A detailed review of blood counts is critical. Severe neutropenia or lymphopenia indicates a high risk of infection. Thrombocytopenia should be quantified and corrected preoperatively; A review of the evolution of guidelines for the minimum platelet count threshold prior to invasive procedures in cirrhosis recommends a platelet count of at least 50×10⁹/l for major invasive procedures to mitigate bleeding risk (36). Coagulation studies, including assessment of prothrombin time, international normalized ratio, activated partial thromboplastin time and fibrinogen level, should be performed to detect DIC or coagulopathy. Any significant abnormalities may require correction with plasma or cryoprecipitate. Anemia is nearly ubiquitous in patients with post-chemotherapy AML. Maintaining a hemoglobin level >8-10 g/dl through transfusion, adjusted for the patient's cardiovascular status, optimizes tissue oxygen delivery (37,38).

A comprehensive preoperative assessment must evaluate the patient's current infection status and colonization history. Fever may be the only sign of serious infection in these population, and untreated infections can progress rapidly. Therefore, preoperative fever or signs of infection should prompt a thorough diagnostic workup and administration of empiric broad-spectrum antibiotics preoperatively. Neutropenia has been identified as an independent predictor of postoperative mortality (21). A single-center series of 237 patients with neutropenia undergoing abdominal surgery reported an overall postoperative mortality of 11.8%; this rate increased to 16.4% for urgent operations but was only 1.4% for elective cases (22). Notably, severe neutropenia, defined as an absolute neutrophil count (ANC) <0.5×10⁹/l, was associated with a high mortality rate of ~50% (22). Patients with AML are often colonized with multidrug-resistant organisms due to prior broad-spectrum antibiotic exposure during neutropenic fever episodes (39). Nutritional status is also a key determinant of postoperative infection risk. Chemotherapy frequently induces weight loss and hypoalbuminemia, both of which are correlated with impaired immunity and delayed wound healing. Malnutrition has been consistently linked to higher rates of postoperative complications, particularly surgical site infections (SSIs) and pneumonia, highlighting its independent prognostic significance (40,41).

Whenever feasible, elective surgery should be scheduled during periods of marrow recovery. Following induction chemotherapy for AML, patients typically have a several-week aplastic phase before blood count recovery if remission is achieved. Elective procedures should ideally be deferred until neutrophils and platelets rebound to safer levels, with an ANC >1,000/µl and platelets at >50×10⁹/l at minimum (42,43). This strategy is supported by clinical observations; patients undergoing elective surgery in a non-neutropenic state have markedly lower morbidity than those operated on while neutropenic (22). However, emergent surgical indications cannot await count recovery, and in such cases, the risks should be accepted and mitigated proactively.

Risk stratification requires a multidisciplinary approach. Key prognostic indicators include preoperative ANC (<500/µl indicates very high risk) (44), persistent neutropenia (45), disease phase (46), surgical urgency (47), underlying diagnosis (48), age or organ failure (49). The surgical team should coordinate with the hematology/oncology teams to understand the patient's leukemia status, including remission status, timing of last chemotherapy and planned treatments. Hematologists can facilitate growth factor support, such as use of granulocyte colony-stimulating factor (G-CSF), to hasten neutrophil recovery perioperatively (34,35). An infectious disease consultation is also recommended to guide appropriate prophylactic antimicrobial therapy.

Infections are the most prevalent and dangerous postoperative complication in patients with immunosuppressed AML due to the lack of a robust immune defense.

Preoperative neutropenia is an independent predictor of SSI (20). In patients with neutropenia, SSIs may present subtly, as the classic indications for infection, such as rubor, heat and pain, are often clinically less apparent. Initial indications are often fever or unexpected wound drainage. However, when neutrophils are absent, pus formation is minimal; therefore, wound infection might only show clear or slightly turbid fluid until later (50,51).

