What we should consider to facilitate recovery of the hematological profile in all patients after pancreaticoduodenectomy: The role of preoperative intravenous ferritin treatment

doi:10.21203/rs.3.rs-2729612/v1

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Research Article

What we should consider to facilitate recovery of the hematological profile in all patients after pancreaticoduodenectomy: The role of preoperative intravenous ferritin treatment

https://doi.org/10.21203/rs.3.rs-2729612/v1

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published 12 Oct, 2023

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Background

In pancreaticoduodenectomy (PD), the duodenum and upper jejunum responsible for iron absorption are removed, which can lead to massive hemorrhage during surgery and cause iron deficiency anemia after PD. The aim of this study was to evaluate overall changes in hematologic profiles of patients who underwent pancreaticoduodenectomy. Effect of preoperative intravenous ferritin treatment on recovery of anemia after surgery was also investigated.

Methods

From March 2021 to December 2021, patients who underwent curative PD at our institution due to periampullary lesions were enrolled. They were divided into two groups according to whether or not ferritin was administered before surgery. In the IV ferritin group, all patients had been routinely administered with 1000 mg of ferric carboxymaltose intravenously once about 3–7 days before the operation day. Contrarily, patients in the control group did not receive intravenous ferritin before PD. Changes in hematological profile were measured preoperatively and at 5, 14, and 30 days postoperatively. Clinical results of the two groups were compared and analyzed. Additionally, a subgroup analysis was performed for selected non-anemic patients who had preoperative hemoglobin level of 12.0g/dl or higher to compare changes in hematologic profiles between the two groups.

Results

Thirty patients of the IV ferritin group and 34 patients of the control group were analyzed. Although no difference was observed in postoperative complications or mortality, hemoglobin and iron levels were recovered significantly faster at two weeks postoperatively in the IV ferritin group than in the control group. Ferritin levels were consistently higher in the IV ferritin group throughout the postoperative period. In subgroup analysis conducted for non-anemic patients, hemoglobin levels were recovered significantly faster and maintained higher in the IV ferritin group throughout the postoperative period, although baseline levels of hemoglobin were similar between the two groups. In addition, the length of intensive care unit stay was significantly shorter in the IV ferritin group than in the control group.

Conclusions

Preoperative intravenous ferritin treatment might be effective in facilitating recovery of hematologic profiles of patients during the recovery period after PD regardless of the presence of preoperative anemia, thus preventing postoperative iron deficiency anemia.

intravenous ferritin

iron-deficiency anemia

pancreaticoduodenectomy

Iron deficiency anemia (IDA) is commonly observed in cancer patients [1]. It has multifactorial etiologies such as bleeding, insufficient iron absorption, and anemia related to malignancy or chronic disease, a cytokine-mediated disorder [2]. In case of cancer surgery, since it generally involves tissue manipulation for organ resection and radical lymph node dissection, systemic inflammation can occur after surgery. It can induce the main regulator of systemic iron hemostasis that impairs intestinal iron absorption, thus increasing the risk of IDA in patients who undergo cancer surgery [3, 4].

Pancreaticoduodenectomy (PD), a representative surgery for periampullary tumorous lesions, is a major operation usually accompanied by moderate bleeding and massive tissual injury that are predisposing factors of IDA. Moreover, PD has vulnerable points for IDA physiologically because it inevitably removes the duodenum which absorbs iron into the body. Thus, the function of iron absorption is impaired after PD. In addition, an insufficient oral intake for a relatively long period after PD is common due to complex anastomosis. Therefore, the risk of IDA after PD can be very high regardless of presence or absence of preoperative anemia. IDA is a well-known risk factor of postoperative morbidities and poor prognosis of patients after surgeries [1]. Allogenic transfusion to correct anemia can be associated with both infectious and noninfectious risks such as cancer recurrence, cardiac complication, and prolonged hospitalization [5]. Several studies have reported that diagnosing anemia before surgery and correcting it using intravenous (IV) ferritin preoperatively can improve postoperative prognosis of patients [5–8]. In the field of colorectal or cardiac surgery, this effect in people diagnosed with IDA before surgery has been reported. However, the standard pattern of changes in hematologic parameters after PD has not been reported. There is a lack of studies about the effect of preoperative ferritin injection on clinical outcome of PD.

