Blood transfusion and postoperative complications: a cautionary comment

In the recent issue of JAMA Surg, Ecker and coworkers (1) reported a large study aimed to evaluate trends in transfusion rates for major abdominal oncologic resections. This retrospective population-based study was using the American College of Surgeons National Surgical Quality Improvement Project database. Another study by Ferraris et al. (2) aimed to determine the role of transfusion for patients’ postoperative outcomes. This study was based on the same database. Ecker et al. (1) found transfusion was associated with occurrence of wound infection, renal insufficiency, and myocardial infarction. Ferraris et al (2) revealed that transfusion has a dose-dependent adverse effect on postoperative outcomes. Though some of these findings were confirmed by another population based study (3), we believe that some issues of these two articles require consideration.

First, though a significant trend toward decreasing rates of transfusion during the past decade was observed, the rate of wound infection or renal insufficiency was not present a declining trend. Moreover, the rate of myocardial infarction was even rising. Since transfusion was associated with such complication, why their rates were not proportional to the declining trend of transfusion?

Among patients with malignant tumors, massive haemorrhage during surgery is the major cause of transfusion within 24 hours. Surgery complication and scope and longer operative time, which are closely related to tumor variables, are main risk factors of massive haemorrhage. Just as Ecker and coworkers’ finding, transfusion rate is the highest among patients who underwent liver resection, while patients underwent gastric resection showed the lowest transfusion rate (1). The more complicated, the bigger scope, and the longer operative time of surgery, the higher rate of postoperative complications will occur. On the other hand, surgeon experience and intraoperative complications may also contribute to blood loss and the decision of transfusion. Therefore, the factors that predispose patients to transfusion may be the real cause of postoperative complications, rather than transfusion. If all tumor variables, such as tumor stage, were comparable between patients with or without transfusion, the conclusion of the significant association between transfusion and postoperative complications would be more reliable. Unfortunately, all tumor variables were not described in these two studies (1,2). Interestingly, studies using propensity score-matching analysis to adjust differences in tumor characteristics found that the worse oncological outcomes after surgery was caused by the clinical circumstances requiring the transfusion, not by the transfusion itself (4-7). On the contrary, meta-analysis without adjusting tumor characteristics supported that transfusion was associated with negative prognoses for patients with gastrointestinal tumors (8-10).

The aim of transfusion is to maintain patients’ total blood volume. Blood loss is the driving force of postoperative complications. If transfusion becomes necessary, it will not jeopardize patients’ life.

Acknowledgements

Funding: This work was supported by Guangxi Science and Technology Development Projects (14124003-4), Guangxi University of Science and Technology Research Projects (KY2015LX056), the Self-Raised Scientific Research Fund of the Ministry of Health of Guangxi Province (Z2015621, Z2015601, GZZC15-34, Z2014241), and the Innovation Project of Guangxi Graduate Education (YCBZ2015030).

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Comment on: Ecker BL, Simmons KD, Zaheer S, et al. Blood Transfusion in Major Abdominal Surgery for Malignant Tumors: A Trend Analysis Using the National Surgical Quality Improvement Program. JAMA Surg 2016;151:518-25.

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