Association for Academic Surgery
Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy

https://doi.org/10.1016/j.jss.2016.07.013Get rights and content

Abstract

Background

Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy.

Materials and methods

Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality.

Results

Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870).

Conclusions

Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.

Introduction

Before 1980s, the perioperative mortality rate for hepatectomy was >10%. Improvements in operative technique, perioperative and anesthetic care, and patient selection have resulted in present-day mortality rates of <2%-4% at experienced centers.1, 2, 3, 4 Improvement in technique and reduction in mortality has been demonstrated to be correlated with decrease in perioperative blood transfusion.5

Hepatectomy remains a high-risk operation with estimated transfusion rates between 20% and 30%.6, 7 Blood transfusion is associated with higher costs and increased risk of associated morbidity. Multiple recent studies have suggested worse oncologic outcomes most notably in patients with primary or metastatic malignancies leading to proposals for transfusion restrictions in patients undergoing hepatectomy.8, 9

Despite the advancements in surgical technique, more extensive liver resections may be associated with greater transfusion requirements.10 Whether blood transfusion represents an independent variable or a surrogate for more complex or extensive liver resection has not been well defined. We hypothesized an independent association between blood transfusion and postoperative morbidity and mortality in patients undergoing hepatectomy, regardless of extent of resection.

Section snippets

Patient selection criteria and outcome definitions

The present study used patient records obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) public use file linked with additional clinical information available from an institutional liver resection database. The NSQIP data set is a comprehensive, national database that collects patient-level, Health Insurance Portability and Accountability Act compliant data provided by participating hospitals. The University of Virginia Institutional Review

Patient demographics and individual risk factors

Five hundred and twenty-two adult patients aged ≥18 y undergoing hepatectomy between 2006 and 2013 were included in this study. Forty-eight (9.2%) patients required a perioperative blood transfusion. The median age of patients who received blood transfusion was 61.4 y (IQR, 52.9-70.0) and was not significantly different from the median age of nontransfused patients (58.1 y [IQR, 49.9-67.8], P value = 0.184). There were no significant differences in the distributions of sex, BMI, or race between

Discussion

Blood transfusion is associated with increased risk of morbidity and mortality after hepatectomy, independent of differences in patient comorbidities and extent of resection. The negative effects of blood transfusion in morbidity and mortality models have large effect sizes and strongly significant independent results. In addition to the well-described transfusion-associated risks of lung injury and hemolytic transfusion reaction, transfusion has been associated with poor immune-modulated

Conclusions

Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with both benign and malignant indications for liver resection.

Acknowledgment

American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of a portion of data used herein; they have not verified and are not responsible for the statistical validity of the data analyses or the conclusions derived by the authors.

This study was supported in part by funding provided by the Institutional National Research Service Award T32 CA 163177 from the National Cancer Institute to A.N.M.

Authors' contributions:

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  • Cited by (0)

    Presented in part at the 11th Annual Academic Surgical Congress, February 2-4, 2016, Jacksonville, FL.

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