Operative Blood Loss and Use of Blood Products After Laparoscopic and Conventional Open Colorectal Operations

ORIGINAL ARTICLE Operative Blood Loss and Use of Blood Products After Laparoscopic and Conventional Open Colorectal Operations

Ravi P. Kiran, MD; Conor P. Delaney, MCh, PhD; Anthony J. Senagore, MD, MS; Bruce L. Millward, MA; Victor W. Fazio, MB, MS

Hypothesis: Blood loss, measured by estimated blood Results: One hundred forty-seven patients undergoing the loss, drop in hemoglobin levels, and transfusion require- same operation using either an open or laparoscopic ap- ments, is lower in patients undergoing laparoscopic colec- proach could be matched for age, sex, and diagnosis re- tomy compared with patients undergoing conventional lated grouping. There was no significant difference in Ameri- open colectomy. can Society of Anesthesiologists class, body mass index, or preoperative and postoperative hemoglobin levels, but the Design: Case-matched study. open colectomy group required significantly more units of blood (P=.003) to maintain similar hemoglobin levels af- Setting: A university hospital. ter surgery. Estimated blood loss (PϽ.001) and the number of patients who received transfusions on the day of sur- Patients: Patients undergoing laparoscopic colectomy gery (P=.002), during the first 48 hours after surgery between January 2000 and December 2001 were matched (P=.005), and during the entire hospital stay (P=.003) were in a prospective database for age, sex, comorbidity, and significantly higher in the open colectomy group. surgical procedure with patients undergoing open colectomy during the same period. Conclusion: A laparoscopic approach for colorectal surgery led to significantly less blood loss than matched open Main Outcome Measures: Estimated blood loss, drop colectomy cases. in hemoglobin levels, and transfusion requirements after surgery were compared. Arch Surg. 2004;139:39-42

INCE THE FIRST REPORTS OF product use in patients undergoing LC or laparoscopic colectomy (LC), OC. Both groups of patients were man- the scope of the technique has aged with the same guidelines for trans- widened to encompass the fusion in the postoperative period. treatment of many colorec- Stal disorders. Advantages of the laparo- METHODS scopic approach include better cosmesis and less postoperative pain owing to All patients undergoing LC in this study were smaller incisions, earlier recovery, and a entered into a database, approved by the in- shorter postoperative hospital stay com- stitutional review board, along with their age, pared with conventional open colectomy sex, diagnosis received, and operative proce- 1,2 dure. Operative details included operating time, (OC). A shorter hospital stay translates American Society of Anesthesiologists class, into lower total costs despite greater com- body mass index, EBL, and complications, in- parative operating room costs.3 cluding readmission within 30 days of hospi- As telescopic views of the operating tal discharge. field during LC mandate a relatively blood- Patients undergoing LC procedures be- less field, LC procedures might be ex- tween January 2000 and December 2001 were pected to lead to less operative blood loss matched with patients undergoing OC during From the Department of than OC. Studies of blood loss after LC had the same period for age, sex, comorbidity as Colorectal Surgery (Drs Kiran, variable results, with some finding lower denoted by the hospital coding system (diag- Delaney, and Senagore and nosis related grouping), and surgical proce- Mr Fazio) and the Section of operative blood loss and others reporting dure. In the OC group, only patients without Transfusion Medicine no significant difference in estimated blood a history of major laparotomy (except chole- 4-7 (Mr Millward), Cleveland loss (EBL). This study compares blood cystectomy, appendectomy, or gynecologic sur- Clinic Foundation, Cleveland, loss as measured by EBL, mean drop in he- gery by a lower abdominal incision) were con- Ohio. moglobin levels with surgery, and blood sidered for comparison with the LC group.

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 1. Characteristics of the Matched Patients Who Underwent Surgery by the Laparoscopic and Open Approaches*

