Predictive value of the surgical Apgar score on postoperative complications in advanced gastric cancer patients treated with neoadjuvant chemotherapy followed by radical gastrectomy: a single-center retrospective study

Prognostic nutritional index combined with carcinoembryonic antigen and carbohydrate antigen 242 for early prediction of anastomotic leakage after radical gastrectomy for gastric cancer

OBJECTIVE

To observe the clinical value of prognostic nutritional index (PNI) combined with carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 242 in early prediction of anastomotic leakage after radical gastrectomy for gastric cancer.

METHODS

We retrospectively collected clinical data of 350 gastric cancer patients who underwent radical gastrectomy in Gansu Provincial Hospital of Traditional Chinese Medicine between January 2018 and May 2022. According to the occurrence of anastomotic leakage, patients were divided into an occurrence group (n=34) and a non-occurrence group (n=316). The clinical value of PNI combined with CEA and CA242 on the 3rd day after surgery in predicting anastomotic leakage was explored. Lasso regression analysis was used to screen predictive indicators of anastomotic leakage and establish a risk model.

RESULTS

In the 350 patients who underwent radical gastrectomy for gastric cancer, anastomotic leakage was observed in 34 cases, with an incidence rate of 9.7%. A higher proportion of patients in the occurrence group exhibited diabetes, hand-sewn anastomosis, advanced tumor node metastasis (TNM) staging, and intraoperative bleeding, when compared to those in the non-occurrence group (P<0.05). Moreover, on the 3rd postoperative day, patients in the occurrence group demonstrated a significantly lower PNI than those in the non-occurrence group, along with elevated levels of CEA and CA242 (P<0.05). The area under the curve (AUC) for PNI, CEA, and CA242 were 0.827, 0.601, and 0.504, respectively, while the AUC for the combination was 0.829. As per the LASSO regression analysis, history of diabetes and PNI were identified as key factors correlating with anastomotic leakage (P<0.05). Employing the risk score formula, we obtained individual risk scores for each sample. Notably, risk scores in the occurrence group significantly surpassed those in the non-occurrence group (P<0.0001). The AUC for the risk score in predicting patient lung infection was 0.854. The internal verification C-index emerged as 0.863 (0.806-0.920), indicating a good model fit. Furthermore, the DeLong test revealed a significantly greater AUC of the risk model, compared to the combination and PNI (P<0.05).

CONCLUSION

CEA and CA242 are not promising predictive indicators for anastomotic leakage after surgery in patients with gastric cancer, but the prediction model we established can improve the predictive efficiency of anastomotic leakage in these patients.

The Relationship between Diabetes Mellitus and Gastric Cancer and the Potential Benefits of Metformin: An Extensive Review of the Literature

The objective of this review is to summarize the findings of published research that investigated the relationship between diabetes mellitus and gastric cancer (GCa) and the potential benefits of metformin on GCa. Related literature has been extensively reviewed, and findings from studies investigating the relationship between diabetes mellitus and GCa suggest that hyperglycemia, hyperinsulinemia and insulin resistance are closely related to the development of GCa. Although not supported by all, most observational studies suggest an increased risk of GCa in patients with type 2 diabetes mellitus, especially in women and in Asian populations. Incidence of second primary malignancy diagnosed after GCa is significantly higher in diabetes patients. Diabetes patients with GCa may have more complications after gastrectomy or chemotherapy and they may have a poorer prognosis than patients with GCa but without diabetes mellitus. However, glycemic control may improve in the diabetes patients with GCa after receiving gastrectomy, especially after procedures that bypass the duodenum and proximal jejunum, such as Roux-en-Y gastric bypass or Billroth II reconstruction. The potential links between diabetes mellitus and GCa may involve the interactions with shared risk factors (e.g., obesity, hyperglycemia, hyperinsulinemia, insulin resistance, high salt intake, smoking, etc.), Helicobacter pylori (HP) infection, medications (e.g., insulin, metformin, statins, aspirin, proton pump inhibitors, antibiotics, etc.) and comorbidities (e.g., hypertension, dyslipidemia, vascular complications, heart failure, renal failure, etc.). With regards to the potential benefits of metformin on GCa, results of most observational studies suggest a reduced risk of GCa associated with metformin use in patients with T2DM, which can be supported by evidence derived from many in vitro and animal studies. Metformin use may also reduce the risk of HP infection, an important risk factor of GCa. In patients with GCa, metformin users may have improved survival and reduced recurrence. More studies are required to clarify the pathological subtypes/anatomical sites of GCa associated with type 2 diabetes mellitus or prevented by metformin, to confirm whether GCa risk can also be increased in patients with type 1 diabetes mellitus and to explore the possible role of gastric microbiota in the development of GCa.

Surgical Apgar Score predictive value for early postoperative organ dysfunction in cancer patients

BACKGROUND

Surgical APGAR Score (SAS) is based only on intraoperative data and has the advantage of being easy to calculate. Low SAS was associated with an increased risk for postoperative complications, but its utility for specific outcomes prediction, such as postoperative cardiovascular, renal, or metabolic dysfunction is less investigated. Our study aimed to investigate SAS predictive value for early postoperative organ dysfunction in a surgical oncological population.

METHODS

This is a prospective observational study that enrolled all consecutive patients submitted to oncologic surgery over 20-days. Registered parameters included demographics, comorbidities, diagnosis and surgery data, SAS score, postoperative complications, organ dysfunction and in-hospital mortality. SAS predictive value for postoperative organ dysfunction was assessed using logistic regression and ROC curves.

RESULTS

The study included 205 oncological patients with a mean age (standard deviation) of 60 (12.8) years. SAS was between 8 and 10 in 60% of patients and between 0 and 7 in 40% of patients. Postoperative complications developed in 33 patients (16.1%) and organ dysfunction in 26 patients (12.7%). The rates of postoperative complications, organ dysfunction and mortality, were significantly higher in patients with a low SAS (0-7) than high SAS (8-10). SAS had a low discrimination capacity to distinguish between patients who will develop postoperative complications and those who will not (AUROC 0.65) but was more accurate in identifying surgical oncological patients at risk for cardiovascular and metabolic dysfunction (AUROC 0.83 and 0.85 respectively).

CONCLUSION

SAS may be a useful tool to identify cancer surgery patients at risk for postoperative cardiovascular and metabolic dysfunction.