Impact of peri-operative blood transfusion on post-operative infections after radical gastrectomy for gastric cancer: a propensity score matching analysis focusing on the timing, amount of transfusion and role of leukocyte depletion

Risk factors for pneumonia after radical gastrectomy for gastric cancer: a systematic review and meta-analysis

OBJECTIVE

The objective is to systematically gather relevant research to determine and quantify the risk factors and pooled prevalence for pneumonia after a radical gastrectomy for gastric cancer.

METHODS

The reporting procedures of this meta-analysis conformed to the PRISMA 2020. Chinese Wan Fang data, Chinese National Knowledge Infrastructure (CNKI), Chinese Periodical Full-text Database (VIP), Embase, Scopus, CINAHL, Ovid MEDLINE, PubMed, Web of Science, and Cochrane Library from inception to January 20, 2024, were systematically searched for cohort or case-control studies that reported particular risk factors for pneumonia after radical gastrectomy for gastric cancer. The pooled prevalence of pneumonia was estimated alongside risk factor analysis. The quality was assessed using the Newcastle-Ottawa Scale after the chosen studies had been screened and the data retrieved. RevMan 5.4 and R 4.4.2 were the program used to perform the meta-analysis.

RESULTS

Our study included data from 20,840 individuals across 27 trials. The pooled prevalence of postoperative pneumonia was 11.0% (95% CI = 8.0% ~ 15.0%). Fifteen risk factors were statistically significant, according to pooled analyses. Several factors were identified to be strong risk factors, including smoking history (OR 2.71, 95% CI = 2.09 ~ 3.50, I2 = 26%), prolonged postoperative nasogastric tube retention (OR 2.25, 95% CI = 1.36-3.72, I2 = 63%), intraoperative bleeding ≥ 200 ml (OR 2.21, 95% CI = 1.15-4.24, I2 = 79%), diabetes mellitus (OR 4.58, 95% CI = 1.84-11.38, I2 = 96%), male gender (OR 3.56, 95% CI = 1.50-8.42, I2 = 0%), total gastrectomy (OR 2.59, 95% CI = 1.83-3.66, I2 = 0%), COPD (OR 4.72, 95% CI = 3.80-5.86, I2 = 0%), impaired respiratory function (OR 2.72, 95% CI = 1.58-4.69, I2 = 92%), D2 lymphadenectomy (OR 4.14, 95% CI = 2.29-7.49, I2 = 0%), perioperative blood transfusion (OR 4.21, 95% CI = 2.51-7.06, I2 = 90%), and hypertension (OR 2.21, 95% CI = 1.29-3.79, I2 = 0%). Moderate risk factors included excessive surgery duration (OR 1.51, 95% CI = 1.25-1.83, I2 = 90%), advanced age (OR 1.91, 95% CI = 1.42-2.58, I2 = 94%), nutritional status (OR 2.62, 95% CI = 1.55-4.44, I2 = 71%), and history of pulmonary disease (OR 1.61, 95% CI = 1.17-2.21, I2 = 79%).

CONCLUSIONS

This study identified 15 independent risk factors significantly associated with pneumonia after radical gastrectomy for gastric cancer, with a pooled prevalence of 11.0%. These findings emphasize the importance of targeted preventive strategies, including preoperative smoking cessation, nutritional interventions, blood glucose and blood pressure control, perioperative respiratory training, minimizing nasogastric tube retention time, and optimizing perioperative blood transfusion strategies. For high-risk patients, such as the elderly, those undergoing prolonged surgeries, experiencing excessive intraoperative blood loss, undergoing total gastrectomy, or receiving open surgery, close postoperative monitoring is essential. Early recognition of pneumonia signs and timely intervention can improve patient outcomes and reduce complications.

Analysis of Early Progression in Advanced Renal Cell Carcinoma Treated With Nivolumab Plus Ipilimumab

Background/Aim

Lymphocyte-to-C-reactive protein ratio (LCR) is a useful biomarker for predicting the prognosis of various cancers. This study examined the effect of LCR on the oncological prognosis of patients with gastric cancer who underwent curative resection at our institution and considered the mechanisms involved.

Patients and Methods

In this retrospective cohort study, 258 subjects were selected from the medical records of patients who underwent curative resection for gastric cancer at Yokohama City University between 2005 and 2020. The LCR was calculated using the following formula: LCR=lymphocyte count (number/μl)/C-reactive protein (mg/dl).

Results

The cutoff value for LCR was set at 9,000, and 258 patients were classified into the LCR-low (<9,000) (58 patients) and LCR-high (>9,000) (200 patients) groups. The overall survival (OS) and recurrence-free survival (RFS) rates of the two groups were compared. The 5-year overall survival rate was 54.2% in the LCR-low group and 75.2% in the LCR-high group (p<0.001), and a multivariate analysis showed that it was a useful prognostic factor [hazard ratio (HR)=1.744, 95% confidence interval (CI)=1.009-3.014, p=0.046]. In addition, with regard to RFS, there was a significant difference in the 5-year RFS between the LCR-low group (50.4%) and the LCR-high group (72.3%) (p<0.001). Regarding the comparison of the postoperative clinical course between the two groups, the peritoneal recurrence rate was 24.1% in the LCR-low group and 7.5% in the LCR-high group (p<0.001).

Conclusion

Preoperative LCR is a useful prognostic factor for predicting the oncological prognosis of patients with gastric cancer undergoing curative resection. Thus, the LCR may be a useful tool for the treatment and perioperative management of patients with gastric cancer.

The effect of the leukoreduction filtration moment on the clinical outcome of transfused patients: A retrospective cohort study

INTRODUCTION

Leukoreduction is performed to decrease the occurrence of adverse effects of transfusion, and can be performed by pre-storage (bench or in-line) or post-storage filtration (bedside) moment. The authors verified the effect of the leukoreduction filtration moment of Red Blood Cell (RBC) and Platelet Concentrate (PC) on the occurrence of Adverse Transfusion Reactions (ATRs), the presence of Healthcare-Associated Infections (HAIs), Length of Hospital Stay (LOS), and hospital death.

