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Autologous blood patch intraparenchymal injection reduces the incidence of pneumothorax and the need for chest tube placement following CT-guided lung biopsy: a systematic review and meta-analysis
Li, T., Zhang, Q., Li, W., Liu, Y.
European journal of medical research. 2024;29(1):108
Abstract
PURPOSE To assess the effectiveness of autologous blood patch intraparenchymal injection during CT-guided lung biopsies with a focus on the incidence of pneumothorax and the subsequent requirement for chest tube placement. METHODS A comprehensive search of major databases was conducted to identify studies that utilized autologous blood patches to mitigate the risk of pneumothorax following lung biopsies. Efficacy was next assessed through a meta-analysis using a random-effects model. RESULTS Of the 122 carefully analyzed studies, nine, representing a patient population of 4116, were incorporated into the final analysis. Conclusion deduced showed a noteworthy reduction in the overall incidence of pneumothorax (RR = 0.65; 95% CI 0.53-0.80; P = 0.00) and a significantly decline in the occasion for chest tube placement due to pneumothorax (RR = 0.45; 95% CI 0.32-0.64; P = 0.00). CONCLUSIONS Utilizing autologous blood patch intraparenchymal injection during the coaxial needle retraction process post-lung biopsy is highly effective in diminishing both the incidence of pneumothorax and consequent chest tube placement requirement.
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Blood salvage and autotransfusion during orthotopic liver transplantation for hepatocellular carcinoma: A systematic review and meta-analysis
Hinojosa-Gonzalez, D. E., Salgado-Garza, G., Tellez-Garcia, E., Escarcega-Bordagaray, J. A., Bueno-Gutierrez, L. C., Madrazo-Aguirre, K., Muñoz-Hibert, M. I., Diaz-Garza, K. G., Ramirez-Mulhern, I., Alvarez de la Reguera-Babb, R., et al
Clinical transplantation. 2023;:e15222
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a significant cause of oncologic mortality worldwide. Liver transplantation represents a curative option for patients with significant liver dysfunction and absence of metastases. However, this therapeutic option is associated with significant blood loss and frequently requires various transfusions and intraoperative blood salvage for autotransfusion (IBS-AT) with or without a leukocyte reduction filter. This study aimed to analyze available evidence on long-term oncologic outcomes of patients undergoing liver transplantation for HCC with and without IBS-AT. METHODS Per PRISMA guidelines, a systematic review of keywords "Blood Salvage," "Auto-transfusion," "Hepatocellular carcinoma," and "Liver-transplant" was conducted in PubMed, EMBASE, and SCOPUS. Studies comparing operative and postoperative outcomes were screened and analyzed for review. RESULTS Twelve studies totaling 1704 participants were included for analysis. Length of stay, recurrence rates, and overall survival were not different between IBS-AT group and non IBS-AT group. CONCLUSION IBS-AT use is not associated with increased risk of recurrence in liver transplant for HCC even without leukocyte filtration. Both operative and postoperative outcomes are similar between groups. Comparison of analyzed studies suggest that IBS-AT is safe for use during liver transplant for HCC.
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Intraoperative cell salvage in revision hip arthroplasty
Walton, T. J., Huntley, D., Whitehouse, S. L., Davies, J., Wilson, M. J., Hubble, M. J. W., Howell, J. R., Kassam, A. M.
The bone & joint journal. 2023;105-b(10):1038-1044
Abstract
AIMS: The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. METHODS An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. RESULTS Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). CONCLUSION We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity.
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Use of Cell Salvage at the time of Cesarean Delivery: A Meta-analysis of Randomized Controlled Trials
Iyer, N. S., Khanuja, K., Roman, A., Al-Kouatly, H. B.
