cox model adjusted for the T state, preoperative Hb concentration, sex, age, histologic type, and grading (hazard ratio, 2.3; p = 0.017). CONCLUSIONS: Our data show that perioperative blood transfusion is significantly correlated to worse prognosis in patients undergoing surgery for stage I lung cancer.     

Storage time of transfused blood and disease recurrence after colorectal cancer surgery

BACKGROUND: Perioperative blood transfusion and subsequent development of postoperative infectious complications may lead to poor prognosis of patients with colorectal cancer. It has been suggested that the development of postoperative infectious complications may be related to the storage time of the transfused blood. Therefore, we studied the relationship between blood storage time and the development of disease recurrence and long-term survival after colorectal cancer surgery. METHODS: Preoperative and postoperative data were prospectively recorded in 740 patients undergoing elective resection for primary colorectal cancer. None of the patients received preoperative or postoperative chemotherapy or radiation therapy. Endpoints were overall survival and disease recurrence in the subgroup of patients operated on with curative intention who also survived the first 30 days after operation. Storage of buffy-coat-depleted red cells suspended in saline, adenine, glucose, and mannitol blood for 21 days was used as cut-off point. RESULTS: Median follow-up was 6.8 years (range, 5.4 years to 7.9 years), and median overall survival was 4.6 years for 288 nontransfused patients and 3.0 years for 452 transfused patients (P = 0.004). The survival of patients receiving blood exclusively stored < 21 days was 2.5 years. For patients receiving any blood stored > or = 21 days, survival was 3.7 years (P = 0.12). Among patients with curative resection (n = 532), the hazard ratio of disease recurrence was 1.5 (95 percent CI; 1.1 to 2.2) and 1.0 (95 percent CI; 0.7 to 1.4) in the two transfused groups, respectively, compared with the nontransfused group after multivariable correction for patient age, gender, colonic/rectal tumor localization, Dukes classification, blood loss, and postoperative infectious complications. CONCLUSION: Transfusion of buffy-coat-depleted red cells suspended in saline, adenine, glucose, and mannitol blood stored for < 21 days may be an independent risk factor for development of recurrence after elective colorectal cancer surgery.     

Feasibility of a Predeposit Autologous Blood Donation Program in Colorectal Cancer Patients: Results from a Randomized Clinical Study

The hematologic and transfusion data of a multicenter randomized trial investigating the effect of blood transfusions on the 5-year survival were used to study the feasibility of an autologous blood donation program in colorectal cancer patients. Three hundred and ten patients were randomized for autologous blood transfusions (predeposition of 2 units) or homologous blood transfusions, and transfusion rules were standardized. The Hb level in the patients who donated blood decreased by 20.1 +/- 1.3 g/l (mean +/- SEM) preoperatively and 4.5 +/- 1.8 g/l postoperatively, and in controls 3.7 +/- 1.1 g/l and 16.5 +/- 1.9 g/l (significantly different between the two groups, both pre- and postoperatively: p less than 0.01). Because blood loss and number of transfusions were similar in both groups, this indicated that either preoperative or postoperative erythropoiesis is stronger in patients who had donated blood. Twenty-three percent of the autologous patients and 61% of the homologous patients were exposed to homologous blood. The effectiveness of the procedure differed per tumor localization. In patients with a right-sided colon carcinoma, 22% of the control patients needed homologous blood, compared to 10% of the autologous patients. In patients with other colon carcinomas, this was 52 and 16%, respectively, and in patients with a rectal carcinoma 85 and 41%. We conclude that predeposition of 2 units of blood for colorectal cancer surgery is feasible and useful to prevent homologous blood usage in a significant number of patients with left colon carcinoma or rectal carcinoma.     

Effects of continuous administration of clopidogrel before off-pump coronary artery bypass grafting in patients with acute coronary syndrome.

