Evaluation of the relationship between lactacidemia and postoperative complications after surgery for peritoneal carcinomatosis

Lactate Levels and Their Relation to Surgical Site Infections in Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Introduction: Peritoneal carcinomatosis (PC) patients undergoing cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) face a high risk of morbidity. Surgical site infections (SSIs) are among the main contributors to this issue. This relation is influenced not only by the effects of major surgical resections but also by the hemodynamic changes induced by HIPEC. Although elevated lactate levels (LL) have been associated with greater complication rates in CRS-HIPEC patients, their direct association with the development of SSIs has not been thoroughly investigated. Methods: Patients who underwent CRS + HIPEC were retrospectively reviewed. Pre-operative demographic data, hemodynamic parameters and records, transfusion records, and all post-operative follow-up and treatment records were analyzed. Patients were categorized into SSI+ and SSI-. Factors contributing to SSI development were examined using regression analysis. Results: A total of 110 patients who underwent CRS + HIPEC between January 2018 and December 2021 were included in the study. LL obtained at intensive care unit (ICU) admission were greater in patients who developed SSIs (p = 0.020). Cutoff point for ICU admission LL in diagnosing SSI was ≥6 mmol/L (area under the curve: 0.640 [0.526-0.753], p = 0.020). SSI development (23% vs. 50%, p = 0.003) was more prevalent in patients with lactate values ≥6 mmol/L. In multi-variable analysis, LL ≥6 mmol/L (odds ratio [OR]: 4.614, p = 0.005) and clean-contaminated wounds (OR: 27.677, p = 0.002) were related with increased SSI development. Conclusion: In patients with PC, LL of 6 mmol/L or greater during the ICU stay have been associated with SSI development. For this high-risk patient subgroup, a readily available peri-operative parameter such as lactate may guide prophylactic antibiotic selection. However, despite its high specificity, the low sensitivity of our findings should be carefully considered before clinical decision-making. Further studies analyzing larger, more homogeneous cohorts are needed to better clarify the relation between LL, SSI development, and prophylactic antibiotic use.

Effect of glucose-insulin-potassium on lactate levels at the end of surgery in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: study protocol for a randomized controlled trial

INTRODUCTION

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been established as an effective treatment for peritoneal cancer (PC). However, this kind of combination therapy is associated with a high lactate level. Moreover, studies have suggested that the rate of complications early after surgery directly increased with elevated lactate levels. Glucose-insulin-potassium (GIP), a potent cardioprotective intervention, has been demonstrated to adjust blood glucose (BG) levels and reduce lactate levels. However, the insulin-glucose ratio should be adjusted according to the surgery performed. Here, we aimed to evaluate the advantages of using modified GIP during CRS/HIPEC to reduce the lactate level at the end of surgery and further reduce the incidence of early postoperative complications.

METHODS AND ANALYSIS

The modified GIP versus conventional management during surgery study is a single-center, randomized, single-blinded outcome assessment clinical trial of 80 patients with PC who are between 18 and 64 years old and undergoing CRS/HIPEC. Participants will be randomly allocated to receive modified GIP or conventional treatment (1:1). The primary outcome will be the plasma lactate level at the end of surgery. The secondary outcomes will include the highest levels and fluctuation ranges of lactate and BG during surgery, extubation time, APACHE-II score 24 h after surgery, postoperative defecation and exhaust time, postoperative lactate clearance time, postoperative liver and kidney function, incidence of complications within 7 days after surgery, length of intensive care unit stay (LIS), length of hospital stay (LHS), and total cost of hospitalization.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Scientific Research Ethics Committee of Beijing Shijitan Hospital Affiliated with Capital Medical University, approval number sjtky11-1x-2022(118). The results will be published in international peer-reviewed journals.

TRIAL REGISTRATION

ChiCTR2200057258. Registered on March 5, 2022.

Clinical significance of serum lactate and lactate dehydrogenase levels for disease severity and clinical outcomes in patients with colorectal cancer admitted to the intensive care unit

Objective

Serum lactate (LA) and lactate dehydrogenase (LDH) levels have a major impact on the clinical treatment of malignant tumors and critically ill patients. Nevertheless, the assessment of disease severity in oncology patients admitted to the intensive care unit (ICU) remains incomplete when considering the serum LA and LDH levels. This study aimed to investigate the significance of serum LDH and LA levels in assessing disease severity and predicting clinical outcomes in patients with colorectal cancer (CRC) admitted to the ICU.

Methods

This retrospective study included patients with CRC who were admitted to the ICU between January 2017 and December 2022. The patients were divided into three groups based on the tumor treatment methods they had received within 3 months before ICU admission: post-chemotherapy group, post-surgery group, and palliative treatment group. The association between serum LA and LDH levels and disease severity and clinical outcomes was analyzed.