American journal of obstetrics & gynecology MFM. 2023;:101257
Abstract
OBJECTIVE Excess blood loss from obstetrical hemorrhage requires transfusion of donor blood, a finite resource. Intraoperative cell salvage collects a patient's own blood that has been lost during cesarean delivery and returns it to their own circulation. We performed a meta-analysis to examine the perioperative outcomes in patients receiving cell salvage at the time of cesarean delivery. DATA SOURCES Scopus, PubMed, Cochrane Central Register of Controlled Trials, Ovid Medline, and clinicaltrials.gov were searched from database inception through October 2023. STUDY CRITERIA Randomized controlled trials comparing the use of cell salvage to standard of care during cesarean delivery. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently extracted data. PRISMA guidelines were used for data extraction and quality assessment. Primary outcomes were the rate of donor blood transfusion and change in hemoglobin level. Secondary outcomes included transfusion reaction, amniotic fluid embolism, and length of hospital stay. Results were summarized as weighted mean difference (MD) or risk ratio (RR) with associated 95% confidence intervals. Heterogeneity was measured using Higgins I(2). RESULTS A total of four RCTs (n=3231) comparing cell salvage to standard care during cesarean delivery met inclusion criteria. Primary analysis showed a significant decrease in receiving allogeneic blood transfusion with intraoperative cell salvage use versus standard care (OR 0.61, 95% CI [0.41,0.92]), with no change in hemoglobin drop (MD -1.03, 95% CI [-2.78,-0.72]). Secondary outcomes showed no difference in transfusion reaction (OR 0.56, 95% CI [0.06,5.59]), and length of hospital stay (MD -1.90, 95% CI [-4.85,1.06]). No cases of amniotic fluid embolism were reported among the 1620 patients who received cell salvage. CONCLUSION Use of cell salvage during cesarean delivery reduced the overall need for allogeneic blood transfusion without increasing the risk of complications including no cases of amniotic fluid embolism.
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The Efficacy and Safety of Autologous Blood Patch for Persistent Air Leaks: A Systematic Review and Meta-Analysis
Umar Z, Nassar M, Ashfaq S, Foster A, Sandhu JK, Ariyaratnam J, Lopez R, Trandafirescu T
Cureus. 2023;15(3):e36466
Abstract
Persistent air leaks (PALs) are associated with prolonged hospital stays, contamination and sustained infection of the pleural space, and significant morbidity. A fistulous tract between the alveoli and the pleural space is referred to as an alveolar-pleural fistula (APF), whereas a fistulous tract between the bronchiole and the pleural space is referred to as a bronchopleural fistula (BPF). There is no consensus on the treatment, and multiple modalities exist for the management of persistent air leak (PAL). Autologous blood patch (ABP) is a relatively safe and inexpensive method that has been used for many years for the treatment of PALs. We conducted an electronic database search between 08/24/2022 and 08/27/2022 in PubMed, Embase, and Cochrane using keywords. The following keywords were used: "Blood patch" OR "Autologous blood patch" AND "pleurodesis." Our study included all original studies with the prime focus on the etiology of PALs, clinical characteristics, procedural details of ABP, and outcomes of the proposed treatment. The primary outcomes that were the focus of our study were the time to seal the air leak, the time to remove the chest tube after air leak cessation, and the time to discharge from the hospital. To determine the safety of ABP, we also evaluated the procedural outcomes. Our findings suggest a statistically significant decrease in the time to air leak cessation when compared to the control group (mean difference of -3.75 {95% CI: -5.65 to -1.85; P=0.001}) with considerable heterogeneity of I(2)=85% and P=0.001. However, the difference was not statistically significant when a lower dose of ABP (50 mL) was compared to a higher dose (100 mL) (mean difference of 1.48 {95% CI: -0.07 to 3.02; P=0.06}) and considerable heterogeneity of I(2)=80% and P=0.03. There was no statistically significant difference in the time to discharge when compared to the control group (mean difference of -2.12 {95% CI: -4.83 to 0.59; P=0.13}) and considerable heterogeneity (I(2)=95% and P<0.001). When compared to the control group, ABP did not provide any statistically significant difference in the risk ratio for infection (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I(2)=33% and P=0.20}), pain (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I(2)=33% and P=0.20}), and fever (0.54 {95% CI: 0.27 to 1.10; P=0.09} and no heterogeneity {I(2)=0% and P=0.50}). Our study concludes that using ABP caused a statistically significant decrease in the time to air leak cessation when compared to the control group. However, the procedure does not provide a statistically significant difference in the time to discharge from the hospital when compared to conservative treatment. Similarly, there was no statistically significant difference in the risk ratio for complications such as infection, pain, and fever when compared to conservative management. More studies need to be conducted to fully understand the efficacy and safety of ABP in the management of PALs.
