Is malnutrition still a risk factor of postoperative complications in gastric cancer surgery?

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

THE VALUE OF PREOPERATIVE PROGNOSTIC NUTRITIONAL INDEX IN GASTRIC CANCER AFTER CURATIVE RESECTION

BACKGROUND

Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries.

AIMS

To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients.

METHODS

A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI.

RESULTS

Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival.

CONCLUSIONS

Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.

The association between sarcopenia, defined by a simplified screening tool, and long-term outcomes

BACKGROUND

Sarcopenia and frailty are frequently observed in older adult patients and linked to unfavorable postoperative outcomes. Identifying low muscle mass and function is primary for diagnosing sarcopenia. The simpler screening, which excludes muscle mass measurement, exhibited strong predictive capabilities in identifying sarcopenia. This research explored the association between sarcopenia, as defined by the C3 formula, and long-term outcomes in older adult cancer patients who underwent surgery.

METHODS

Surgical cancer patients aged 60 and older were enrolled. Sarcopenia was identified using the C3 formula, assessing muscle strength through handgrip strength, physical performance via a 6-m walk test, and nutrition status via the Mini Nutritional Assessment-Short Form. Long-term outcomes were evaluated with the Barthel Index for activities of daily living (B-ADL) at 3 months, as well as 1-year mortality rates.

RESULTS

The study enrolled 251 patients, with 130 classified as sarcopenic according to the C3 formula. Compared with nonsarcopenic patients, patients with sarcopenia exhibited a higher frequency of moderate to severe disability (B-ADL ≤70) 3 months postdischarge (19.5% vs 5.2%; P = 0.001) and elevated 1-year mortality rates (29.5% vs 14.9%; P = 0.006). No significant differences were observed in infection rates, hospital stay duration, or in-hospital mortality. Distant organ metastasis (HR = 3.99; 95% CI = 2.25-7.07) and sarcopenia defined by the C3 formula (HR = 1.78; 95% CI = 1.01-3.15) were identified as independent risk factors for 1-year mortality.

CONCLUSION

The simplified sarcopenia screening tool was associated with increased rates of moderate to severe disability 3 months postdischarge and higher 1-year mortality rates compared with nonsarcopenic patients.

C-Reactive Protein-Albumin Ratio (CAR): A More Promising Inflammation-Based Prognostic Marker for Patients Undergoing Curative Hepatectomy for Hepatocellular Carcinoma

Background

Systemic inflammatory response is a hallmark of cancer and plays a significant role in the development and progression of various malignant tumors. This research aimed to estimate the prognostic function of the C-reactive protein-albumin ratio (CAR) in patients undergoing hepatectomy for hepatocellular carcinoma (HCC) and compare it with other inflammation-based prognostic scores, including the neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, systemic immune inflammation index, prognostic index, Glasgow prognostic score, and modified Glasgow prognostic score.

Methods

Retrospective analysis was conducted on data from 1039 HCC cases who underwent curative liver resection. The prognostic performance of CAR was compared with other scores using the area under the time-dependent receiver operating characteristic (t-ROC) curve. Multivariable Cox regression analyses were performed to confirm independent predictors for disease-free survival (DFS) and overall survival (OS).

Results

The area under the t-ROC curve for CAR in the evaluation of DFS and OS was significantly greater than that of other scores and alpha-fetoprotein (AFP). Patients were stratified based on the optimal cut-off value of CAR, and the data revealed that both DFS and OS were remarkably worse in the high-CAR set compared to the low-CAR set. Multivariable Cox analysis demonstrated that CAR was an independent prognostic parameters for assessing DFS and OS. Regardless of AFP levels, all patients were subsequently divided into significantly different subgroups of DFS and OS based on CAR risk stratification. Similar results were observed when applying CAR risk stratification to other scoring systems. CAR also showed good clinical applicability in patients with different clinical features.

Conclusion

CAR is a more effective inflammation-based prognostic marker than other scores and AFP in predicting DFS as well as OS among patients with HCC after curative hepatectomy.

Value of the Prognostic Nutritional Index in Surgery for Crohn Disease in China and the Effects on Outcome: A Retrospective Study

PURPOSE

To investigate the value of the Prognostic Nutritional Index (PNI) in the surgery of Crohn Disease and examine the ability of PNI to predict poor outcomes with surgery.

METHODS

One hundred fifty-seven patients were divided into a good nutrition group (PNI ≥40) and a poor nutrition group (PNI <40). The retrospective univariate analysis, logistic regression multivariate analysis, and receiver operating characteristic (ROC) curve analysis were used to screen out independent risk factors for postoperative complications and postoperative recurrences that required reoperation.

RESULTS

Penetrating behavior was an independent risk factor for postoperative complications. Emergency surgery, penetrating behavior, hypoalbuminemia, and low PNI were independent risk factors for reoperation. By the receiver operating characteristic analysis, low PNI was superior to hypoproteinemia in predicting postsurgical recurrence.

CONCLUSIONS

PNI is a good marker for predicting surgical recurrence, but it cannot predict postoperative complications. The nutritional status in patients before elective surgery can be modified to improve PNI. It can reduce surgical recurrence to a minimum level.

