Mamoun A. Rahman Surgical SHO Mr Osborne’s team

Introduction Blood transfusion: -Preoperative ( elective) -Intra/postoperative ( urgent) Blood transfusion and prognosis has been a topic of debate in colorectal cancer surgery Over 100 retrospective and at least 3 prospective RT have been published in the literature Vamvakas et al, Deleterious clinical effects of transfusion-associated immunomodulation: fact or fiction? Blood 2001 ? Immuno- suppressive effects of blood transfusion might adversely affect prognosis : - Enhancement of tumour growth -Recurrence and metastasis -Increased susceptibility to postoperative infection Circumstances that necessitate transfusion may be responsible for the adverse outcome

Large Bowel Cancer Project is a collaborative prospective study involving 94 surgeons and 38 pathologists in 23 hospitals in the United Kingdom in the period 1976 to1980 Objective: To establish the effect of blood transfusion on outcome of patients underwent curative resection for large bowel cancer Results: 961 patients studied 591 (61%) received a blood transfusion 370(39%) did not Age, sex, presence of bowel obstruction or perforation and tumour differentiation were equal variables Tumour site, Dukes’ stage and tumour fixity were unequaly distributed Not transfused n=370(%) Transfused n=591 (%) Statistical comparison Local recurrence Present Absent 58 (16) 312 (84) 113 (19) 478 (81) x2= 1.8 P=NS Distant metastasis Present Absent 63 (17) 307 (83) 98 (17) 493 (83) x2=0.o3 P=NS

Results ( cont..): survival Small difference in survival between the two groups Statistically not significant

This study showed No overall effect of blood transfusion on large bowel cancer patient survival

Blood transfusion and survival in colorectal cancer D. M. Sibbering, A. P. Locker 1, J. D. Hardcastle 1 and N. C. Armitage 1 Department of Surgery, University Hospital, Queen's Medical Centre, Nottingham, UK Department of Surgery, City Hospital, NG5 1PB Nottingham, UK April, 1994

Purpose: To examine the effect of blood transfusion on the prognosis of patients undergoing surgery for colorectal cancer Methods: 266 patients Potentially curative resections for colorectal cancer Prospective study Minimum follow-up: 41 months. Transfused (n=121) and nontransfused (n=145) Results: Conclusion: No statistically significant effect of perioperative blood transfusion on the prognosis of colorectal cancer patients VariablesX2dfP Rectal tumours : more in transfused Fixed tumours : more in transfused Recurrence-free survival : no significant difference Overall survival: no significant difference

Background: Indications for preoperative and intra/postoperative transfusion are different but they were usually pooled together Objective Compared outcome of patients who received preoperative blood with patients who did not receive any transfusion Methods: January 1980 and December 1995 Retrospective study Sample size was 333, 61 transfused & 272 were not Mean follow-up period: 58.6 months

Results: Preoperative Transfusion (n=61) No transfusionP Total complications (n=316)13/55 (23.6%)81/261 (31.0%)0.275 Wound infection1 (1.9%)37 (14.2%)0.011 Postoperative death (n=315)3/54 (5.6%)11/261 (4.2%)0.441 Loco-regional recurrence (n =175) 4/26 (15.4%)23/149 (15.4%)0.630 Distant metastasis (n=183)7/30 (23.3%)31/153 (20.3%)0.716 Death on follow-up (n=265)17/43 (39.5%)59/222 (26.6%)0.085 Disease-free survival was not significantly different between the groups (p=0.134)

Conclusion: Preoperative blood transfusion in this series: -Did not increase postoperative complications -Did not affect local or distant recurrence -Did not affect disease-free survival rate

Diseases of the COLON & RECTUM, 2006

Purpose: To determine whether type or number of blood units transfused affected short and long-term outcome in patients undergoing surgery for rectal cancer Methods: Between January 1984 and July patients Results for type (autologous or allogenic) and number of units transfused were recorded Follow-up ended February 2005

Type of bloodMultivariate Analysis of Overall Survival Multivariate Analysis of Disease-Free Survival Autologous transfusionP= P= Allogenic transfusionP= P= Autologous and allogenic transfusion P= P= No transfusion-- Results Number of units transfusedMultivariate Analysis of Overall Survival Multivariate Analysis of Disease-Free Survival 1–3 transfusionsP= >3 transfusionsP= No transfusion--

In this study Type or number of perioperative blood transfusions did not influence local recurrence, distant metastases, or disease-free survival in rectal cancer patients Tumour-related factors and adjuvant therapy determined oncologic outcome

Background: Blood transfusions have been indicated as having an adverse effect on the prognosis of colorecatal cancer Objective: Is autologous better than allogeneic blood transfusion Methods: Randomized, multicenter trial 420 patients who underwent curative operations for colorectal cancer Follow-up period of was 2.3 years

Results: 143 patients :no transfusion 277 transfused (134 allogeneic, 101 autologus & 42 both) Disease-free survival was better in untransfused group

Results ( cont..) Dukes’ A Dukes’ B Dukes’ C 2% 23% 49% < % 10% 27% Well differentiated Moderately differ. Poorly differ. 20% 249% 25% % 14% 4% NS MetastasesLog Rank p Value Local Recurrence Log Rank p Value Randomization: Allogeneic group Autologous group 27% 25% NS11% 17% NS No transfusion Transfusion 25% 27% NS3% 20% Blood loss (mL) <500 >500 and <1000 > % 28% NS 4% 14% 24% 0.001

The current study shows Both types of blood transfusion are associated with increased risk of local recurrences but not of metastatic disease Circumstances that necessitate transfusions lead to the development of local recurrences

Conclusion It’s has been suggested that blood transfusion adversely affect prognosis in colorectal cancer Immunologic factors believed to be implicated Presented evidence showed: - No overall effect of blood transfusion on prognosis - No difference between allogenic and autologus blood on prognostic effect - Immunogenic effect has been eliminated - Circumstances that necessitate transfusions lead to the development of local recurrences: Extent of the disease Experience of the surgeon Specialized units improve prognosis