| ironjustice@aol.com 2006-06-04, 9:21 am |
| The effects of perioperative blood transfusion on morbidity and
mortality after esophagectomy.
Fields RC, Meyers BF
Thorac Surg Clin. 2006 Feb ; 16(1): 75-86
The effect of blood transfusion on outcomes in esophageal surgery
remains controversial. The contrasting conclusions drawn from a number
of retrospective analyses with different methodologies create a
landscape that is difficult to interpret. Because of the scope of
esophageal resection, the need for blood transfusion cannot be
eliminated. What recommendations then, if any, can be made for the
practicing surgeon? First, surgeons and anesthesiologists need to
reevaluate their transfusion thresholds. The age-old practice of
keeping the hemoglobin above 10 g/dL has very little evidence-based
support. A multicenter, randomized, controlled clinical trial in Canada
demonstrated that a restrictive strategy of blood transfusion, in which
patients were transfused only for a hemoglobin level of less than 7
g/dL, was at least as effective as and possibly was superior to a
liberal transfusion strategy in critically ill patients. It has also
been estimated that more than 25% of patients undergoing colorectal
resections may receive at least one unit of unnecessary blood. Further,
the immediate reduction in the hemoglobin concentration caused by the
normovolemic hemodilution associated with surgery and crystalloid fluid
replacement is not associated with any increased morbidity or
mortality. If these data are examined in the context of the results of
Langley and Tachibana indicating that a threshold amount of blood needs
to be transfused to impact outcomes, it becomes even more important to
limit transfusion to only the amount that is essential. Thus, surgeons
and anesthesiologists should adopt a more stringent set of requirements
for blood transfusion. Second, with the proven feasibility and
reduction in infectious complications associated with autologous
blood-donation programs, any patient who meets the criteria discussed
here should be encouraged to participate in such a program. Although
the effect of autologous blood on cancer outcomes remains unclear, the
other advantages certainly make such a program worthy of consideration.
This discussion leads to a final point, namely that patients should be
encouraged, whenever possible, to participate in clinical trial
research. The only way that the community of surgeons treating patients
who have esophageal cancer can hope to address properly the question of
how blood transfusion affects outcomes is with well-designed clinical
trials. A large, multicenter, randomized trial (level I) would be
ideal. Short of such a trial, inclusion criteria and study methodology
should be discussed among various institutions to avoid the differences
in studies that make direct comparisons of results among different
investigators difficult and potentially meaningless. This measure would
at least allow different level II to IV data to be compared directly
with some validity.
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Tom
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