C-reactive protein on postoperative day 3 as a predictor of infectious complications following gastric cancer resection

Usefulness of Serum Biomarkers in Predicting Anastomotic Leakage After Gastrectomy

BACKGROUND/OBJECTIVES

Anastomotic leakage (AL) is one of the most concerning complications following gastrectomy. The aim of this study was to assess and compare the predictive accuracy of C-reactive protein (CRP), procalcitonin (PCT), the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), fibrinogen, and the mean platelet volume (MPV) in the early diagnosis of post-gastrectomy AL.

METHODS

A prospective bicentric observational study was conducted including all patients undergoing elective gastrectomy between August 2018 and December 2022. The performance of the selected biomarkers in predicting the existence of AL within the first 7 postoperative days (PODs) was assessed.

RESULTS

A total of 107 patients were included for analysis. The incidence of AL was 20.56%, and the median day of diagnosis was on POD5 (interquartile range 4-6). CRP, PCT, the NLR, the PLR, and fibrinogen showed significant associations with the presence of AL (from POD2 for CRP and fibrinogen and from POD3 for PCT, NLR, and PLR). CRP demonstrated a superior predictive accuracy on POD4, with a threshold value of 181.4 mg/L (NPV 99%; AUC 0.87, p < 0.001); PCT demonstrated a superior predictive accuracy on POD7, with a threshold value of 0.13 μg/L (NPV 98%; AUC 0.84, p < 0.001); the NLR showed a superior predictive accuracy on POD6, with a threshold ratio of 6.77 (NPV 95%; AUC 0.86, p < 0.001); the PLR achieved a superior predictive accuracy on POD7, with a ratio of 234 (NPV 98%; AUC 0.71; p = 0.002); and fibrinogen demonstrated a superior predictive accuracy on POD5, with a threshold of 7.344 g/L (NPV 98%; AUC 0.74; p = 0.003). In the comparison of predictive accuracy, CPR, PCT, and the NLR were found to be superior to all other biomarkers.

CONCLUSIONS

CRP, PCT, and the NLR are biomarkers with a sufficient predictive ability to clinically discard the presence of AL within the first postoperative week.

The effect of supplementary parenteral nutrition with different energy intakes on clinical outcomes of patients after gastric cancer surgery

BACKGROUND

To investigate the effect of postoperative supplementary parenteral nutrition (SPN) containing varying energy intake levels during the early postoperative period on the clinical outcomes of patients diagnosed with gastric cancer.

METHODS

Data from 237 patients, who were diagnosed with gastric cancer between January 2016 and June 2022, were retrospectively analyzed. Patients were divided into 2 groups based on mean daily SPN energy intake: low (L-SPN; < 20 kcal/kg/day); and high (H-SPN; ≥ 20 kcal/kg/day). Data regarding gender, age, body mass index, preoperative Nutrition Risk Screening 2002 (NRS 2002) score, American Society of Anesthesiologists Physical Status classification system, age-adjusted Charlson Comorbidity Index, diabetes, hypertension, chronic lung disease, and the Tumor-Node-Metastasis (TNM [Eighth edition]) classification were collected for propensity score matching (PSM). Postoperative indicators were monitored. A power analysis was performed during the design phase of this study to ensure that statistical power exceeded 80% to reliably detect differences between the 2 groups.

RESULTS

After PSM, data from 128 patients were analyzed (H-SPN, n = 64; L-SPN, n = 64). The H-SPN group experienced shorter postoperative hospital stay (8.11 ± 6.00 days vs. 10.38 ± 7.73 days; P = 0.045) and a lower number of infectious complications (36 [56.3%] vs. 60 [93.8%]; P < 0.001), particularly pulmonary infections, compared with the L-SPN group. Additionally, no increase in hospitalization costs or non-infectious complications occurred in the H-SPN group. Subgroup analysis revealed that H-SPN significantly reduced the incidence of infectious complications among those < 65 years of age (hazard ratio [HR] [95% confidence interval (CI) 0.240 0.069-0.829]; P = 0.024), NRS 2002 score ≥ 3 (HR 0.417 [95% CI 0.156-0.823]; P = 0.028), age-adjusted Charlson Complexity Index < 2 (HR 0.106 [95% CI 0.013-0.835]; P = 0.033), and TNM stage III (HR 0.504 [95% CI 0.224-0.921]; P = 0.046).

CONCLUSIONS

H-SPN effectively reduced postoperative infectious complications and the length of hospital stay, suggesting that early postoperative H-SPN may be an advantageous nutritional support strategy for patients diagnosed with gastric cancer.

Role of Biomarkers in the Diagnosis of Anastomotic Leakage After Colorectal Surgery: A Systematic Review and Meta-Analysis

Due to its diverse presentation, anastomotic leakage (AL) following colorectal surgery is challenging to detect and frequently discovered when the patient becomes critically ill. When diagnosing AL in its early stages, biomarkers play a large role. This review was conducted to evaluate the diagnostic value of biomarkers in AL after colorectal surgeries. A literature search was undertaken electronically in major search engines such as Medline (PubMed), Google Scholar, ScienceDirect, EMBASE, and CENTRAL (Cochrane Library) databases. Observational studies of both retrospective and prospective nature were included. Origin Pro 2022 (Origin Labs) software was used to assess the prevalence of AL and generate the forest plot. A total of 13 articles fulfilled the eligibility criteria. A pooled prevalence of 9.19% was noted for AL in colorectal surgeries. In the present review, the observed sensitivity for C-reactive protein (CRP) was 80.5% and the specificity was 84% (postoperative day three). In contrast, these were 100% and 83.9% for procalcitonin on postoperative day five. CRP showed the highest diagnostic accuracy and excels at eliminating AL, but combining biomarkers can increase the diagnostic precision of early detection of AL.

Interleukin-6 on postoperative day three as an early predictor of infections following laparoscopic gastric cancer resection

BACKGROUND

To investigate the role of C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) as early predictors of infectious complications after laparoscopic gastric cancer surgery.

METHODS

Patients who underwent laparoscopic gastric cancer surgery between January 2020 and June 2022 were retrospectively enrolled. IL-6, PCT, and CRP levels were assessed before surgery and on postoperative days (PODs) 3 and 5. Differences in serum IL-6, PCT, and CRP levels between the infected and non-infected groups were compared. The diagnostic accuracy was determined using the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 206 patients were enrolled, and 21 patients (10.19%) developed postoperative infections. Serum IL-6, PCT, and CRP levels in the infected group were significantly higher than those in the non-infected group on PODs 3 and 5. IL-6 with an optimal cutoff value of 84.00 pg/mL (AUC 0.84), PCT with an optimal cutoff value of 1.39 ng/mL (AUC 0.80), CRP with an optimal cutoff value of 150.00 mg/L (AUC 0.76) on POD 3 had superior diagnostic accuracy in predicting postoperative infections. Multivariate analysis identified PCT and IL-6 levels on POD 3 as independent risk factors, the AUC of the combination of IL-6 and PCT was 0.89. The Delong test showed no difference between the AUC of IL-6 alone and IL-6 combined with PCT prediction (P = 0.07, Z = 1.81).