BACKGROUND: Clopidogrel has become standard treatment after urgent percutaneous coronary revascularization. Due to its enhanced and irreversible platelet inhibition, patients undergoing urgent surgical revascularization have a higher risk of bleeding complications and transfusions. Therefore, the effect of preoperative continuous administration of clopidogrel on the incidence of hemorrhagic complications in patients undergoing off-pump coronary artery bypass surgery with acute coronary syndrome was evaluated. METHODS AND RESULTS: From March 2004 to September 2006, 172 patients with acute coronary syndrome underwent isolated off-pump coronary artery bypass surgery; 70 (40.7%) and 102 (59.3%) of these patients did or did not take clopidogrel before surgery respectively. Seventy patients in each group were matched using propensity scores and associations between preoperative continuous administration of clopidogrel and postoperative bleeding, hemostatic reoperation, blood products received, the need for multiple transfusions and early graft patency by coronary computed tomography were assessed. Univariate analysis showed the continuous clopidogrel group had similar levels of postoperative bleeding for 24 h (601.4+/-312.6 ml vs 637.2+/-452.4 ml, p=0.616) and rates of reexploration (1.4% vs 1.4%), perioperative blood transfusion (33.3% vs 34.3%, p>0.05) and platelet transfusion (2.9% vs 7.1%, p=0.44) compared with the non-continuous group. CONCLUSIONS: Preoperative continuous administration of clopidogrel did not increase the risk of hemorrhagic complications in patients with acute coronary syndrome undergoing isolated off-pump coronary artery bypass surgery. These findings indicate that surgery after clopidogrel treatment in patients with acute coronary syndrome should not be delayed until platelet function returns to normal because they may have a higher risk of recurrent myocardial ischemic events.     

Long-lasting discussion: Adverse effects of intraoperative blood loss and allogeneic transfusion on prognosis of patients with gastric cancer

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.     

Long-term survival after colorectal surgery associated with buffy-coat-poor and leucocyte-depleted blood transfusion: a follow-up study

A Danish clinical trial showed that transfusion with leucocyte-depleted red blood cells reduces postoperative infectious complications compared with cells without buffy-coat. However, the effect on long-term outcome is unknown. We followed up the 142 cancer patients transfused with buffy-coat-poor red cells, the 118 transfused with leucocyte-depleted blood, and the 329 who were not transfused, until 2003. After 7 years' follow-up, survival for those with leucocyte-depleted blood transfusion (46 [41%]) was not significantly different from transfusion of blood without buffy-coat (59 [45%], p=0.51). Although survival is reduced by blood transfusion, it does not differ between the two transfusion regimens.     

Leukocyte-depletion of blood components does not significantly reduce the risk of infectious complications

Allogeneic blood transfusions are claimed to be an independent risk factor for postoperative infections in open colorectal surgery due to immunomodulation. Leukocyte-depletion of erythrocyte suspensions has been shown in some open randomized studies to reduce the rate of postoperative infection to levels observed in nontransfused patients. Using a double-blinded, randomized design, we studied the postoperative infection rate in patients undergoing open colorectal surgery transfused with either leukocyte-depleted erythrocyte suspensions (LD-SAGM) or non-leukocyte-depleted erythrocyte suspensions (SAGM). Unselected patients (n 279) were allocated to receive LD-SAGM (n 139) or SAGM (n 140) if transfusion was indicated. Forty-five percent were transfused, yielding 48 patients in the LD-SAGM group and 64 in the SAGM group. Thirteen patients were excluded because they received one type of transfusion in spite of randomization to the other type. No significant differences in the rates of postoperative infections (P=0.5250) or postoperative complications (P=0.1779) were seen between the two transfused groups. Infection rates were 45% and 38% in the transfused groups and 21% and 23% in the nontransfused groups. No significant difference between the transfused groups was seen on any single infectious event, mortality rate, or duration of hospitalization. Leukocyte-depletion of erythrocyte suspensions transfused to patients undergoing open colorectal surgery does not reduce postoperative infection rates.     

