Original Article
The Impact of Perioperative Iron on the Use of Red Blood Cell Transfusions in Gastrointestinal Surgery: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.tmrv.2014.05.004Get rights and content

Abstract

Perioperative anemia is common, yet detrimental, in surgical patients. However, red blood cell transfusions (RBCTs) used to treat anemia are associated with significant postoperative risks and worse oncologic outcomes. Perioperative iron has been suggested to mitigate perioperative anemia. This meta-analysis examined the impact of perioperative iron compared to no intervention on the need for RBCT in gastrointestinal surgery. We systematically searched Medline, Embase, Web of Science, Cochrane Central, and Scopus to identify relevant randomized controlled trials (RCTs) and nonrandomized studies (NRSs). We excluded studies investigating autologous RBCT or erythropoietin. Two independent reviewers selected the studies, extracted data, and assessed the risk of bias using the Cochrane tool and Newcastle-Ottawa scale. Primary outcomes were proportion of patients getting allogeneic RBCT and number of transfused patient. Secondary outcomes were hemoglobin change, 30-day postoperative morbidity and mortality, length of stay, and oncologic outcomes. A meta-analysis using random effects models was performed. The review was registered in PROSPERO (CRD42013004805). From 883 citations, we included 2 RCTs and 2 NRSs (n = 325 patients), all pertaining to colorectal cancer surgery. Randomized controlled trials were at high risk for bias and underpowered. One RCT and 1 NRS using preoperative oral iron reported a decreased proportion of patients needing RBCT. One RCT on preoperative intravenous iron and 1 NRS on postoperative PO iron did not observe a difference. Only 1 study revealed a difference in number of transfused patients. One RCT reported significantly increased postintervention hemoglobin. Among 3 studies reporting length of stay, none observed a difference. Other secondary outcomes were not reported. Meta-analysis revealed a trend toward fewer patients requiring RBCT with iron supplementation (risk ratio, 0.66 [0.42, 1.02]), but no benefit on the number of RBCT per patient (weighted mean difference, − 0.91 [− 1.61, − 0.18]). Although preliminary evidence suggests that it may be a promising strategy, there is insufficient evidence to support the routine use of perioperative iron to decrease the need for RBCT in colorectal cancer surgery. Well-designed RCTs focusing on the need for RBCT and including long-term outcomes are warranted.

Section snippets

Search Strategy

We systematically searched Medline (1966 to May 2013), EMBASE (1974 to May 2013), the Cochrane Register for Controlled Trials, Web of Knowledge (Web of Science and BIOSIS), and the Scopus database (1966 to May 2013), without restrictions regarding language or type of publication. We also searched the gray literature through OpenSIGLE, Intute (until closing in July 2011), the Trip database, and Google Scholar, as of May 2013. With assistance from an information specialist, the search strategy

Systematic Search

The initial electronic and gray literature search identified 878 citations, excluding duplicates, from which we selected 8 studies for full-text review (Fig 1). Among those, 4 studies were excluded: 1 narrative review [23], 1 with no details provided on the comparison group [24], 1 not reporting on transfusion outcomes [25], and 1 without available full-text format [26]. Interrater agreement on study selection was high. No additional citation was identified from meetings' proceedings or review

Discussion

We systematically reviewed data from 4 comparative studies investigating the association between perioperative iron supplementation and the need for allogeneic RBCT [27], [28], [29], [30]. Although our search considered all elective GI surgeries, all studies meeting inclusion criteria pertained to elective CRC surgery [27], [28], [29], [30]. A trend toward fewer patients requiring RBCT with perioperative iron supplementation was observed but did not reach statistical significance (RR, 0.66

Conclusion

In our study, we observed a nonsignificant trend toward a lower proportion of patients requiring RBCTs with the use of perioperative iron supplementation for CRC surgery. Current studies supporting the use of perioperative iron supplementation for CRC surgery are limited by heterogeneous interventions, small sample size, patient selection not based on anemia status, and use of surrogate outcomes. Therefore, there is insufficient evidence to support the routine use of perioperative iron to

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    Funding: No external funding was received for this study.

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