CONCLUSIONS

IL-6 level on POD 3 is an excellent predictor of infectious complications following laparoscopic gastric cancer surgery. Patients with IL-6 levels lower than 84.00 pg/mL on POD 3 can ensure safe early discharge with a low probability of infection.

Predictive Postoperative Inflammatory Response Indicators of Infectious Complications Following Gastrectomy for Gastric Cancer

BACKGROUND

Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy.

METHODS

We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification).

RESULTS

Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×102/μL, and 37.4°C, respectively.

CONCLUSIONS

Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×102/μL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

Prognostic Value of Inflammatory Burden Index in Advanced Gastric Cancer Patients Undergoing Multimodal Treatment

Since increasing evidence underlines the prominent role of systemic inflammation in carcinogenesis, the inflammation burden index (IBI) has emerged as a promising biomarker to estimate survival outcomes among cancer patients. The IBI has only been validated in Eastern gastric cancer (GC) patients; therefore, the aim of this study was to evaluate the IBI as a prognostic biomarker in Central European GC patients undergoing multimodal treatment. Ninety-three patients with histologically confirmed GC who underwent multimodal treatment between 2013 and 2021 were included. Patient recruitment started with the standardization of neoadjuvant chemotherapy (NAC). Blood samples were obtained one day prior to surgical treatment. The textbook outcome (TO) served as the measure of surgical quality, and tumor responses to NAC were evaluated according to Becker's system tumor regression grade (TRG). A high IBI was associated with an increased risk of postoperative complications (OR 2.95, 95% CI 1.13-7.72). In multivariate analysis, a high IBI (HR = 2.56, 95% CI 1.28-5.13) and a high neutrophil-to-lymphocyte ratio (NLR, HR = 2.55, 95% CI 1.32-4.94) were associated with an increased risk of death, while NAC administration (HR = 0.40, 95% CI 0.18-0.90) and TO achievement (HR = 0.42, 95% CI 0.22-0.81) were associated with a lower risk of death. The IBI was associated with postoperative complications and mortality among GC patients undergoing multimodal treatment.

Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis

Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.

Can prospective monitoring improve complication rates after gastrectomy? Experience of Billroth I reconstruction at a high-volume tertiary center

INTRODUCTION

Prospective database is imperative in surgical outcome monitoring and has shown success in providing a comprehensive complication index to monitor surgical quality. This study aims to review whether prospective monitoring has an effect on postoperative complication rates, especially leakage after Billroth I (BI) anastomosis and to identify risk factors of anastomosis leakage after BI anastomosis.

MATERIALS AND METHODS

Patients who underwent distal gastrectomy with BI reconstruction at Seoul National University Hospital between January 2018 and April 2021 were enrolled. Clinicopathological characteristics and perioperative variables were retrieved. The risk factor that was statistically significant in univariate analysis was further analyzed by binomial logistic regression analysis.

RESULTS

BI leakage rate in three years has declined by half on a yearly basis from 5.7% to 1.8%. The leakage group patients were predominantly male (100%) when compared to the non-leakage group (67.6%) (p = 0.04). The BMI (25.00 ± 1.42 vs. 24.16 ± 3.15, p = 0.048) and CRP measured on POD#2 (16.47 ± 5.64 vs. 9.99 ± 5.42, p < 0.001) showed significant differences between the two groups. POD#2 CRP greater than 12.7 mg/dL was able to predict risk of anastomosis leak with sensitivity 73.3% and specificity 73.1%.

CONCLUSION

Understanding variations in outcomes is important for improvements in surgical care, and through prospective monitoring and intra-departmental feedback, it is possible to reduce complication rates after gastrectomy. This study shows that age, gender and BMI are risk factors to BI leakage and POD#2 CRP greater than 12.7 mg/dL can be used to suspect leakage after BI anastomosis.

Identification of potential hub genes linked to immune and metabolic alterations in postoperative systemic inflammatory dysregulation

Background

Postoperative systemic inflammatory dysregulation (PSID) is characterised by strongly interlinked immune and metabolic abnormalities. However, the hub genes responsible for the interconnections between these two systemic alterations remain to be identified.

Methods

We analysed differentially expressed genes (DEGs) of individual peripheral blood nucleated cells in patients with PSID (n = 21, CRP > 250 mg/L) and control patients (n = 25, CRP < 75 mg/L) following major abdominal surgery, along with their biological functions. Correlation analyses were conducted to explore the interconnections of immune-related DEGs (irDEGs) and metabolism-related DEGs (mrDEGs). Two methods were used to screen hub genes for irDEGs and mrDEGs: we screened for hub genes among DEGs via 12 algorithms using CytoHubba in Cytoscape, and also screened for hub immune-related and metabolic-related genes using weighted gene co-expression network analysis. The hub genes selected were involved in the interaction between changes in immunity and metabolism in PSID. Finally, we validated our results in mice with PSID to confirm the findings.

Results

We identified 512 upregulated and 254 downregulated DEGs in patients with PSID compared with controls. Gene enrichment analysis revealed that DEGs were significantly associated with immune- and metabolism-related biological processes and pathways. Correlation analyses revealed a close association between irDEGs and mrDEGs. Fourteen unique hub genes were identified via 12 screening algorithms using CytoHubba in Cytoscape and via weighted gene co-expression network analysis. Among these, CD28, CD40LG, MAPK14, and S100A12 were identified as hub genes among both immune- and metabolism-related genes; these genes play a critical role in the interaction between alterations in immunity and metabolism in PSID. The experimental results also showed that the expression of these genes was significantly altered in PSID mice.

Conclusion

This study identified hub genes associated with immune and metabolic alterations in patients with PSID and hub genes that link these alterations. These findings provide novel insights into the mechanisms underlying immune and metabolic interactions and new targets for clinical treatment can be proposed on this basis.

C-Reactive Protein/Albumin Ratio on the First Day after Surgery Predicts Short-Term Complications of Gastrectomy for Gastric Cancer

Postoperative complications of gastrectomy for gastric cancer affect the efficacy of surgery. It is of clinical significance to identify high-risk patients with postoperative complications as early as possible. A total of 206 patients who underwent gastrectomy were enrolled in this study. Univariate and multivariate analyses were used to determine the risk factors for postoperative complications. The cutoff value and diagnostic accuracy of the C-reactive protein/albumin ratio were calculated by receiver operating characteristic curves. A total of 64 (31.1%) patients developed postoperative complications. Multivariate analysis confirmed that the C-reactive protein/albumin ratio on the first day after operation was an independent risk factor for postoperative complications (OR = 2.538, 95%CI: 1.346-4.785, P = 0.004). The cutoff value of the C-reactive protein/albumin ratio on the first day after operation was 2.105 calculated by receiver operating characteristic curves. Patients with a C-reactive protein/albumin ratio greater than 2.105 had a higher incidence of postoperative complications (43.2% vs 22.0%, P = 0.001) and longer postoperative hospital stay (15.3 ± 1.2 vs 13.0 ± 0.5, P = 0.042) than patients with less than 2.105. Patients with C-reactive protein/albumin ratio greater than 2.105 on the first day after operation are more likely to have postoperative complications.