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Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery
Lloyd, T. D., Geneen, L. J., Bernhardt, K., McClune, W., Fernquest, S. J., Brown, T., Dorée, C., Brunskill, S. J., Murphy, M. F., Palmer, A. J.
The Cochrane database of systematic reviews. 2023;9(9):Cd001888
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Abstract
BACKGROUND Concerns regarding the safety and availability of transfused donor blood have prompted research into a range of techniques to minimise allogeneic transfusion requirements. Cell salvage (CS) describes the recovery of blood from the surgical field, either during or after surgery, for reinfusion back to the patient. OBJECTIVES To examine the effectiveness of CS in minimising perioperative allogeneic red blood cell transfusion and on other clinical outcomes in adults undergoing elective or non-urgent surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers for randomised controlled trials (RCTs) and systematic reviews from 2009 (date of previous search) to 19 January 2023, without restrictions on language or publication status. SELECTION CRITERIA We included RCTs assessing the use of CS compared to no CS in adults (participants aged 18 or over, or using the study's definition of adult) undergoing elective (non-urgent) surgery only. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 106 RCTs, incorporating data from 14,528 participants, reported in studies conducted in 24 countries. Results were published between 1978 and 2021. We analysed all data according to a single comparison: CS versus no CS. We separated analyses by type of surgery. The certainty of the evidence varied from very low certainty to high certainty. Reasons for downgrading the certainty included imprecision (small sample sizes below the optimal information size required to detect a difference, and wide confidence intervals), inconsistency (high statistical heterogeneity), and risk of bias (high risk from domains including sequence generation, blinding, and baseline imbalances). Aggregate analysis (all surgeries combined: primary outcome only) Very low-certainty evidence means we are uncertain if there is a reduction in the risk of allogeneic transfusion with CS (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.59 to 0.72; 82 RCTs, 12,520 participants). Cancer: 2 RCTs (79 participants) Very low-certainty evidence means we are uncertain whether there is a difference for mortality, blood loss, infection, or deep vein thrombosis (DVT). There were no analysable data reported for the remaining outcomes. Cardiovascular (vascular): 6 RCTs (384 participants) Very low- to low-certainty evidence means we are uncertain whether there is a difference for most outcomes. No data were reported for major adverse cardiovascular events (MACE). Cardiovascular (no bypass): 6 RCTs (372 participants) Moderate-certainty evidence suggests there is probably a reduction in risk of allogeneic transfusion with CS (RR 0.82, 95% CI 0.69 to 0.97; 3 RCTs, 169 participants). Very low- to low-certainty evidence means we are uncertain whether there is a difference for volume transfused, blood loss, mortality, re-operation for bleeding, infection, wound complication, myocardial infarction (MI), stroke, and hospital length of stay (LOS). There were no analysable data reported for thrombosis, DVT, pulmonary embolism (PE), and MACE. Cardiovascular (with bypass): 29 RCTs (2936 participants) Low-certainty evidence suggests there may be a reduction in the risk of allogeneic transfusion with CS, and suggests there may be no difference in risk of infection and hospital LOS. Very low- to moderate-certainty evidence means we are uncertain whether there is a reduction in volume transfused because of CS, or if there is any difference for mortality, blood loss, re-operation for bleeding, wound complication, thrombosis, DVT, PE, MACE, and MI, and probably no difference in risk of stroke. Obstetrics: 1 RCT (1356 participants) High-certainty evidence shows there is no difference between groups for mean volume of allogeneic blood transfused (mean difference (MD) -0.02 units, 95% CI -0.08 to 0.04; 1 RCT, 1349 participants). Low-certainty evidence suggests there may be no difference for risk of allogeneic transfusion. There were no analysable data reported for the remaining outcomes. Orthopaedic (hip only): 17 RCTs (2055 participants) Very low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, or if there is any difference between groups for mortality, blood loss, re-operation for bleeding, infection, wound complication, prosthetic joint infection (PJI), thrombosis, DVT, PE, stroke, and hospital LOS. There were no analysable data reported for MACE and MI. Orthopaedic (knee only): 26 RCTs (2568 participants) Very low- to low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, and whether there is a difference