Thus, the aim of this study was to evaluate changes in hematologic profiles throughout the entire period of treatment in patients who underwent PD due to periampullary lesions. Effects of preoperative ferritin treatment on correction of postoperative anemia and improvement of clinical outcomes within 30 days after this surgery were also evaluated.

Study design and patient enrollment

This prospective cohort observational study was approved and carefully monitored by our Institutional Review Board (IRB No. KC22RISI0417). From March 2021 to December 2021, patients who underwent curative PD at our institution due to periampullary lesions were enrolled. PD was performed by one surgeon specialized in hepato-biliary-pancreas surgery. From August 2021, patients who underwent PD had been routinely administered ferritin intravenously at the outpatient department visit about 3–7 days before the operation day regardless of their preoperative hemoglobin (Hb) levels. Contrarily, patients who underwent PD before August 2021 did not receive intravenous ferritin treatment before the surgery. For analysis of the current study, we categorized participants into two groups: an IV ferritin group and a control group. Exclusion criteria were: (a) palliative or emergent surgery, (b) non-curable or metastatic disease status, (c) absence or insufficient data of essential laboratory values, (d) concomitant hematological disorders that might cause anemia, or (e) loss of follow-up. Patients who met the exclusion criteria were excluded. Contraindications for using intravenous ferritin were as follows: pregnant or lactation, age ≤ 18 years, history of severe asthma or infections, chronic renal failure, simultaneous oral iron or intravenous administration, or having any allergic reaction to iron [9, 10].

Preoperative Intravenous Ferritin Infusion

After the elective surgery was planned, patients in the IV ferritin group received the intravenous ferritin once about 3–7 days before the operation day. The preparation used was 1000 mg of ferric carboxymaltose (Ferinject™, Vifor Pharma, Glattbrugg, Dwitzerland) that was diluted in 250 ml of 0.9% normal saline using an aseptic technique. It was intravenously infused over 15 minutes under the supervision of a clinician according to the manufacturer’s recommendation [6, 7, 11, 12]. Clinical monitoring was carefully conducted by a nurse, including vital signs or any signs of hypersensitivity.

Data Recruitment And Clinical Outcome Assessment

All medical data and operative records were prospectively collected from patients and retrospectively reviewed. For all participants, laboratory data were routinely obtained preoperatively and on the 5th day, 14th day, and 30th day postoperatively. Laboratory values included hematologic profiles such as hemoglobin, iron, transferrin, and ferritin. For oncologic profiles, TNM cancer staging was defined based on pathologic reports using the American Joint Committee on Cancer Staging Manual, 8th edition [13]. Postoperative complications were reviewed and classified according to the Clavien-Dindo classification [14]. Complications of grades 1 and 2 were considered as minor complications, whereas grades 3 to 5 complications were defined as major complications. Postoperative pancreatic fistula (POPF) was defined according to the updated definition of the International Study Group in Pancreatic Surgery in 2016 [15]. Postoperative mortality was defined as any mortality within 30 days of surgery or within the same hospitalization as the surgery. All patients underwent the same clinical protocol during hospitalization regardless of the diagnosis or type of surgery. They were given parenteral nutritional support on the first day after operation if their vital signs were stable. Oral feeding was resumed on postoperative day 3 unless there was any evidence of pancreas leakage. On postoperative day 5, patients were routinely evaluated by abdominal computed tomography scans to confirm the absence of pancreas leakage and any other intraoperative complications. Regarding red blood cell transfusion postoperatively, it was conducted according to the Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee guidelines for surgery [16]. Transfusion is recommended if hemoglobin levels are lower than 7.0-8.0g/dL. However, the final decision of red blood cell transfusion was based on clinical conditions of the patient. Considerations for discharge were fine condition with oral analgesics and tolerable resumption of oral diet.