The ratio of serum C-reactive protein level on postoperative day 3 to day 2 is a good marker to predict postoperative complications after laparoscopic radical gastrectomy for gastric cancer

PURPOSE

Study reported that C-reactive protein (CRP) would peak at 48 h after the initiation of an acute inflammatory response. We proposed that the ratio of CRP level on postoperative day 3 to day 2 (POD3/2 CRP) can be used to early predict major postoperative complications (PCs) for patients who underwent laparoscopic radical gastrectomy.

METHODS

Patients were randomized into training cohort and validation cohort at a ratio of 7:3. PCs greater than grade II or more, according to Clavien-Dindo classification, were defined as major PCs. Three predictive models for major PCs based on CRP level were constructed, including POD3/2 CRP, the CRP level on POD3 (POD3 CRP), and the ratio of CRP level on POD3 to POD1 (POD3/1 CRP). The performances of three prediction models were assessed by AUC. Univariate and multivariate logistic regression analyses were performed to identify risk factors of major PCs.

RESULTS

344 patients were included. Major PCs were observed in 57 patients (16.6%). In the training cohort, POD3/2 CRP provided the best diagnostic accuracy with an AUC of 0.929 at an optimal cut-off value of 1.08, and the sensitivity and specificity were 0.902 and 0.880, respectively. In the validation cohort, the corresponding AUC was 0.917. BMI ≥ 25 kg/m² and POD3/2 CRP > 1 were identified as risk factors for major PCs.

CONCLUSION

POD3/2 CRP is a reliable marker to predict major PCs after laparoscopic radical gastrectomy. If CRP is higher on POD3 than on POD2, major PCs are highly likely.

A comparative study on perioperative outcomes between robotic versus laparoscopic D2 total gastrectomy

OBJECTIVE

Robotic surgery has been increasingly used worldwide owing to its advanced features. However, the significant benefits of robotic total gastrectomy (RTG) over laparoscopic total gastrectomy (LTG) have yet to be demonstrated. We conducted a prospective cohort study to compare the safety and efficacy of robotic and laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy for AGC.

METHODS

Between March 26, 2018 and July 30, 2021, 155 patients between 18 and 80 years of age with locally advanced gastric cancer (cT2-4a, N0/+, M0) were enrolled. The perioperative outcomes within 30 days after surgery were compared between the RTG (n = 69) and LTG (n = 73) groups on a per-protocol (PP) basis. Postoperative complications were evaluated according to the Clavien-Dindo classification.

RESULTS

The overall postoperative morbidity rate was 21.74% in the RTG group and 28.77% in the LTG group with no significant difference (P = 0.44), RTG was associated with a lower incidence of pneumonia (4.35% vs. 15.07%, P = 0.047). No mortality was observed in either group. There was no significant difference in the total operative time (284.48 vs. 271.73 min, P = 0.171), but RTG was associated with a lower estimated volume of blood loss (110 vs. 150 ml, P < 0.001) and more total retrieved lymph nodes (LNs) (41.36 vs 35.1, P = 0.019), more extraperigastric LNs (14.91 vs. 12.19, P = 0.024) and more LNs in the suprapancreatic areas (14.68 vs. 11.82, P = 0.017). The laboratory data (amylase, inflammatory, Albumin and T lymphocyte levels) of the RTG group were better than those of the LTG group.

CONCLUSION

According to the results of this prospective cohort study, for patients with locally advanced gastric cancer, Robotic surgery has advantages over laparoscopic surgery for radical total gastrectomy with D2 lymphadenectomy performed by well-trained doctors.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

Lymphocyte C-reactive protein ratio: A new biomarker to predict early complications after gastrointestinal oncologic surgery

BACKGROUND

Lymphocyte-to-C-reactive protein ratio (LCR) has been used as a post-surgical prognostic biomarker in patients with gastric and colorectal cancer. However, its relationship with early postoperative complications in these patients is unknown. In this study, we aimed to reveal the relationship between LCR and postoperative complications.

METHODS

Eighty-one patients operated for stomach and colorectal cancer between January 2020 and August 2020 were prospectively analyzed. On preoperative and postoperative days 1, 3 and 5, other inflammatory parameters, mainly LCR, neutrophil lymphocyte ratio (NLR), were recorded. The patients were divided into two groups according to Clavien-Dindo classification as stage III and higher complications major, stage I-II/non-complication minor.

RESULTS

Fifty seven patients were operated for colorectal cancer, 24 patients for gastric cancer. The mean age of the patients was 65.6 ± 12.6, 34.6% of them was women. Age, operation time and hospital stay were significantly different between the groups (p= 0.004, p= 0.002, p< 0.001). Major complications developed in 18 patients. On postoperative day 5, LCR found superior diagnostic accuracy in predicting major postoperative complications compared to other inflammatory markers. On the postoperative 5th day, the cut-off value of LCR was 0.0034, 88.8% (71.9-94.8) sensitivity, and 85.7% (73.6-95.4) selectivity.

CONCLUSION

Among different inflammatory markers, postoperative LCR is a safe and effective predictor of postoperative complications, especially after gastric and colorectal cancer surgery on day 5.

Assessment of Robotic Versus Laparoscopic Distal Gastrectomy for Gastric Cancer: A Randomized Controlled Trial

OBJECTIVE

To evaluate the short-term outcomes of patients with GC who received RDG or LDG.

SUMMARY BACKGROUND DATA

Despite the increasing use of RDG in patients with GC, its safety and efficacy compared to those of LDG have not been elucidated in a randomized controlled trial.

METHODS

Three hundred patients with cT1-4a and N0/+ between September 2017 and January 2020 were enrolled in this randomized controlled trial at a high-volume hospital in China. The short-term outcomes were compared between the groups.

RESULTS

The modified intention-to-treat analysis included data from 283 patients (RDG group: n = 141) and (LDG group: n = 142). Patients in the RDG group exhibited faster postoperative recovery, milder inflammatory responses, and reduced postoperative morbidity (9.2% vs 17.6%, respectively, P = 0.039). Higher extraperigastric lymph nodes (LNs) were retrieved in the RDG group (17.6 ± 5.8 vs 15.8 ± 6.6, P = 0.018) with lower noncompliance rate (7.7% vs 16.9%, respectively, P = 0.006). Additionally, patients in the RDG group were more likely to initiate adjuvant chemotherapy earlier [median (interquartile range) postoperative days: 28 (24-32) vs 32 (26-42), P = 0.003]. Although total hospital costs were higher in the robotic group than in the laparoscopic group, the direct cost was lower for RDG than for LDG (all P < 0.001).

CONCLUSIONS

RDG is associated with a lower morbidity rate, faster recovery, milder inflammatory responses, and improved lymphadenectomy. Additionally, faster postoperative recovery in the RDG group enables early initiation of adjuvant chemotherapy. Our results provide evidence for the application of RDG in patients with GC.

Association between low preoperative skeletal muscle quality and infectious complications following gastrectomy for gastric cancer

PURPOSE

It is known that sarcopenia affects the overall short- and long-term outcomes of patients with gastric cancer (GC); however, the effect of muscle quality on infectious complications after gastrectomy for GC remains unclear. We investigated the associations between the preoperative quantity and quality of skeletal muscle on infectious complications following gastrectomy for GC.