Association of Neutrophil-to-Lymphocyte Ratio with Nutrition in Patients with Various Types of Malignant Tumors: A Multicenter Cross-Sectional Study

Aim

Neutrophil-to-lymphocyte ratio (NLR) is an index of systemic inflammation. This study is to clarify the role of NLR in body functional status, nutritional risk and nutritional status in the course of tumor.

Methods

A multi-center cross-sectional study of patients with various types of malignant tumors was accrued from the whole country. There were 21,457 patients with completed clinical data, biochemical indicators, physical examination, the Patient-Generated Subjective Global Assessment (PG-SGA) and Nutrition Risk Screening 2002 (NRS2002) survey. Logistic regression analysis was used to figure out the influencing factors of NLR, and four models were established to evaluate the influence of NLR on body functions, nutritional risks and nutritional status.

Results

Male patients, TNM stage IV, total bilirubin, hypertension and coronary atherosclerotic heart disease (CAHD) were independent predictors of NLR >2.5. BMI, digestive systemic tumors and triglyceride negatively affect NLR in multivariable logistic regression. NLR was an independent predictor of Karnofsky Performance Scale (KPS), fat store deficit in all degrees, moderate and severe muscle deficit, mild fluid retention and PG-SGA grade.

Conclusion

Male patients and those with hypertension and CAHD are prone to systemic inflammation. Systemic inflammation significantly degrades body function status and nutritional status, increases nutritional risk and influences fat and muscle metabolism in patients with malignant tumor. Improving the intervenable indicators such as elevating albumin and pre-albumin, decreasing total bilirubin and enhancing nutrition support are imperative. Obesity and triglyceride behave like anti-systemic inflammation, which is misleading due to reverse causation in the course of malignancy.

Comparison of laparoscopic and open radical gastrectomy for gastric cancer patients with GLIM-defined malnutrition

PURPOSE

Malnutrition is common in the patients with gastric cancer. Radical gastrectomy remained the primary strategy of curable treatment for gastric cancer. This study is performed to explore the effect of laparoscopic radical gastrectomy on clinical outcomes in gastric cancer patients with malnutrition.

METHODS

Gastric cancer patients with GLIM-defined malnutrition between 2014 and 2019 at our center were enrolled. The patients were divided into two groups according to the different type of surgery. Propensity score match analysis was used to balance the clinicopathologic characteristics of two groups. Postoperative outcomes and survival were compared. Multivariate analysis was used to independent risk factors of complication, overall survival (OS), and disease-free survival (DFS).

RESULTS

Compared with patients underwent open radical gastrectomy, patients who underwent laparoscopic radical gastrectomy had lower rate of total, surgical and severe complications. They also had shorter postoperative hospital stay with better OS and DFS. Hypoalbuminemia (P = 0.003) was the independent risk factor of complications. Old age (≥75, P = 0.035) and TNM stage (III: P < 0.001, II: P = 0.015) were the independent risk factors of OS. Combined resection (P = 0.003) and TNM stage (III: P < 0.001, II: P = 0.001) posed independent risk factors of lacking DFS. Laparoscopic surgery proved to be the independent protective factor of complications (P = 0.014), OS (P < 0.001) and DFS (P < 0.001).

CONCLUSION

Laparoscopic radical gastrectomy was relative safe and showed favorable outcomes in malnourished gastric cancer patients.

Poor Pre-operative Nutritional Status Is a Risk Factor of Post-operative Infections in Patients With Gastrointestinal Cancer—A Multicenter Prospective Cohort Study

Objective

This study aimed to assess the prognostic value of the Nutritional Risk Score 2002 (NRS2002) and patient-generated subjective global assessment (PG-SGA) for post-operative infections in patients with gastric cancer (GC) and colorectal cancer (CRC) who underwent curative surgery.

Methods

This prospective study included 1,493 GC patients and 879 CRC patients who underwent curative surgery at 18 hospitals in China between April 2017 and March 2020. The NRS2002 and PG-SGA were performed on the day of admission. The relationship between the nutritional status of patients before surgery and post-surgical incidence of infection was analyzed using univariate and multiple logistic regression analyses.

Results

According to NRS2002, the prevalence of nutritional risk was 51.1% in GC patients and 63.9% in CRC patients. According to the PG-SGA, 38.9% of GC patients and 54.2% of CRC patients had malnutrition. Approximately 4.4% of the GC patients and 9.9% of the CRC patients developed infectious complications after surgery. The univariate and multiple logistic regression analyses showed that the risk of infections was significantly higher in GC patients with a high nutritional risk score (NRS2002 ≥5) than in those with a low score (NRS2002 <3), and the PG-SGA score was identified as a predictor of post-operative infection complications of CRC.

Conclusion

The pre-operative nutritional status of patients with GC or CRC has an impact on post-operative infection occurrence. NRS2002 ≥5 was a risk factor for post-operative infection in patients with GC, and the PG-SGA B/C was a predictor of infections in patients with CRC.

Preoperative fibrinogen-to-albumin ratio predicts the prognosis of patients with hepatocellular carcinoma subjected to hepatectomy

Background

Systemic inflammatory response (SIR) plays a crucial role in every step of tumorigenesis and development. More recently, the fibrinogen-to-albumin ratio (FAR), an inflammation-based model, was suggested as a prognostic maker for various cancer patients. This research aimed to estimate the prognostic abilities of FAR, neutrophil–lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet– lymphocyte ratio (PLR), and systemic immune–inflammation index (SII) in patients with hepatocellular carcinoma (HCC) subjected to curative hepatectomy.