for blood loss, re-operation for bleeding, infection, wound complication, PJI, DVT, PE, MI, MACE, stroke, and hospital LOS. There were no analysable data reported for mortality and thrombosis. Orthopaedic (spine only): 6 RCTs (404 participants) Moderate-certainty evidence suggests there is probably a reduction in the need for allogeneic transfusion with CS (RR 0.44, 95% CI 0.31 to 0.63; 3 RCTs, 194 participants). Very low- to moderate-certainty evidence suggests there may be no difference for volume transfused, blood loss, infection, wound complication, and PE. There were no analysable data reported for mortality, re-operation for bleeding, PJI, thrombosis, DVT, MACE, MI, stroke, and hospital LOS. Orthopaedic (mixed): 14 RCTs (4374 participants) Very low- to low-certainty evidence means we are uncertain if there is a reduction in the need for allogeneic transfusion with CS, or if there is any difference between groups for volume transfused, mortality, blood loss, infection, wound complication, PJI, thrombosis, DVT, MI, and hospital LOS. There were no analysable data reported for re-operation for bleeding, MACE, and stroke. AUTHORS' CONCLUSIONS In some types of elective surgery, cell salvage may reduce the need for and volume of allogeneic transfusion, alongside evidence of no difference in adverse events, when compared to no cell salvage. Further research is required to establish why other surgeries show no benefit from CS, through further analysis of the current evidence. More large RCTs in under-reported specialities are needed to expand the evidence base for exploring the impact of CS.
PICO Summary
Population
Adults undergoing elective surgery (106 randomised controlled trials, n= 14,528).
Intervention
Intraoperative red blood cell salvage (CS).
Comparison
No CS (usual care).
Outcome
Cancer surgery (2 studies, n= 79) and vascular surgery (6 studies, n= 384): there is inconclusive evidence of the impact of cell salvage. Heart surgery without bypass (6 studies, n= 372): there is probably a reduction in the risk of needing a transfusion of donated blood because of cell salvage. Heart surgery with bypass (29 studies, n= 2,936): there may be a reduction in the risk of needing a transfusion of donated blood because of cell salvage. Caesarean section (1 study, n= 1,356): inconclusive evidence suggests there may be no difference in the risk of needing a transfusion of donated blood, alongside strong evidence that suggests there is no difference in the average amount of donated blood that is needed by the patient, because of cell salvage. Hip replacement surgery (17 studies, n= 2,055) and knee replacement surgery (26 studies, n= 2,568): there is inconclusive evidence of the impact of cell salvage. Spinal surgery (6 studies, n= 404): there is probably a reduction in the risk of needing a transfusion of donated blood because of cell salvage.
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Safety of Intraoperative Blood Salvage During Liver Transplantation in Patients With Hepatocellular Carcinoma: A Systematic Review and Meta-analysis
Aijtink, V. J., Rutten, V. C., Meijer, B. E. M., de Jong, R., Isaac, J. L., Polak, W. G., Perera, Mtpr, Sneiders, D., Hartog, H.
Annals of Surgery. 2022;276(2):239-245
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Abstract
OBJECTIVE The effects of intraoperative blood salvage (IBS) on time to tumor recurrence, disease-free survival and overall survival in hepatocellular carcinoma (HCC) patients undergoing liver transplantation were assessed to evaluate the safety of IBS. BACKGROUND IBS is highly effective to reduce the use of allogeneic blood transfusion. However, the safety of IBS during liver transplantation for patients with HCC is questioned due to fear of disseminating malignant cells. METHODS Comprehensive searches through June 2021 were performed in 8 databases. The methodological quality of included studies was assessed using the Robins-I tool. Meta-analysis with the generic inverse variance method was performed to calculate pooled hazard ratios (HRs) for disease-free survival, HCC recurrence and overall survival. RESULTS Nine studies were included (n=1997, IBS n=1200, no-IBS n=797). Use of IBS during liver transplantation was not associated with impaired disease-free survival [HR=0.90, 95% confidence interval (CI)=0.66-1.24, P=0.53, IBS n=394, no-IBS n=329], not associated with increased HCC recurrence (HR=0.83, 95% CI=0.57-1.23, P=0.36, IBS n=537, no-IBS n=382) and not associated with impaired overall survival (HR=1.04, 95% CI=0.79-1.37, P=0.76, IBS n=495, no-IBS n=356). CONCLUSIONS Based on available observational data, use of IBS during liver transplantation in patients with HCC does not result in impaired disease-free survival, increased HCC recurrence or impaired overall survival. Therefore, use of IBS during liver transplantation for HCC patients is a safe procedure.
