OGC P09 Optimising the management of perioperative anaemia in patients with oesophagogastric cancer
Authors: Hughes Tara , MacCarthy Tobias , O’Neill Robert , Tham Ji 
Published: December 2022

Abstract

Background
Patients with oesophagogastric malignancy are predisposed to anaemia due to iron deficiency from chronic luminal blood loss. In the pre and post-operative periods, anaemia is associated with increased morbidity and mortality, principally through an increased blood transfusion (BTF) requirement. Anaemia of iron deficiency can be treated with oral or parenteral iron therapy. Newer preparations of parenteral iron therapy have lower rates of complications and are increasingly available. This study explored the effects of an anaemia management pathway on the detection and treatment of perioperative anaemia, as well as the post-operative course of patients undergoing staging and surgical resection of oesophagogastric malignancy. The impact of different forms of iron therapy was also examined.

Methods
A retrospective analysis was performed of patients undergoing resection of oesophageal, oesophagogastric or gastric malignancies between 12/11/2014 and 31/12/2021 at a tertiary oesophagogastric malignancy centre. A structured pathway for the management of perioperative anaemia was introduced on 1/4/2019 and patients were split into those receiving treatment on the anaemia management pathway compared to historical controls receiving standard treatment before this point. Clinicopathological variables were recorded from the hospital system tracking the haemoglobin (Hb) from diagnosis, through to the day of surgery and in the postoperative period. Other variables identified included iron therapy in the pre or postoperative period, blood transfusion rates, length of stay data and survival as of 01/03/2022. Anaemia was defined using both strict anaemia (Hb &lt; 100g/L) and WHO anaemia (Hb &lt; 120g/L for females and Hb &lt; 130g/L for males) criteria. All analyses and statistical tests were conducted using R software.

Results
There were 171 patients treated under the new anaemia management pathway, and 343 historical controls receiving standard management. The overall prevalence of anaemia at the point of diagnosis was 33.7% using WHO criteria. Anaemia was more prevalent in patients with gastric malignancies (49%) than those with oesophageal malignancies (19%, p= 0.008) or OGJ malignancies (32%, p=0.017). Following the introduction of the anaemia management pathway, the blood transfusion (BTF) rates and the average length of stay did not change. The proportion of patients with WHO defined anaemia receiving IV iron therapy increased from 0.3% to 18% in the pre-operative period (p &lt; 0.001), and from 2% to 39% in the post-operative period (p &lt; 0.001). In the postoperative period, in-patient IV iron was more effective than oral (p &lt; 0.001) or no iron treatment (p &lt; 0.001) in improving haemoglobin post-operatively at a 6-week follow-up.

Conclusions
Anaemia is common in patients with oesophagogastric malignancy and patients with gastric cancer were more likely to be anaemic than other patient groups. The introduction of a perioperative anaemia management pathway can improve the use of iron therapy for anaemic patients, but we did not detect a difference in postoperative blood transfusions. IV iron treatment is significantly better than oral or no iron treatment in improving postoperative haemoglobin. IV iron should therefore be incorporated into post-operative management guidelines for post-operative anaemia and used preferentially to oral iron. Further studies should look to prospectively characterise the impacts of iron treatment and explore further variables such as quality of life in the postoperative period.