We analyzed and compared patterns of changes in hematologic profiles by measurement period (preoperatively, the 5th day, 14th day and 30th day postoperatively) and clinical outcomes between the IV ferritin group and the control group during the entire observational period. In addition, by applying the criteria used in several previous studies [17–19], patients with a preoperative Hb level of 12.0 g/dL or higher were selected and defined as preoperative non-anemic patients. We then performed a subgroup analysis comparing differences of changes in hematologic profiles between the IV ferritin group and the control group of preoperative non-anemic patients.

Statistical analysis

All statistical analyses were conducted using SPSS statistical package software version 22.0 for Windows (SPSS Inc., Chicago, IL, USA). For continuous variables with normal distribution, data were analyzed with Student’s t-test. Whether variables were normally distributed was tested using the Kolmogorov-Smirnov test. If variables were not normally distributed, independent data were analyzed by means of Mann-Whitney U test while paired data were compared using the Wilcoxon signed rank test. Categorical variables were calculated using Fisher’s exact test or the χ2 test. Descriptive statistics are presented as mean ± SD. Differences were regarded as statistically significant at P < 0.05.

During the study period, a total of 100 patients underwent PD due to periampullary lesions in our institution. Among them, 36 patients were excluded according to the exclusion criteria: two patients with emergent surgery, 23 patients with insufficient data for analysis, and 11 patients with contraindication for intravenous ferritin administration. Finally, a total of 64 patients were analyzed for this study, including 30 patients who were administered with intravenous ferritin preoperatively (46.9%, IV ferritin group) and 34 patients who had no intravenous ferritin treatment (53.1%, control group). In enrolled participants, 34 (53.1%) patients were classified as preoperative non-anemic patients (defined as preoperative Hb level above 12.0 g/dl), including 16 (47.1%) patients who underwent intravenous ferritin treatment preoperatively and 18 (52.9%) patients who had no ferritin administration. Figure 1 shows a schematic diagram of patient enrollment. Comparative analysis of baseline characteristics between the IV ferritin group and the control group of participants are presented in Table 1. There was no difference in demographic characteristics such as age, gender, presence of preoperative anemia, preoperative transfusion, and or tumor profiles between the two groups. Table 2 shows results of comparing clinical outcomes of the two groups. There was no significant difference in the incidence of postoperative complications, in-hospital mortality, length of hospitalization, or intensive care unit (ICU) stay. During the study period, 26 (40.6%) patients (13 patients in the IV ferritin group and 13 patients in the control group, p = 0.800) developed postoperative complications, including six patients who had major complications [3 patients in the IV ferritin group (one case of bile leak treated by percutaneous transhepatic biliary drainage, one case of POPF grade B treated by percutaneous drainage, and one case of delayed gastric emptying with ileus) and 3 patients in the control group (one case of bile leak treated by percutaneous transhepatic biliary drainage and two cases of POPF grade B treated by drainage), p = 1.000].