METHODS

The subjects of this retrospective study were 353 GC patients who underwent radical gastrectomy between 2009 and 2018. We examined the relationships between their clinical factors, including skeletal muscle mass index and intramuscular adipose tissue content (IMAC), and infectious complications after gastrectomy.

RESULTS

Infectious complications developed in 59 patients (16.7%). The independent risk factors for infectious complications identified by multivariate analysis were male gender (P < 0.001), prognostic nutritional index below 45 (P = 0.006), and high IMAC (P = 0.011). Patients with a high IMAC were older and had a higher body mass index, as well as a greater age-adjusted Charlson comorbidity index, than those with low or normal IMAC.

CONCLUSIONS

Low skeletal muscle quality defined by a high IMAC is a risk factor for infectious complications following gastrectomy. When feasible, preoperative nutritional intervention and rehabilitation aiming to improve muscle quality could reduce infectious complications after gastrectomy for GC.

Clinical impact of creatine phosphokinase and c-reactive protein as predictors of postgastrectomy complications in patients with gastric cancer

Background

Postoperative complications have been linked to the morbidity and mortality of several cancers. However, predicting whether complications will occur in the early period after surgery or not is challenging. Hence, this study aimed to examine the diagnostic accuracy of serum creatine phosphokinase (CPK) and c-reactive protein (CRP) in predicting the development of postgastrectomy complications.

Methods

We retrospectively analyzed 188 patients with gastric cancer (GC) who underwent gastrectomy. The diagnostic accuracy of serum CPK and CRP was investigated using the areas under the curves (AUC). The CPK ratio was defined as the CPK on postoperative day (POD) 1 to the CPK on a preoperative day.

Results

Out of 188 patients, 48 (25.5%) developed postoperative complications. The complications group had a greater operative time (p = 0.037), higher CPK ratio on POD1 (p < 0.0001), and a higher serum CRP level on POD3 (p = 0.001). The AUC for the CPK ratio was 0.772, with an optimal cutoff value of 7.05, whereas that for CRP was 0.659, with an optimal cutoff value of 11.4 mg/L. The CPK ratio on POD1 (p < 0.0001) and the CRP on POD3 (p = 0.007) were independent factors for predicting the development of postgastrectomy complications. The CPK ratio on POD1 and the CRP on POD3 predicted postgastrectomy complications in 41 patients (85.4%). According to combined value of both CPK ratio and CRP level, the positive predictive value and the negative predictive value was 0.70 and 0.829. And sensitivity and specificity were 0.438 and 0.936.

Conclusion

The CPK ratio on POD1 and the CRP on POD3 after gastrectomy for GC were predictive factors for complication development and may be employed to prevent the development of such complications and improve the prognosis of patients with GC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07801-z.

Perioperative CRP: A novel inflammation-based classification in gastric cancer for recurrence and chemotherapy benefit

Background

Perioperative C‐reactive protein (CRP) levels have effects on the prognosis of cancer patients. We intended to determine the prognostic value of combining the two for gastric cancer (GC).

Methods

Data were extracted from a clinical trial. By calculating the area under the curve (AUC) and the C‐index, the predictive value of CRPs among different time points, including preoperative (pre‐CRP), postoperative days 1, 3, and 5 (post‐CRPs), and postoperative maximum CRP (post‐CRP_max), was derived. Multivariate analysis was performed to further explore the independent variates for recurrence‐free survival (RFS).

Results

Finally, 401 patients were available in the present study. For RFS, higher AUC (0.692) and concordance index (0.678) of pre‐CRP were observed when compared with those of post‐CRPs. Further, among post‐CRPs, post‐CRP_max had the highest predictive values (AUC: 0.591; concordance index: 0.585) among the other post‐CRPs. The threshold values in predicting RFS for pre‐CRP and post‐CRP_max were 3.1 mg/L and 77.1 mg/L. Multivariate analysis showed both pre‐CRP≥3.1 mg/L (high‐pre‐CRP) and post‐CRP_max≥77.1 mg/L (high‐post‐CRP_max) were risk factors for RFS. Postoperative chemotherapy benefit was further analyzed for patients with stage II/III GC and indicated that patients with pre‐CRP<3.1 mg/L had better prognosis without benefit from postoperative adjuvant chemotherapy (ACT), p = 0.557. In high‐pre‐CRP patients, only patients with post‐CRP_max≥77.1 mg/L but not post‐CRP_max<77.1 mg/L benefited from postoperative ACT (RFS: 33.2% vs 49.9% for non‐chemotherapy group and chemotherapy group, respectively, p = 0.037). Analyses for overall survival obtained the similar outcomes.

Conclusions

Both high‐pre‐CRP and high‐post‐CRP_max are associated with worse prognosis in GC. ACT seems to only improve the prognosis for stage II/III GC with pre‐CRP≥3.1 mg/L and post‐CRP_max≥77.1 mg/L after radical gastrectomy. Further studies are needed to confirm these findings and explore the potential mechanism.

C-Reactive Protein and Cancer-Diagnostic and Therapeutic Insights

Cancer disease describes any pathology involving uncontrolled cell growth. As cells duplicate, they can remain localized in defined tissues, forming tumor masses and altering their microenvironmental niche, or they can disseminate throughout the body in a metastatic process affecting multiple tissues and organs. As tumors grow and metastasize, they affect normal tissue integrity and homeostasis which signals the body to trigger the acute phase inflammatory response. C-reactive protein (CRP) is a predominant protein of the acute phase response; its blood levels have long been used as a minimally invasive index of any ongoing inflammatory response, including that occurring in cancer. Its diagnostic significance in assessing disease progression or remission, however, remains undefined. By considering the recent understanding that CRP exists in multiple isoforms with distinct biological activities, a unified model is advanced that describes the relevance of CRP as a mediator of host defense responses in cancer. CRP in its monomeric, modified isoform (mCRP) modulates inflammatory responses by inserting into activated cell membranes and stimulating platelet and leukocyte responses associated with acute phase responses to tumor growth. It also binds components of the extracellular matrix in involved tissues. Conversely, CRP in its pentameric isoform (pCRP), which is the form quantified in diagnostic measurements of CRP, is notably less bioactive with weak anti-inflammatory bioactivity. Its accumulation in blood is associated with a continuous, low-level inflammatory response and is indicative of unresolved and advancing disease, as occurs in cancer. Herein, a novel interpretation of the diagnostic utility of CRP is presented accounting for the unique properties of the CRP isoforms in the context of the developing pro-metastatic tumor microenvironment.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety

OBJECTIVE

This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety.

DESIGN

Quality improvement initiatives using the KAIZEN as a problem-solving method.

SETTING

Department of surgery in a referral and educational hospital.

PARTICIPANTS

Surgical team and quality management team.

INTERVENTION

The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was performed to understand the current situations in our department. To achieve continuous improvement, periodical feedback of the current status was obtained from all staff. Bundles, including nontechnical skills, were established. Briefing and debriefing were performed by the surgical team.

MAIN OUTCOME MEASURES

Excessively long operation rates with a standard procedure.