METHODS

Retrospective cohort conducted at the Hospital das Clínicas of the Medicine Faculty of the University of São Paulo, and at the Fundação Pró-Sangue Hemocentro in São Paulo, Brazil. Adult patients, hospitalized for >24 hours, who received leukoreduced RBC and/or PC transfusion between 2017‒2020 were included. The generalized mixed effects model and the Wald test were applied in the analysis with a significance level of 5 %.

RESULTS

The authors evaluated 3668 patients who received 23,782 transfusions and we found no evidence of a leukoreduction filtration moment effect for ATR (p = 0.991) or HAI (p = 0.982), regardless of the transfused blood component. Meanwhile, the leukoreduction filtration moment had an effect (p < 0.001) on LOS, depending on the blood component transfused (p = 0.023), with pre-storage RBC filtration showing better performance, while in-line filtration stood out for PC. Both the leukoreduction filtration moment and the blood component (p = 0.041) influenced hospital death, with emphasis on the protective effect of bench RBC filtration and pre-storage PC filtration.

CONCLUSION

The leukoreduction filtration moment associated with the blood component had an effect on the LOS and hospital death of patients undergoing transfusion.

Blood transfusion might not be recommended for gastric cancer patients with pretransfusion minimum hemoglobin values higher than 90 g/l: a real-world study covering 20 years of 13 470 patients

BACKGROUND

There was no consistent evidence of whether perioperative blood transfusion (PBT) affects the long-term survival of gastric cancer (GC) patients after undergoing gastrectomy. This study aimed to investigate the effects of PBT on the long-term survival of GC patients, as well as to determine the threshold of PBT and provide evidence for future surgical practice.

METHODS

We performed this real-world study of GC patients undergoing gastrectomy at China National Cancer Center from January 1, 2000 to December 30, 2019. Overall survival (OS) curves were plotted using the Kaplan-Meier method and compared statistically using the log-rank test. Univariate and multivariate Cox proportional hazard models were used to determine the risk factors for OS.

RESULTS

In total, 13 470 GC patients undergoing gastrectomy from 2000 to 2019 were included, of whom 3465 (34.6%) GC patients received PBT. PBT ratios declined from 29.1% (114/392) in 2000 to 11.2% in 2019 (149/1178), with the highest blood transfusion ratio in 2005 at 43.7% (220/504). For patients transfused with red blood cells, the median value of hemoglobin (Hb) before transfusion in the PBT group decreased from 110 g/l in 2000 to 87 g/l in 2019. Compared with patients who not receiving PBT, PBT group are more likely to be older (≥65, 39.1% vs. 30.1%, P <0.001), open operation (89.7% vs. 78.1%, P <0.001), higher American Society of Anesthesiologists score (>2, 25.3% vs. 14.9%, P <0.001) and in the later pTNM stage (pTNM stage III, 68.5% vs. 51.5%, P <0.001). Results of multivariable Cox regression analysis showed that PBT was an independent prognostic factor for worse OS in GC patients undergoing gastrectomy [HR=1.106, 95% confidence interval (CI): 1.01-1.211, P =0.03). After stratified according to tumor stage, we found that PBT group had a worse prognosis only in pTNM stage III (HR=1.197, 95% CI: 1.119-1.281, P <0.001). OS was obviously poor in the PBT group when Hb levels were higher than 90 g/l (90 g/l120 g/l: HR=1.207, 95% CI: 1.098-1.327, P <0.001), while there was no difference between the two groups when Hb levels were lower than or equal to 90 g/l (Hb≤90 g/l: HR=1.162, 95% CI: 0.985-1.370, P =0.075).

CONCLUSION

In conclusion, PBT was an independent prognostic factor for worse OS. Blood transfusion might not be recommended for GC patients with perioperative minimum Hb values higher than 90 g/l.

Effect of perioperative blood transfusion on complications and prognosis after radical gastrectomy in elderly patients: a retrospective study of 1,666 cases

Background

Multiple studies have examined the effect of perioperative blood transfusion (BTF) on postoperative complications and the prognosis of gastric cancer patients, but the conclusions remain controversial, and few studies related to elderly patients are present. This study sought to examine the effect of perioperative BTF on postoperative complications and the prognosis of elderly patients who underwent radical gastrectomy.

Methods

The clinical data of 1,666 elderly patients (aged ≥60 years) at Xijing Hospital from October 2013 to October 2021 were retrospectively analyzed. The patients were stratified into the perioperative BTF group and the perioperative non-BTF group. The clinicopathological characteristics, postoperative complications, and long-term prognoses of the patients were compared.

Results

There were significant differences in terms of sex, tumor location, tumor size, gastrectomy range, tumor differentiation, T stage, N stage, tumor-node-metastasis (TNM) stage, preoperative anemia, and intraoperative blood loss between the two groups (P<0.05). The incidence of postoperative fever in the BTF group was significantly higher than that in the non-BTF group (31.6% vs. 15.4%, P<0.001), but there were no significant differences in the other complications between the two groups (P>0.05). The survival analysis showed that in stage III patients, the prognosis of the BTF group was inferior to that of the non-BTF group [the 3-year overall survival (OS) rates of the groups were 33.7% vs. 47.9% respectively, P<0.001], while there was no significant difference between the two groups among the stage I and stage II patients (P>0.05). There was no significant difference in the prognosis of patients with different transfusion times (preoperative/intraoperative/postoperative) (P>0.05). The multivariate analysis indicated that perioperative BTF was not an independent risk factor for prognosis in elderly patients with gastric cancer overall or elderly patients with gastric cancer in stage III (P>0.05).

Conclusions

Perioperative BTF may elevate the incidence of fever but has no significant effect on other complications in elderly patients after radical gastrectomy. Perioperative BTF is not an independent risk factor affecting the postoperative prognosis of elderly patients with gastric cancer.