Table 1

Comparative analysis of baseline characteristics
Variables	Preoperative IV ferritin	No IV ferritin	p-value
Variables	n = 30 (46.9%)	n = 34 (53.1%)	p-value
Demographics
Age (years)	67.5 ± 13.4	69.8 ± 13	0.502
Gender (male, %)	10 (33.3)	18 (52.9)	0.136
Body mass index (kg/m^− 2)	23.6 ± 2.3	23.3 ± 2.4	0.589
ASA class over III	5 (16.7)	4 (11.8)	0.723
Diabetes mellitus	8 (26.7)	5 (14.7)	0.351
Hypertension	14 (46.7)	13 (38.2)	0.613
History of stroke	3 (10)	2 (5.9)	0.659
Preoperative anemia^* (%)	14 (46.7)	15 (44.1)	1.000
Transfusion before operation	2 (6.7)	0	0.216
Use of anticoagulant	7 (23.3)	10 (29.4)	0.777
Tumor location
Pancreas	16 (53.3)	16 (47.1)	0.802
Duodenum	1 (3.3)	1 (2.9)	1.000
Common bile duct	9 (30)	11 (32.4)	1.000
Ampulla of Vater	4 (13.3)	5 (14.7)	1.000
Others	0	1 (2.9)	1.000
Tumor staging^**
Stage I	11 (36.7)	13 (38.2)	1.000
Stage II	10 (33.3)	13 (38.2)	0.796
Stage III	9 (30)	7 (20.6)	0.405
Tumor manifestations
Concomitant malignancy	9 (30)	3 (8.8)	0.052
^*Patients with a preoperative hemoglobin level less than 12.0 g/dL were defined as preoperative anemic patients according to the criteria used in several previous studies (17–19).
^**Cancer stage was evaluated based on the AJCC Cancer Staging Manual, 7th edition (13).

Table 2

Comparative analysis of clinical outcomes
Variables		Preoperative IV ferritin	No IV ferritin	p-value
Variables		n = 30 (46.9%)	n = 34 (53.1%)	p-value
Perioperative outcome
Operative time (min)		354.6 ± 46	328.3 ± 67.1	0.071
Estimated blood loss (ml)		410 ± 450	390 ± 490	0.799
Length of ICU stay (day)		1.4 ± 0.7	1.1 ± 0.4	0.093
Length of hospital stay (day)		11 ± 6.1	11.5 ± 4.1	0.750
Postoperative transfusion		4 (13.3)	9 (26.5)	0.228
Postoperative morbidities (%)		13 (43.3)	13 (38.2)	0.800
Complication grade^** (%)	Grade I/II	10 (33.3)	10 (29.4)	0.791
	Grade III/IV/V	3 (10)	3 (8.8)	1.000
In hospital mortality (%)		0	1 (2.9)	1.000
^**Postoperative morbidities were reviewed and classified according to the Clavien-Dindo classification (14). In complications grading system by Clavien-Dindo classification, grades 1 and 2 are considered as minor, and grades 3 to 5 are defined as major complications.

Figure 2 shows trends of changes in iron status parameters (such as hemoglobin, iron, transferrin, and ferritin) over time in both groups (IV ferritin group and control group). The hemoglobin level decreased immediately after surgery compared to baseline hemoglobin level. It then gradually increased thereafter in both groups. It was significantly higher in the IV ferritin group from immediately after surgery to later time point. Serum iron level was decreased significantly in both groups after surgery. It remained low until 14 days after surgery, but increased thereafter. The iron level was significantly higher in the IV ferritin group on day 14 postoperatively. At other observation points, its mean value was higher in the IV ferritin group, although the difference between the two groups was not statistically significant. Serum transferrin level showed no significant difference between the two groups during the whole observational period. However, ferritin levels were consistently higher in the IV ferritin group throughout the postoperative period with statistical significance.