RESULTS

We included 1573 operations in this initiative. Excessively long operation rates were reduced in all types of surgeries, from 27.1% to 15.2% for herniorrhaphy (P = 0.005), 58.3-40.0% for gastrectomy (P = 0.03), 50.0-4.1% for total gastrectomy (P = 0.12), 65.6-45.0% for colectomy (P = 0.004), 67.8-43.2% for high anterior resection (P = 0.02) and 69.6-47.9% for low anterior resection (P = 0.03). The adherence to briefing and debriefing were improved, and majority of the surgeons favored the bundle elements.

CONCLUSIONS

The KAIZEN initiative was effective in clinical healthcare settings. In the event of scaling-up this initiative, the educational program for physicians should include project management strategies and leadership skills.

Procalcitonin as an Early Predictor of Intra-abdominal Infections Following Gastric Cancer Resection

BACKGROUND

The purpose of this study was to investigate the prognostic value of postoperative procalcitonin (PCT) and C-reactive protein (CRP) for their ability to detect Intra-abdominal infections (IAIs) in patients after GC surgery.

METHODS

Patients who underwent elective gastrectomy for primary GC were retrospectively enrolled between October 2018 and October 2019. The PCT and CRP levels and white blood cell (WBC) count were measured before surgery and on postoperative days (POD) 1, 3, 5, and 7. The differences in serum PCT, CRP, and WBC levels between IAIs and non-IAIs groups were compared. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve. Univariate and multivariate logistic regression analyses identified independent clinical factors that predicted postoperative IAIs.

RESULTS

A total of 155 patients who underwent GC surgery were enrolled. IAIs were observed in 12 patients (7.74%). The postoperative CRP and PCT values in the IAI group were higher than those in the non-IAI group. PCT had superior diagnostic accuracy on POD 3 (area under the curve 0.769) with an optimal cutoff value of 2.03 ng/mL, yielding 75% sensitivity, 87.4% specificity, and 97.6% negative predictive value. Multivariate analysis identified a PCT level of 2.03 mg/mL or greater on POD 3 as a significant predictive factor for IAIs after gastrectomy (odds ratio: 21.447, 95% confidence interval: 5.081-91.672).

CONCLUSIONS

PCT values less than 2.03 ng/mL on POD 3 is an excellent negative predictor of IAIs, which may ensure a safe early discharge after gastric cancer surgery.

The effect of the visceral fat area on the predictive accuracy of C-reactive protein for infectious complications after laparoscopy-assisted gastrectomy

AIM

To investigate the influence of visceral fat area on postoperative C-reactive protein levels and whether it affects its ability to diagnose infectious complications after laparoscopy-assisted gastrectomy.

METHODS

A total of 435 consecutive patients who underwent laparoscopy-assisted resection for gastric cancer from 2008 to 2017 were reviewed and divided into four groups according to visceral fat area quartiles. We evaluated the relationship between C-reactive protein and visceral fat area and whether visceral fat area affects the sensitivity and specificity of C-reactive protein in diagnosing postoperative infectious complications.

RESULTS

Postoperative C-reactive protein levels increased with increasing visceral fat areas at every postoperative assessment. Multiple linear regression revealed that levels on postoperative day 3 significantly positively correlated with visceral fat area. Postoperative day 3 levels also showed moderate accuracy for diagnosing infectious complications (area under the curve, 0.78; sensitivity, 0.86; specificity, 0.65), with an optimal cut-off of 11.8 mg/dL. The sensitivity for predicting infectious complications was low in the 1st visceral fat area quartile group but high in the 2nd, 3rd, and 4th groups (0.43 vs 1.0 vs 1.0 vs 0.94, respectively). By contrast, the specificity was high in the 1st and 2nd group but low in the 3rd and 4th (0.84 vs 0.70 vs 0.54 vs 0.48, respectively).

CONCLUSION

Visceral fat area positively correlated with postoperative C-reactive protein levels and this affected its accuracy in diagnosing infectious complications. A uniform C-reactive protein cut-off may not provide accurate predictions in patients with more extreme visceral fat areas.

The C-reactive protein to albumin ratio predicts postoperative complication in patients who undergo gastrectomy for gastric cancer

The aim of this study was to evaluate the preoperative C-reactive protein (CRP) to albumin ratio (CAR) of patients with gastric cancer and to investigate the factors correlated with perioperative complications. From March 2016 to December 2019, 128 patients who underwent curative gastrectomy for gastric cancer were enrolled in a retrospective study. The preoperative cutoff value of the CAR for predicting postoperative complications was 0.265 on receiver operating characteristic (ROC) curve analysis. Clinical characteristics were compared between patients with complications (Clavien-Dindo grade ≥2, n = 20) and without complications (Clavien-Dindo grade <2, n = 108). On univariate and multivariate analyses, estimated blood loss (EBL) during the operation (HR 1.003, p = 0.039) and CAR (HR 2.832, p = 0.045) were independent predictors of postoperative complications. In conclusion, preoperative CAR appears to be a predictor of postoperative complications in the patients undergoing surgical treatment of gastric cancer.

The Advantages of Robotic Gastrectomy over Laparoscopic Surgery for Gastric Cancer

Background

We compared short- and long-term clinical outcomes including inflammatory marker levels between robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) to define the advantages of RG over LG.

Methods

We enrolled 209 patients with gastric cancer who underwent curative distal gastrectomy. We compared short- and long-term clinical outcomes including inflammatory marker levels between RG and LG to define the advantages of RG over LG. C-reactive protein (CRP) levels; the CRP-to-albumin, neutrophil-to-lymphocyte, and platelet-to-lymphocyte ratios; and the prognostic nutritional index were compared as systemic inflammatory markers.

Results

RG was associated with a longer operative time. The incidence of postoperative infectious complications of grade II or higher according to the Clavien-Dindo classification was not significantly different between the two groups. Amylase levels in drainage fluid on postoperative days 1 and 3 were significantly lower in the RG group than in the LG group. The incidence of pancreatic fistula in the RG group (4.3%) was lower than that in the LG group (7.5%), albeit without significance. There were no significant differences in inflammatory marker levels either before or after surgery between the two groups. The 3-year overall survival rate did not significantly differ between the RG and LG groups (91.1% vs. 91.1%). Similar results were observed regarding the 3-year disease-specific survival rate (100% vs. 97.1%).

Conclusion

RG might be feasible and safe for treating gastric cancer from both surgical and oncological perspectives. The use of robotic assistance is associated with decreased amylase levels in drainage fluid, which may reduce the risk of pancreatic fistula and prevent pancreatic injury.

The impact of postoperative inflammation on recurrence in patients with colorectal cancer

BACKGROUND

Systemic inflammatory response is strongly linked to among cancer development, progression and poor prognosis. The aim of this study was to clarify the impact of postoperative serum C-reactive protein (CRP) levels on the prognoses of patients with colorectal cancer (CRC).

METHODS

A total of 467 patients with stage I-III CRC who underwent curative surgery were retrospectively analyzed. To precisely evaluate the effect of postoperative inflammatory status on prognosis in CRC patients, we excluded patients with postoperative complication or elevated preoperative CRP level (CRP > 1.0 mg/dL). Patients were divided into two groups based on their highest post-resection CRP levels (max CRP): the low CRP group (LCG; < 9.0 mg/dL, n = 385) and high CRP group (HCG; ≥ 9.0 mg/dL, n = 82). Furthermore, the effect of inflammation on malignant potential of CRC cells was evaluated using in vitro peritoneal dissemination model.