Methods

A total of 1,502 cases who underwent hepatectomy for HCC were included. The predictive performances of FAR, NLR, MLR, PLR and SII were assessed with regards to overall survival (OS) and disease-free survival (DFS). The area under the time-dependent receiver operating characteristic curve was used to compare prognostic performances.

Results

Data revealed that FAR had higher predictive accuracy than other inflammation-based models and alpha-fetoprotein (AFP) in assessing OS and DFS. Indeed, the OS and DFS of patients with high FAR (> 8.9), differentiated by the optimal cut-off value of FAR, were remarkably reduced (p < 0.05 for OS and DFS). Multivariate Cox regression analyses identified that AFP, FAR, clinically significant portal hypertension, tumor size, Barcelona Clinical Liver Cancer staging system, major resection and blood loss were independent indicators for predicting OS and DFS. Furthermore, these patients could be classified according to their FAR into significantly different subgroups, regardless of AFP levels (p < 0.05 for DFS and OS). Similar results were obtained in other inflammation-based prognostic models.

Conclusions

Compared with NLR, MLR, PLR, SII and AFP, FAR showed significant advantages in predicting survival of HCC patients subjected to liver resection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02328-4.

Managing Cachexia in Head and Neck Cancer: a Systematic Scoping Review

INTRODUCTION

Patients with head and neck cancer (HNC) are usually confronted with functional changes due to the malignancy itself or its treatment. These factors typically affect important structures involved in speech, breathing, chewing, swallowing, and saliva production. Consequently, the intake of food will be limited, which further contributes to loss of body weight and muscle mass, anorexia, malnutrition, fatigue, and anemia. This multifactorial condition can ultimately lead to cancer cachexia syndrome. This study aims to examine the treatment of cachexia in HNC patients.

METHODS

We systematically searched OvidMedline, PubMed, Scopus, and Web of Science for articles examining the treatment of cachexia in HNC.

RESULTS

A total of nine studies were found, and these suggested interventions including nutritional, pharmacologic, therapeutic exercise, and multimodal approaches. The nutritional intervention includes essential components such as dietary counseling, oral nutritional supplements, and medical nutritional support. Individualized nutritional interventions include oral, enteral (feeding tubes i.e., percutaneous endoscopic gastrostomy [PEG], nasogastric tube [NGT]) and parenteral nutrition. The pharmacologic interventions aim at increasing the appetite and weight of cachectic patients. Therapeutic exercise and increased physical activity can help to enhance the synthesis of muscle protein, reducing inflammation and the catabolic effects of cachexia syndrome.

CONCLUSION

Owing to the multifactorial nature of this syndrome, it is expected that the management approach should be multi-interventional. Early implementation of these interventions may help to improve survival and quality of health and life of cachectic HNC patients.

A simpler screening tool for sarcopenia in surgical patients

BACKGROUND

Sarcopenia is defined as decreased skeletal muscle mass and muscle functions (strength and physical performance). Muscle mass is measured by specific methods, such as bioelectrical impedance analysis and dual-energy X-ray absorptiometry. However, the devices used for these methods are costly and are usually not portable. A simple tool to screen for sarcopenia without measuring muscle mass might be practical, especially in developing countries. The aim of this study was to design a simple screening tool and to validate its performance in screening for sarcopenia in older adult cancer patients scheduled for elective surgery.

METHODS

Cancer surgical patients aged >60 years were enrolled. Their nutritional statuses were evaluated using the Mini Nutrition Assessment-Short Form. Sarcopenia was assessed using Asian Working Group for Sarcopenia (AWGS) criteria. Appendicular skeletal muscle mass was measured by bioelectrical impedance analysis. Four screening formulas with differing combinations of factors (muscle strength, physical performance, and nutritional status) were assessed. The validities of the formulas, compared with the AWGS definition, are presented as sensitivity, specificity, accuracy, and area under a receiver operating characteristic curve.

RESULTS

Of 251 enrolled surgical patients, 84 (34%) were diagnosed with sarcopenia. Malnutrition (odds ratio [OR]: 2.89, 95% CI: 1.40-5.93); underweight status (OR: 2.80, 95% CI: 1.06-7.43); and age increments of 5 years (OR: 1.78, 95% CI: 1.41-2.24) were independent predictors of preoperative sarcopenia. The combination of low muscle strength and/or abnormal physical performance, plus malnutrition/risk of malnutrition had the highest sensitivity, specificity, and accuracy (81.0%, 78.4%, and 79.3%, respectively). This screening formula estimated the probability of sarcopenia with a positive predictive value of 65.4% and a negative predictive value of 89.1%.

CONCLUSION

Sarcopenia screening can be performed using a simple tool. The combination of low muscle strength and/or abnormal physical performance, plus malnutrition/risk of malnutrition, has the highest screening performance.

Fibrinogen-to-Albumin Ratio is Associated with All-Cause Mortality in Cancer Patients

Background

Past studies have identified fibrinogen-to-albumin ratio (FAR) as a novel prognostic immune biomarker in various diseases. Here, we investigated the prognostic value of FAR in all combined cancer mortality.