Results

Of 137 patients with CRC admitted to the ICU were finally studied. Patients in the post-chemotherapy group exhibited higher serum LA and LDH levels compared to those in the other two groups. Additionally, they had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, longer ICU length of stay, and a higher 30-day mortality. We found a significant positive correlation between serum LA levels and APACHE II scores as well as ICU length of stay and 30-day mortality. In contrast, we only observed a significant positive correlation between serum LDH levels and disease severity in the post-chemotherapy group, whereas no significant correlation between LDH levels and 30-day mortality in any of the three groups.

Conclusion

Our study concludes that elevated serum LA levels, rather than LDH levels, are more effective in assessing disease severity and could be used as predictors for clinical outcomes in patients with CRC admitted to the ICU.

Analysis of Intraoperative Variables Responsible for the Increase in Lactic Acid in Patients Undergoing Debulking Surgery

Background: Cytoreductive surgery (CRS) is a complex procedure with a high incidence of perioperative complications. Elevated lactacidaemia levels have been associated with complications and perioperative morbidity and mortality. This study aims to analyse the intraoperative variables of patients undergoing CRS and their relationship with lactacidaemia levels. Methods: This retrospective, observational study included 51 patients with peritoneal carcinomatosis who underwent CRS between 2014 and 2016 at the Abdomino-Pelvic Oncological Surgery Reference Unit (URCOAP) of the General University Hospital of Castellón (HGUCS). The main variable of interest was the level of lactic acid at the end of surgery. Intraoperative variables, including preoperative haemoglobin, duration of surgery, intraoperative bleeding, fluid therapy administered, administration of blood products, and intraoperative peritoneal cancer index (PCI), were analysed. Results: Positive correlations were found between lactic acid levels and PCI, duration of intervention, fluid therapy, intraoperative bleeding, and transfusion of blood products. Additionally, a negative correlation was observed between haemoglobin levels and lactic acid levels. Notably, the strongest correlations were found with operative PCI (ρ = 0.532; p-value < 0.001) and duration of surgery (ρ = 0.518; p-value < 0.001). Conclusions: PCI and duration of surgery are decisive variables in determining the prognosis of patients undergoing debulking surgery. This study suggests that, for each minute of surgery, lactic acid levels increase by 0.005 mmol/L, and for each unit increase in PCI, lactic acid levels increase by 0.060 mmol/L.

Targeting Oncometabolites in Peritoneal Cancers: Preclinical Insights and Therapeutic Strategies

Peritoneal cancers present significant clinical challenges with poor prognosis. Understanding the role of cancer cell metabolism and cancer-promoting metabolites in peritoneal cancers can provide new insights into the mechanisms that drive tumor progression and can identify novel therapeutic targets and biomarkers for early detection, prognosis, and treatment response. Cancer cells dynamically reprogram their metabolism to facilitate tumor growth and overcome metabolic stress, with cancer-promoting metabolites such as kynurenines, lactate, and sphingosine-1-phosphate promoting cell proliferation, angiogenesis, and immune evasion. Targeting cancer-promoting metabolites could also lead to the development of effective combinatorial and adjuvant therapies involving metabolic inhibitors for the treatment of peritoneal cancers. With the observed metabolomic heterogeneity in cancer patients, defining peritoneal cancer metabolome and cancer-promoting metabolites holds great promise for improving outcomes for patients with peritoneal tumors and advancing the field of precision cancer medicine. This review provides an overview of the metabolic signatures of peritoneal cancer cells, explores the role of cancer-promoting metabolites as potential therapeutic targets, and discusses the implications for advancing precision cancer medicine in peritoneal cancers.

Transparency considerations for describing statistical analyses in research

Researchers who use the results of statistical analyses to draw conclusions about collected data must write a statistical analysis section in their manuscript. Describing statistical analyses in precise detail is as important as presenting the dosages of drugs and methodology of interventions. It is also essential for scientific accuracy and transparency in scientific research. We evaluated the quality of the statistical analysis sections of clinical research articles published in the Korean Journal of Anesthesiology between February 2020 and February 2021. Using a Likert scale where 1, 2, and 3 represented “not described at all,” “partially described,” and “fully described,” respectively, the following 6 items were assessed: 1) stating of the statistical analysis methods used, 2) rationale for and detailed description of the statistical analysis methods used, 3) parameters derived from the statistical analyses, 4) type and version of the statistical software package used, 5) significance level, and 6) sidedness of the test (one-sided vs. two-sided). The first 3 items evaluate issues directly related to the statistical analysis methods used and last 3 are indirectly related items. In all the included articles, the statistical analysis methods used were stated (score of 3). However, only 4 articles (12.9%) fully described the sidedness of the test (score of 3). Authors tend not to describe the sidedness of statistical analysis tests in the methodology section of clinical research articles. It is essential that the sidedness be described in research studies.