Laparoscopic Procedures Open Procedures (n = 143) (n = 143) P Value Characteristic Age, y† 53 ± 17 54 ± 16 .12 No. of female patients 74 74 .99 Body mass index, kg/m2† 25.7 ± 4.5 26.7 ± 6.2 .20 Operation time, min‡ 90 (IQR 70-123.8) 120 (IQR 90-148.8) Ͻ.001 Length of stay, d‡ 3 (IQR 2-4) 6 (IQR 5-9) Ͻ.001 Estimated blood loss‡ 100 (IQR 50-150) 200 (IQR 100-450) Ͻ.001 Preoperative hemoglobin level, g/dL‡ 13.8 (IQR 12.7-14.8) 13.5 (IQR 11.9-14.7) .12 Postoperative hemoglobin level, g/dL† 10.9 ± 1.8 10.8 ± 1.7 .65 Hemoglobin level drop, g/dL† 2.6 ± 1.6 2.3 ± 1.7 .24 Day of surgery Units of red blood cells transfused†‡ 0.03 ± 0.25; 0 (0-2) 0.24 ± 0.77; 0 (0-4) .003 No. of patients receiving transfusion (No. of units) 3 (5) 17 (35) .002§ Day of surgery and 48 h after Units of red blood cells transfused†‡ 0.10 ± 0.48; 0 (0-4) 0.35 ± 0.95; 0 (0-6) .003 No. of patients receiving transfusion (No. of units) 7 (14) 22 (50) .005§ Duration of stay Units of red blood cells transfused†‡ 0.16 ± 0.60; 0 (0-4) 0.66 ± 1.83; 0 (0-16) .004 No. of patients receiving transfusion (No. of units) 11 (23) 29 (92) .003§

Abbreviation: IQR, interquartile range. *P values were determined using the Wilcoxon matched pairs test or the paired t test depending on data type. †Values are expressed as mean ± SD. ‡Values are expressed as median (range). §Values were determined using the Fisher exact test.