Methods

We extracted patient data from the Multiparameter Intelligent Monitoring in Intensive Care Database III. FAR was measured prior to hospital admission. Only first admission data from each patient were used. Baseline data were extracted within 24 h after admission. The clinical endpoints were 90- and 365-day all-cause cancer mortality. Cox proportional hazards models and subgroup analyses were used to determine the relationship between FAR and these clinical endpoints.

Results

A total of 652 eligible patients were enrolled. Upon adjusting for age and gender, multivariate analysis revealed correlation between higher FAR values and increased risk of all-cause mortality. After adjusting for more confounding factors, higher FAR values significantly correlated with 90- and 365-day all-cause mortality relative to low FAR values (tertile 3 vs tertile 1: HR, 95% CI: 1.65, 1.15-2.39; 1.52, 1.10-2.10).

Conclusion

Our findings indicate that FAR may predict the risk of cancer mortality and is an independent prognostic indicator of all-cause mortality in cancer patients.

Psoas muscle mass, nutritional status, inflammation, and their relationship with prognosis in patients with pancreatic adenocarcinoma

INTRODUCTION

some factors have been shown to be associated with survival in patients with pancreatic adenocarcinoma. Recently, some studies suggested that malnutrition, muscle mass, and inflammation might have an effect on survival in patients with pancreatic malignancy.

OBJECTIVES

to investigate the association between psoas muscle mass, inflammation, nutritional status at the time of diagnosis, and survival in patients with pancreatic adenocarcinoma.

METHODS

this retrospective study included 219 patients diagnosed with pancreatic carcinoma. The nutritional status, inflammation, and psoas muscle mass of the patients at the time of diagnosis were evaluated. Nutritional status was assessed using the Prognostic Nutritional Index (PNI). Leucocyte count and neutrophil/lymphocyte ratio (NLR) were used for inflammation assessment. Psoas muscle mass was calculated by using abdominal computed tomography images of the patients.

RESULTS

the mean age of patients (80 female and 139 male) was 66.6 ± 11.7 years. According to the PNI results, 155 patients had a normal nutritional status (70 %), whereas 64 patients were malnourished (30 %). The survival of the patients with normal nutritional status was significantly longer than that of those who were malnourished (p < 0.001). There was no significant relationship between psoas muscle area, leucocyte count, NLR, and survival time.

CONCLUSION

the survival of pancreatic adenocarcinoma patients with malnutrition at the time of diagnosis was significantly shorter than for patients without malnutrition.

Predicting Postoperative Events in Patients With Gastric Cancer: A Comparison of Five Nutrition Assessment Tools

BACKGROUND/AIM

We compared the adequacy of five nutrition assessment tools with respect to their predictive value in patients with locally advanced gastric cancer (GC) receiving radical surgery.

PATIENTS AND METHODS

Five nutrition assessment tools-Glasgow prognostic score (GPS), malnutritional universal screening tool (MUST), nutritional risk screening, patient generated subjective global assessment (PG-SGA), and prognostic nutritional index (PNI)-were assessed preoperatively for stage III GC patients. The correlation between postoperative events and nutritional status was further analyzed.

RESULTS

Most of the nutritional tools accurately predicted length of hospital stay and grade 3 or higher surgical complications, while only the GPS correlated with 30-day readmission and surgical complications. The PG-SGA performed the poorest among the five tools and failed to predict any postoperative event.

CONCLUSION

The application of GPS is recommended as a prognostic index for patients with locally advanced GC prior to radical surgery.

Different muscle mass indices of the Global Leadership Initiative on Malnutrition in diagnosing malnutrition and predicting survival of patients with gastric cancer

OBJECTIVE

Malnutrition is common and related to negative prognosis in patients with gastric cancer (GC). The Global Leadership Initiative on Malnutrition (GLIM), a novel consensus for the diagnosis of malnutrition, was proposed recently. However, the roles of GLIM in diagnosing malnutrition and predicting overall survival (OS) in patients with GC have been unclear.

METHOD

We conducted a multicenter, observational cohort study including 877 hospitalized patients with GC 2013 through 2018. Different anthropometric measurements were compared to assess reduced muscle mass. Kaplan-Meier curves and multivariate Cox regression were used to analyze the relationship between GLIM-defined malnutrition and the OS of patients with GC. Independent prognostic variables were incorporated to develop a nomogram for individualized survival prediction. The calibration curve was used to determine the predictive accuracy and discriminatory capacity of the nomogram. In addition, 219 patients with GC were enrolled for external validation.

RESULTS

A total of 464 (53%) patients with GC were diagnosed with malnutrition. Patients diagnosed with severe malnutrition based on either midarm circumference or body weight-standardized hand grip strength had a shorter median survival time (16.7 mo; interquartile range, 8.4-32.7 mo) and a higher hazard ratio (HR, 1.49; 95% CI, 1.15-1.92; P = 0.002). Severe malnutrition was an independent risk factor for OS (HR, 1.32; 95% CI, 1.02-1.71; P = 0.038). The GLIM nomogram showed good performance in predicting 3-y survival in patients with GC.

