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Clin Colon Rectal Surg 2023; 36(03): 161-166
DOI: 10.1055/s-0043-1760868
Review Article

Preoperative Identification and Management of Anemia in the Colorectal Surgery Patient

Kevin T. Lynch
1   Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
,
Taryn E. Hassinger
2   Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
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Abstract

Preoperative anemia is a common finding in patients undergoing colorectal surgery, particularly those with cancer. While often multifactorial, iron deficiency anemia remains the most common cause of anemia in this patient population. Although seemingly innocuous, preoperative anemia is associated with an increased risk of perioperative complications and need for allogenic blood transfusions, both of which may worsen cancer-specific survival. Preoperative correction of anemia and iron deficiency is thus necessary to diminish these risks. Current literature supports preoperative screening for anemia and iron deficiency in patients slated to undergo colorectal surgery for malignancy or for benign conditions with associated patient- or procedure-related risk factors. Accepted treatment regimens include iron supplementation—either oral or intravenous—as well as erythropoietin therapy. Autologous blood transfusion should not be utilized as a treatment for preoperative anemia when there is time to implement other corrective strategies. Additional study is still needed to better standardize preoperative screening and optimize treatment regimens.

Keywords

preoperative anemia - iron deficiency - iron supplementation - blood transfusion


Publication History

Article published online:
25 January 2023

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  • References

  • 1 Ristescu I, Pintilie G, Filip D. et al. Perioperative anemia and transfusion in colorectal cancer patients. Chirurgia (Bucur) 2019; 114 (02) 234-242
    CrossrefPubMedGoogle Scholar
  • 2 Ploug M, Kroijer R, Qvist N, Lindahl CH, Knudsen T. Iron deficiency in colorectal cancer patients: a cohort study on prevalence and associations. Colorectal Dis 2021; 23 (04) 853-859
    CrossrefPubMedGoogle Scholar
  • 3 Musallam KM, Tamim HM, Richards T. et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011; 378 (9800): 1396-1407
    CrossrefPubMedGoogle Scholar
  • 4 Leichtle SW, Mouawad NJ, Lampman R, Singal B, Cleary RK. Does preoperative anemia adversely affect colon and rectal surgery outcomes?. J Am Coll Surg 2011; 212 (02) 187-194
    CrossrefPubMedGoogle Scholar
  • 5 Benoist S, Panis Y, Pannegeon V, Alves A, Valleur P. Predictive factors for perioperative blood transfusions in rectal resection for cancer: a multivariate analysis of a group of 212 patients. Surgery 2001; 129 (04) 433-439
    CrossrefPubMedGoogle Scholar
  • 6 Dunne JR, Malone D, Tracy JK, Gannon C, Napolitano LM. Perioperative anemia: an independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res 2002; 102 (02) 237-244
    CrossrefPubMedGoogle Scholar
  • 7 Gvirtzman R, Livovsky DM, Tahover E, Goldin E, Koslowsky B. Anemia can predict the prognosis of colorectal cancer in the pre-operative stage: a retrospective analysis. World J Surg Oncol 2021; 19 (01) 341
    CrossrefPubMedGoogle Scholar
  • 8 Goubran HA, Elemary M, Radosevich M, Seghatchian J, El-Ekiaby M, Burnouf T. Impact of transfusion on cancer growth and outcome. Cancer Growth Metastasis 2016; 9: 1-8
    CrossrefPubMedGoogle Scholar
  • 9 Aksan A, Farrag K, Aksan S, Schroeder O, Stein J. Flipside of the coin: iron deficiency and colorectal cancer. Front Immunol 2021; 12: 635899
    CrossrefPubMedGoogle Scholar
  • 10 Phipps O, Brookes MJ, Al-Hassi HO. Iron deficiency, immunology, and colorectal cancer. Nutr Rev 2021; 79 (01) 88-97
    CrossrefPubMedGoogle Scholar
  • 11 Phipps O, Al-Hassi HO, Quraishi MN, Kumar A, Brookes MJ. Influence of iron on the gut microbiota in colorectal cancer. Nutrients 2020; 12 (09) E2512
    CrossrefPubMedGoogle Scholar
  • 12 Bird CL, Witte JS, Swendseid ME. et al. Plasma ferritin, iron intake, and the risk of colorectal polyps. Am J Epidemiol 1996; 144 (01) 34-41
