Blood
Preoperative Intravenous Iron Reduces the Need for Blood Transfusion in Colorectal Cancer Surgery
Nov
Approximately 30% to 60% of the general surgical population is commonly affected by preoperative anemia. This form of anemia is associated with an increased risk of postoperative morbidity, prolonged hospital stay, and impaired recovery.[1]
In colorectal cancer, anemia is more prevalent, affecting between 60% and 80% of patients. As many as 40% of non-anemic patients diagnosed with colorectal cancer experience iron deficiency, which is also considered an important but modifiable risk factor for surgical patients.
In planning potentially high-blood-loss surgery, preoperative anemia is defined as hemoglobin <13 g/dL for both male and female patients.
Among the most common treatable cause of preoperative anemia is iron-deficiency anemia. The management of this form of anemia includes iron supplementation with IV iron therapy when oral iron is ineffective or not tolerated, there is severe anemia, and there is insufficient time to surgery (<4 weeks). In other situations, erythropoiesis-stimulating agents designed to boost the production of red blood cells in the bone marrow, may be considered. This may be particularly for patients with multiple alloantibodies or patients with religious objections to blood transfusion.
Not a Harmless Problem
Although anemia has long been accepted to a relatively harmless problem that can be corrected easily with blood transfusion as a default management strategy, multiple studies have shown an association between preoperative anemia and increased postoperative mortality and morbidity.[2][3] In a study published in 2019 in JAMA, preoperative anemia was strongly associated with increased in-hospital mortality (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.48-2.95) and increased morbidity. [2]
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Clinical Practice
Change in clinical practice can have clear benefits for patients undergoing major bowel surgery, according to analysis conducted by researchers from UCL and the Royal Devon and Exeter Hospital. [1]
The study, published in The British Journal of Surgery, provides evidence that giving iron intravenously before colorectal surgery improves outcomes for patients, reducing the need for blood transfusion by 33%.
Anemia is a common problem in patients undergoing colorectal surgery due to bleeding from the gut and blood loss during the operation. Anemia is also associated with feeling tired and unwell, a slower recovery and other complications after surgery.
A higher rate of complications
Blood transfusion is generally used when blood levels are low, but there has been concern that colorectal cancer patients may have higher rates of complications and cancer recurrence if they’ve had a blood transfusion. Iron is commonly used to treat anemia, with a full course of treatment being administered intravenously in 15-30 minutes. To date intravenous iron infusion has been used sparingly, with a question remaining whether treating patients before major surgery would reduce the need for blood transfusion.
In the study, researchers from UCL conducted a meta-analysis of five randomized controlled trials. They focused on a subset of patients from those trials who had undergone colorectal surgery. In these trials, patients were split into two groups, a control group and a group who received iron intravenously prior to surgery.
The analysis showed that patients who had received iron infusion were 33% less likely to require a blood transfusion during or after surgery.
“This is the first time that clinical trials have shown a patient benefit from treatment with an iron infusion before surgery, which has the potential to treat anemia and reduce the need for blood transfusion,” said Professor Toby Richards, senior author of the study from UCL Division of Surgery & Interventional Sciences.
“Previous studies had not shown this benefit for all patients undergoing surgery in the NHS, but this analysis identifies a subset of patients undergoing bowel surgery who will see a benefit,” Richards added.
Reducing mortality
“With over 20,000 major colorectal cancer resections per year in the United Kingdom, the findings of this study have the potential to improve outcomes for the second most common cause of cancer mortality,” noted professor Neil Smart, a colorectal surgeon from the Royal Devon and Exeter Hospital and co-lead of the study.
“In the past, surgeons were uncertain whether the benefits of iron infusion could be realized in the short time frames of cancer care and consequently the uptake of this treatment was limited. Our findings show that improved outcomes can be achieved if iron infusion is given in the period between cancer diagnosis and surgery,” Smart added.
Avoiding transfusion
“The recent shortage of blood supply in the United Kingdom means it is more important than ever to focus on ways to avoid blood transfusions and their associated risks,” explained Sue Pavord, Vice President of British Society for Hematology.
“This analysis shows a reduction of over one-third in blood transfusions when anemic patients are treated with intravenous iron before their colorectal surgery. If we could combine this insight with others from the previous PREVENTT study, then hospital readmissions could potentially be cut even more, which would be important for both patients and the NHS,” she concluded.
Reference[1] Lederhuber H, Massey LH, Abeysiri S, Roman MA, Rajaretnam N, McDermott FD, Miles LF, Smart NJ, Richards T. Preoperative intravenous iron and the risk of blood transfusion in colorectal cancer surgery: meta-analysis of randomized clinical trials. Br J Surg. 2023 Nov 23:znad320. doi: 10.1093/bjs/znad320. Epub ahead of print. PMID: 37994900.[2] Fowler AJ, Ahmad T, Phull MK, Allard S, Gillies MA, Pearse RM. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg. 2015 Oct;102(11):1314-24. doi: 10.1002/bjs.9861. PMID: 26349842.[3] Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, Fergusson D, Folléa G, French C, Frey KP, Gammon R, Levy JH, Murphy MF, Ozier Y, Pavenski K, So-Osman C, Tiberghien P, Volmink J, Waters JH, Wood EM, Seifried E; ICC PBM Frankfurt 2018 Group. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA. 2019 Mar 12;321(10):983-997. doi: 10.1001/jama.2019.0554. PMID: 30860564.
Featured image: by Aman Chaturvedi on Unsplash Used with permission.