In addition, a subgroup analysis was performed for clinical outcomes and changes in hematological profiles of 34 preoperative non-anemic patients following IV ferritin treatment. Demographic characteristics were similar between the two groups (Table 3). In the comparison of clinical outcomes (Table 4), the length of ICU stay was significantly shorter in the IV ferritin group. Postoperative morbidities were developed in 14 cases (9 cases in IV ferritin group and 5 cases in control group, p = 0.163). Major complication were observed in three cases (two cases in the IV ferritin group included one case of grade B POPF and another case of intraabdominal abscess treated by radiologic intervention, and one case in the control group that was developed grade B POPF), showing no significant (p = 0.591) difference between the two groups. Figure 3 shows comparison of changes in hematologic profiles over time in preoperative non-anemic patients. In the case of the control group, levels of all hematologic profiles except for ferritin level were decreased immediately after surgery and gradually increased at 5 days after operation. However, they failed to return to preoperative levels by 30 days postoperatively. In the case of ferritin level, it was maintained at a relatively similar level to the preoperative level. On the contrary, the level of hemoglobin was recovered to the preoperative level on the 30th day after surgery, although the overall pattern of changes in hematologic profiles of the IV ferritin group was the same as that of the control group. Also, the ferritin level was increased rapidly immediately after surgery. It then remained significantly elevated compared to that before surgery until 30 days after surgery. Baseline hemoglobin level measured at preoperatively was similar between the two groups. Thereafter, hemoglobin levels were significantly higher in the IV ferritin group throughout the postoperative period. In particular, when 12.0 g/dL of Hb was used as the standard for preoperative anemia, mean Hb levels decreased to less than 12.0 g/dL in both groups immediately after surgery. However, in the IV ferritin group, it recovered to 12.0 g/dL or higher from 14 days postoperatively and maintained thereafter, whereas it did not reach 12.0 g/dL of Hb level in the control group by 30 days postoperatively. Regarding serum iron, it showed similar patterns in both groups after surgery, although its mean value was higher in the IV ferritin group without showing statistically significant difference at 30 days postoperatively (59 mcg/dL in the IV ferritin group and 49 mcg/dL in the control group, p = 0.249). Ferritin levels remained significantly higher in the IV ferritin group throughout the postoperative observational period, as same as shown in all patients.

Table 3

Comparative analysis of baseline characteristics in preoperative non-anemic patients who had preoperative Hb level above 12.0 g/dL.
Variables	Preoperative IV ferritin	No IV ferritin	p-value
Variables	n = 16 (47.1%)	n = 18 (52.9%)	p-value
Demographics
Age (years)	65.3 ± 9.2	68.9 ± 11	0.306
Gender (male, %)	14 (87.5)	10 (55.6)	0.063
Body mass index (kg/m^− 2)	24.3 ± 2	23.6 ± 2.5	0.349
ASA class over III	3 (18.8)	2 (11.1)	0.648
Diabetes mellitus	3 (18.8)	3 (16.7)	1.000
Hypertension	7 (43.8)	8 (44.4)	1.000
History of stroke	0	2 (11.1)	0.487
Use of anticoagulant	5 (31.2)	6 (33.3)	1.000
Tumor location
Pancreas	8 (50)	10 (55.6)	1.000
Duodenum	1 (6.2)	0	0.471
Common bile duct	4 (25)	6 (33.3)	0.715
Ampulla of Vater	3 (18.8)	1 (5.6)	0.323
Tumor staging^**
Stage I	8 (50)	10 (55.6)	1.000
Stage II	4 (25)	6 (33.3)	0.715
Stage III	4 (25)	1 (5.6)	0.164
Tumor manifestations
Concomitant malignancy	4 (25)	2 (11.1)	0.387
^*Cancer stage was evaluated based on the AJCC Cancer Staging Manual, 7th edition (13).

Table 4

Comparative analysis of clinical outcomes in preoperative non-anemic patients who had preoperative Hb level above 12.0 g/dL.
Variables		Preoperative IV ferritin	No IV ferritin	p-value
Variables		n = 16 (47.1%)	n = 18 (52.9%)	p-value
Perioperative outcome
Operative time (min)		362.7 ± 45.4	331.8 ± 49.3	0.072
Estimated blood loss (ml)		390 ± 230	310 ± 170	0.249
Length of ICU stay (day)		1 ± 0.1	1.7 ± 0.9	0.012
Length of hospital stay (day)		12.9 ± 7.9	11.1 ± 4.8	0.445
Postoperative transfusion		0	2 (11.1)	0.487
Postoperative morbidities (%)		9 (56.2)	5 (27.8)	0.163
Complication grade^* (%)	Grade I/II	7 (43.8)	4 (22.2)	0.274
	Grade III/IV/V	2 (12.5)	1 (5.6)	0.591
In hospital mortality (%)		0	0	-
^*Postoperative morbidities were reviewed and classified according to the Clavien-Dindo classification (14). In complications grading system by Clavien-Dindo classification, grades 1 and 2 are considered as minor, and grades 3 to 5 are defined as major complications.

