Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs.

Blood Transfusions and Adverse Events after Colorectal Surgery: A Propensity-Score-Matched Analysis of a Hen-Egg Issue

Leonardo Solaini;Giorgio Ercolani;
2023

Abstract

Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs.
2023
Catarci, Marco; Guadagni, Stefano; Masedu, Francesco; Montemurro, Leonardo Antonio; Ciano, Paolo; Benedetti, Michele; Delrio, Paolo; Garulli, Gianluca; Pirozzi, Felice; Scatizzi, Marco; Giacomo Ruffo, Massimo Giuseppe Viola, Ferdinando Ficari, Felice Borghi, Raffaele De Luca, Alberto Patriti, Walter Siquini, Stefano D'Ugo, Stefano Scabini, Marco Caricato, Giusto Pignata, Andrea Liverani, Roberto Campagnacci, Pierluigi Marini, Ugo Elmore, Francesco Corcione, Roberto Santoro, Massimo Carlini, Antonio Giuliani, Mario Sorrentino, Giovanni Ferrari, Gianandrea Baldazzi, Alberto Di Leo, Augusto Verzelli, Giuseppe Sica, Stefano Rausei, Davide Cavaliere, Gian Luca Baiocchi, Marco Milone, Giovanni Ciaccio, Giovanni Tebala, Luigi Boni, Stefano Mancini, Mario Guerrieri, Roberto Persiani, Andrea Lucchi, Dario Parini, Antonino Spinelli, Michele Genna, Vincenzo Bottino, Andrea Coratti, Dario Scala, Andrea Muratore, Maurizio Pavanello, Umberto Rivolta, Micaela Piccoli, Carlo Talarico, Alessandro Carrara, Mauro Totis, Franco Roviello, Alessandro Anastasi, Gianluca Guercioni, Giuseppe Maria Ettorre, Mauro Montuori, Pierpaolo Mariani, Nicolò de Manzini, Annibale Donini, Mariano Fortunato Armellino, Lucio Taglietti, Gabriele Anania, Mariantonietta Di Cosmo, Carlo Vittorio Feo, Paolo Millo, Corrado Pedrazzani, Silvio Guerriero, Andrea Costanzi, Nereo Vettoretto, Federico Marchesi, Massimo Basti, Graziano Longo, Moreno Cicetti, Maria Sole Mattei, Elena Belloni, Matteo Di Carlo, Daniela Apa, Marco Clementi, Ugo Pace, Andrea Fares Bucci, Francesco Monari, Antonio Sciuto, Lorenzo Pandolfini, Alessandro Falsetto, Elisa Bertocchi, Gaia Masini, Amedeo Altamura, Francesco Rubichi, Francesco Giudici, Fabio Cianchi, Desirée Cianflocca, Marco Migliore, Alessandro Rizzo, Anna Albano, Marcella Lodovica Ricci, Alessandro Cardinali, Marcello Spampinato, Alessandra Aprile, Domenico Soriero, Gabriella Teresa Capolupo, Jacopo Andreuccetti, Ilaria Canfora, Andrea Scarinci, Angela Maurizi, Grazia Maria Attinà, Giulia Maggi, Umberto Bracale, Roberto Peltrini, Maria Michela Di Nuzzo, Pietro Maria Amodio, Domenico Spoletini, Rosa Marcellinaro, Giorgio Lisi, Giovanni Del Vecchio, Massimo Stefanoni, Carmelo Magistro, Diletta Cassini, Lorenzo Crepaz, Andrea Budassi, Bruno Sensi, Silvia Tenconi, Leonardo Solaini, Giorgio Ercolani, Sarah Molfino, Giovanni Domenico De Palma, Paolo Locurto, Antonio Di Cintio, Elisa Cassinotti, Andrea Sagnotta, Monica Ortenzi, Alberto Biondi, Alban Cacurri, Maurizio De Luca, Francesco Carrano, Francesca Fior, Antonio Ferronetti, Giuseppe Giuliani, Roberto Benigni, Graziella Marino, Battistino Puppio, Patrizia Marsanic, Nicoletta Sveva Pipitone Federico, Carlo Di Marco, Camillo Leonardo Bertoglio, Francesca Pecchini, Vincenzo Greco, Michele Motter, Giuseppe Tirone, Nicolò Tamini, Riccardo Piagnerelli, Giuseppe Canonico, Simone Cicconi, Marco Colasanti, Enrico Pinotti, Roberta Carminati, Edoardo Osenda, Luigina Graziosi, Ciro De Martino, Giovanna Ioia, Arianna Birindelli, Matteo Chiozza, Daniele Zigiotto, Fioralba Pindozzi, Manuela Grivon, Cristian Conti, Lorenzo Organetti, Michela Monteleone, Emanuele Botteri, Giorgio Dalmonte, Diletta Frazzini, Simone Santoni, Gabriele La Gioia.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11585/953635
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