CONCLUSIONS

Our findings support the effectiveness of GLIM in diagnosing malnutrition and predicting OS in patients with GC.

Importance of the preoperative prognostic nutritional index score as a predictor of chronic lung allograft dysfunction after lung transplantation: a Japanese single-institution study

PURPOSES

Numerous indicators have been discussed as predictive markers for the incidence of chronic allograft dysfunction (CLAD) after lung transplantation (LTX). The aim of this study was to evaluate whether or not the preoperative prognostic nutrition index (PNI) correlated with the development of CLAD.

METHOD

This study is a single-center and retrospective cohort study. Forty-six patients underwent cadaveric lung transplantation between 2000 and 2016 at our institution. The primary endpoint of this study was the CLAD-free survival of the patients.

RESULT

CLAD was diagnosed in 11 patients (23%) during the follow-up period. Potential risk factors included recipient factors, donor factors, number of HLA mismatches, operation-related factors, and preoperative blood test results, including the preoperative PNI. The patients with a higher PNI showed a longer CLAD-free survival after LTX than those with lower values according to univariate and multivariate analyses (p = 0.01, 0.04, respectively). The 5-year CLAD-free survival rates in the higher-PNI patients and lower-PNI patients were 94% and 62%, respectively.

CONCLUSION

We found that a lower preoperative PNI of the recipient was significantly associated with a higher incidence rate of CLAD. The preoperative PNI may, therefore, be useful as a predictor of the development of CLAD.

The prognostic nutritional index is correlated negatively with the lung allocation score and predicts survival after both cadaveric and living-donor lobar lung transplantation

PURPOSE

The prognostic nutritional index (PNI), calculated based on the serum albumin levels and the total lymphocyte count, has been identified as a predictor of clinical outcomes in various fields of surgery. In this study, we investigated the relationship between the PNI and the lung allocation score (LAS) as well as the impact of the PNI on the outcomes of both cadaveric lung transplantation (CLT) and living-donor lobar lung transplantation (LDLLT).

METHODS

We reviewed retrospective data for 127 recipients of lung transplantation (LT), including 71 recipients of CLT and 56 recipients of LDLLT.

RESULTS

The PNI was correlated significantly and negatively with the LAS (r = - 0.40, P = 0.0000037). Multivariate analysis revealed that age (P = 0.00093), BMI (P = 0.00087), and PNI (P = 0.0046) were independent prognostic factors of a worse outcome after LT. In a subgroup analysis, survival after both CLT (P = 0.015) and LDLLT (P = 0.041) was significantly worse in the low PNI group than in the high PNI group.

CONCLUSION

Preoperative nutritional evaluations using the PNI can assist with the assessment of disease severity in LT recipients and may predict survival after both CLT and LDLLT.

Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe

BACKGROUND

Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay.

METHODS

This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed.

RESULTS

Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin.

CONCLUSION

A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children.

LEVELS OF EVIDENCE

Level II treatment study.

The Influence of Pretherapeutic and Preoperative Sarcopenia on Short-Term Outcome after Esophagectomy

Simple Summary

Although introducing minimally invasive surgery reduced postoperative morbidity after esophagectomy esophageal cancer still is a malignancy with poor prognosis. This study aimed to investigate whether preoperative sarcopenia has an influence on short-term postoperative outcome after esophagectomy in esophageal cancer patients. Our findings suggest that preoperative sarcopenia is no independent prognostic factor for postoperative outcome after esophagectomy but that patients’ nutritional status consists of more factors than only body mass index (BMI) and muscle mass. Prehabilitation and preoperative optimization of the patients’ nutritional status seems to be an important factor for short-term postoperative outcome after esophagectomy.

Abstract

By introducing minimally invasive surgery the rate of postoperative morbidity in esophageal cancer patients could be reduced. But esophagectomy is still associated with a relevant risk of postoperative morbidity and mortality. Patients often present with nutritional deficiency and sarcopenia even at time of diagnosis. This study focuses on the influence of skeletal muscle index (SMI) on postoperative morbidity and mortality. Fifty-two patients were included in this study. SMI was measured using computer tomographic images at the time of diagnosis and before surgery. Then, SMI and different clinicopathological and demographic features were correlated with postoperative morbidity. There was no correlation between SMI before neoadjuvant therapy (p = 0.5365) nor before surgery (p = 0.3530) with the short-term postoperative outcome. Regarding cholesterol level before surgery there was a trend for a higher risk of complications with lower cholesterol levels (p = 0.0846). Our findings suggest that a low preoperative SMI does not necessarily predict a poor postoperative outcome in esophageal cancer patients after esophagectomy but that there are many factors that influence the nutritional status of cancer patients. To improve nutritional status, cancer patients at our clinic receive specialized nutritional counselling during neoadjuvant treatment as well as after surgery.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.

The prognostic value of preoperative fibrinogen-to-prealbumin ratio and a novel FFC score in patients with resectable gastric cancer

Background

Chronic inflammation is considered as a hallmark of gastric cancer (GC) and plays a critical role in GC progression and metastasis. This study aimed to explore the prognostic values of preoperative fibrinogen-to-prealbumin ratio (FPR), fibrinogen-to-albumin ratio (FAR), and novel FPR-FAR-CEA (FFC) score in patients with GC undergoing gastrectomy.

