Safety of Intraoperative Cell Salvage in Cancer Surgery: An Updated Meta-Analysis of the Current Literature

Abstract

<b><i>Background:</i></b> 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. <b><i>Methods:</i></b> 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. <b><i>Results:</i></b> 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 (<i>n</i> = 2,311) or filtered (<i>n</i> = 850) IOCS (total <i>n</i> = 3,161) versus non-IOCS use (<i>n</i> = 5,342). Control patients were either treated with autologous predonated blood (<i>n</i> = 484), with allogeneic transfusion (<i>n</i> = 4,113), or did not receive a blood transfusion (<i>n</i> = 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. <b><i>Conclusion:</i></b> 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.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

“…683 The use of ICS with a leukocyte depletion filter was not associated with significant differences in short-term complications, mortality or cancer recurrence in oncological patients undergoing radical prostatectomy, cystectomy, open nephrectomy or liver resection for colorectal liver metastases. [684][685][686][687][688] An updated meta-analysis of 34 observational trials showed a reduced RR for cancer recurrence and metastasis when ICS is used in cancer surgery. 688…”

Preoperative Identification and Management of Anemia in the Colorectal Surgery Patient

“…Recent studies have begun to challenge the convention that intraoperative blood conservation strategies, such as autotransfusion, are precluded in patients undergoing CRC surgery due to both infection risk and the risk that autotransfusion may reintroduce cancer cells. 40,49 There is evidence that autotransfusion may be less immunosuppressive and associated with decreased risk of CRC recurrence relative to allogenic transfusion. 45,50 Despite this, intraoperative blood conservation and autotransfusion are not commonly employed for CRC cancer surgery.…”

Patient blood management and patient safety

“…In major surgery, often autologous cell salvage is performed to re-transfuse the patient‘s own red blood cells. In 2022, Fischer et al have summarized the most recent evidence for the use of autologous cell salvage in cancer patients [8 ▪▪ ]. The authors summarize that cell salvage can also be used in cancer patients, if surgery is performed without touching the area of cancer, or with the use of leukocyte depletion filters, that have been shown in numerous studies to wash out cancer cells prior to re-transfusion of the patient‘s own blood.…”