Effect of Perioperative Blood Transfusions and Infectious Complications on Inflammatory Activation and Long-Term Survival Following Gastric Cancer Resection

Background: The aim of this study was to evaluate the impact of perioperative blood transfusion and infectious complications on postoperative changes of inflammatory markers, as well as on disease-free survival (DFS) in patients undergoing curative gastric cancer resection. Methods: Multicenter cohort study in all patients undergoing gastric cancer resection with curative intent. Patients were classified into four groups based on their perioperative course: one, no blood transfusion and no infectious complication; two, blood transfusion; three, infectious complication; four, both transfusion and infectious complication. Neutrophil-to-lymphocyte ratio (NLR) was determined at diagnosis, immediately before surgery, and 10 days after surgery. A multivariate Cox regression model was used to analyze the relationship of perioperative group and dynamic changes of NLR with disease-free survival. Results: 282 patients were included, 181 in group one, 23 in group two, 55 in group three, and 23 in group four. Postoperative NLR changes showed progressive increase in the four groups. Univariate analysis showed that NLR change > 2.6 had a significant association with DFS (HR 1.55; 95% CI 1.06−2.26; p = 0.025), which was maintained in multivariate analysis (HR 1.67; 95% CI 1.14−2.46; p = 0.009). Perioperative classification was an independent predictor of DFS, with a progressive difference from group one: group two, HR 0.80 (95% CI: 0.40−1.61; p = 0.540); group three, HR 1.42 (95% CI: 0.88−2.30; p = 0.148), group four, HR 2.85 (95% CI: 1.64−4.95; p = 0.046). Conclusions: Combination of perioperative blood transfusion and infectious complications following gastric cancer surgery was related to greater NLR increase and poorer DFS. These findings suggest that perioperative blood transfusion and infectious complications may have a synergic effect creating a pro-inflammatory activation that favors tumor recurrence.

Nomogram of intra-abdominal infection after surgery in patients with gastric cancer: A retrospective study

Background

Surgical resection is still the primary way to treat gastric cancer. Therefore, postoperative complications such as IAI (intra-abdominal infection) are major problems that front-line clinical workers should pay special attention to. This article was to build and validate IAI’s RF (regression function) model. Furthermore, it analyzed the prognosis in patients with IAI after surgery for stomach cancer. The above two points are our advantages, which were not involved in previous studies.

Methods

The data of this study was divided into two parts, the training data set and the validation data set. The training data for this article were from the patients treated surgically with gastric cancer in our center from December 2015 to February 2017. We examined IAI’s morbidity, etiological characteristics, and prognosis in the training data set. Univariate and multivariate logistic regression analyses were used to screen risk factors, establish an RF model and create a nomogram. Data from January to March 2021 were used to validate the accuracy of the RF model.

Results

The incidence of IAI was 7.2%. The independent risk factors for IAI were hypertension (Odds Ratio [OR] = 3.408, P = 0.001), history of abdominal surgery (OR = 2.609, P = 0.041), combined organ excision (OR = 4.123, P = 0.010), and operation time ≥240 min (OR = 3.091, P = 0.005). In the training data set and validation data set, the area under the ROC curve of IAI predicted by the RF model was 0.745 ± 0.048 (P<0.001) and 0.736 ± 0.069 (P=0.003), respectively. In addition, IAI significantly extended the length of hospital stay but had little impact on survival.

Conclusions

Patients with hypertension, combined organ excision, a history of abdominal surgery, and a surgical duration of 240 min or more are prone to IAI, and the RF model may help to identify them.

Predictive value of prognostic nutritional index on infection after radical gastrectomy: a retrospective study

BACKGROUND

The prognostic nutritional index (PNI) is a useful tool to evaluate nutritional status, which is associated with postoperative complications and prognosis of patients with cancer. Recent studies have shown that PNI has important predictive value for postoperative infection in cancer patients. However, the role and clinical value of PNI in infection after radical gastrectomy remains unclear. This study investigated the relationship between PNI and infection after radical surgery for gastric cancer (GC), focusing on the predictive value of PNI.

METHODS

A total of 1,111 patients with primary gastric cancer who underwent radical surgery in our hospital from December 2010 to December 2020 were included in this retrospective study. The demographic and clinicopathological data of all patients were acquired through hospital information system (HIS). Preoperative serum albumin (ALB) level and peripheral blood lymphocyte count were obtained for PNI calculation. We selected 812 patients by propensity score matching to reduce biases due to the different distributions of co-variables among the comparable groups. The factors influencing postoperative infection in the matched patients were explored using univariate and multivariate analyses.

RESULTS

Baseline characteristics significantly differed among patients with different PNI scores. After one-to-one matching, the clinicopathological data of the 2 groups were comparable, and 812 patients were included for further analysis. Among these patients, 101 developed infections, with an infection rate of 12.4%, which were mainly caused by gram-negative bacteria. The incidence of infection was significantly higher in the low PNI group than in the high PNI group. Univariate and multivariate analyses identified body mass index (BMI) ≥25 kg/m2 [odds ratio (OR) =2.314, P=0.004], diabetes mellitus (OR =1.827, P=0.042), PNI score <45 (OR =2.138, P=0.037), combined multi-organ resection (OR =2.946, P<0.001), operation time ≥240 minutes (OR =2.744, P=0.023), and perioperative blood transfusion (OR =2.595, P=0.025) as risk factors for infection after radical surgery for GC.

CONCLUSIONS

Infection is the most common complication after radical gastrectomy for GC, and a low preoperative PNI score is a risk factor for postoperative infection.

Association among prognostic nutritional index, post-operative infection and prognosis of stage II/III gastric cancer patients following radical gastrectomy

Background/objective

To investigate the influence of pre-operative immunological and nutritional status, assessed by the prognostic nutritional index (PNI) score, on post-operative infection, and the potential additive effects of low PNI and infection on prognosis after radical resection of stage II/III gastric cancer (GC).

Methods

The medical records of 2352 consecutive stage II/III GC patients who underwent radical gastrectomy were retrospectively reviewed. The independent predictors for infections were identified using univariate and multivariate analyses. Cox regression analysis was used to assess any associations between PNI, infection and OS.