RESULTS

HCG patients showed significantly worse recurrence-free survival (RFS) than LCG patients (p = 0.012). Multivariate analysis revealed that a higher max CRP was an independent prognostic factor for RFS (HR: 2.07, 95% CI 1.04-3.96, p = 0.038). Concerning the risk factors for high max CRP level, multivariate analysis revealed that older age (p < 0.001), male sex (p < 0.001), higher BMI (p = 0.005), right-sided colorectal cancer (p = 0.008), and longer operative time (p = 0.007) were independent risk factors. A higher max CRP was also significantly associated with peritoneal recurrence (p < 0.001). Additionally, recombinant cytokines enhanced the adhesive ability of CRC cells to mesothelial cell in vitro (p < 0.05).

CONCLUSIONS

Postoperative inflammation may be a possible mechanism portending the poor prognosis of CRC patients.

Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery

Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL.

C-reactive protein elevation ratio as an early predictor of postoperative severe complications after laparoscopic gastrectomy for gastric cancer: a retrospective study

Background

In gastrectomy, postoperative elevation of C-reactive protein (CRP) is thought to be useful for predicting complications. Laparoscopic gastrectomy (LG) is less invasive than laparotomy and the elevation of CRP is also mild. Postoperative complications such as anastomotic leakage not only increase the severity of the condition, but also carry a poor prognosis when treatment is delayed. Early treatment is therefore necessary.

Method

This retrospective study examined the relationship between occurrence of complications and the ratio of CRP levels on postoperative days 1 and 3 (CRP ratio) for 449 gastric cancer patients who underwent LG in the Department of Gastrointestinal Surgery at Osaka City University Hospital between 2006 and 2016.

Results

We observed that factors associated with postoperative complications were preoperative renal failure and CRP ratio. No significant associations with surgical procedure, operation time, bleeding volume, age, obesity, measured CRP concentration, or white blood cell count were evident. The optimal cut-off for CRP ratio to predict postoperative complications from the receiver operating characteristic curve was 2.13.

Conclusion

Our results suggested that the risk of severe postoperative complications after LG could be predicted using the CRP ratio.

Reduction rate of C-reactive protein as an early predictor of postoperative complications and a reliable discharge indicator after gastrectomy for gastric cancer

Purpose

Postoperative complications (PCs) after gastrectomy are associated with readmission and longer hospital stay. This study aimed to determine the role of CRP as an early predictor of PCs and a reliable discharge indicator after gastrectomy.

Methods

Clinicopathologic data and PCs of 613 patients who underwent gastrectomy for gastric cancer in 2015–2016 were retrospectively analyzed, including consecutive blood samples for CRP obtained preoperatively, at the operative day, and postoperatively. Following the Clavien-Dindo classification, the patients were divided into a group with major PCs and a group with minor/no PCs. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Clinical factors related to major PCs were identified using univariate and multivariate logistic regression analyses.

Results

PCs occurred in 89 patients (14.5%). The most significant predictive factor for major PCs was a CRP concentration reduction rate of ≤38.1% (AUC, 0.82; sensitivity, 76.4%; specificity, 76.1%) between postoperative day (POD) 3 and 5 (R5), followed by ≤11.1% (AUC, 0.75; sensitivity, 73%; specificity, 76%) between POD 2 and 3 (R4). When both factors were applied (R4 ≤ 11.1% and R5 ≤ 38.1%), the specificity was 91.6%; when only one condition was satisfied (R4 ≤ 11.1% or R5 ≤ 38.1%), the sensitivity was 91%.

Conclusion

CRP concentration reduction rates between POD 3 and 5 and between POD 2 and 3 were the best combination factors to predict PCs and indicate a safe discharge after gastrectomy for gastric cancer.

Change in serum albumin level predicts short-term complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer

BACKGROUND

The purpose of this study was to evaluate the correlation between serum albumin level change (ΔALB) and post-operative complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer.

METHODS

A total of 193 patients undergoing curative (R0) gastrectomy from September 2015 to May 2017 were enrolled in this study. The risk factors for predicting post-operative complications were identified by univariate and multivariate analysis. The cut-off value and diagnostic accuracy of ΔALB were measured by receiver operating characteristic curves. ΔALB was defined as: (albumin level before surgery - albumin on post-operative day (POD) 1)/albumin level before surgery × 100%.

RESULTS

A total of 60 patients (31.0%) had post-operative complications. Our results showed that the cut-off value of ΔALB was 19.0%. Using a cut-off value of 19.0%, multivariate analysis identified that ΔALB was able to predict post-operative complications as an independent factor (odds ratio 13.98, 95% confidence interval 6.048-32.32, P < 0.001). In addition, the area under the curve of ΔALB is higher than C-reactive protein on POD 3 (0.773 versus 0633). Compared with patients with ΔALB <19.0%, patients with ΔALB ≥19.0% have higher risk of post-operative complications suffered (62.3 versus 13.7%, P < 0.001) and longer post-operative stay (22.1 ± 13.5 versus 17.5 ± 4.2, P < 0.001).

CONCLUSION

ΔALB acted as an independent predictor in short-term complications for patients with normal preoperative serum albumin and its diagnostic accuracy was higher than C-reactive protein on POD 3. It is promising to be a precise and straight predictor for incidence of post-operative complications to patients with normal preoperative serum albumin.

Postoperative Serum C-Reactive Protein Level Predicts Long-term Outcomes in Stage I Gastric Cancer

BACKGROUND

The aim of this study was to investigate the prognostic impact of postoperative systemic inflammation in patients with stage I gastric cancer.

METHODS

This study reviewed the medical records of 470 patients with stage I gastric cancer who underwent gastrectomy. The postoperative serum C-reactive protein (CRP) level on postoperative days (PODs) 1 and 3 and its peak value were evaluated as prognostic factors. A receiver operating characteristics curve analysis was performed to determine their cut-off values.

RESULTS

The CRP level on POD 3 (P = 0.001) and the peak CRP level (P = 0.007) were significantly associated with the overall survival rate. In the multivariate analysis, the CRP level on POD 3 (P = 0.002) and the peak CRP level (P = 0.008) were identified as independent predictors of the overall survival. The high CRP on POD3 group had significantly higher mortality rate from relapse of gastric cancer (P = 0.001) and infectious disease (P = 0.003) than the low CRP on POD 3 group. The CRP level on POD 3 was significantly associated with the patient sex, surgical procedure, duration of the operation, amount of blood loss, postoperative infectious complication, and peak CRP level.

CONCLUSIONS

The serum CRP level during the early postoperative period predicts the long-term outcomes in stage I gastric cancer. The present study suggests a significant influence of postoperative systemic inflammation on the survival of patients with stage I gastric cancer.

