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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.30 no.3 Barcelona may./jun. 2008

 

ARTÍCULO CLÍNICO

 

Analysis of allogeneic blood transfusion in oral and maxillofacial cancer surgery. Analysis of variables

Análisis de la transfusión sanguínea alogénica en cirugía oncológica oral y maxilofacial. Análisis de variables

 

 

O. Altura Guillén1, A. Serrablo Requejo2, I. Iso Rivera1, V. Simón Sanz1, T. Rodríguez-Cachero1, E. Saura Fillat2, I. Moral Saez2, Uson Bouthelier2, F. Hernández Altemir3

1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial.
Hospital Universitario Miguel Servet. Zaragoza, España.

Correspondence

 

 


ABSTRACT

Objective. Analyze the variables that influence blood transfusion in patients undergoing surgery for cancer.
Material and method. Data from 44 patients who underwent surgery for neoplasms and required perioperative blood transfusion was analyzed to evaluate: age, sex, tumor location, diagnostic code, treatment, preoperative hematocrit, preoperative hemoglobin and pretransfusion hemoglobin, number of units transfused, TNM stage, ASA risk, and surgical time.
Results. Forty-four patients received transfusions (32 men). The mean age of patients was 65 years and the tumor was lingual in 36.36%. The most frequent intervention was tumor exeresis, which was associated with bone resection and cervical lymph node clearance in 56.82% of cases and with simple reconstruction in 63% of cases. The mean duration of the intervention was 5.7 hours, mean ASA risk was 3, and mean transfusion volume was 2.9 units. Seventy percent of patients had stage IV tumors. Mean hemoglobin concentration before transfusion was 7.71 g/dl. Surgical time, preoperative hemoglobin concentration, and preoperative hematocrit were statistically significant in multivariate analysis.
Conclusions. Allogeneic blood transfusions originate adverse effects that can condition the evolution of patients with cancer. Strict transfusion criteria should be followed (Hb < 8g/dl) to prevent or diminish these deleterious effects. Preoperative Hb is the only variable that we can act on to reduce transfusion volume. Blood-sparing programs should be implemented.

Key words: Oncologic surgery; Anemia; Allogeneic blood transfusion; Autologous blood transfusion.


RESUMEN

Objetivo. Analizar las variables que influyen en los pacientes transfundidos y sometidos a cirugía oncológica.
Material y método. Se han revisado y analizado los datos de 44 pacientes intervenidos quirúrgicamente de neoplasia, a los que se les ha practicado transfusión sanguínea peri operatoria, evaluando: edad, sexo, localización de la lesión, código de diagnostico, tratamiento realizado, hematocrito preoperatorio, hemoglobina preoperatoria y hemoglobina pretransfusional, numero de unidades transfundidas, estadio TNM, riesgo ASA y tiempo quirúrgico.
Resultados. 44 pacientes fueron transfundidos, 32 varones, con una media de edad de 65 años y con localización lingual en un 36,36%. La cirugía mas frecuente fue la exéresis tumoral asociándose resecciòn ósea y vaciamiento cervical en el 56,82% y con reconstrucción simple en el 63% de los casos. La duración media fue 5,7 horas, con un riesgo ASA medio de 3 y con una media de 2,9 unidades transfundidas. Un 70% se encontraban en estadio IV. La Hb pretransfusional fue de media 7,71 g/dl. El tiempo quirúrgico, la Hb preoperatoria y el HTC preoperatorio son las variables que ha resultado estadísticamente significativas en el análisis multivariante.
Conclusiones. La transfusión sanguínea alogénica presenta una serie de efectos adversos que pueden condicionar la evolución del paciente oncológico, para evitar o disminuir estos efectos deletéreos se debe mantener criterios transfusionales restrictivos con Hb<8 g/dl, debemos actuar sobre la Hb preoperatoria, como única variable en la que podemos incidir para disminuir el volumen transfundido y promover programas de ahorro de hemoderivados.

Palabras clave: Cirugía oncológica; Anemia; Transfusión sanguínea alogénica; Autotransfusión.


 

Introduction

In recent years the use of allogeneic blood transfusions (ABT) has declined significantly in industrialized countries. The investigation and use of alternative therapies, such as different modalities of autologous transfusion, is flourishing.