Results

A total of 160 (6.8%) cases developed infections and low PNI (< 43.9) was confirmed as an independent predictor. Both PNI < 43.9 and infections independently predicted poor OS (hazard ratio: 1.163, 95% confidence interval: 1.007–1.343; HR: 1.347, 95%CI: 1.067–1.700), and an additive effect was confirmed as patients with both low PNI and infection had worst OS. Further stratified analyses showed that complete peri-operative adjuvant chemotherapy (PAC, ≥ 6 cycles) could significantly improve OS in patients with low PNI and/or infection, which was comparable to those with PNI ≥ 43.9 and/or infection (P = 0.160).

Conclusions

Infection was the most common complication after gastrectomy and PNI < 43.9 was identified as an independent predictor. Low PNI was associated with poorer OS in stage II/III GC, independent of infections, and low PNI and infections had a synergistic effect that was associated with worst OS. However, complete PAC could significantly improve OS in these patients. Thus, strategies to decrease infection and complete PAC should be further investigated.

Nomogram to Predict Intensive Care Following Gastrectomy for Gastric Cancer: A Useful Clinical Tool to Guide the Decision-Making of Intensive Care Unit Admission

BACKGROUND

We aimed to generate and validate a nomogram to predict patients most likely to require intensive care unit (ICU) admission following gastric cancer surgery to improve postoperative outcomes and optimize the allocation of medical resources.

METHODS

We retrospectively analyzed 3,468 patients who underwent gastrectomy for gastric cancer from January 2009 to June 2018. Here, 70.0% of the patients were randomly assigned to the training cohort, and 30.0% were assigned to the validation cohort. Least absolute shrinkage and selection operator (LASSO) method was performed to screen out risk factors for ICU-specific care using the training cohort. Then, based on the results of LASSO regression analysis, multivariable logistic regression analysis was performed to establish the prediction nomogram. The calibration and discrimination of the nomogram were evaluated in the training cohort and validated in the validation cohort. Finally, the clinical usefulness was determined by decision curve analysis (DCA).

RESULTS

Age, the American Society of Anesthesiologists (ASA) score, chronic pulmonary disease, heart disease, hypertension, combined organ resection, and preoperative and/or intraoperative blood transfusions were selected for the model. The concordance index (C-index) of the model was 0.843 in the training cohort and 0.831 in the validation cohort. The calibration curves of the ICU-specific care risk nomogram suggested great agreement in both training and validation cohorts. The DCA showed that the nomogram was clinically useful.

CONCLUSIONS

Age, ASA score, chronic pulmonary disease, heart disease, hypertension, combined organ resection, and preoperative and/or intraoperative blood transfusions were identified as risk factors for ICU-specific care after gastric surgery. A clinically friendly model was generated to identify those most likely to require intensive care.

Subcutaneous irrigation with rifampicin vs. povidone-iodine for the prevention of incisional surgical site infections following caesarean section: a prospective, randomised, controlled trial

The aim is to investigate the effect of irrigation of subcutaneous tissue with saline, rifampicin, or povidone-iodine on incisional surgical site infections following caesarean section. Three hundred patients scheduled for caesarean section were randomly assigned into one of three groups of 100 members each, as follows: the subcutaneous tissue was irrigated with saline in group 1 (control); saline + rifampicin in group 2; saline + 10% povidone-iodine in group 3. Patients who developed a superficial incisional surgical site infection within 30 days were recorded. The surgical site infection rate did not differ when using rifampicin or povidone-iodine (p = .202). It was observed that there was a statistically significant increase in the rate of incisional surgical site infections as the existence of comorbidities (p = .001), perioperative blood transfusion (p = .020), and midline incision (p = .004). Irrigation of subcutaneous tissue with rifampicin or 10% povidone-iodine is not effective in preventing surgical site infections after caesarean section.IMPACT STATEMENTWhat is already known on this subject? An increase has recently been observed in the incidence of SSI particularly in caesarean sections due to reasons, such as that elderly mothers are more commonly operated on compared to the past and long and complicated operations (Lachiewicz et al. 2015) and there are no clear decisions on measures to be taken. Also, there are not many studies on this subject (De Nardo et al. 2016; Solomkin et al. 2017).What do the results of this study add? In our study, we investigated the effectiveness of subcutaneous agents that have been used by many surgeons for years and we've revealed that it's not effective. There is no study in the literature comparing 3 different irrigation agents as we did in our study. For this reason, we think that we will make an important contribution to the measures to be taken in this important issue.What are the implications of these findings for clinical practice and/or further research? This study may contribute to reaching a sufficient level of evidence on surgical wound infections after caesarean sections, which are still missing in the literature, and that may be guiding for the studies that will be conducted on this subject in the future.

Inflammatory prognostic scoring systems are risk factors for surgical site infection following wide local excision of soft tissue sarcoma

Introduction

Limb-sparing surgery with negative margins is possible in most soft tissue sarcoma (STS) resections and focuses on maximising function and minimising morbidity. Various risk factors for surgical site infections (SSIs) have been reported in the literature specific to sarcoma surgery. The aim of this study is to determine whether systemic inflammatory response prognostic scoring systems can predict post-operative SSI in patients undergoing potentially curative resection of STS.

Methods

Patients who had a planned curative resection of a primary STS at a single centre between January 2010 and December 2019 with a minimum follow-up of 6 months were included. Data were extracted on patient and tumour characteristics, and pre-operative blood results were used to calculate inflammatory prognostic scores based on published thresholds and correlated with risk of developing SSI or debridement procedures.

Results

A total of 187 cases were included. There were 60 SSIs. On univariate analysis, there was a statistically significant increased risk of SSI in patients who are diabetic, increasing specimen diameter, American Society of Anaesthesiology (ASA) grade 3, use of endoprosthetic replacement, blood loss greater than 1 L, and junctional tumour location. Modified Glasgow prognostic score, C-reactive protein/albumin ratio and neutrophil–platelet score (NPS) were statistically associated with the risk of SSI. On multivariate analysis, ASA grade 3, junctional tumour location and NPS were independently associated with the risk of developing a SSI.

