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Perioperative Blood Transfusion is Associated With an Increased Risk of Infectious Complications Following Enterocutaneous Fistula Surgical Repair: A Nationwide Analysis From ACS-NSQIP Database
Osaid Alser, MSc(Oxon); Mathias A. Christensen BSc; Jonathan Parks, MD, Noelle Saillant, MD; April Mendoza, MD; Peter Fagenholz, MD; David King, MD; Haytham M.A. Kaafarani, MD; George Velmahos, MD, PhD; Jason Fawley, MD
Massachusetts General Hospital, Harvard Medical School, Boston, MA

Objective: To investigate the association between perioperative blood transfusion (BT) and postoperative infectious complications in patients undergoing enterocutanous fistula (ECF) surgical repair.
Design: Retrospective cohort study.
Setting: The American College of Surgeon National Surgical Quality Improvement Project (ACS-NSQIP) 2006-2017 database.
Patients: All consecutive patients who underwent ECF repair as their main operation.
Main outcome measures: The main outcome of interest was 30-day postoperative infectious complications. Patient characteristics were compared between those who received perioperative BT (+/- 72 hours from surgery) and those who did not. Multivariable logistic regression analyses were performed to assess the determinants of postoperative infections.
Results: 2,603 patients were identified, of which 519 (20%) received perioperative BT. Perioperative BT patients were generally older and had higher ASA (III-V). After adjusting for relevant covariates (demographics, preoperative anemia, other comorbidities and operative details), perioperative BT patients had higher odds of postoperative infectious complications compared to those who did not receive perioperative BT (OR=1.84, 95% CI 1.37-2.48). Specifically, they had higher odds of organ-space SSI (OR=1.96, 95% CI 1.33-2.87), pneumonia (OR=2.77, 95% CI 1.58-4.84) and sepsis (OR=5.17, 95% CI 1.65-16.20) but not superficial SSI, deep SSI, wound dehiscence or UTI (Table 1). No difference was found in 30-day recurrence rates (10.5% vs 13.1%, p=0.48). Intra and/or postoperative (and not preoperative) BT was an independent determinant for infectious complications (OR = 1.92; 95% CI=1.43-2.59; p<0.001).
Conclusions: Perioperative BT is a strong independent risk factor for infectious complications in ECF repair. Strategies should be employed to mitigate these risks.
Table 1: Univariate and multivariable analysis of risk of infections following ECF repair
Outcome variableUnivariate analysisMultivariable (logistic regression) analysis*
+ perioperative BT, n (%)-perioperative BT, n (%)p-value ORp-value95% CI
Superficial SSI41 (7.9%)198 (9.5%)0.260.730.220.45-1.20
Deep SSI36 (6.9%)101 (4.8%)0.060.990.970.61-1.62
Organ-space SSI89 (17.1%)153 (7.3%)<0.0011.960.001 1.33-2.87
Wound dehiscence41 (7.9%)105 (5.0%) 0.010.570.500.07-3.58
Pneumonia54 (10.4%)91 (4.4%)<0.0012.77 <0.001 1.58-4.84
UTI36 (6.9%)91 (4.4%) 0.021.510.240.75-2.99
Sepsis (including septic shock)162 (31.2%)306 (14.7%)<0.0015.170.005 1.65-16.20
Any infectious complication269 (51.8%)658 (31.6%) <0.0011.84 <0.0011.37-2.48
*Independent variable is perioperative blood transfusion (BT)


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