Physicians are aware of the risks of allogeneic transfusions, which, in fact, are cellular transplantations that expose the transfusion receptor to an antigen overload. Many of the risks involved are well known, such as the possibility of transmitting infective diseases and immunologic adverse effects, including hemolytic, febrile, allergic, and anaphylactic reactions, respiratory distress syndrome (ARDS), graft-versushost disease (GVHD), post-transfusion purpura, and others. To these must be added transfusion-related immunomodulation (TRIM), which is probably the adverse effect that causes most concern in cancer surgery.1

The mechanisms that induce transfusion-related immunomodulation are still not fully known, but immunomodulation is involved in numerous adverse effects that can condition the outcome of patients with cancer who undergo allogeneic blood transfusion. These include an increased incidence of nosocomial infection and tumor recurrence. 2,3 The transfusion of more than 3 units of allogeneic blood may reduce survival, as suggested by Taniguchi.4

Blood-sparing protocols should be initiated to prevent these adverse effects. However, transfusion criteria must first be clear in order to introduce blood-sparing strategies.

We evaluated the transfusion criteria of our department by means of a retrospective study of the factors that influence transfusion strategies in patients undergoing surgery for cancer of the oral and maxillofacial region.

 

Material and method

A retrospective study was made of the variables that influence blood transfusion in patients undergoing surgery for cancer.

The medical records of patients who underwent surgery for cancer and received blood transfusions during and 18- month period (1 July 2002 to 31 December 2003) were analyzed. We evaluated patient age and sex, tumor location, TNM stage, surgical time, ASA (American Society of Anesthesiologists) risk, preoperative hemoglobin, pretransfusion hemoglobin and hematocrit, type of surgery, type of reconstruction, and number of units transfused. Variables were then categorized (Table 1).

Data were processed using the G-Stat statistical program. The Student test was used to analyze the relation between the number of units transfused and dichotomic variables. The relation between the number of units transfused and variables with more than two categories was examined by ANOVA. The relation between the number of units transfused and age was analyzed by linear correlation. A multivariate test of multiple linear regression (Table 2) was used to determine the relation between the number of units transfused and quantitative variables.

Results

Forty-four patients who underwent surgery for cancer of the oral and maxillofacial region received blood transfusions in an 18-month period (1 July 2003 to 31 December 2004) in the oral and maxillofacial surgery department of Miguel Servet University Hospital of Zaragoza. The patients included 32 men and 12 women; mean age was 65 years (range 29-88 years). The most frequent tumor location was the tongue (16 cases), followed by the floor of the mouth (5 cases) and other locations of similar frequency (Figure 1). Of the 44 patients studied, 29 had stage IV disease (70%), 8 had stage III disease, and 7 had stage II disease. The mean duration of the surgical procedure was 5.7 ± 1.3 hours (range 2–8 hours). Twenty-eight patients (64%) presented an ASA risk of III, 12 patients (27%) ASA risk II, and only 4 patients (9%) ASA risk IV.

The surgical procedure most often performed was tumor exeresis associated with bone resection and cervical lymph node clearance. The type of cervical lymph node clearance performed was not differentiated, but 25 patients (57%) underwent this procedure. In 10 cases (23%), tumor excision was associated with cervical lymph node clearance alone and in 9 cases (20%), tumor excision was associated with bone resection alone. The reconstruction procedure was most frequently simple reconstruction, in 28 cases (64%). This was understood to be reconstruction without mobilizing any skin flap. Complex reconstruction requiring some type of flap was performed in 16 cases (36%). Preoperative hemoglobin concentration was stratified by sex: mean preoperative hemoglobin concentration in men was 13.7 ± 2.3 g/dl and in women, 12.4 ± 1.7 g/dl. Mean pretransfusion hemoglobin concentration was 7.7 ± 0.9 g/dl and mean preoperative hematocrit was 24.1 ± 1.9%. The mean transfusion volume was 2.9 ± 1.2 units (Figure 2).

No statistically significant differences were found between the number of units transfused and sex, age, tumor stage, surgical procedure, or bone resection.

Nonetheless, a tendency to transfuse more blood was observed in cases of complex reconstruction (p = 0.0652). Likewise, there was a tendency to transfuse more blood in patients with tumors of the floor of the mouth and upper maxilla (p = 0.0545) than in tumors in other locations.