Conclusion

This study supports the routine use of simple inflammation-based prognostic scores in identifying patients at increased risk of developing infectious complications in patients undergoing potentially curative resection of STS.

Association between perioperative allogeneic red blood cell transfusion and infection after clean-contaminated surgery: a retrospective cohort study

BACKGROUND

Allogeneic red blood cell (RBC) transfusion can induce immunosuppression, which can then increase the susceptibility to postoperative infection. However, studies in different types of surgery show conflicting results regarding this effect.

METHODS

In this retrospective cohort study conducted in a tertiary referral centre, we included adult patients undergoing clean-contaminated surgery from 2014 to 2018. Patients who received allogeneic RBC transfusion from preoperative Day 30 to postoperative Day 30 were included into the transfusion group. The control group was matched for the type of surgery in a 1:1 ratio. The primary outcome was infection within 30 days after surgery, which was defined by healthcare-associated infection, and identified mainly based on antibiotic regimens, microbiology tests, and medical notes.

RESULTS

Among the 8098 included patients, 1525 (18.8%) developed 1904 episodes of postoperative infection. Perioperative RBC transfusion was associated with an increased risk of postoperative infection after controlling for 27 confounders by multivariable regression analysis (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.39-1.84; P<0.001) and propensity score weighing (OR: 1.64; 95% CI: 1.45-1.85; P<0.001) and matching (OR: 1.70; 95% CI: 1.43-2.01; P<0.001), and a dose-response relationship was observed. The transfusion group also showed higher risks of surgical site infection, pneumonia, bloodstream infection, multiple infections, intensive care admission, unplanned reoperation, prolonged postoperative length of hospital stay, and all-cause death.

CONCLUSIONS

Perioperative allogeneic RBC transfusion is associated with an increased risk of infection after clean-contaminated surgery in a dose-response manner. Close monitoring of infections and enhanced prophylactic strategies should be considered after transfusion.

Procalcitonin and C-Reactive Protein as an Early Predictor of Infection in Elective Gastrointestinal Cancer Surgery-a Prospective Observational Study

BACKGROUND

Postoperative infections are a common entity following elective gastrointestinal surgery among which intra-abdominal infection is notorious and life threatening. Early detection could reduce postoperative morbidity and permit safe and early discharge. This study was aimed to establish the usefulness of procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day 3 as reliable markers for early detection of intra-abdominal infection and other postoperative infections following elective gastrointestinal cancer surgery.

METHODS

A total of 125 patients following elective gastrointestinal cancer surgery were prospectively observed until discharge from January 2018 to December 2019. The incidence of intra-abdominal infections and other postoperative infections was recorded. Serum PCT and CRP were estimated on postoperative day 3 for all the patients. ROC analysis of PCT and CRP was performed to establish their predictability in detecting these infections. Risk factors for postoperative infections were also studied.

RESULTS

The incidence of intra-abdominal infection (IAI) was 24%. The difference in PCT between the infected and non-infected patients was statistically significant (p = 0.001) but not in CRP (p = 0.223). On ROC analysis of CRP and PCT in detecting IAI, the areas under the curve were 0.494 and 0.615 respectively.

CONCLUSION

Raised serum PCT values on postoperative day 3 indicate the presence of infections and should prompt the surgeon to consider other investigations to confirm the presence of IAI and other postoperative infections and plan early intervention thus expediting the postoperative recovery.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2018/12/016695.

The Impact of Intraoperative Donor Blood on Packed Red Blood Cell Transfusion During Deceased Donor Liver Transplantation: A Retrospective Cohort Study

BACKGROUND

Blood from deceased organ donors, also known as donor blood (DB), has the potential to reduce the need for packed red blood cells (PRBCs) during liver transplantation (LT). We hypothesized that DB removed during organ procurement is a viable resource that could reduce the need for PRBCs during LT.

METHODS

We retrospectively examined data on LT recipients aged over 18 y who underwent a deceased donor LT. The primary aim was to compare the incidence of PRBC transfusion in LT patients who received intraoperative DB (the DB group) to those who did not (the nondonor blood [NDB] group).

RESULTS

After a propensity score matching process, 175 patients received DB and 175 did not. The median (first-third quartile) volume of DB transfused was 690.0 mL (500.0-900.0), equivalent to a median of 3.1 units (2.3-4.1). More patients in the NDB group received an intraoperative PRBC transfusion than in the DB group: 74.3% (95% confidence intervals, 67.8-80.8) compared with 60% (95% confidence intervals, 52.7-67.3); P = 0.004. The median number of PRBCs transfused intraoperatively was higher in the NDB group compared with the DB group: 3 units (0-6) compared with 2 units (0-4); P = 0.004. There were no significant differences observed in the secondary outcomes.

CONCLUSIONS

Use of DB removed during organ procurement and reinfused to the recipient is a viable resource for reducing the requirements for PRBCs during LT. Use of DB minimizes the exposure of the recipient to multiple donor sources.

Development and validation of a nomogram to predict intraoperative blood transfusion for gastric cancer surgery

OBJECTIVE

To construct and validate a nomogram composed of preoperative variables to predict intraoperative blood transfusion for gastric cancer surgery.

BACKGROUND

Intraoperative transfusion for gastric cancer surgery is a common medical procedure that is associated with increased postoperative complications.

METHODS

A total of 999 patients who underwent gastrectomy between January 2010 and June 2019 were randomly allocated into the primary and validation cohorts in a 2:1 ratio. In the primary cohort, logistic analyses were performed to identify independent predictors for transfusion. Using the Akaike information criterion, selected variables were incorporated to construct a nomogram. Validations of the nomogram were performed in the primary and validation cohorts. The discrimination ability of the nomogram was assessed by the concordance index (C-index), and calibration was assessed by calibration curves and the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

The following risk factors for transfusion were identified and used to construct the nomogram: ASA status (III-IV vs I-II: odds ratio [OR] 1.74), comorbidities (yes vs no: OR 1.57), tumour location (diffuse vs lower: OR 4.05), cTNM stage (III vs I: OR 1.95), and a preoperative haemoglobin level less than 80 g/L (vs over 120 g/L: OR 35.30). The C-index was 0.859 and 0.850 in the primary and validation cohorts, respectively, which both indicated good discrimination of the nomogram. Additionally, both calibration curves and Hosmer-Lemeshow tests (p-value 0.184 and 0.887, respectively) demonstrated high agreement between the predictions and actual outcomes.