Our results revealed that patients who underwent PD had similar patterns of postoperative changes in hematologic profiles regardless of the presence of a preoperative anemia. Values of hematologic parameters were significantly decreased immediately after surgery. They showed a gradual recovery during the observation period. Hemoglobin and iron levels were significantly higher in patients receiving preoperative IV ferritin than those in patients without receiving preoperative IV ferritin. The same result was observed not only in the group with preoperative anemia, but also in the group with a serum hemoglobin value of 12 or higher.

In addition to etiologic factors (such as bleeding, malignancy, and chronic disease) of surgery, surgically induced inflammatory responses can promote the synthesis of hepcidin and reduce iron bioavailability. It can inhibit iron absorption from the gastrointestinal tract and reduce the release of stored iron [20]. The level of ferritin, an acute phase reactant, may temporarily change under the condition of post-operative inflammation. An insufficient red blood cell production can result in IDA when stored iron is depleted. These phenomena are evidently observed in results of our study, especially more pronounced in the control group without receiving preoperative IV ferritin. Hemoglobin and iron levels were decreased after surgery. After that, iron depletion continued and ferritin levels remained low without showing a recovery, whereas transferrin levels were increased. On the other hand, patients who received preoperative IV ferritin did not show a decrease in ferritin level, but rather maintained high levels during the observation period, although hemoglobin and iron levels were similarly decreased immediately after surgery. At two weeks after surgery, hemoglobin and iron levels were significantly higher in patients who received preoperative IV ferritin than in patients who did not receive preoperative IV ferritin. Therefore, preoperative IV ferritin management might be helpful for preventing IDA caused by postoperative physiological changes and iron depletion.

In fact, several studies have previously reported that preoperative ferritin supplementation is helpful in the prevention of postoperative IDA [5–8]. However, results of this study showed effects of preoperative IV ferritin treatment in all patients who underwent PD with or without preoperative IDA. Similar to patients diagnosed with preoperative IDA, the hemoglobin level was significantly decreased immediately after surgery in normal patients without IDA prior to surgery. The preoperative IV ferritin group also showed a significantly faster recovery of hemoglobin level. These results might be due to characteristics of the PD surgery itself. PD is a complex and difficult surgical procedure that requires resection of the entire duodenum together with the head of the pancreas, proximal jejunum, distal common bile duct, and the gastric antrum sometimes. Considering that most iron is absorbed into the body through the duodenum and proximal portion of jejunum, in the case of PD with total removal of those organs during surgery, a significant change occurs in the normal iron absorption process after surgery. Thus, the risk of IDA is increased after PD due to an absolute lack of iron absorption from the intestinal tract. This suggests that even non-specific patients without preoperative IDA can be high-risk candidates for developing postoperative IDA due to physiological characteristics of the surgical technique of PD itself. In addition, in the case of cancer surgery, the risk of postoperative anemia may increase due to the high invasiveness caused by resection of adjacent organs and radical lymph node dissection. Prolonged fasting is common after PD due to concerns about anastomotic leakage, which can lead to insufficient iron supplementation for a long time. Since patients after PD become vulnerable to IDA regardless of the presence of preoperative anemia, preoperative IV ferritin treatment should be considered for all patients who are planned to undergo PD.