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Effect of Autotransfusion in HCC Surgery on Survival and Recurrence: A Systematic Review and Meta-Analysis
Murtha-Lemekhova A, Fuchs J, Ritscher E, Hoffmann K
Cancers. 2022;14(19)
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Editor's Choice
Abstract
BACKGROUND The chronic blood shortage has forced clinicians to seek alternatives to allogeneic blood transfusions during surgery. Due to anatomic uniqueness resulting in a vast vasculature, liver surgery can lead to significant blood loss, and an estimated 30% of patients require blood transfusions in major hepatectomy. Allogeneic transfusion harbors the risk of an immunologic reaction. However, the hesitation to reinfuse a patient's own blood during cancer surgery is reinforced by the potentiality of reintroducing and disseminating tumor cells into an individual undergoing curative treatment. Two methods of autotransfusions are common: autotransfusion after preoperative blood donation and intraoperative blood salvage (IBS). We aim to investigate the effect of autotransfusion on recurrence and survival rates of patients undergoing surgery for HCC. METHODS The protocol for this meta-analysis was registered at PROSPERO prior to data extraction. MEDLINE, Web of Science and Cochrane Library were searched for publications on liver surgery and blood salvage (autologous transfusion or intraoperative blood salvage). Comparative studies were included. Outcomes focused on long-term oncologic status and mortality. Hazard ratios (HR) estimated outcomes with a fixed-effects model. Risk of bias was assessed using ROBINS-I, and certainty of evidence was evaluated with GRADE. Separate analyses were performed for liver transplantation and hepatectomies. RESULTS Fifteen studies were included in the analysis (nine on transplantation and six on hepatectomies), and they comprised 2052 patients. Overall survival was comparable between patients who received intraoperative blood salvage (IBS) or not for liver transplantation (HR 1.13, 95% CI [0.89, 1.42] p = 0.31). Disease-free survival also was comparable (HR 0.97, 95% CI [0.76, 1.24], p = 0.83). Autotransfusion after prior donation was predominantly used in hepatectomy. Patients who received autotransfusion had a significantly better overall survival than the control (HR 0.71, 95% CI [0.58, 0.88], p = 0.002). Disease-free survival was also significantly higher in patients with autotransfusion (HR 0.88, 95% CI [0.80, 0.96], p = 0.005). Although overall, the certainty of evidence is low and included studies exhibited methodological heterogeneity, the heterogeneity of outcomes was low to moderate. CONCLUSION Autotransfusion, including intraoperative blood salvage, does not adversely affect the overall or disease-free survival of patients with HCC undergoing resection or transplantation. The results of this meta-analysis justify a randomized-controlled trial regarding the feasibility and potential benefits of autotransfusion in HCC surgery.
PICO Summary
Population
Patients undergoing liver surgery for hepatocellular carcinoma (15 studies, n= 2,052).
Intervention
Autologous transfusion (including intraoperative blood salvage).
Comparison
No autologous transfusion.
Outcome
Overall survival was comparable between patients who received intraoperative blood salvage or not for liver transplantation (Hazard ratio (HR): 1.13, 95% CI: 0.89-1.42). Disease-free survival also was comparable (HR: 0.97, 95% CI: 0.76-1.24). Autotransfusion after prior donation was predominantly used in hepatectomy. Patients who received autotransfusion had a significantly better overall survival than the control (HR, 0.71, 95% CI: 0.58-0.88). Disease-free survival was also significantly higher in patients with autotransfusion (HR, 0.88, 95% CI: 0.80-0.96). Although overall, the certainty of evidence is low and included studies exhibited methodological heterogeneity, the heterogeneity of outcomes was low to moderate.
