Effect of Perioperative Blood Transfusion on Postoperative Complications of Free-Flap Reconstruction for Oral Cancer: Analysis of Propensity Score-Matched Cohorts

Abstract

Background It has been confirmed in other fields that perioperative blood transfusion (PBT) will increase the incidence of complications after free-flap reconstruction and increase the risk of patients returning to the operating room within 48 hours after the initial operation. However, for head and neck tumors, whether PBT is related to postoperative complications is debatable. The aim of this study was to control the demographic and comorbidity characteristics of patients by propensity score matching (PSM) as well as to investigate the relationship between PBT and postoperative complications after oral cancer free-flap reconstruction.

Methods A total of 597 patients who underwent microvascular free tissue transfer in two top three hospitals in Southwest China from January 2015 to July 2023 were retrospectively reviewed. The study population was divided based on PBT within 24 hours of the start of the operation and to ensure homogeneity between groups by using the PSM. The primary outcomes were postoperative complications; secondary outcomes were to explore the intraoperative risk factors of PBT.

Results A total of 597 patients were included. Among them, 90 patients received a PBT. Those patients were successfully matched with 86 similar patients who did not receive a transfusion on a ratio of 1:1. This study did not find that patients receive a transfusion had a significantly higher risk of vascular pedicle thrombosis (p = 1.000), hematoma (p = 1.000), flap failure (p = 0.398), flap-related complications (p = 0.470), and other medical complications (p = 1.000). After controlling the preoperative confounding factors and adjusting the logistic regression model, it was concluded that the tumor location-mandible (odds ratio [OR] = 19.923, 95% confidence interval [CI]: 1.213–327.302, p = 0.036) and operation time (OR = 1.011, 95% CI: 1.008–1.014, p < 0.001) were the intraoperative risk factors for PBT.

Conclusion PBT is not associated with an increased probability of postoperative complications. Mandibular tumor may have a higher risk of PBT.

Keywords

blood transfusion - complication - free flap - perioperative - flap reconstruction

Authors' Contributions

Y.C. and M.T. contributed to the conception of the study. Y.C. and Y.L. contributed significantly to analysis and manuscript preparation. H.W. and X.P. performed the data analyses. D.G. and L.Z. helped perform the analyses with constructive discussions. All authors read and approved the final manuscript.

Availability of Data and Materials

The datasets generated and analyzed during the current study are not publicly available due to ownership of data but available from the corresponding author on a reasonable request.

Ethics Approval

This study is a retrospective study, without the informed consent of the patients but has passed the ethical permission of the Affiliated Hospital of Southwest Medical University and Zunyi Medical University. This research was conducted in accordance with international guidelines and the ethical standards outlined in the Declaration of Helsinki.

^* Yu Chen and Yinfu Lei contributed equally to this study.

