The Effects of Perioperative Blood Transfusion on Morbidity and Mortality After Esophagectomy
Section snippets
Perioperative allogeneic blood transfusion and mortality: data from other surgical fields
In the 1970s, observations that allogeneic blood transfusions were associated with improved renal allograft survival (level III) sparked intense research on the immunomodulatory properties of allogeneic blood transfusion [5], [6]. It became clear that allogeneic blood transfusion acted as a nonspecific immunosuppressant and led to improved renal allograft survival (level Ib), although the mechanisms were not fully understood [5], [6], [7], [8], [9].
Although such an effect is apparently
The immunomodulatory properties of allogeneic blood transfusion
When the association between allogeneic blood transfusion and prolonged kidney allograft survival was documented in the 1970s [5], [6], [7], basic scientists began to explore the underlying mechanisms behind this phenomenon. This exploration led to a thorough characterization of the effect of allogeneic blood on the immune system (Box 1).
Allogeneic blood transfusion increases the number of suppressor T cells in kidney transplant patients [59]. These T cells have the unique property of
Perioperative allogeneic blood transfusion and survival in patients undergoing esophagectomy
A summary of all studies investigating the effect of perioperative allogeneic blood transfusion on outcomes after esophageal surgery for malignancy is shown in Table 2.
In 1996, Swisher and colleagues [86] applied the notion that allogeneic blood transfusion negatively affects survival to the field of esophageal cancer. The effect of perioperative (defined as beginning 48 hours before surgery and ending 48 hours after surgery) blood transfusion on survival after esophageal resection was studied
The effect of autologous blood transfusion in place of allogeneic blood transfusion in patients undergoing esophagectomy
As the debate continued across the field of surgical oncology, investigators began to ask whether the substitution of self-donated autologous blood transfusion would result in better survival. This interest stems from the previously described mechanism by which allogeneic blood induces immunosuppression and allows increased tumor growth and metastases. Namely, because autologous blood contains autologous leukocytes, no immunosuppression would occur [92]. Thus, in the early 1990s, investigators
Future directions
It is clear from a review of the literature that the issue of allogeneic blood transfusions leading to increased tumor recurrence and mortality after resection of cancer is not resolved. As was discussed earlier, disparate results and differences in methodology between studies make it difficult to draw any universal conclusions.
There are, however, a number of points worth mentioning concerning the future direction of blood transfusion in general, because these changes may help surgeons answer
Summary
The effect of blood transfusion on outcomes in esophageal surgery remains controversial. The contrasting conclusions drawn from a number of retrospective analyses with different methodologies create a landscape that is difficult to interpret. Because of the scope of esophageal resection, the need for blood transfusion cannot be eliminated. What recommendations then, if any, can be made for the practicing surgeon?
First, surgeons and anesthesiologists need to re-evaluate their transfusion
Acknowledgments
The authors thank Ankit Bharat and Laura Rothman for critical review and for helpful discussions of the manuscript.
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