Preoperative values for hemoglobin level and the correspond- other operation for bleeding, but 2 patients in the OC group ing postoperative values taken routinely on the first day after did and were excluded from the study. Two other patients surgery (between 4 AM and 6 AM) were gathered by reviewing in the OC group and 1 in the LC group had rectal bleed- the laboratory computer software system (Lastword 4-TD04084; ing during the postoperative period, which stopped spon- IDX Systems Corp, Burlington, Vt) into which all laboratory taneously. They were also excluded from the study. results were entered. Details of blood product use were entered into a database (version 5.23; Misys Healthcare Systems, The 143 patients in the matched groups were com- Lawrence, Kan). The number of units of blood transfused on parable in age, sex, American Society of Anesthesiolo- the day of surgery, during the first 48 hours after surgery, and gists class (P=.87), and body mass index (Table 1). Di- for the duration of the patient’s hospital stay were determined agnosis (benign or malignant) (P=.07) and operations from the database. Patients were compared for operative EBL, performed were also similar (Table 2). Patients who un- duration of surgery, body mass index, American Society of An- derwent OC had a significantly longer operating time and esthesiologists class, and all complications, including hospital length of hospital stay than those undergoing LC. The 2 readmission. groups had similar preoperative and postoperative levels of hemoglobin. Patients who underwent LC had sig- STATISTICAL ANALYSIS nificantly less blood loss, as measured by the EBL, and a Data are presented as mean±SD for parametric data and as me- significantly lower use of blood products and transfu- dian (interquartile range) for nonparametric data. For matched sion rate. There was no significant difference in hemo- groups, the paired t test was used to compare the significance globin level drop, which was not unexpected because of the difference between means of parametric data, and the many patients received transfusions prior to the routine Wilcoxon matched pairs test was used for nonparametric data. 6 AM hemoglobin level sample the day after surgery and The significance level for all analyses was PϽ.05, and GraphPad were therefore increased to a similar level of hemoglo- InStat software version 3.05, 32 bit for Windows 95/NT, (Graph- bin. The number of units transfused during the first 48 Pad Software, San Diego, Calif) was used. hours after surgery and during the total hospital stay were also significantly lower in the LC group. RESULTS Other potentially confounding factors were also evaluated. Table 3 presents the number of units of blood trans- One hundred forty-seven patients in the LC group from fused in the postoperative period in the LC and OC groups. the database could be matched manually for age, sex, di- The distribution of units of blood required by patients was agnosis related grouping, and type of procedure with the similar in the 2 groups (P=.14). The mean±SD age of the same number of patients undergoing OC surgery for col- patients who received transfusions was 51±22 years in the orectal disorders. Patients in the LC group who under- LC group and 56±19 years in the OC group. The recom- went conversion for reasons other than intraoperative bleed- mended standard transfusion trigger for the institution is ing were included in the same group based on intention to give packed red blood cells to patients with a hemoglo- to treat. None of the patients in the LC group needed an- bin level lower than 7 g/dL, unless the patient has a his-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 tory of cardiac disease or there is active bleeding. Overall, 55 of the 286 patients had a hematocrit lower than 36%, Table 2. Procedure Performed and Diagnosis and the transfusion rate was significantly greater for pa- for the 143 Matched Patients Undergoing Laparoscopic and Open Procedures* tients with a hematocrit lower than 36% compared with patients with a hematocrit higher than 36% (n=231) Ͻ Procedure Surgical Approach (P .001). The LC and OC groups had similar numbers of (No. of Matched patients with hematocrit lower than 36% (21 in the LC Cases) Diagnosis Laparoscopy Open group and 34 in the OC group) (P=.07), and the transfu- Small-bowel resection Inflammatory 22 sion rate was similar for patients with similar hematocrit (2) bowel disease (Ͻ36% or Ͼ36%) in the 2 groups (P=.99). None of the Ileocecal resection (14) Inflammatory 14 13 patients undergoing LC and 2 patients undergoing OC had bowel disease preoperative blood transfusion (P=.50). Polyp 0 1 Right hemicolectomy Inflammatory 55 (33) bowel disease COMMENT Adenoma 11 6 Cancer 13 20 Surgery using the laparoscopic approach is performed in- Others 4 2 creasingly for a variety of colorectal disorders. Despite Left hemicolectomy (4) Adenoma 1 0 Diverticular disease 0 1 numerous advantages, the role of laparoscopy in the treat- Cancer 3 3 ment of benign and malignant colorectal disorders is still Sigmoid colectomy (78) Inflammatory 03 under evaluation. The main advantages include re- bowel disease duced pain during the postoperative period, earlier re- Diverticular disease 57 43 covery of ileus, earlier discharge from the hospital, and Adenoma 5 1 earlier recovery and return to normal activity.1,8-10 Most Cancer 14 21 Others 2 10 studies report that LC takes longer to perform than OC, Subtotal colectomy (5) Inflammatory 24 although some suggest that the operative length may be bowel disease comparable.11,12 There is no uniform consensus on the Diverticular disease 0 1 relative blood loss when patients are operated on using Others 1 0 the 2 procedures. While some studies1,9,13-15 found that Anterior resection (7) Diverticular disease 1 1 EBL during LC was significantly lower than during OC, Cancer 5 6 7,16,17 Others 1 0 others found the loss to be comparable. The reason Total Benign 108 93 for this difference may be that these studies compare the Malignant 35 50 EBL as a sole measure of blood loss during surgery. The EBL has been previously reported to be an inconsistent *Values expressed as number of patients. estimate of blood loss.18,19 Further, the number of patients undergoing LC in the individual studies was small, varying from 7 to 80 patients. Table 3. Number of Units of Blood Transfused This study compares blood loss for 143 patients with in the Laparoscopic and Open Groups* colorectal disorders undergoing LC with a similar number of patients undergoing OC during the same period. No. of Units Laparoscopic Open Data from this institution support improvements in length Transfused Colectomy Group Colectomy Group of hospital stay, costs, and complications with no sig- 0 136 121 nificant increase in operative times.3,20-22 In this study, 12 5 patients who were comparable in age, sex, comorbidity 2412 30 1 (diagnosis related grouping), diagnosis, body mass in- 41 3 dex, and American Society of Anesthesiologists class had 60 1 less operative blood loss after LC than OC. This was mani- fested as significantly lower EBL and use of blood prod- *Values expressed as number of patients unless otherwise indicated. ucts in the setting of a similar postoperative hemoglo- P = .14 using the ␹2 test. bin level drop. The hemoglobin level reduction is similar because most transfusions have already occurred dur- 48 hours after surgery and for the duration of their hospi- ing surgery or in the early postoperative period, some- tal stay. To reduce bias, we also excluded patients in the times without formal complete blood cell count and based OC group who had a previous major laparotomy because on an estimate of EBL or blood gas analysis. more extensive surgery is sometimes indicated in these pa- Previous studies have found that the incidence of com- tients and such patients may not be candidates for a lap- plications after the 2 procedures is similar.8,9,12,13,17,23 There- aroscopic approach. The possibility of the data being skewed fore, we excluded from the study the 2 patients in the OC owing to a small number of patients in the OC group re- group who needed reoperation for bleeding because in- ceiving a large amount of blood was also excluded (Table cluding such patients could potentially lead to a spurious 3). The number of patients with malignant disorders was finding of increased blood loss in the OC group. As blood similar in the 2 groups, which strengthens the compara- loss during surgery can sometimes manifest after a lag pe- bility of the groups because patients with malignancy may riod, we also compared the number of units transfused and be more likely to bleed during surgery when compared with the transfusion rate for both groups of patients in the first patients with benign disorders. The relative number of pa-

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