20 Outcome of Perioperative Blood Transfusion in Patients Undergoing Esophagectomy for Esophageal Cancer: Systematic Review and Meta-Analysis of Outcomes

Abstract Aim Perioperative allogeneic red blood cell [RBC] transfusion is frequently used in patients undergoing esophagectomy for esophageal cancer, particularly due to neoadjuvant therapy–associated anemia. However, concerns have emerged regarding its potential association with adverse oncologic and postoperative outcomes. This study systematically reviews and synthesizes evidence on the impact of perioperative blood transfusion on survival and postoperative outcomes in patients undergoing esophagectomy for esophageal cancer. Method A systematic review and meta-analysis were conducted using PRISMA guidelines and registered in PROSPERO. We searched PubMed, Scopus, and Embase from inception through March 2025 for studies comparing outcomes in transfused versus non-transfused esophagectomy patients. The primary outcome was long-term survival, while secondary outcomes included postoperative complications and length of hospital stay. Pooled hazard ratios [HR], odds ratios [OR], and mean differences [MD] with 95% confidence intervals [CI] were calculated using random-effects models. The risk of bias was assessed, and sensitivity analyses were performed. Results Twenty-five retrospective cohort studies comprising 11,545 patients were included; 5,140 received perioperative transfusions. Meta-analysis of 17 studies [n=9,457] demonstrated significantly reduced long-term survival in transfused patients [HR=1.38; 95% CI: 1.09–1.74; p=0.007]. Transfusion was associated with higher odds of overall postoperative complications [OR=2.87; 95% CI: 1.17–7.04; p =0.02] and pulmonary complications [OR=2.00; 95% CI: 1.00–3.99; p=0.05], and prolonged hospital stays [MD=4.61 days; 95% CI: 0.3–8.92; p=0.04]. Conclusions Perioperative blood transfusion during esophagectomy is associated with worse long-term survival, higher complication rates, and longer hospitalization. These findings support restrictive transfusion practices and proactive perioperative anemia management in esophageal cancer surgery.