Postoperative infections in colorectal cancer patients

BACKGROUND/AIMS: Colorectal surgery is associated with some of the highest rates of infective complications, and especially surgical site infections. It has recently been reported that postoperative infection in colorectal cancer surgery increases the risk of recurrence. The aim of this study was to analyze factors associated with the occurrence of postoperative infections in patients with colorectal cancer. METHODOLOGY: A total of 81 patients operated for colorectal cancer was included. Patients' characteristics and postoperative course were recorded and analyzed. RESULTS: Patients with tumors located in the rectum had significantly higher rate of postoperative infectious complications compared to patients with tumors located in the colon (p=0.002). In a logistic regression model, among all evaluated predictors, only preoperative hemoglobin concentration was found to be an independent significant predictor of postoperative infection (p=0.01). CONCLUSIONS: Preoperative anemia was found to be significant independent predictor of postoperative infection. Meticulous surgical technique with minimal blood loss is an important means of reduction of postoperative infections in colorectal surgery.     

Influence of Autologous Blood Transfusion on Natural Killer and Lymphokine-Activated Killer Cell Activities in Cancer Surgery

Background and objectives: Immunosuppression associated with blood transfusion may influence postoperative infection rates. It may also affect the prognosis of patients treated surgically for colorectal cancer. To control this effect, study protocols have applied autologous blood donation programs, which are thought to be immunologically neutral. However, evidence has emerged that blood donation itself might have suppressive effects on natural killer (NK) cell activities. At present, there are no data available on the effects of autologous blood transfusion on NK or lymphokine-activated killer (LAK) cells. This might be of interest as LAK cells may be active in tumor control. Materials and methods: 26 patients who underwent surgical resection for colorectal cancer, were assigned at random into two groups: (1) autologous blood donation and transfusion, or (2) allogeneic blood transfusion. NK and LAK activities were determined before blood donation, at surgery, and on the 3rd and 8th postoperative day. Results: Blood donation induced a small decrease in NK and LAK activities. The postoperative courses of the two groups differed. In the allogeneic group, NK activity (?50%, p = 0.018) and LAK activity decreased (?60.7%, p = 0.043), whereas in the autologous group the decline in LAK was less pronounced (?33.7%, p = 0.091), and their NK activity even increased (+17.4%, p = 0.315). NK activity was modulated differently in the two study groups (0.0036). Differences in LAK activities were found between the 3rd and 8th day postoperatively (p = 0.354). Conclusions: In patients receiving autologous blood transfusion, postoperative suppressed NK and LAK activities were modulated. This implies that autologous blood transfusion is not immunologically neutral, but has an intrinsic immunomodulatory potential.     

The effect of peroperative transfusion on survival in resected lung carcinomas

This paper analyzes the influence of perioperative transfusion on survival after lung cancer surgery. Between January 1991 and December 1995, we enrolled 405 patients, 196 of whom received transfusions and 209 of whom did not. Follow-up extended to December 1997. Excluded were patients undergoing exploratory thoracotomy (n = 92), those who died during the postoperative period (n = 19) and those lost to follow-up (n = 13). The final number of patients in the study was 281 (136 who received transfusions and 145 who did not). We analyzed age, sex, general clinical status measured on the Eastern Cooperative Oncology Group (ECOG) scale, histological type and TNM staging. Single and multiple variable analyses were performed. At the end of the study 158 patients were alive and 123 had died. Transfusions were used more often in pneumonectomies (p < 0.001) and in patients with an ECOG score of 2 (p < 0.01). Survival at 36 and 60 months, calculated using the Kaplan-Meier method was 52% and 30%, respectively, for those who had received transfusions, and 53% and 49%, respectively, for those who had not. The differences were not statistically significant (p > 0.1). Multivariant analysis failed to demonstrate an influence of transfusion on survival (relative risk of 1.08; 95% confidence interval 0.72-1.61; p > 0.1). We conclude that there is no negative prognostic effect of perioperative transfusion.     