Methods

A total of 273 patients with resectable GC were included in this retrospective study. We performed Kaplan-Meier and Cox regression analyses to assess the prognostic role of preoperative FPR, FAR, and FFC score in patients with GC and analyze their relationships with clinicopathological features.

Results

Receiver operating characteristic curve (ROC) analysis revealed that the optimal cutoff values for FPR and FAR were 0.0145 and 0.0784, respectively. The FFC score had a higher area under the ROC curve than FAR and CEA. Elevated FPR (≥ 0.0145) and FAR (≥ 0.0784) were significantly associated with old age, large tumor size, tumor invasion depth, lymph nodes metastasis, advanced TNM stage, large Borrmann type, and anemia status. Kaplan-Meier analysis showed that high FPR, FAR, and FFC score were related to poor survival. Multivariate analyses indicated that FPR, FFC score, TNM stage, and tumor size were significant independent factors for survival.

Conclusions

Preoperative FPR and FFC score could be used as prospective noninvasive prognostic biomarkers for resectable GC.

Prognostic value of muscle depletion assessed by computed tomography for surgical outcomes of cancer patients undergoing total esophagectomy and gastrectomy

INTRODUCTION

Considering the high morbimortality rate in oncologic surgeries of the gastrointestinal tract, especially in patients with malnutrition, the use of predictive tools is necessary, since preoperative strategies could improve postoperative outcomes.

OBJECTIVES

To evaluate body composition by computed tomography and its association with morbimortality post esophagectomy and total gastrectomy.

METHODS

Prospective cohort study (n = 80). Sociodemographic, diagnostic, treatment and postoperative data were collected. Anthropometric and biochemical (hemoglobin, transferrin, and albumin) data were evaluated. The muscle mass was calculated through two methods, the muscle mass index (MMI) and the psoas total area (PTA). For postoperative complications classification, the Clavien-Dindo scale was used.

RESULTS

The prevalence of muscle depletion found was 33.8% by MMI and 61% by PTA (poor agreement, kappa = 0.25). Complication rates were 18.5% in gastrectomies and 50% in esophagectomies. No statistically significant difference was found between the presence of muscle depletion and complications. However, when stratified by surgery, a borderline association was found between the MMI and post esophagectomies complications (P = .05).

CONCLUSION

Despite the high prevalence of muscle loss, it was not possible to correlate it with surgical outcomes for gastrectomies, but for esophagectomies, there may be relevance due to borderline association, although patients received nutritional therapy.

Nutrition in surgical patients: how soon is too soon?

PURPOSE OF REVIEW

Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes.

RECENT FINDINGS

Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based.

SUMMARY

Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.

Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival

It has frequently been shown that patients with cancer are one of the largest hospital patient groups with a prevalence for malnutrition. Weight loss is a frequent manifestation of malnutrition in patients with cancer. Several large-scale studies over the past 35 y have reported that involuntary weight loss affects 50% to 80% of these patients with the degree of weight loss dependent on tumor site and type and stage of disease. The aim of this review was to determine the consequences of malnutrition, weight loss, and muscle wasting in relation to chemotherapy tolerance, postoperative complications, quality of life, and survival in patients with cancer. The prognostic impact of weight loss on overall survival has long been recognised with recent data suggesting losses as little as 2.4% predicts survival independent of disease, site, stage or performance score. Recently the use of gold-standard methods of body composition assessment, including computed tomography, have led to an increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation, as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities are highly prevalent (ranging from 10-90%, depending on cancer site and the diagnostic criteria used). Both low muscle mass and low muscle attenuation have been associated with poorer tolerance to chemotherapy; increased risk of postoperative complications; significant deterioration in a patients' performance status, and poorer psychological well-being, overall quality of life, and survival.

Adverse impact of malnutrition markers on major abdominopelvic cancer surgery

BACKGROUND

Malnutrition has been associated with adverse postoperative outcomes in a range of procedures but none have evaluated the interaction between clinical indicators of malnutrition. We aimed to comparatively evaluate how combinations of nutritional parameters impact postoperative outcomes amongst patients undergoing major cancer operations.

METHODS

Major abdominopelvic cancer surgery cases (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, nephrectomy, pancreatectomy, pneumonectomy and prostatectomy) were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2007-2016. Malnutrition was defined by the presence of the following parameters: body mass index <18.5 kg/m² ; preoperative serum albumin <3.0 g/dL or more than 10% weight loss in the last 6 months. Malnourished cases were matched with cases with satisfactory nutritional status using propensity scores. The primary outcome was the incidence of Clavien III-IV complications.

RESULTS

Of the 30 207 cases included, 8.5% had at least one marker of malnutrition. The incidence of Clavien III-IV complications across all cases was 5.8%. In the matched cohort, malnourished cases had a higher rate of complications than those with adequate nutritional status (11.3% versus 9.6%, P = 0.018). A correlation was observed between the number of malnutrition markers possessed and the incidence of Clavien III-V complications. Cases with all three makers had the highest likelihood of experiencing a complication (odds ratio 5.47, 95% confidence interval 1.85-16.17).

