Evaluation and Treatment of Anemia Prior to Surgery: A Challenge to Improve

We have carefully read the recent article by Dr. Bruna et al. about the results of a national survey on perioperative care in gastric resection surgery. In their study, no reference is made to the management of perioperative anemia.¹ However, 2 other recent articles published by Cirugía Española about the application of multimodal rehabilitation in gastric and esophageal resection surgery^2,3 (with the collaboration of the same author and some of the collaborators) do recommend the evaluation and treatment of preoperative anemia. However, it is surprising that different levels of recommendation based on evidence are given, even more so when both articles refer to the National Clinical Pathway for Enhanced Recovery in Abdominal Surgery (RICA), endorsed by Guía Salud.⁴

RICA was published in 2015 by the Spanish Ministry of Health and includes among its 50 recommendations at least 6 regarding the preoperative management of anemia. Two merit mentioning here: Point 7: “The detection of preoperative anemia is recommended as it is associated with increased perioperative mortality.” (Strong recommendation+High level of evidence); and Point 8: “Hemoglobin (Hb) determination is recommended in patients scheduled for elective surgery at least 28 days before the procedure, which allows for sufficient time to stimulate erythropoiesis, if necessary.” (Strong recommendation+Moderate level of evidence).⁴ However, paradoxically, the Clinical Practice Guidelines for perioperative care in Major Abdominal Surgery, published by the Spanish Ministry of Health (latest version from 2016), makes no reference to the diagnosis and treatment of anemia.⁵

In our country, these RICA programs are promoted and updated periodically by the Spanish Multimodal Rehabilitation Group (GERM), who have recently conducted a new study using the Delphi methodology, the results of which have been presented at their national meeting in 2018 held in Salamanca, Spain. The GERM, aware of the approach necessary for preoperative anemia, have included the following recommendations, approved in consensus by the panel of experts: (1) to postpone or delay surgery up to 4 weeks for the study and treatment of anemia and/or iron deficiency; and (2) to avoid differentiation between sexes of the target Hb level, whose recommended goal should be equal to or higher than 13 g/dL at admission prior to surgery, both for men and for women.⁶

In conclusion, because anemia is one of the most frequently observed comorbidities in surgical patients that direct influences patient prognosis as it is associated with longer hospital stay and greater morbidity and mortality, and because it is also a modifiable factor, proper etiological and etiopathogenic diagnosis is essential. This should be done as soon as possible and with enough time to be able to correct Hb levels prior to the intervention.^7,8

The management of anemia in the perioperative period, together with other Patient Blood Management (PBM) measures based on the optimal use of patient-centered blood transfusion,⁹ should be included in the evaluation of multimodal rehabilitation programs.¹⁰

Conflict of Interests

This article has been developed and promoted by its own initiative, with no influence from third parties, and with no funding. All the authors have participated in its composition.

We declare that we have no conflicts of interest in the writing of this letter.

However, in the past Drs. CJA and JAGE have given talks, moderated tables in congresses and conferences and organized courses with grants or funding from Amgen, Jansen, Sandoz, Vifor or Zambon.