Use of survival analysis to determine the clinical significance of new Q waves after coronary bypass surgery

There are few data on the long-term effects of new Q waves on survival and morbidity after coronary bypass graft surgery (CABG). We followed 1340 patients who underwent CABG in 1978 at 10 hospitals participating in the Coronary Artery Surgery Study (CASS). The incidence of perioperative Q-wave infarction was 4.76% (range 0.0-10.3% by hospital). The rate of infarction was higher in patients who had an increased left ventricular end-diastolic pressure or cardiomegaly on the preoperative chest radiograph. Patients who received more grafts or who had longer cardiopulmonary bypass time were also at higher risk of infarction. In a stepwise discriminant analysis of 44 clinical, angiographic and surgical variables, cardiopulmonary bypass time, topical cardiac hypothermia and cardiomegaly entered the stepwise selection of variables. Long-term survival was adversely affected by the appearance of new postoperative Q waves. The hospital mortality was 9.7% in the 62 patients who had new postoperative Q waves and 1.0% in the 1278 patients who did not (p less than 0.001); the 3-year cumulative survival rates were 85% and 95%, respectively (p less than 0.001). In patients who survived to hospital discharge, the presence of new postoperative Q waves did not adversely affect 3-year survival (94% and 96%, respectively). The survival rates were worse in patients who had a history of infarction or who had impaired left ventricular function preoperatively. The number of readmissions to hospital after CABG among the patients who had a transmural perioperative infarction was similar to to that among patients who did not. We conclude that the appearance of new Q waves after CABG adversely affects survival. The major impact on mortality occurs before hospital discharge. Patients who are destined to have a perioperative infarct cannot be predicted from commonly measured preoperative and angiographic variables.     

Comparison of Multivisceral Resection and Standard Operation for Locally Advanced Colorectal Cancer: Analysis of Prognostic Factors for Short-Term and Long-Term Outcome

PURPOSE The aim of the present study is to clarify the characteristics of multivisceral resection and to discuss strategies for improving the overall outcome of multivisceral resection for locally advanced colorectal cancer.METHODS The study included 323 patients who electively underwent curative surgery for pT3–pT4 colorectal carcinoma without distant metastasis. We evaluated the short-term and long-term outcome of multivisceral resection relative to that of the standard operation by means of multivariate analysis of the prognostic factors.RESULTS Of 323 patients, 53 (16.4 percent) received multivisceral resection because of adhesion to other organs. Multivisceral resection was significantly associated with tumor size, depth of invasion, operative blood loss, operation time, and blood transfusion (all: P < 0.0001). Overall morbidity rates were 49.1 percent after multivisceral resection vs. 17.8 percent after the standard operation (P < 0.0001), and postoperative mortality rate was 0 percent in both groups (not significant). Only multivisceral resection (odds ratio, 2.725; 95 percent confidence interval, 1.125–6.623; P = 0.0264) was an independent factor for overall postoperative complications. The survival rate of patients after multivisceral resection was similar to that after the standard operation (5-year rate, 76.6 percent vs. 79.5 percent, P = 0.9347). Lymph node metastasis (hazard ratio, 2.510; 95 percent confidence interval, 1.460–4.315; P = 0.0009) and blood transfusion (hazard ratio, 2.353; 95 percent confidence interval, 1.185–4.651; P = 0.0145) were independently associated with patient survival.CONCLUSIONS For locally advanced colorectal cancer, the long-term outcome after multivisceral resection is comparable to that after the standard operation. However, it should be recognized that multivisceral resection is associated with higher postoperative morbidity. In addition, a reduction in the incidence of blood transfusion may contribute to improving patient survival.     

Surgery for perforated colorectal malignancy in an Asian population: an institution’s experience over 5 years

Introduction  

Perforated colorectal malignancy is associated with numerous peri-operative complications and dismal long-term survival. The study aimed to review the outcome and factors predicting peri-operative complications and long-term survival of patients who underwent surgery for perforated colorectal malignancy.     