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Safety of Intraoperative Cell Salvage in Cancer Surgery: An Updated Meta-Analysis of the Current Literature
Frietsch T, Steinbicker AU, Horn A, Metz M, Dietrich G, Weigand MA, Waters JH, Fischer D
Transfusion medicine and hemotherapy : offizielles Organ der Deutschen Gesellschaft fur Transfusionsmedizin und Immunhamatologie. 2022;49(3):143-157
Abstract
BACKGROUND Allogeneic blood transfusions in oncologic surgery are associated with increased recurrence and mortality. Adverse effects on outcome could be reduced or avoided by using intraoperative autologous blood cell salvage (IOCS). However, there are concerns regarding the safety of the autologous IOCS blood. Previous meta-analyses from 2012 and 2020 did not identify increased risk of cancer recurrence after using autologous IOCS blood. The objective of this review was to reassess a greater number of IOCS-treated patients to present an updated and more robust analysis of the current literature. METHODS This systematic review includes full-text articles listed in PubMed, Cochrane, Cochrane Reviews, and Web of Science. We analyzed publications that discussed cell salvage or autotransfusion combined with the following outcomes: cancer recurrence, mortality, survival, allogeneic transfusion rate and requirements, length of hospital stay (LOS). To rate the strength of evidence, a Grading of Recommendations Assessment, Development and Evaluation (GRADE) of the underlying evidence was applied. RESULTS In the updated meta-analysis, 7 further observational studies were added to the original 27 observational studies included in the former 2020 analysis. Studies compared either unfiltered (n = 2,311) or filtered (n = 850) IOCS (total n = 3,161) versus non-IOCS use (n = 5,342). Control patients were either treated with autologous predonated blood (n = 484), with allogeneic transfusion (n = 4,113), or did not receive a blood transfusion (n = 745). However, the current literature still contains only observational studies on these topics, and the strength of evidence remains low. The risk of cancer recurrence was reduced in recipients of autologous salvaged blood with or without LDF (odds ratio [OR] 0.76, 95% confidence interval [CI]: 0.64-0.90) compared to nontransfused patients or patients with allogeneic transfusion. There was no difference in mortality (OR 0.95, 95% CI: 0.71-1.27) and LOS (mean difference -0.07 days, 95% CI: -0.63 to 0.48) between patients treated with IOCS blood or those in whom IOCS was not used. Due to high heterogeneity, transfusion rates or volumes could not be analyzed. CONCLUSION Randomized controlled trials comparing mortality and cancer recurrence rate of IOCS with or without LDF filtration versus allogeneic blood transfusion were not found. Outcome was similar or better in patients receiving IOCS during cancer surgery compared to patients with allogeneic blood transfusion or nontransfused patients.
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Should Cell Salvage be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis
Rajendran L, Lenet T, Shorr R, Abou Khalil J, Bertens KA, Balaa FK, Martel G
Annals of surgery. 2022
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Editor's Choice
Abstract
OBJECTIVE To evaluate the effect of intraoperative blood salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS Electronic databases were searched from inception until May 2021. All studies comparing IBSA use to control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival (OS) and disease-free survival (DFS), transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS Twenty-one observational studies were included (16 transplant, 5 resection, n=3,433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion (MD -1.81, 95% CI[-3.22, -0.40], P=0.01, I2=86%, very-low certainty). Few resection studies reported on transfusion for meta-analysis. No significant difference existed in OS or DFS in liver transplant (HR=1.12[0.75, 1.68], P=0.59, I2=0%; HR=0.93[0.57, 1.48], P=0.75, I2=0%) and liver resection (HR=0.69[0.45, 1.05], P=0.08, I2=0%; HR=0.93[0.59, 1.45], P=0.74, I2=0%). CONCLUSION IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.
PICO Summary
Population
Patients undergoing oncologic and non-oncologic liver surgery (either resection or transplantation), (21 studies, n= 3,433).
Intervention
Any intraoperative blood salvage and autotransfusion (IBSA) device.
Comparison
No IBSA use.
Outcome
Data from transplant and resection studies were analyzed separately. Despite significant heterogeneity, most studies reported lower rates and volumes of intraoperative allogeneic red blood cell transfusion in patients undergoing IBSA. In transplant, IBSA was associated with decreased allogeneic red blood cell transfusion (mean difference: -1.81, very-low certainty). Few resection studies reported on transfusion for meta-analysis. There was no significant difference in overall survival or disease-free survival in liver transplant and liver resection.