    CrossrefPubMedGoogle Scholar
  • 13 Michailidou M, Nfonsam VN. Preoperative anemia and outcomes in patients undergoing surgery for inflammatory bowel disease. Am J Surg 2018; 215 (01) 78-81
    CrossrefPubMedGoogle Scholar
  • 14 Gomollón F, Gisbert JP. Anemia and inflammatory bowel diseases. World J Gastroenterol 2009; 15 (37) 4659-4665
    CrossrefPubMedGoogle Scholar
  • 15 Muse A, Wusterbarth E, Thompson S. et al. The role of preoperative anemia in patients undergoing colectomy for diverticular disease: does surgical urgency matter?. Int J Colorectal Dis 2021; 36 (11) 2463-2470
    CrossrefPubMedGoogle Scholar
  • 16 Muñoz M, Acheson AG, Auerbach M. et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia 2017; 72 (02) 233-247
    CrossrefPubMedGoogle Scholar
  • 17 Frew N, Alexander D, Hood J, Acornley A. Impact of a blood management protocol on transfusion rates and outcomes following total hip and knee arthroplasty. Ann R Coll Surg Engl 2016; 98 (06) 380-386
    CrossrefPubMedGoogle Scholar
  • 18 Kearney B, To J, Southam K, Howie D, To B. Anaemia in elective orthopaedic surgery: Royal Adelaide Hospital, Australia. Intern Med J 2016; 46 (01) 96-101
    CrossrefPubMedGoogle Scholar
  • 19 Styron JF, Klika AK, Szubski CR, Tolich D, Barsoum WK, Higuera CA. Relative efficacy of tranexamic acid and preoperative anemia treatment for reducing transfusions in total joint arthroplasty. Transfusion 2017; 57 (03) 622-629
    CrossrefPubMedGoogle Scholar
  • 20 Wilson MJ, Koopman-van Gemert AWMM, Harlaar JJ, Jeekel J, Zwaginga JJ, Schipperus M. Patient blood management in colorectal cancer patients: a survey among Dutch gastroenterologists, surgeons, and anesthesiologists. Transfusion 2018; 58 (10) 2345-2351
    CrossrefPubMedGoogle Scholar
  • 21 Laso-Morales M, Jericó C, Gómez-Ramírez S. et al. Preoperative management of colorectal cancer-induced iron deficiency anemia in clinical practice: data from a large observational cohort. Transfusion 2017; 57 (12) 3040-3048
    CrossrefPubMedGoogle Scholar
  • 22 Lin Y. Preoperative anemia-screening clinics. Hematology (Am Soc Hematol Educ Program) 2019; 2019 (01) 570-576
    CrossrefPubMedGoogle Scholar
  • 23 Lidder PG, Sanders G, Whitehead E. et al. Pre-operative oral iron supplementation reduces blood transfusion in colorectal surgery: a prospective, randomised, controlled trial. Ann R Coll Surg Engl 2007; 89 (04) 418-421
    CrossrefPubMedGoogle Scholar
  • 24 Quinn EM, Meland E, McGinn S, Anderson JH. Correction of iron-deficiency anaemia in colorectal surgery reduces perioperative transfusion rates: a before and after study. Int J Surg 2017; 38: 1-8
    CrossrefPubMedGoogle Scholar
  • 25 Tolkien Z, Stecher L, Mander AP, Pereira DIA, Powell JJ. Ferrous sulfate supplementation causes significant gastrointestinal side-effects in adults: a systematic review and meta-analysis. PLoS One 2015; 10 (02) e0117383
    CrossrefPubMedGoogle Scholar
  • 26 Mahalhal A, Williams JM, Johnson S. et al. Oral iron exacerbates colitis and influences the intestinal microbiome. PLoS One 2018; 13 (10) e0202460
    CrossrefPubMedGoogle Scholar
  • 27 Lee T, Clavel T, Smirnov K. et al. Oral versus intravenous iron replacement therapy distinctly alters the gut microbiota and metabolome in patients with IBD. Gut 2017; 66 (05) 863-871
    CrossrefPubMedGoogle Scholar
  • 28 Kaye P, Abdulla K, Wood J. et al. Iron-induced mucosal pathology of the upper gastrointestinal tract: a common finding in patients on oral iron therapy. Histopathology 2008; 53 (03) 311-317
    CrossrefPubMedGoogle Scholar
  • 29 Powell JJ, Cook WB, Hutchinson C. et al. Dietary fortificant iron intake is negatively associated with quality of life in patients with mildly active inflammatory bowel disease. Nutr Metab (Lond) 2013; 10 (01) 9
    CrossrefPubMedGoogle Scholar
  • 30 Love AL, Billett HH. Obesity, bariatric surgery, and iron deficiency: true, true, true and related. Am J Hematol 2008; 83 (05) 403-409
    CrossrefPubMedGoogle Scholar
  • 31 Ng O, Keeler BD, Mishra A. et al. Iron therapy for preoperative anaemia. Cochrane Database Syst Rev 2019; 12 (12) CD011588
    PubMedGoogle Scholar