Since postoperative IDA is well known to be associated with poor prognosis of clinical outcomes, an active intervention by clinicians for the prevention of IDA before surgery is important. This association between IDA and postoperative outcome has already been reported in many previous studies. Epidemiological studies have reported that anemia is associated with increased rates of postoperative morbidity and mortality [21, 22]. In a study of Khalafallah et al. the group receiving IV ferritin treatment showed shorter length of hospital stay probably due to fewer postoperative blood transfusions or infections [12]. In our results, the length of hospital stay was also significantly shorter in the IV ferritin group having no preoperative anemia than in the control group. Therefore, preoperative IV ferritin treatment for patients undergoing PD not only can help prevent postoperative anemia and early recovery of hematologic profiles, but also can improve postoperative clinical outcomes. Additionally, IDA that occurs after surgery would be more proper to prevent before it occurs than to treat it through blood transfusions after it occurs. As seen in many previous studies [23–26], allogeneic blood transfusion has a risk of transfusion-transmitted infections. Emerging pathogens can infect the blood supply [27]. From a non-infectious aspect, it can cause immune-mediated acute transfusion reactions [28]. In cancer patients, blood transfusion can have a negative oncologic effect such as promoting a protumor state that might cause cancer recurrence [7]. Therefore, it is necessary to avoid unnecessary blood transfusions after surgery by actively preventing the occurrence of postoperative IDA before the surgery through ferritin supplement.

Despite these interesting results, our study has inevitable limitations that warrant caution when interpreting results. First, due to its prospective cohort design of study, there might be a selection bias of enrolled patients with different characteristics in disease or demographics by phase. In addition, participants might have different treatment protocols that might have changed slightly over time. However, a single, same clinician has been managing all critically ill patients after surgery at our intensive care unit since 2016. Therefore, the treatment strategy remained relatively constant during the study period and the treatment principle for anemia patients, the focus of this study, remained constant without change. Therefore, potential treatment bias was minimized. Additionally, we did not measure or analyze some laboratory profiles such as hepcidin or transferrin saturation known to be potential biomarkers for responses to iron treatment. Finally, our study included a relatively small number of cases in a single institution. In order to overcome these limitations, a prospective randomized-controlled trial with a larger number of participants should be conducted in the near future along with analysis of more diverse hematologic profiles. However, to the best of our knowledge, this was the first study that analyzed the pattern of hematologic profiles before and after surgery in patients undergoing PD. In particular, it compared patterns of changes in hematological values according to IV ferritin treatment before surgery even in non-specific patients without preoperative anemia. Given that there is currently insufficient evidence to establish IV ferritin treatment for patients undergoing PD, our findings suggest that preoperative IV ferritin administration can be an effective treatment option for all patients with PD for the prevention and early recovery of postoperative IDA.

In conclusion, most patients undergoing PD showed significantly decreased hemoglobin levels after surgery regardless of the presence of preoperative anemia. Preoperative IV ferritin treatment might be effective in facilitating recovery of hematologic profiles of patients during the recovery period after PD regardless of the presence of preoperative IDA, consequently resulting in prevention of postoperative IDA.

IDA iron deficiency anemia

PD pancreaticoduodenectomy

IV intravenous

Hb hemoglobin

POPF postoperative pancreatic fistula

ICU intensive care unit

Conflicts of interest

The authors have no potential conflicts of interest relevant to this article to disclose.

Acknowledgments

No additional investigators were involved in this research project.

Consent for publication

Not applicable.

Data availability

The research data that support the findings of this study are available from the corresponding author upon reasonable request. These research data are not publicly available due to privacy or ethical restrictions.

Author contributions

Study conception and design: EYK and HTH; Acquisition of data: EYK and SEP; Statistical analysis: EYK; Analysis and interpretation of data: EYK and SEP; Drafting of manuscript: EYK; Critical revision: EYK, HTH; Guarantor of article: HTH. All authors approved the final version of the article, including the list of authors.

Funding

The authors received no specific funding for this work.

Ethical statement

All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved and carefully monitored by our Institution Review Board (KC22RISI0417) of the Catholic University of Korea. Written informed consent was obtained from all participants. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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No competing interests reported.

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published 12 Oct, 2023

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What we should consider to facilitate recovery of the hematological profile in all patients after pancreaticoduodenectomy: The role of preoperative intravenous ferritin treatment

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Abstract

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Introduction

Methods

Study design and patient enrollment

Preoperative Intravenous Ferritin Infusion

Data Recruitment And Clinical Outcome Assessment

Statistical analysis

Results

Discussion

Abbreviations

Declarations

References

Additional Declarations

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Journal Publication

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