Publication History

Received: 19 February 2023

Accepted: 18 December 2023

Article published online:
03 April 2024

• References

• 1 Crawley MB, Sweeny L, Ravipati P. et al. Factors associated with free flap failures in head and neck reconstruction. Otolaryngol Head Neck Surg 2019; 161 (04) 598-604
• 2 Ferrari S, Copelli C, Bianchi B. et al. Free flaps in elderly patients: outcomes and complications in head and neck reconstruction after oncological resection. J Craniomaxillofac Surg 2013; 41 (02) 167-171
• 3 Wang SJ, Shen SY, Lin B, Wang F, Yang HY. Factors affecting postoperative sleep quality of patients undergoing flap transfer for head and neck reconstruction. Oral Oncol 2022; 127 (187) 105804
• 4 Karamanos E, Shah AR, Kim JN, Wang HT. Impact of blood transfusion in free flap breast reconstruction using propensity score matching. J Reconstr Microsurg 2021; 37 (04) 315-321
• 5 Bosboom JJ, Klanderman RB, Migdady Y. et al. Transfusion-associated circulatory overload: a clinical perspective. Transfus Med Rev 2019; 33 (02) 69-77
• 6 Semple JW, Rebetz J, Kapur R. Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood 2019; 133 (17) 1840-1853
• 7 Goel R, Tobian AAR, Shaz BH. Noninfectious transfusion-associated adverse events and their mitigation strategies. Blood 2019; 133 (17) 1831-1839
• 8 Puram SV, Yarlagadda BB, Sethi R. et al. Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type. Otolaryngol Head Neck Surg 2015; 152 (03) 449-457
• 9 Zhao EH, Nishimori K, Brady J. et al. Analysis of risk factors for unplanned reoperation following free flap surgery of the head and neck. Laryngoscope 2018; 128 (12) 2790-2795
• 10 Grill FD, Wasmaier M, Mücke T. et al. Identifying perioperative volume-related risk factors in head and neck surgeries with free flap reconstructions - an investigation with focus on the influence of red blood cell concentrates and noradrenaline use. J Craniomaxillofac Surg 2020; 48 (01) 67-74
• 11 Torres Fuentes CE, Rodríguez Mantilla IE, Cáceres DNG, Camargo Gonzalez DF. Red blood cell transfusion and its relationship with pedicle thrombosis in microvascular free flaps. J Reconstr Microsurg 2022; 38 (05) 402-408
• 12 Nguyen A, Shin H, Saint-Cyr M, Verheyden C. Blood loss and transfusion rates in microsurgical head and neck reconstruction. Plast Reconstr Surg Glob Open 2018; 6 (11) e1988
• 13 Skoog H, Chisolm P, Altonji SJ. et al. Moving to a more restrictive transfusion protocol: outcomes in head and neck free flap surgery. Am J Otolaryngol 2022; 43 (01) 103268
• 14 Szakmany T, Dodd M, Dempsey GA. et al. The influence of allogenic blood transfusion in patients having free-flap primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Cancer 2006; 94 (05) 647-653
• 15 Lin PC, Kuo PJ, Kuo SCH, Chien PC, Hsieh CH. Risk factors associated with postoperative complications of free anterolateral thigh flap placement in patients with head and neck cancer: analysis of propensity score-matched cohorts. Microsurgery 2020; 40 (05) 538-544
• 16 Sanati-Mehrizy P, Massenburg BB, Rozehnal JM, Ingargiola MJ, Hernandez Rosa J, Taub PJ. Risk factors leading to free flap failure: analysis from the National Surgical Quality Improvement Program Database. J Craniofac Surg 2016; 27 (08) 1956-1964
• 17 Sweeny L, Curry JM, Crawley MB. et al. Age and comorbidities impact medical complications and mortality following free flap reconstruction. Laryngoscope 2022; 132 (04) 772-780
• 18 Crippen MM, Patel N, Filimonov A. et al. Association of smoking tobacco with complications in head and neck microvascular reconstructive surgery. JAMA Facial Plast Surg 2019; 21 (01) 20-26
• 19 Kim MJ, Woo KJ, Park BY, Kang SR. Effects of transfusion on free flap survival: searching for an optimal hemoglobin threshold for transfusion. J Reconstr Microsurg 2018; 34 (08) 610-615
• 20 Miller H, Bush K, Delancy M. et al. Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: an updated systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75 (02) 743-752
• 21 Lee HK, Kim DH, Jin US, Jeon YT, Hwang JW, Park HP. Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction. Microsurgery 2014; 34 (06) 434-438
• 22 Jiang P, Wang Z, Yu X. et al. Effects of long-term high-altitude exposure on fibrinolytic system. Hematology 2021; 26 (01) 503-509
• 23 Franchini M, Marano G, Mengoli C. et al. Red blood cell transfusion policy: a critical literature review. Blood Transfus 2017; 15 (04) 307-317
• 24 Carson JL, Stanworth SJ, Roubinian N. et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10 (10) CD002042
• 25 Kolbenschlag J, Schneider J, Harati K. et al. Predictors of intraoperative blood transfusion in free tissue transfer. J Reconstr Microsurg 2016; 32 (09) 706-711
• 26 Zhao Y, Li X, Wang Y. et al. Maximum surgical blood order schedule for flap reconstruction in oral and maxillofacial cancer patients. BMC Oral Health 2022; 22 (01) 322