Preoperative Blood Augmentation in Jehovah’s Witness Patients Undergoing Transfusion-Free Surgery for Gastrointestinal or Hepato-biliary-pancreatic Cancer: Retrospective Cohort Study

BACKGROUND: Patients with anemia preparing for abdominal cancer surgery in whom transfusion is not an option require careful preoperative management. Cancer-related anemia is often multifactorial. Therefore, we applied a blood augmentation protocol based on patient blood management (PBM), which optimizes the patient's own red cell mass. We aimed to evaluate the effect of this protocol on surgical outcomes in patients with gastrointestinal and hepato-biliary-pancreatic cancers requiring transfusion-free surgery by comparing outcomes between patients with and without preoperative anemia (the anemic and non-anemic groups). All participants were Jehovah's Witnesses for whom transfusion was not an option. METHODS: We retrospectively analyzed consecutive Jehovah's Witness patients admitted to Shonan Atsugi Hospital between January 2017 and December 2020. Patients with preoperative anemia underwent a blood augmentation protocol from their first visit until surgery. They received iron and vitamin supplementation (folic acid, vitamin C, B12, and B6), and an erythropoiesis-stimulating agent. The primary outcomes were 30-day postoperative mortality and complications (Clavien-Dindo grade >IIIa). The secondary outcomes included waiting time to surgery and perioperative hemoglobin (Hb) values measured at protocol initiation, 1 to 3 days before surgery, and postoperative days (PODs) 1, 3, and 7. RESULTS: Of the 125 registered cases, 100 patients were analyzed (44 patients in the anemic group receiving blood augmentation (mean ± standard deviation [SD] age 70.9 ± 7.8 years; 26 [59.1%] female); 56 patients in the nonanemic group (age 66.4 ± 10.4 years; 35 [62.5%] female). The 30-day mortality rate (0/44 [0%] vs 0/56 [0%]) and the incidence of severe complications (9/44 [20.6%] vs 11/56 [19.6%]) did not differ between the two groups. Age-adjusted logistic regression for complications confirmed no significant difference (unadjusted odds ratio [OR] = 1.05; 95% confidence interval [CI], 0.39-2.82, P =.92 and age-adjusted OR = 0.94; 95% CI, 0.34-2.64, P =.91). The waiting time to surgery-which corresponds to the blood augmentation period for the anemic group-did not differ significantly (median 27 [interquartile range {IQR}, 15-39] vs 20 [IQR, 13-27] days, P =.13). In the anemic group, Hb improved from 10.8 ± 2.0 at baseline to 11.5 ± 1.2 g/dL preoperatively and then postoperatively recovered to levels comparable to those of the non-anemic group by POD 7 (10.5 ± 1.8 vs 10.9 ± 1.6 g/dL). Perioperative Hb levels showed significant time-by-intervention interactions (F4,368 = 13.9; P <.001). CONCLUSIONS: Proactive blood augmentation in patients with preoperative anemia enables safe and effective transfusion-free cancer surgery without delaying the indicated procedure. Multidisciplinary PBM approaches incorporating blood augmentation yielded short-term outcomes comparable to those of patients without preoperative anemia.