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Impact of Transfusion Threshold on Infectious Complications After Ileal Pouch-Anal Anastomosis
Emre Gorgun*1, Volkan Ozben1, Luca Stocchi1, Gokhan Ozuner1, Xiaobo Liu2, Feza H. Remzi1
1Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH; 2Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
Purpose
The effects of hemoglobin threshold level for administering blood transfusions on the postoperative infectious complications after ileal pouch-anal anastomosis (IPAA) are not known. The aim of this study was to investigate the impact of a lower transfusion threshold on the infectious complications by comparing the use of different hemoglobin (hgb) level-based transfusion practices.
Methods
Patients who underwent IPAA for ulcerative colitis (UC) between 01/2008 and 12/2013 were identified from the prospective IRB-approved institutional database. Patients were divided into four groups according to the perioperative lowest hgb level and transfusion status: Group 1 with hgb level≥ 10 g/dL and Group 2 with hgb level≥ 7 and <10 g/dL who did not receive transfusion, and Group 3 with hgb level≥ 7 and <10 g/dL and Group 4 with hgb level< 7 g/dL who received transfusion. Patient demographics, clinical and operative characteristics, septic complications including surgical site infections (SSIs), anastomotic leak, urinary tract infections, pneumonia and sepsis within postoperative 30 days were compared. Multivariate analyses were performed to evaluate the association between different transfusion practices and the infectious complications.
Results
A total of 802 patients underwent IPAA surgery. 638 patients (366 [57.4%] males) with a mean age of 39.0±13.1 years met the inclusion criteria. There were 237 (37.1%), 341 (53.4%), 40 (6.2%) and 20 (3.2%) patients in the Group 1, 2, 3, and 4, respectively. All the groups were comparable in terms of perioperative characteristics except for age (p=0.03), gender (p<0.001), preoperative albumin (p=0.006) and hgb levels (p<0.001), and operative blood loss (p<0.001). The rates of overall infectious complications were 18.6%, 26.7%, 47.5% and 40% in the group 1, 2, 3 and 4, respectively (Table). In the multivariate analysis, compared to Group 2, Group 3 was associated with an increased likelihood of developing organ/space SSIs (OR=4.34, 95% CI=1.58-11.93, p=0.004) and overall SSIs (OR=2.81, 95% CI=1.24-6.39, p=0.01).
Conclusion
Blood transfusion in the presence of perioperative hgb level above 7 mg/dl is associated with higher overall and organ space SSIs in UC patients without hemodynamic instability. A restrictive transfusion strategy is recommended in these patients.
Table. Comparison of the perioperative characteristics and infectious outcomes among the groups.
Perioperative
Characteristics | Group 1
(Hgb≥10
non-transfused)
n=237 | Group 2
(Hgb≥7 and <10
non-transfused)
n=341 | Group 3
(Hgb≥7 and <10 transfused)
n=40 | Group 4
(Hgb<7
transfused)
n=20 | P value | | Age, years, mean (sd) | 37.2 (12.9) | 40.2 (13.2) | 41.0 (13.7) | 36.1 (11.0) | 0.03 | | Gender, male, n (%) | 183 (77.2) | 155 (45.5) | 15 (37.5) | 13 (65.0) | <0.001 | | BMI, kg/m2, mean (sd) | 25.9 (4.3) | 25.8 (5.0) | 26.1 (4.5) | 25.1 (3.9) | 0.89 | ASA status, n (%) 1
2
3 | 5 (2.1)
196 (82.7)
36 (15.2) | 5 (1.5)
260 (76.2)
76 (22.3) | 0 (0)
34 (85.0)
6 (15.0) | 0 (0)
14 (70.0)
6 (30.0) | 0.26 | | Diabetes, n (%) | 8 (3.4) | 13 (3.8) | 5 (12.5) | 1 (5.0) | 0.06 | | Cardiac disease, n (%) | 13 (5.5) | 20 (5.9) | 6 (15.0) | 1 (5.0) | 0.13 | | Hypertension, n (%) | 36 (15.2) | 45 (13.2) | 7 (17.5) | 5 (25.0) | 0.46 | | Vascular disease, n (%) | 27 (11.4) | 34 (10.0) | 6 (15.0) | 3 (15.0) | 0.71 | | Preop albumin level, mg/dL, mean (sd) | 4.3 (0.4) | 4.2 (0.4) | 4.2 (0.7) | 4.1 (0.4) | 0.006 | | Preop hgb level, g/dL, mean (sd) | 14.3 (1.3) | 12.9 (1.5) | 12.6 (2.0) | 12.4 (2.6) | <0.001 | | Steroid use, n (%) | 64 (27.0) | 90 (26.4) | 13 (32.5) | 7(35.0) | 0.73 | | Immunomodulator use, n (%) | 11 (4.6) | 26 (7.6) | 3 (7.5) | 2 (10.0) | 0.48 | Operative procedure, n (%)
CP & IPAA
TPC & IPAA | 172 (72.6)
65 (27.4) | 228 (66.9)
113 (33.1) | 26 (65.0)
14 (35.0) | 13 (65.0)
7 (35.0) | 0.46 | Approach, n (%) lap
open | 86 (36.3)
151 (63.7) | 109 (32.0)
232 (68.0) | 8 (20.0)
32(80.0) | 4 (20.0)
16 (80.0) | 0.12 | Anast technique, n (%)
double stapled
mucosectomy & hand-sewn | 235 (99.2)
2 (0.84) | 337 (98.8)
4 (1.2) | 40 (100)
0(0) | 19 (95.0)
1 (5.0) | 0.34 | Pouch type, n (%) J
S | 237 (100)
0 (0) | 340 (99.7)
1 (0.3) | 39 (97.5)
1 (2.5) | 20(100)
0 (0) | 0.18 | | Op. time, min, mean (SD) | 190.1 (69.1) | 195.8 (71.9) | 209.1 (73.4) | 198.7 (67.7) | 0.4321 | | Op. blood loss, ml, mean (SD) | 201.2 (140.9) | 248.4 (161.4) | 296.3 (209.2) | 281.3 (175.2) | <0.001 | Overall SSI
Superficial
Deep
Organ/Space | 30 (12.7)
17 (7.2)
2 (0.8)
13 (5.5) | 59 (17.3)
36 (10.6)
9 (2.6)
23 (6.7) | 15 (37.5)
4 (10.0)
1 (2.5)
11 (27.5) | 7 (35.0)
3 (15.0)
0 (0)
5 (25) | | | Anastomotic leak | 8 (3.4) | 21 (6.2) | 4 (10.0) | 3 (15.0) | | | Pouch leak | 1 (0.4) | 5 (1.5) | 2 (5.0) | 0 (0) | | | Fistula/sinus | 5 (2.1) | 11 (3.2) | 3 (7.5) | 2 (10.0) | | | UTI | 8 (3.4) | 23 (6.7) | 4 (10.0) | 0 (0) | | | Pneumonia | 1 (0.4) | 1 (0.3) | 2 (5.0) | 0 (0) | | | Sepsis | 0 (0) | 4 (1.2) | 5 (12.5) | 8 (40.0) | | | Overall infectious complications | 44 (18.6) | 91 (26.7) | 19 (47.5) | 8 (40.0) | |
CP: completion proctectomy, TPC: total proctocolectomy
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