CONCLUSION

A nomogram composed of preoperative variables to predict blood transfusion for gastric cancer surgery was effectively developed and validated. This nomogram could be used to improve the utilisation of red blood cells for gastrectomy.

Association Among Blood Transfusion, Postoperative Infectious Complications, and Cancer-Specific Survival in Patients with Stage II/III Gastric Cancer After Radical Gastrectomy: Emphasizing Benefit from Adjuvant Chemotherapy

OBJECTIVES

This study was designed to investigate the potential additive influence of perioperative blood transfusion (BTF) and postoperative infections on cancer-specific survival (CSS) in patients with stage II/III gastric cancer (GC) after radical gastrectomy.

METHODS

The medical records of 2114 consecutive stage II/III GC patients who underwent curative resection and planned to receive adjuvant chemotherapy (AC) were retrospectively reviewed. The independent predictive factors for infections were identified using univariate and multivariate analyses. Cox regression analysis was used to assess any associations between BTF, infection and CSS.

RESULTS

A total of 507 (24.0%) received perioperative BTF and 148 (7.0%) developed infections with BTF being identified as an independent predictor for infections. Both BTF and infections independently predicted poor CSS (hazard ratio [HR]: 1.193, 95% confidence interval [CI] 1.007-1.414; HR 1.323, 95% CI 1.013-1.727) and an additive effect was confirmed as patients who had both BTF and infection had even worse CSS. Further stratified analyses showed that complete AC (≥ 6 cycles) could significantly improve CSS in patients who had BTF and/or infection, which was comparable to those without BTF and/or infection (P = 0.496).

CONCLUSIONS

Infection was the most common complication after gastrectomy and BTF was identified as an independent risk factor. BTF was associated with shorter CSS in stages II/III GC, independent of infections, and receiving BTF and developing infections had an additive effect that was associated with even worse CSS. However, complete AC could significantly improve CSS in these patients. Thus, strategies designed to ensure the completion of AC, such as neoadjuvant chemotherapy, should be further investigated.

International multicentre observational study to evaluate the association between perioperative red blood cell transfusions and 1-year mortality after major cancer surgery (ARCA-1): study design, statistical analysis plan and study protocol

INTRODUCTION

Blood transfusion is still common in patients undergoing major cancer surgery. Blood transfusion can be associated with poor prognosis in patients with cancer. Perioperative Care in the Cancer Patient -1 (ARCA-1) aims to assess in a large cohort of patients the current incidence, pattern of practice and associations between perioperative blood transfusions and 1-year survival in patients undergoing major cancer surgery.

METHODS AND ANALYSIS

ARCA-1 is a prospective international multicentre observational study that will include adult patients scheduled to have major cancer surgical procedures with the intention to cure, and an overnight planned hospital admission. The study will be opened for 1 year for enrolment (7 January 2020-7 February 2021). Each centre will enrol patients for 30 days. The primary endpoint of this study is all-cause mortality 1 year after major cancer surgery. Secondary endpoints are rate of perioperative blood product use, cancer-specific mortality at 1 year and PFSs and 30-day morbidity and mortality.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board at The University of Texas-MD Anderson Cancer Center. The study results will be published in peer-reviewed journals and disseminated at international conferences.

TRIAL REGISTRATION NUMBER

NCT04491409.

Current status of robotic gastrectomy for gastric cancer: comparison with laparoscopic gastrectomy

Robotic systems were developed to overcome limitations of laparoscopic surgery with its mechanical advantages. Along with the technical advances, robotic gastrectomy for gastric cancer is increasing. However, the evidence regarding safety and efficacy for robotic gastrectomy for gastric cancer is not mature yet. Although studies are limited, it is evident that robotic gastrectomy has a longer operation and less blood loss compared with laparoscopic gastrectomy. Studies revealed long-term oncological outcomes after robotic gastrectomy was comparable to those after laparoscopic gastrectomy. Taken together, robotic gastrectomy with systemic lymph node dissection is suggested as a safe procedure with equivalent short- and long-term oncologic outcomes to either laparoscopic or open gastrectomy for the surgical treatment of gastric cancer. However, high cost is the most significant barrier to justify robotic surgery as a routine and standard treatment for patients with gastric cancer. In the meanwhile, robotic surgery will be expansively used as long as technologic developments continue.

Interactions between the enhanced recovery after surgery pathway and risk factors for lung infections after pulmonary malignancy operation

Background

Lung infection is a common complication after thoracic surgery and can lead to severe consequences. Our study was designed to explore the risk factors for postoperative lung infections (POLI) following pulmonary malignancy operation and assess the protective effect of enhanced recovery after surgery (ERAS) and their potential interactive relationships.

Methods

A retrospective study included 1,768 patients who underwent surgery between 2013 and 2017 in Ruijin Hospital, Shanghai Jiaotong University School of Medicine was performed. Uni- and multivariate analyses were performed to identify risk factors. Andersson’s model was applied to evaluate the additive interaction between these factors.

Results

Smoking [95% confidence interval (CI): 1.178–2.198], preoperative heart disease (95% CI: 1.448–4.091), and massive intraoperative blood loss (95% CI: 1.568–3.674) were independent risk factors for postoperative lung infections (POLI), whereas ERAS implementation was protective (95% CI: 0.249–0.441). Interaction analyses indicated that non-ERAS was reciprocally independent with smoking and surgical procedure. It had a synergistic interaction with heart disease [attributable proportion due to interaction (AP) =0.540 (95% CI: 0.179–0.901), synergy index (S) =2.580 (95% CI: 1.016–6.551)], and poor lung function [AP =0.395 (95% CI: 0.016–0.775)], as well as a tendency of antagonistic interaction with blood loss.

