Head and Neck Cancer (HNC) surgery
Bleeding and subsequent RBC transfusions are relatively common in major HNC surgery. Goel et al. found a 5.4% incidence rate of bleeding and post-operative transfusion within 72 hours.8 In our non-epistaxis related RBC transfusion patient cohort, major HNC surgery with and without reconstruction (n=20) made up 58.8% of post-operative blood transfusions and 25.1% of overall blood transfusions over the study period. These results are reflected in the available literature where one study identified 14% to 80% of patients undergoing major Head and Neck surgery required allogeneic RBC transfusions.7
Figure 3 shows HNC surgery without reconstruction required fewer units than with reconstruction. Additionally, the total number of units transfused declined with time and was statistically significant (P=0.01) for HNC surgery without reconstruction.
Krupp et al. validated a transfusion prediction and risk assessment (TPRA) model for a patient to receive a perioperative transfusion: higher tumour stages, use of a flap and pre-operative anaemia were associated with higher rates of peri-operative transfusions. This tool allows clinicians to appropriately counsel patients on blood transfusions and address pre-existing anaemias in the pre-operative period.7 A similar model was also replicated by Shah et al. who additionally found female sex, underweight BMI and osseous free flap reconstructions also contributed to higher rates of transfusion.6 However, these models have been shown to predict peri-operative transfusion risk rather than post-operative transfusion risk. Further research is required to identify if a similar model can accurately predict post-operative transfusions in HNC patients undergoing surgery. It is however our experience that this patient group harbors risk factors such as low BMI, high tumour stage, and the use of composite grafts in reconstructions.
On closer review of our HNC data, the majority of patients undergoing a laryngectomy were for radio-recurrent disease. This in itself is a risk factor as it is a procedure with higher morbidity compared with primary laryngectomy due to the need for reconstruction, poor tissue quality and unpredictable angiogenesis following radiotherapy.19In addition, our HNC surgery patients are either borderline or anaemic prior to surgery, which could be secondary to the burden of their prior cancer treatment.