Risk factors for 30-day hospital readmission after radical gastrectomy: a single-center retrospective study

BACKGROUND

Hospital readmission is gathering greater attention as a measure of health care quality. The introduction of fast-track surgery has led to shorter lengths of hospitalization without increasing the risk of postoperative complications and readmission. The collection of comprehensive readmission data is essential for the further improvement of patient care. The aim of the present study is to evaluate the risk factors for readmission within 30 days of discharge after gastrectomy.

METHODS

A total of 1929 patients who underwent radical gastrectomy at Shizuoka Cancer Center were included in this study. A risk analysis with a stepwise logistic regression model was conducted to identify the risk factors for 30-day hospital readmission.

RESULTS

The 30-day readmission rate was 2.70%. Common causes of readmission were an intolerance of oral intake and the presence of an intra-abdominal abscess. The C reactive protein (CRP) level on postoperative day (POD) 3 was significantly higher in the readmitted group; however, the other surgical outcomes, including the incidence of postoperative complications, did not differ to a statistically significant extent. The stepwise logistic regression analysis revealed that CRP on POD3 ≥ 12 mg/dl [odds ratio (OR) 2.08, 95% confidence interval (CI) 1.09-3.95, p = 0.025], laparoscopic surgery (OR 2.25, 95% CI 1.17-4.31, p = 0.015), and TG (OR 2.23, 95% CI 1.17-4.78, p = 0.023) were found to be independent risk factors for readmission.

CONCLUSIONS

CRP on POD3 ≥ 12 mg/dl, laparoscopic surgery, and TG were identified as independent risk factors for readmission.

Abdominal Drainage and Amylase Measurement for Detection of Leakage After Gastrectomy for Gastric Cancer

PURPOSE

To investigate the value of daily measurement of drain amylase for detecting leakage in gastric cancer surgery.

METHODS

This was a retrospective analysis including all patients who underwent a gastrectomy for gastric cancer. From January 2013 until December 2015, an intra-abdominal drain was routinely placed. Drain amylase was measured daily. Receiver operator characteristic curves were created to assess the ability of amylase to predict leakage. Sensitivity, specificity, and negative and positive predictive value of amylase in drain fluid were determined. Leakage of the gastrojejunostomy or esophagojejunostomy, enteroenterostomy, duodenal stump, or pancreas was diagnosed by CT scan, endoscopy, or during re-operation. From January 2016 until April 2017, no drain was inserted. Surgical outcome and postoperative complications were compared between both groups.

RESULTS

Median drain amylase concentrations were higher for each postoperative day in patients with leakage. The optimal cutoff value was 1000 IU/L (sensitivity 77.8%, specificity 98.2%, negative predictive value 96.6%). Sixty-seven consecutive procedures were performed with a drain and 40 procedures without. No differences in group characteristics were observed except for gender. Fourteen patients (13.1%) had a leakage. The incidence and severity of leakage were not different between the patients with and without a drain. There was no significant difference in time to diagnosis (1 vs. 0 days; p 0.34), mortality rate (7.5 vs. 2.5%; p 0.41), and median length of hospital stay (9 days in both groups; p 0.46).

CONCLUSION

Daily amylase measurement in drain fluid does not influence the early recognition and management of leakage in gastric cancer surgery.

Prediction of postoperative inflammatory complications after esophageal cancer surgery based on early changes in the C-reactive protein level in patients who received perioperative steroid therapy and enhanced recovery after surgery care: a retrospective analysis

BACKGROUND

Serum C-reactive protein (CRP) level can be an indicator of the early stage of infectious complications. However, its utility in advanced esophageal cancer patients who receive radical esophagectomy with two- or three-field lymph node dissection with perioperative steroid therapy and enhanced recovery after surgery (ERAS) care is unclear.

METHODS

The present study retrospectively examined 117 consecutive esophageal cancer patients who received neoadjuvant chemotherapy followed by radical esophagectomy. All patients received perioperative steroid therapy and ERAS care. The utility of the CRP value in the early detection of serious infectious complications (SICs) was evaluated based on the area under the receiver operating characteristic curve (AUC). Univariate and multivariate logistic regression analyses were performed to identify the risk factors for SICs.

RESULTS

SICs were observed in 20 patients (17.1%). The CRP level on postoperative day (POD) 4 had superior diagnostic accuracy for SICs (AUC 0.778). The cut-off value for CRP was determined to be 4.0 mg/dl. A multivariate analysis identified CRP ≥ 4.0 mg/dl on POD 4 (odds ratio, 18.600; 95% confidence interval [CI], 4.610-75.200) and three-field lymph node dissection (odds ratio, 7.950; 95% CI, 1.900-33.400) as independent predictive factors.

CONCLUSIONS

CRP value on POD 4 may be useful for predicting SICs in esophageal cancer patients who receive radical esophagectomy with perioperative steroid therapy and ERAS care. This result may encourage the performance of imaging studies to detect the focus and thereby lead to the early medical and/or surgical intervention to improve short-term outcomes.

Postoperative C-reactive protein/albumin ratio as a novel predictor for short-term complications following gastrectomy of gastric cancer

BACKGROUND

Postoperative complications following gastric cancer resection remain a clinical problem. Early detection of postoperative complications is needed before critical illness develops. The purpose of this study was to evaluate the prognostic value of C-reactive protein/albumin ratio in patients with gastric cancer.

METHODS

A total of 322 patients undergoing curative (R0) gastrectomy between 2015 and 2017 were retrospectively analyzed. Univariate and multivariate analyses were performed to identify clinical factors predicting postoperative complications. The cutoff values and diagnostic accuracy of C-reactive protein/albumin ratio and C-reactive protein were determined by receiver-operating characteristic curves.

RESULTS

Among all of the patients, 85 (26.4%) developed postoperative complications. The optimal cutoff of C-reactive protein/albumin ratio was set at 3.04 based on the ROC analysis. Multivariate analysis identified C-reactive protein/albumin ratio was an independent risk factors for complications after gastrectomy (OR 3.037; 95% CI 1.248-7.392; P = 0.014). Additionally, C-reactive protein/albumin ratio showed a higher diagnostic accuracy than C-reactive protein on postoperative day 3 (AUC: 0.685 vs 0.660; sensitivity: 0.624 vs 0.471; specificity: 0.722 vs 0.835).

CONCLUSIONS

Elevated C-reactive protein/albumin ratio was an independent predictor for postoperative complications following gastrectomy of gastric cancer, and the diagnostic accuracy was higher than C-reactive protein alone. Overall, postoperative C-reactive protein/albumin ratio may help to identify patients with high probability of postoperative complications.

Postoperative decrease of serum albumin predicts short-term complications in patients undergoing gastric cancer resection

AIM

To find an accurate and simple predictor for postoperative short-term complications after gastrectomy.

METHODS

Two hundred and twenty-three patients undergoing gastric cancer resection between October 1, 2015 and September 30, 2016 were enrolled in this study. Univariate and multivariate analyses were used to identify risk factors for complications after gastrectomy. The cutoff values and diagnostic accuracy were examined by receiver operating characteristic curves.