Conclusions

Intraoperative blood loss, heart disease, and smoking are independent risk factors of POLI. ERAS implementation is a protective factor and is firstly verified to be more effective on reducing POLI in patients with heart diseases, poor lung function, and less intraoperative blood loss. We provide evidences to implement ERAS and a clue of the most optimal indications for ERAS.

Diagnostic accuracy of procalcitonin as an early predictor of infection after radical gastrectomy for gastric cancer: A prospective bicenter cohort study

OBJECTIVE

To investigate the diagnostic accuracy of procalcitonin (PCT) as an early predictor of infection following radical gastrectomy to treat gastric cancer (GC).

METHODS

A prospective, observational, cohort study was conducted in two high-volume tertiary centers (registered under ClinicalTrials.gov). A total of 552 consecutive adult patients undergoing radical gastrectomy for GC from June 2018 to July 2019 were included. Routine blood tests (white blood cell count (WBC); neutrophil count; the neutrophil:WBC ratio, N%) and PCT were measured on post-operative day (POD) 3 and 5. Post-operative infection was recorded based on the criteria of the Center for Disease Control. The area under the curve (AUC) summarizing receiver-operating characteristic was calculated and compared for each biomarker measured.

RESULTS

Ninety three adverse events occurred in 70 patients (12.7%), with infections being the most common (n = 37, 6.7%). With cutoff values of 0.695 ng/mL at POD 3 and 0.515 ng/mL at POD 5, specificity and negative predictive value for infections were 0.656 and 96.3%, 0.816 and 96.1%, respectively. PCT had a better AUC than the WBC and neutrophil count to detect post-operative complications, especially infections (AUC: 0.678, 0.600, 0.592, P = 0.028 and 0.017, respectively) at POD 3, but which were comparable at POD 5. Additionally, 4 of the 8 patients with PCT levels ≥3 ng/mL on POD 5 were confirmed to have an infection.

CONCLUSION

PCT is a more reliable predictor than WBC and neutrophil count to detect infections following radical gastrectomy for GC. PCT levels <0.695 ng/mL at POD 3 and < 0.515 ng/mL at POD 5 makes post-operative infections very unlikely but extreme high PCT levels should alert the surgeon to the possibility of infections.

Epidemiological Characteristics of Postoperative Sepsis

BACKGROUND

Postoperative sepsis is a major type of sepsis. Sociodemographic characteristics, incidence trends, surgical procedures, comorbidities, and organ system dysfunctions related to the disease burden of postoperative sepsis episodes are unclear.

METHODS

We analyzed epidemiological characteristics of postoperative sepsis based on the ICD-9-CM codes for the years 2002 to 2013 using the Longitudinal Health Insurance Databases of Taiwan's National Health Insurance Research Database.

RESULTS

We identified 5,221 patients with postoperative sepsis and 338,279 patients without postoperative sepsis. The incidence of postoperative sepsis increased annually with a crude mean of 0.06% for patients aged 45-64 and 0.34% over 65 years. Patients with postoperative sepsis indicated a high risk associated with the characteristics, male sex (OR:1.375), aged 45-64 or ≥ 65 years (OR:2.639 and 5.862), low income (OR:1.390), aged township (OR:1.269), agricultural town (OR:1.266), and remote township (OR:1.205). Splenic surgery (OR:7.723), Chronic renal disease (OR:1.733), cardiovascular dysfunction (OR:2.441), and organ system dysfunctions had the highest risk of postoperative sepsis.

CONCLUSION

Risk of postoperative sepsis was highest among men, older, and low income. Patients with splenic surgery, chronic renal comorbidity, and cardiovascular system dysfunction exhibited the highest risk for postoperative sepsis. The evaluation of high-risk factors assists in reducing the disease burden.

Development and validation of a prognostic nomogram for predicting post-operative pulmonary infection in gastric cancer patients following radical gastrectomy

The aim of this retrospective study was to develop and validate a nomogram for predicting the risk of post-operative pulmonary infection (POI) in gastric cancer (GC) patients following radical gastrectomy. 2469 GC patients who underwent radical gastrectomy were enrolled, and randomly divided into the development and validation groups. The nomogram was constructed based on prognostic factors using logistic regression analysis, and was internally and crossly validated by bootstrap resampling and the validation dataset, respectively. Concordance index (C-index) value and calibration curve were used for estimating the predictive accuracy and discriminatory capability. Sixty-five (2.63%) patients developed POI within 30 days following surgery, with higher rates of requiring intensive care and longer post-operative hospital stays. The nomogram showed that open operation, chronic obstructive pulmonary disease (COPD), intra-operative blood transfusion, tumor located at upper and/or middle third and longer operation time (≥4 h) in a descending order were significant contributors to POI risk. The C-index value for the model was 0.756 (95% CI: 0.675−0.837), and calibration curves showed good agreement between nomogram predictions and actual observations. In conclusion, a nomogram based on these factors could accurately and simply provide a picture tool to predict the incidence of POI in GC patients undergoing radical gastrectomy.

The effect of red blood cell transfusion on plasma hepcidin and growth differentiation factor 15 in gastric cancer patients: a prospective study

Background

Hepcidin and growth differentiation factor 15 (GDF-15) have been reported to be highly expressed in various cancers. Serum hepcidin and GDF-15 levels were demonstrated to be potential prognostic markers in cancers. This study aims to evaluate the effect of red blood cell (RBC) transfusion on plasma hepcidin and GDF-15 in gastric cancer patients.

Methods

In this prospective study, 40 patients with gastric cancer were eligible for this study. Peripheral blood samples were obtained before and within 24 h after RBC transfusion. A routine blood test was performed before transfusion and within 24 h post-transfusion. Plasma hepcidin, GDF-15, interleukin 6 (IL-6) and erythropoietin were determined by ELISA.

Results

In patients with metastasis, plasma hepcidin (P=0.02), and GDF-15 (P=0.01) levels were higher than without metastasis. Plasma hepcidin was increased after RBC transfusion (P=0.001), while plasma erythropoietin was decreased after transfusion (P=0.03). However, RBC transfusion did not affect plasma GDF-15 (P=0.32) and IL-6 (P=0.12). The effect of RBC transfusion on variables did not differ between metastatic and non-metastatic patients. The mean percentage change of hepcidin in transfusion volume 4 unit (U) was more than 2 U.