Following abdominal surgery, patients with neutropenia are at a high risk of intra-abdominal abscesses and anastomotic leaks, leading to peritonitis. Neutropenic enterocolitis is a distinct entity, and while typically not postoperative in origin, it may be precipitated or exacerbated by intestinal manipulation in a neutropenic patient (19).

Systemic infection is a leading cause of postoperative mortality in the patients with neutropenia (34,35). Early postoperative sepsis can originate from an anastomotic leak, pneumonia, urinary tract infection or central-line infection. Progression from stable neutropenia to septic shock can be rapid, with early indicators limited to fever and mild tachycardia (52).

Postoperative pneumonia is common in patients with AML. Patients are often colonized by nosocomial organisms from prior hospitalization. Mucositis and oropharyngeal colonization by gram-negative bacteria or fungi can lead to aspiration pneumonia (53). Radiographic presentations are often atypical; chest x-ray may show only faint infiltrates rather than dense lobar consolidations or abscesses. High-resolution computed tomography provides a much higher yield for detecting pulmonary infections (54), revealing subtle findings, such as ground-glass opacities or small nodules that are frequently missed on standard radiographs (54).

The risk of opportunistic infections increases with the duration of postoperative neutropenia. Fungal infections, particularly invasive candidiasis and aspergillosis, pose a major threat (55). The mortality rate among neutropenic patients with intra-abdominal candidiasis was 81.8%, whereas the mortality rate among non-neutropenic patients was ~24.3% (56).

Bleeding is not merely a nuisance complication; it serves as a marker for and actively contributes to worse outcomes. Among patients with acute leukemia receiving induction chemotherapy, those who experienced major bleeding had significantly worse overall survival rates than those who did not (11,57). Therefore, bleeding complications represent a significant postoperative concern in patients with chemotherapy-treated AML.

Patients may develop prolonged sanguineous drainage from the incision or drain region due to impaired clot formation. In patients with thrombocytopenia, clots fail to stabilize, leading to postoperative bleeding even from well-ligated vessels. Prophylactic platelet transfusions are typically administered immediately postoperatively to maintain a platelet count of >50×10⁹/l until the risk of bleeding is low (58).

Patients with APL can present with DIC, and severe infections can trigger DIC postoperatively (59). This condition may manifest as oozing from intravenous sites, mucous membranes and surgical wounds.

Certain surgeries pose unique bleeding risks. For example, low platelet counts predispose patients to intraluminal bleeding from anastomotic staple or suture lines following gastrointestinal surgery (60,61).

Managing bleeding often requires multiple transfusions, which carries risks. Volume overload can precipitate heart failure or pulmonary edema, particularly in older patients with AML who may have reduced cardiac function. Transfusion reactions or alloimmunisations can complicate further transfusions (62,63).

Wound healing impairment is a direct consequence of the compromised regenerative capacity in patients with chemotherapy-treated AML.

Surgical incisions in patients with neutropenia often result in slow healing, significantly prolonging the typical healing timeline. Cioce et al noted that leukopenia may disrupt wound healing due to impaired inflammatory cell communication and prolonged inflammation (64).

In severe cases, surgical incision may undergo partial or complete dehiscence. Malnutrition and chronic steroid use may further exacerbate the risk in this population (65). Dehiscence typically manifests at 7–14 days postoperatively (66).

Anastomotic leakage is potentially the most dreaded complication of colorectal or intestinal surgery, and immunosuppressed patients are particularly vulnerable. In neutropenic patients, even if the anastomosis is well-constructed, the risk of leakage is elevated due to impaired healing, as is the inability to maintain a minor leak that might have normally sealed spontaneously (17).