RESULTS

Sixty-two (27.8%) patients had short-term complications after gastric cancer resection. The postoperative decrease in serum albumin (∆ALB) was an independent risk factor for complications (OR = 17.957, 95%CI: 6.073-53.095, P < 0.001). The cutoff value was 14.0% and the area under the curve was higher than that of C-reactive protein on postoperative day 3 (area under the curve: 0.806 vs 0.709). Patients with ∆ALB ≥ 14.0% were more likely to have short-term complications after gastrectomy (46.7% vs 5.0%, P < 0.001), prolonged hospital stay (17.2 ± 10.8 d vs 14.1 ± 4.2 d, P = 0.007) and higher comprehensive complication index (P < 0.001) than those with ∆ALB < 14.0%.

CONCLUSION

Postoperative ∆ALB with a cutoff of 14.0% can be used to recognize patients who have high risk of short-term complications following gastric cancer resection.

C-Reactive Protein Was an Early Predictor of Postoperative Infectious Complications After Pancreaticoduodenectomy for Pancreatic Cancer

Objective

The study objective was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications (PICs) after pancreaticoduodenectomy.

Summary of Background Data

The incidence of PICs after pancreaticoduodenectomy still remains high and a clinically relevant problem, despite improvements in the surgical procedure.

Methods

We examined 110 consecutive patients who underwent pancreaticoduodenectomy for primary pancreatic cancer between 2006 and 2014. The predictive value was assessed by estimating the area under the receiver operating characteristic curve (AUC). Clinical and laboratory data, including CRP, were analyzed with univariate and multivariate logistic regression analyses to identify predictors of PICs of grade III or higher according to the Clavien-Dindo classification.

Results

PICs of grade III or higher occurred in 13 patients [11.8%; 95% confidence interval (CI), 6.45%–19.36%]. CRP level on postoperative day 3 (POD 3) was a good predictor of PICs (AUC, 0.815; 95% CI, 0.651–0.980), showing the highest accuracy among clinical and laboratory data. A cutoff value of 13.2 mg/dL yielded a sensitivity of 0.846 and a specificity of 0.794. On multivariate analysis, a POD 3 CRP level of 13.2 mg/dL or higher (odds ratio, 20.0; 95% CI, 4.07–97.9; P = 0.002) was a significant predictor of PICs after pancreaticoduodenectomy.

Conclusions

CRP elevation above 13.2 mg/dL on POD 3 is a significant predictive factor for PICs and should prompt an intense clinical search and therapeutic approach for PICs.

The Granulocyte-to-Lymphocyte Ratio as a Marker of Surgical Stress and a Predictor of Postoperative Infectious Complications After Gastric Cancer Surgery: An Analysis of Patients Enrolled in a Prospective Randomized Trial

BACKGROUND

The granulocyte-to-lymphocyte ratio (GLR) in the blood may be a useful marker of surgical stress (SS) following surgery for cancer. The aim of the present study was to compare the SS by measuring the GLR, and further study the value of the GLR in predicting postoperative infectious complications (ICs).

METHODS

Data from 201 gastric cancer patients at Fujian Medical University Union Hospital who were enrolled in our prospective randomized controlled trial were extracted for this study. Blood samples to perioperatively measure the GLR were routinely taken. Additional external validation was performed using the dataset (n = 135) from Nanfang Hospital who were enrolled in the same trial.

RESULTS

Patients undergoing either laparoscopic or open resection showed a similar preoperative GLR, as well as similar GLRs, on postoperative days (PODs) 1 and 3. The GLR on POD 5 was lower in the laparoscopic group compared with the open group (p = 0.014), and the optimal predictive GLR thresholds of postoperative ICs in both the laparoscopic and open groups were the same on POD 5, i.e. 6.5 and 7.4, respectively. The GLR on POD 5 was identified as an independent factor for postoperative ICs in both the laparoscopic and open groups. Similar results were found in the validation dataset.

CONCLUSION

The GLR status not only correlates with SS but may also be a reliable predictor of ICs for gastric cancer patients after gastrectomy. The ideal GLR thresholds on POD 5 for ICs following laparoscopic and open gastrectomy are 6.5 and 7.4, respectively.

C-reactive protein can be an early predictor of postoperative complications after gastrectomy for gastric cancer

BACKGROUND

The clinical outcomes for postoperative complications (PCs) after gastrectomy depend on early diagnosis and intensive treatment. The aim of this study was to investigate the role of C-reactive protein (CRP) as an early predictor of PCs after gastrectomy for gastric cancer.

METHODS

A total of 334 consecutive patients who underwent gastrectomy for gastric cancer in 2014 were enrolled in this study. Blood samples were obtained preoperatively, and at postoperative days 1 and 4 for the measurement of inflammatory markers (white blood cell, neutrophil, and platelet counts, and CRP). Patients were classified into groups of major and minor/no PCs, which were defined as patients with PCs of more than grade III and those with grade I/II or without PCs, respectively, according to the Clavien-Dindo classification.

RESULTS

Twenty-five patients developed major PCs. The CRP on postoperative day 4 provided superior diagnostic accuracy in predicting major PCs compared to the other systematic inflammatory markers. Multivariate analysis identified a CRP level of 16.8 mg/dl or greater on postoperative day 4 as a significant predictive factor for major PCs.

CONCLUSIONS

Among the various systemic inflammatory markers, CRP on postoperative day 4 is the most reliable predictor of PCs after gastrectomy for gastric cancer.

Ability of Serum C-Reactive Protein Concentrations to Predict Complications After Laparoscopy-Assisted Gastrectomy: A Prospective Cohort Study

Inflammatory markers, including C-reactive protein (CRP) and white blood cell (WBC), are widely available in clinical practice. However, their predictive roles for infectious complications following laparoscopy-assisted gastrectomy (LAG) have not been investigated. Our aim was to investigate the diagnostic accuracy of CRP concentrations and WBC counts for early detection of infectious complications following LAG and to construct a nomogram for clinical decision-making.The clinical data of consecutive patients who underwent LAG with curative intent between December 2013 and March 2015 were prospectively collected. Postoperative complications were recorded according to the Clavien-Dindo classification. The diagnostic value of CRP concentrations and WBC counts was evaluated by area under the curve of receiver-operating characteristic curves. Optimal cutoff values were determined by Youden index. Univariate and multivariate logistic regression analyses were performed to identify risk factors for complications, after which a nomogram was constructed.Twenty-nine of 278 patients (10.4%) who successfully underwent LAG developed major complications (grade ≥III). CRP concentration on postoperative day 3 (POD 3) and WBC count on POD 7 had the highest diagnostic accuracy for major complications with an area under the curve value of 0.86 (95% confidence interval [CI], 0.79-0.92] and 0.68 (95% CI, 0.56-0.79) respectively. An optimal cutoff value of 172.0 mg/L was identified for CRP, yielding a sensitivity of 0.79 (95% CI, 0.60-0.92) and specificity 0.74 (95% CI, 0.68-0.80). Multivariate analysis identified POD3 CRP concentrations ≥172.0 mg/L, Eastern Cooperative Oncology Group Performance Status ≥1, presence of preoperative comorbidity, and operation time ≥240 min as risk factors for major complications after LAG.The optimal cut-off value of CRP on POD3 to predict complications following LAG was 172.0 mg/L and a CRP-based nomogram may contribute to early detection of complications after LAG.