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June 15, 2009

Operative Blood Loss and Survival in Pancreatic Cancer

Arch Surg. 2009;144(6):591-595. doi:10.1001/archsurg.2009.101

Kazanjian et al1 recently reported determinants of survival in 182 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the pancreatic head. Through multivariate analysis, the authors found that operative estimated blood loss (EBL) and time of surgery (1987-1995 or 1996-2005) were significantly related to survival, whereas perioperative blood transfusion was not. We have 3 comments on this important study. First, the significance of EBL should be interpreted with caution, because this variable is highly subjective and notoriously inaccurate.2-4 Simulations have found that operative personnel (including surgeons) visually underestimate EBL. Because surgeons have an obvious bias, which is amplified when EBL becomes a performance indicator or the end point of a study, it is not surprising that the most accurate estimations of EBL are from anesthesiologists.2

Second, the lack of significance for perioperative transfusion should be interpreted with caution because patients who undergo pancreaticoduodenectomy may receive blood preoperatively for anemia, postoperatively during adjuvant therapy, or at other points during their overall care. Consideration of nonperioperative transfusions is essential.

Third, while we fully agree that minimization of EBL and blood transfusion is important and more than 90% of our patients do not receive transfusions, the effect of patient selection must be acknowledged. For example, modern imaging has allowed early recognition of metastatic disease and precise assessment of perivascular planes. Furthermore, increased use of neoadjuvant therapy removes patients who develop early metastatic disease from the operative pool, and performance status has been recognized as being important. Attention to these and other patient selection factors can minimize EBL and improve postoperative survival.

Correspondence: Dr Conway, Department of Surgical Oncology, John Wayne Cancer Institute, 2200 Santa Monica Blvd, Santa Monica, CA 90404 (wcconway2@gmail.com).

Author Contributions:Study concept and design: Conway and Gagandeep. Acquisition of data: Conway and Gagandeep. Analysis and interpretation of data: Conway and Gagandeep. Drafting of the manuscript: Conway. Critical revision of the manuscript for important intellectual content: Conway and Gagandeep. Administrative, technical, and material support: Conway and Gagandeep. Study supervision: Gagandeep.

Financial Disclosure: None reported.

Kazanjian  KKHines  OJDuffy  JPYoon  DYCortina  GReber  HA Improved survival following pancreaticoduodenectomy to treat adenocarcinoma of the pancreas: the influence of operative blood loss.  Arch Surg 2008;143 (12) 1166- 1171PubMedGoogle ScholarCrossref
Meiser  ACasagranda  OSkipka  GLaubenthal  H Quantification of blood loss: how precise is visual estimation and what does its accuracy depend on [in German]?  Anaesthesist 2001;50 (1) 13- 20PubMedGoogle ScholarCrossref
Brecher  MEMonk  TGoodnough  LT A standardized method for calculating blood loss.  Transfusion 1997;37 (10) 1070- 1074PubMedGoogle ScholarCrossref
Razvi  KChua  SArulkumaran  SRatnam  SS A comparison between visual estimation and laboratory determination of blood loss during the third stage of labour.  Aust N Z J Obstet Gynaecol 1996;36 (2) 152- 154PubMedGoogle ScholarCrossref