CONCLUSION

Poor nutritional status confers an increased risk of major postoperative complications and being discharged to a facility in non-upper gastrointestinal cancer patients. There was a correlation between the number of malnutrition parameters and the risk of complications.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Usefulness of the preoperative prognostic nutritional index score as a predictor of the outcomes of lung transplantation: A single-institution experience

BACKGROUND & AIMS

There is increasing evidence that preoperative nutritional status is a predictor of disease severity and mortality after lung transplantation (LTX). This study aimed to evaluate preoperative nutritional assessment as a predictor of LTX outcomes.

METHODS

We included 132 patients who underwent single or double LTX at Severance Hospital, Yonsei University, between October 2010 and April 2016. The Prognostic Nutritional Index (PNI) scores were calculated as follows: 10 × serum albumin value (g/dL) + 0.005 × peripheral lymphocyte count (/mm³). The optimal cut-off PNI score for the prediction of postoperative overall survival was set at 41.15 using receiver operating characteristics analysis. The efficacies of PNI and other clinical factors in predicting LTX outcomes were determined using univariate and multivariate Cox proportional hazard analyses.

RESULTS

Patients with PNI <41.15 (PNI-low group) were older, had higher preoperative C-reactive protein levels, and had lower nutritional status scores than did those in the PNI-high group (PNI ≥ 41.15). Based on Kaplan-Meier analysis, the overall survival rate was significantly better in the PNI-high group (78.3%) than in the PNI-low group (28.6%) (P < 0.001). Age, sex, body mass index, use of preoperative mechanical ventilation, C-reactive protein level, neutrophil-to-lymphocyte ratio, and PNI score were independent prognostic factors. Survival was significantly higher in the PNI-high group (hazard ratio: 0.220; P < 0.001) than in the PNI-low group, and incidence of complications ≥ grade IV was higher in the PNI-low group than in the PNI-high group (P < 0.001). Multivariate regression analysis showed that preoperative PNI score was significantly associated with postoperative survival, even after adjusting for other confounding factors.

CONCLUSIONS

Our findings suggest that PNI is a useful prognostic marker for the identification of high-risk lung transplant recipients. Preoperative nutritional assessment using PNI may provide useful information for reducing postoperative morbidity and mortality.

Does high body mass index negatively affect the surgical outcome and long-term survival of gastric cancer patients who underwent gastrectomy: A systematic review and meta-analysis

BACKGROUND

Whether high body mass index (BMI) was associated with increased postoperative complications and unfavorable prognosis of gastric cancer (GC) patients remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the impact of high BMI on surgical outcome, postoperative complications and long-term survival of GC patients.

METHODS

The related studies were identified by searching PubMed and Embase databases. According to the BMI, all GC patients were classified into BMI ≥25 kg/m² group and BMI <25 kg/m² group. The relevant data was extracted and pooled effect size was assessed using a fixed effect model or random effect model.

RESULTS

A total of 36 relevant studies involving 30,642 GC patients were included in this meta-analysis. The results indicated that high BMI patients had longer operation time, fewer number of retrieved lymph nodes and larger amount of intraoperative blood loss than other patients, regardless of open gastrectomy or laparoscopic gastrectomy. In addition, the risk of postoperative complications was significantly higher in the patients with BMI ≥25 kg/m² than in those with BMI <25 kg/m², especially for infectious complications. However, high BMI had no negative impact on postoperative mortality and long-term survival of GC patients.

CONCLUSION

Despite the increased surgical difficulty and postoperative complications, high BMI was not associated with the prognosis of GC patients. To reduce the risk of postoperative complications, more meticulous operation technique and improved perioperative management should be necessary for high BMI patients.

Neck Muscle Mass Index as a Predictor of Post-Laryngectomy Wound Complications

OBJECTIVE

We investigated the relationship between paravertebral muscle cross-sectional area (PVM CSA) at the third vertebra (C3) level using computerized tomography (CT) neck images and its relationship with complications after total laryngectomy.

DESIGN

Retrospective analysis of 60 advanced laryngeal cancer patients who underwent total laryngectomy was performed. The cross-sectional areas of paravertebral neck muscles using neck CT at C3 level images obtained preoperatively were analyzed.

RESULTS

A significant difference in PVM CSA between complication and no complication groups, F(1, 53 = 4.319, P = .043), was identified by ANCOVA. There were no significant differences in between-subject effects: T-stage ( F = 1.652, P = .204), body mass index ( F = 0.889, P = .35), albumin ( F = .359, P = .552), age ( F = 1.623 P = .208), and smoking ( F = 4.319, P = .41).

CONCLUSION

The PVM CSA measured at C3 level on pretreatment CT may help identify patients at higher risk of postoperative wound complications after total laryngectomy and who may particularly benefit from preoperative optimization of nutritional status.

Nutritional Insufficiency as a Predictor for Adverse Outcomes in Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

The effect of malnutrition on outcomes after general surgery has been well reported in the literature. However, there is a paucity of data on the effect of malnutrition on postoperative complications during adult deformity surgery. The study attempts to explore and quantify the association between hypoalbuminemia and postoperative complications.

METHODS

A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing adult deformity surgery were separated into cohorts based serum albumin (<3.5 or >3.5 g/dL). Chi-square and multivariate logistic regression models were used to identify independent risk factors.