Statistically significant differences appeared in multivariate analysis when multiple linear regression was used to analyze the number of units transfused and surgical time (p = 0.0054), preoperative hematocrit (p = 0.0077), and preoperative hemoglobin (P = 0.0022).

 

Discussion

Francis and Sentón5 demonstrated in the 1980s that allogeneic blood transfusions stimulate tumor development in rats. Gantt6 proposed that allogeneic blood transfusions could benefit kidney transplant receptors by producing a state of immunosuppression but that this effect could be adverse for patients with cancer. Since then, many authors have studied the topic, although there is little bibliography on allogeneic blood transfusion in patients with neoplasms of the head and neck or randomized studies of the adverse effects of the procedure.

For this reason, blood-sparing protocols are needed and we should act on the variables that influence the total amount of blood transfused.

In first place, we need to know what factors make blood transfusion necessary. According to V. Pinto García,7 there are two fundamental risk factors: the first are related to the diagnosis and the second, to the surgical technique. Patients diagnosed of neoplasm have a relative risk of transfusion of 1. The risk of transfusion then depends on the surgical technique used, being 14.1 in ablative soft tissue surgery, 13.9 in ablative bone surgery, and 24.6 in reconstructive bone surgery.

It is important to know what variables we can try to act on to reduce transfusion requirements. Our study showed that these variables were preoperative hematocrit, preoperative hemoglobin, and surgical time. Surgical time can be addressed by ensuring that all surgical procedures are performed by teams experienced in oncologic and reconstructive surgery.

Hemoglobin concentration and preoperative hematocrit can be addressed by evaluating patients to detect anemia (Hb < 11.5 g/dl in women and Hb < 13 g/dl in men). According to Okuyama,8 the administration of simple oral iron sulfate supplements to anemic patients for two weeks prior to surgery diminishes the risk of blood transfusion from 27.7% to 9.4% compared to patients with untreated anemia.

The hematologic values at which blood transfusion is indicated should be as strict as possible. In this study we applied a strict transfusion criterion of pretransfusion mean hemoglobin concentration 7.7 ± 0.9 g/dl. Moreover, when the hemoglobin concentration is 7-10 g/dl, the decision to initiate blood transfusion is not taken solely on the basis of hematologic values, but also the patient’s clinical situation. In some cases, compensatory mechanisms are sufficient to address metabolic demands, thus making blood transfusion unnecessary.9

We should identify patients from whom autologous blood can be collected and encourage the patient to do this. An autologous blood collection program can be initiated when the risk of transfusion is greater than 5%.10 In our study, the overall transfusion rate was 33%, so an autologous blood donation collection would have been indicated. It should be noted that the amount of blood from autologous extractions that is finally used varies widely. Transfusion needs may be overestimated. In the literature reviewed, Nath and Pogrel reported that only 24.2% of the units obtained are used,11 although other authors reports rates of use of 50% and even 73%.12,13 Use of a blood-sparing model not only avoids the adverse effects of allogeneic transfusions but also reduces costs.14

Other blood-sparing strategies, such as normovolemic hemodilution, can reduce allogeneic transfusions by up to 89%.15 Such blood-sparing measures include controlled hypotension,16 reinfusion of washed and centrifuged blood harvested from the operating field,17 and the administration of erythropoietin.16,18

 

Conclusions

Perioperative allogeneic blood transfusions are accompanied by a series of adverse effects that aggravate morbidity and mortality in patients undergoing surgery for cancer. Blood-sparing strategies should be used to prevent or reduce the deleterious effects of allogeneic transfusions. Likewise, we must act on any variables that can condition the need for blood transfusion. The only variable of this type on which we can act directly is preoperative hemoglobin. Anemic patients must be identified before surgery and oral iron supplements should be given. We also must adhere strictly to transfusion criteria, transfusing only when hemoglobin concentration is below 8 g/dl and only if the patient’s clinical situation makes blood transfusion necessary.

 

 

Correspondence:
Dr. Oscar Miguel Altura Guillen
c/ Mayor 43, 2º Izq, 50001-Zaragoza, España.
Email: oscaralt1@hotmail.com

Recibido: 09.06.2005
Aceptado: 16.06.2008

 

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