Comparison of long-term outcome of laparoscopic and conventional surgery for advanced colon and rectosigmoid cancer

BACKGROUND/AIMS: Although after laparoscopic surgery for colorectal cancer postoperative recovery is better than after open surgery, oncologic outcome after this minimally invasive technique remains unclear. In this study we tested the null hypothesis that there is no difference in the outcome of advanced colorectal cancer according to whether it is treated by laparoscopic or conventional open resection. METHODOLOGY: The long-term outcome of 79 patients with advanced colorectal cancer who underwent laparoscopic surgery between 1996 and 2002 was compared with that of 79 who underwent open surgery during the same period, being well-matched patients for age, gender, tumor site, and pathological TNM stage (II or III). Adjuvant therapy and postoperative follow-up were the same in both groups. RESULTS: The median follow-up time after laparoscopic and open surgery was 36 months and 47 months, respectively (p = 0.0756). No significant difference was found between the groups in overall or disease-free survival rates (96% versus 88%, p = 0.12; 96% versus 86%, p = 0.09, respectively). The recurrence rate was 23% in both groups, and liver metastasis was the most frequent form of recurrence. No port site recurrence was observed in the laparoscopic surgery group. CONCLUSIONS: The laparoscopic approach is an acceptable alternative to open surgery for advanced colorectal cancer because of the comparable medium-term outcome. Longer follow-up and large scale RCT is needed to fully assess the oncologic outcome.     

Prognostic significance of perioperative blood transfusions in resectable thoracic esophageal cancer

OBJECTIVE: The perioperative blood transfusions have been associated with tumor recurrence and decreased survival in various types of alimentary tract cancer. There exist, however, contradictory studies showing no relationship between blood transfusions and survival. For patients with esophageal cancer, only one report suggested that blood transfusions did not by itself decrease the chance of cure after esophagectomy. METHODS: Among 235 patients with primary squamous cell carcinoma of the thoracic esophagus between December 1979 and March 1998, 143 patients (60.9%) underwent esophagectomy with curative intent (RO). To exclude the effects of surgery-related postoperative complications, 14 patients who died within 90 days during the hospital stay were excluded. Thus, clinicopathological characteristics and prognostic factors were retrospectively investigated between patients with no or few transfusions (< or = 2 units) (n = 58), and much transfused patients (> or = 3 units) (n = 71). RESULTS: Sixty-three patients are alive and free of cancer, and 66 patients are dead. A total of 98 patients (76%) received blood transfusions, whereas 31 patients (24%) had no transfusion. The amount of blood transfused was 1 or 2 units in 27 patients (27.6%), 3 or 4 units in 33 (33.7%), 5 or 6 units in 20 (20.4%), and > or = 7 units in 18 (18.4%). The 5-yr survival rate for patients with no or few transfusions was 69%, whereas that for much transfused patients was 31.7% (p < 0.0001). The much transfused patients had more prominent ulcerative tumor, longer time of operation, more estimated blood loss, and more marked blood vessel invasion than the group with no or few transfusions. The factors influencing survival rate were tumor location, Borrmann classification, size of tumor, depth of invasion, number of lymph node metastases, time of operation, amount of blood transfusions, lymph vessel invasion, and blood vessel invasion. Among those nine significant variables verified by univariate analysis, independent prognostic factors for survival determined by multivariate analysis were number of lymph node metastasis (0 or 1 vs > or = 2, p < 0.0001), amount of blood transfusions (< or = 2 units vs > or = 3 units, p < 0.0001), and blood vessel invasion (marked vs non-marked, p = 0.0207). CONCLUSIONS: There is an association between high amount of blood transfusions and decreased survival for patients with resectable esophageal cancer. To improve the prognosis, surgeons must be careful to reduce blood loss during esophagectomy with extensive lymph node dissection and subsequently must minimize blood transfusions.