title: Impact of blood transfusions and transfusion practices on long-term outcome following hepatopancreaticobiliary surgery.
abstract: BACKGROUND
  The long-term impact of transfusions with packed red blood cells (PRBC) among patients undergoing hepatopancreaticobiliary (HPB) surgery remains ill-defined. We sought to determine the impact of overall blood utilization, as well as a restrictive transfusion strategy, on long-term outcomes among patients undergoing an HPB resection for a malignancy.
  
  
  METHODS
  Data on overall blood utilization and hemoglobin (Hb) levels that triggered a transfusion were obtained for patients with cancer undergoing pancreas or liver surgery between 2009 and 2013. Risk-adjusted recurrence-free (RFS) and overall survival (OS) were assessed based on receipt of PRBC and whether the patient received a transfusion using a restrictive transfusion strategy (intraoperative: Hb <10 g/dL; postoperative: Hb <8 g/dL).
  
  
  RESULTS
  Four hundred forty-two patients underwent either a pancreas (58.1 %) or liver (41.9 %) resection. Most tumors were pancreatic in origin (41.8 %), while a subset were primary (23.1 %) or secondary (18.8 %) liver tumors. One hundred seventy-five (39.6 %) patients received ≥1 PRBC transfusion either intraoperatively (16.7 %), postoperatively (12.7 %), or both (10.2 %). There was a higher incidence of PRBC transfusion among patients undergoing a pancreas resection, those with higher comorbidities, and those with lower preoperative Hb levels. Perioperative morbidity was higher among patients receiving either 1-2 units (OR 3.14) or 3 or more units of PRBC (OR 8.54). Median OS was 31.9 months. Receipt of a blood transfusion was associated with a worse OS (1-2 units: HR 1.76; 3+units: HR 2.50; both P<0.05), and RFS (3+units: HR 2.91; P=0.02). Utilization of a restrictive transfusion strategy did not impact perioperative morbidity or long-term RFS or OS.
  
  
  CONCLUSIONS
  Adoption of a more restrictive transfusion strategy in patients undergoing resection for cancer may preserve a limited resource, reduce costs, as well as avoid exposing oncology patients to the unnecessary risks associated with a transfusion.
authors.affiliation: Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.
authors.forename: Aslam
authors.initials: A
authors.lastname: Ejaz
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.forename: Georgios A
authors.initials: GA
authors.lastname: Margonis
authors.forename: Rohan
authors.initials: R
authors.lastname: Gupta
authors.forename: Neda
authors.initials: N
authors.lastname: Amini
authors.forename: Steven M
authors.initials: SM
authors.lastname: Frank
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D004386:Duodenum / Q000601:surgery; D017707:Erythrocyte Transfusion; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016896:Treatment Outcome