Although bleeding is the dominant issue, paradoxical thromboembolic complications occur with an increased frequency. One study reported that 65 out of 250 (26%) patients with acute leukemia developed venous thromboembolism (VTE) during induction therapy (11). Postoperative immobility, the presence of central venous catheters and certain chemotherapeutic agents (such as Cisplatin, Thalidomide, Tamoxifen and Doxorubicin), elevate the risk of deep vein thrombosis (DVT) and pulmonary embolism (67–69). Indwelling catheters can precipitate local thrombosis in the subclavian, jugular or femoral veins. Pharmacological prophylaxis with low-dose unfractionated heparin or low-molecular-weight heparin is typically initiated once the postoperative bleeding risk is deemed acceptable. While all surgical patients should generally receive VTE prophylaxis, initial management in thrombocytopenic patients often relies on mechanical methods (70,71).

Elective surgery should be scheduled for when blood counts have recovered. Whenever feasible, surgeons should avoid operating during the nadir of chemotherapy-induced neutropenia (28). There must be coordination with oncologists to determine if chemotherapy can be delayed or if growth factors can be used to expedite recovery.

Proactive transfusion should be performed to optimize hemoglobin and platelet counts preoperatively. The transfusion of 1 or 2 units of platelets on the day of surgery occurs frequently, even with a count is 50–70×10⁹/l, which is an adequate threshold for most non-neurosurgical operations (72). For major surgeries with a high bleeding risk, the maintenance of platelet counts >100×10⁹/l is recommended to provide a safety margin.

All active infections should be preoperatively identified and treated. Decolonization protocols, such as chlorhexidine baths and nasal mupirocin for methicillin-resistant Staphylococcus aureus carriers, should be implemented to reduce the risk of endogenous infection (73,74). Prophylactic broad-spectrum antibiotics should be administered perioperatively to patients with profound neutropenia. Per the Infectious Diseases Society of America/American Society of Clinical Oncology guidelines, broad-spectrum antibiotics should be continued until the patient is stable and afebrile, and the neutrophil count has recovered to 500/µl (75).

Correct malnutrition is also important for preoperative optimization. A number of cancer centers administer immunonutritional formulas, enriched with arginine, glutamine and omega-3 fatty acids, preoperatively for 5–7 days in malnourished surgical patients, which has been shown to reduce infectious complications in gastrointestinal cancer procedures (76,77).

Surgical morbidity can be minimized through several key strategies. These include utilizing experienced surgical teams to reduce operative time, handling tissues gently to prevent necrotic foci for infection and employing prophylactic measures, such as subcutaneous heparin and sequential compression devices, to reduce DVT risk. Furthermore, ensuring effective intraoperative antibiotic coverage, with appropriate redosing during lengthy procedures, and responding to contamination events, such as bowel content spillage, with thorough lavage and potential drain placement are critical (78).

Anesthesiologists should employ strategies to reduce the immunosuppressive effects of surgery. These include maintaining normothermia with warming devices, potentially using a high fraction of inspired oxygen to optimize tissue oxygenation and providing adequate analgesia to mitigate excessive stress responses (58,79).

Transfusions can be performed to maintain hemoglobin at an acceptable range (often ≥8 g/dl, or higher in patients with coronary disease). If the preoperative platelet count is 50–70×10⁹/l, intraoperative consumption and dilution should be anticipated, with additional platelets added intraoperatively to maintain hemostasis. Surgeons should be prepared to administer freshly frozen plasma or cryoprecipitate if coagulopathy is evident or massive transfusion is anticipated (80,81).

Broad-spectrum antibiotic prophylaxis should be administered with an extended duration. In patients with neutropenia, surgeons frequently continue coverage beyond the usual 24-h window (82). For high-risk surgeries, particularly gastrointestinal procedures, several protocols also include antifungal coverage during and after the operation due to the risk of fungal infection in this population (83).

Surgeons often adapt their approach to mitigate risks. Core principles include minimizing operative time and tissue trauma. Less invasive techniques, such as laparoscopy, are favored in order to reduce the risk of SSI and potentially attenuate the inflammatory response (84,85). In select cases, a more conservative procedure may be warranted; for example, for a with neutropenic patient with AML and colon cancer, a surgeon might choose a diverting stoma over a primary anastomosis after resection to avoid the severe outcome of an anastomotic leak (86).