Conclusions

RBC transfusion could increase plasma hepcidin and have no effect on plasma GDF-15 in gastric patients.

Perioperative use of blood products is associated with risk of morbidity and mortality after surgery

BACKGROUND

Administration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients.

METHODS

Patients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions.

RESULTS

Among 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10).

CONCLUSIONS

The use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products.

Clinicopathological features and prognosis of young gastric cancer patients following radical gastrectomy: a propensity score matching analysis

The aim of the this retrospective study was to investigate the clinicopathological features of gastric cancer (GC) in young patients and the potential impact of age on the prognosis of patients undergoing radical gastrectomy for GC. From November 2010 to November 2016, 317 young (≤45 years) and 1344 older patients (>45 years) who underwent radical gastrectomy for stage I-III GC were enrolled. The association between age and prognosis was estimated by univariate and multivariate analyses after propensity score matching (PSM). Compared with older patients, the proportion of females, poorly differentiated tumors, good nutritional status, and who received neo-adjuvant and/or adjuvant chemotherapy was significant higher in younger patients, but were less likely to suffer from comorbidities or post-operative complications (all P < 0.05). PSM analysis created 310 pairs of patients. After matching, the long-term survival in younger patients was significantly longer than in older patients at stage I, but similar at stages II and III. However, a young age was not identified as a significant prognostic factor. In conclusion, the prognosis of young GC patients is comparable with and even better than that in older patients after radical gastrectomy when matched for baseline characteristics. Early detection could improve the prognosis of young GC patients.

The effect of preoperative smoking cessation and smoking dose on postoperative complications following radical gastrectomy for gastric cancer: a retrospective study of 2469 patients

Background

To investigate whether smoking adversely affects the short-term outcomes and the potential effects of cigarette dose and preoperative smoking cessation, in patients who underwent gastric cancer (GC) surgery.

Methods

Two thousand, four hundred sixty-nine consecutive patients who underwent radical gastrectomy from November 2010 to July 2018 were included in the present study. Smokers (current or former smokers) were divided into 3 groups in accordance with the duration of smoking cessation preoperatively (≤ 2, 2 to 4, or ≥ 4 weeks) and the cigarette dose (≤ 20, 20 to 40, and ≥ 40 pack-years). The primary endpoint was postoperative complications (surgical site infection, pulmonary problems, bleeding, and others).

Results

A total of 1056 patients (42.8%) were smokers. Compared with non-smokers, smokers had significantly higher overall postoperative complications (11.3% vs 7.5%, P = 0.001), and in particular pulmonary problems. Smokers also had more major complications, needing intensive care unit care, and longer postoperative hospital stays. Multivariate analysis confirmed that smoking (odds ratio = 1.506, 95% confidence interval 1.131–2.004, P = 0.005) was an independent risk factor for postoperative complications. Further subgroup analysis identified that there was a positive relationship between the incidence of complications and cigarette dose, and > 20 pack-years was demonstrated to have increased significantly the risk of complications. Smokers who stopped smoking ≥ 4 weeks before surgery had lower pulmonary problems than those with a shorter period of smoking cessation.

Conclusions

Preoperative smoking cessation should be encouraged to reduce postoperative complications in GC patients, especially for heavy smokers.

Robotic-assisted gastrectomy for gastric cancer: a European perspective

Gastrectomy is the mainstay treatment for gastric cancer. To reduce the associated patient burden, minimally invasive gastrectomy was introduced in almost 30 years ago. The increase in the availability of surgical robotic systems led to the first robotic-assisted gastrectomy to be performed in 2002 in Japan. Robotic gastrectomy however, particularly in Europe, has not yet gained significant traction. Most reports to date are from Asia, predominantly containing observational studies. These cohorts are commonly different in the tumour stage, location (particularly with regards to gastroesophageal junctional tumours) and patient BMI compared to those encountered in Europe. To date, no randomised clinical trials have been performed comparing robotic gastrectomy to either laparoscopic or open equivalent. Cohort studies show that robotic gastrectomy is equal oncological outcomes in terms of survival and lymph node yield. Operative times in the robotic group are consistently longer compared to laparoscopic or open gastrectomy, although evidence is emerging that resectional surgical time is equal. The only reproducibly significant difference in favour of robot-assisted gastrectomy is a reduction in intra-operative blood loss and some studies show a reduction in the risk of pancreatic fistula formation.

Prealbumin and lymphocyte-based prognostic score, a new tool for predicting long-term survival after curative resection of stage II/III gastric cancer

The aim of this retrospective study was to investigate the prognostic significance of pre-treatment immunological and nutritional statuses in patients with locally advanced gastric cancer (GC), and to use the risk factors to develop a predictive score. A total of 731 patients who underwent gastrectomy for stage II/III GC from November 2010 to December 2015 were recruited into this retrospective study. On the basis of univariate and further multivariate Cox regression analyses, decreased pretreatment lymphocyte count (<1·5×109/litre) and prealbumin concentrations (<180 mg/l) were identified to be independently associated with poorer overall survival (OS) and disease-free survival (DFS). Low albumin concentrations (<33 g/l) were identified as an independent risk factor only for OS, but not for DFS. Thereafter, patients who had a decreased prealbumin concentration and lymphocyte count were given a combination of serum prealbumin concentration and lymphocyte count (Co-PaL) score of 2. Patients with only one or neither of these concentrations were given a Co-PaL score of 1 or 0, respectively. Both the OS and the DFS time were inversely related to the Co-PaL scores, and the differences among the three groups were all significant. In contrast, the prognosis did not differ significantly between patients with good nutrition and those with mild to moderate malnutrition according to the prognostic nutritional index. This study indicated that the simple scoring system could accurately predict the prognosis of patients who underwent gastrectomy for stage II/III GC. The score might be helpful in terms of clinical preoperative decision-making.