  • 32 Muñoz M, Gómez-Ramírez S, García-Erce JA. Intravenous iron in inflammatory bowel disease. World J Gastroenterol 2009; 15 (37) 4666-4674
    CrossrefPubMedGoogle Scholar
  • 33 Muñoz M, Gómez-Ramírez S, Besser M. et al. Current misconceptions in diagnosis and management of iron deficiency. Blood Transfus 2017; 15 (05) 422-437
    PubMedGoogle Scholar
  • 34 Muñoz M, Gómez-Ramírez S, Martín-Montañez E, Pavía J, Cuenca J, García-Erce JA. Perioperative intravenous iron: an upfront therapy for treating anaemia and reducing transfusion requirements. Nutr Hosp 2012; 27 (06) 1817-1836
    PubMedGoogle Scholar
  • 35 Avni T, Bieber A, Grossman A, Green H, Leibovici L, Gafter-Gvili A. The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clin Proc 2015; 90 (01) 12-23
    CrossrefPubMedGoogle Scholar
  • 36 DeLoughery TG. Safety of oral and intravenous iron. Acta Haematol 2019; 142 (01) 8-12
    CrossrefPubMedGoogle Scholar
  • 37 Hallet J, Hanif A, Callum J. et al. The impact of perioperative iron on the use of red blood cell transfusions in gastrointestinal surgery: a systematic review and meta-analysis. Transfus Med Rev 2014; 28 (04) 205-211
    CrossrefPubMedGoogle Scholar
  • 38 Miller CB, Jones RJ, Piantadosi S, Abeloff MD, Spivak JL. Decreased erythropoietin response in patients with the anemia of cancer. N Engl J Med 1990; 322 (24) 1689-1692
    CrossrefPubMedGoogle Scholar
  • 39 Christodoulakis M, Tsiftsis DD. Hellenic Surgical Oncology Perioperative EPO Study Group. Preoperative epoetin alfa in colorectal surgery: a randomized, controlled study. Ann Surg Oncol 2005; 12 (09) 718-725
    CrossrefPubMedGoogle Scholar
  • 40 Hung CM, Chen JJ, Zeng BY. et al. Efficacy of different interventions to reduce pre- or perioperative blood transfusion rate in patients with colorectal cancer: a network meta-analysis of randomized controlled trials. Curr Oncol 2021; 28 (04) 3214-3226
    CrossrefPubMedGoogle Scholar
  • 41 Calleja JL, Delgado S, del Val A. et al; Colon Cancer Study Group. Ferric carboxymaltose reduces transfusions and hospital stay in patients with colon cancer and anemia. Int J Colorectal Dis 2016; 31 (03) 543-551
    CrossrefPubMedGoogle Scholar
  • 42 Acheson AG, Brookes MJ, Spahn DR. Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis. Ann Surg 2012; 256 (02) 235-244
    CrossrefPubMedGoogle Scholar
  • 43 Kwon YH, Lim HK, Kim MJ. et al. Impacts of anemia and transfusion on oncologic outcomes in patients undergoing surgery for colorectal cancer. Int J Colorectal Dis 2020; 35 (07) 1311-1320
    CrossrefPubMedGoogle Scholar
  • 44 Wilson MJ, van Haaren M, Harlaar JJ. et al. Long-term prognostic value of preoperative anemia in patients with colorectal cancer: a systematic review and meta-analysis. Surg Oncol 2017; 26 (01) 96-104
    CrossrefPubMedGoogle Scholar
  • 45 Heiss MM, Mempel W, Delanoff C. et al. Blood transfusion-modulated tumor recurrence: first results of a randomized study of autologous versus allogeneic blood transfusion in colorectal cancer surgery. J Clin Oncol 1994; 12 (09) 1859-1867
    CrossrefPubMedGoogle Scholar
  • 46 Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev 2006; 2006 (01) CD005033
    PubMedGoogle Scholar
  • 47 Wu HL, Tai YH, Lin SP, Chan MY, Chen HH, Chang KY. The impact of blood transfusion on recurrence and mortality following colorectal cancer resection: a propensity score analysis of 4,030 patients. Sci Rep 2018; 8 (01) 13345
    CrossrefPubMedGoogle Scholar
  • 48 Weng M, Guo M, Li T. et al. Anemia tolerance versus blood transfusion on long-term outcomes after colorectal cancer surgery: a retrospective propensity-score-matched analysis. Front Oncol 2022; 12: 940428
    CrossrefPubMedGoogle Scholar
  • 49 Frietsch T, Steinbicker AU, Horn A. et al. Safety of intraoperative cell salvage in cancer surgery: an updated meta-analysis of the current literature. Transfus Med Hemother 2022; 49 (03) 143-157
    CrossrefPubMedGoogle Scholar
  • 50 Heiss MM, Fraunberger P, Delanoff C. et al. Modulation of immune response by blood transfusion: evidence for a differential effect of allogeneic and autologous blood in colorectal cancer surgery. Shock 1997; 8 (06) 402-408
    CrossrefPubMedGoogle Scholar