RESULTS

A total of 2236 patients met the inclusion criteria for the study, of which 2044 (91.4%) patients were nutritionally sufficient while 192 (8.6%) patients were nutritionally insufficient. Multivariate logistic regressions revealed nutritional insufficiency as a risk factors for mortality (odds ratio [OR] = 15.67, 95% confidence interval [CI] = 6.01-40.84, P < .0001), length of stay ≥5 days (OR = 2.22, 95% CI = 1.61-3.06, P < .0001), any complications (OR = 1.82, 95% CI = 1.31-2.51, P < .0001), pulmonary complications (OR = 2.29, 95% CI = 1.29-4.06, P = .005), renal complications (OR = 2.71, 95% CI = 1.05-7.00, P = .039), and intra-/postoperative red blood cell transfusion (OR = 1.52, 95% CI = 1.08-2.12, P = .015).

CONCLUSIONS

This study demonstrates that preoperative hypoalbuminemia is a significant and independent risk factor for postoperative complications, 30-day mortality, and increased length of hospital in patients undergoing adult deformity surgery surgery. Nutritional status is a modifiable risk factor that can potentially improve surgical outcomes after adult deformity surgery.

Nutritional assessment methods as predictors of postoperative mortality in gastric cancer patients submitted to gastrectomy

ABSTRACT Objectives: to determine the nutritional evaluation method that best predicts mortality in 90 days of patients submitted to gastrectomy for gastric cancer. Methods: we conducted a prospective study with 44 patients with gastric cancer, stages II to IIIa, of whom nine were submitted to partial gastrectomy, 34 to total gastrectomy, and one to esophago-gastrectomy. All patients were nutritionally evaluated through the same protocol, up to 72h after hospital admission. The parameters used were Patient-Generated Subjective Global Assessment (PGSGA), classical anthropometry, current weight and height, percentage of weight loss (%WL) and body mass index (BMI). We also measured the thickness of the thumb adductor muscle (TAM) in both hands, dominant hand (TAMD) and non-dominant hand (TAMND), as well as the calculated the prognostic nutritional index (PNI). The laboratory profile included serum levels of albumin, erythrocytes, hemoglobin, hematocrit, leukocytes, and total lymphocytes count (TLC). Results: of the 44 patients studied, 29 (66%) were malnourished by the subjective method, 15 being grade A, 18 grade B and 11 grade C. Cases with PGSGA grade B and TAMD 10.2±2.9 mm were significantly associated with higher mortality. The ROC curves (95% confidence interval) of both PGSGA and TAMD thickness reliably predicted mortality at 30 and 90 days. No laboratory method allowed predicting mortality at 90 days. Conclusion: PGSGA and the TAMD thickness can be used as preoperative parameters for risk of death in patients undergoing gastrectomy for gastric cancer.

Actual 5-Year Nutritional Outcomes of Patients with Gastric Cancer

Purpose

In this study, we aimed to evaluate the rarely reported long-term nutritional results of patients with gastric cancer after curative gastrectomy.

Materials and Methods

We retrospectively reviewed the prospectively collected medical records of 658 patients who underwent radical gastrectomy with curative intent for gastric cancer from January 2008 to December 2009 and had no recurrences. All patients were followed for 5 years. Nutritional statuses were assessed using measurements of body weight, serum hemoglobin, total lymphocyte count (TLC), protein, albumin, cholesterol, and nutritional risk index (NRI).

Results

Patients who underwent total gastrectomy had lower body weights, hemoglobin, protein, albumin, and cholesterol levels. TLC and NRI valued after the first postoperative year (P<0.05), and lower hemoglobin and NRI valued during the fifth postoperative year than patients who underwent distal gastrectomy (P<0.05). Patients who received adjuvant chemotherapy after gastrectomy had lower hemoglobin, protein, albumin, and cholesterol levels. TLC and NRI valued during the first postoperative year, than those who underwent gastrectomy only (P<0.05). Regarding post-distal gastrectomy reconstruction, those who underwent Roux-en-Y had lower cholesterol levels than did those who underwent Billroth-I and Billroth-II reconstruction at the first and fifth years after gastrectomy, respectively (P<0.05).

Conclusions

Patients undergoing total or distal gastrectomy with Roux-en-Y anastomosis or adjuvant chemotherapy after surgery should be monitored carefully for malnutrition during the first postoperative year, and patients undergoing total gastrectomy should be monitored for malnutrition and anemia for 5 years.

A Novel Inflammation- and Nutrition-Based Prognostic System for Patients with Laryngeal Squamous Cell Carcinoma: Combination of Red Blood Cell Distribution Width and Body Mass Index (COR-BMI)

Background

Laryngeal squamous cell carcinoma (LSCC) is a head and neck cancer type. In this study, we introduced a novel inflammation- and nutrition-based prognostic system, referred to as COR-BMI (Combination of red blood cell distribution width and body mass index), for LSCC patients.

Methods

A total of 807 LSCC patients (784 male and 23 female, 22–87 y of age) who underwent surgery were enrolled in this retrospective cohort study. The patients were stratified by COR-BMI into three groups: COR-BMI (0) (RDW ≤ 13.1 and BMI ≥ 25); COR-BMI (1) (RDW ≤ 13.1 and BMI < 18.5 or 18.5 ≤ BMI < 25; RDW > 13.1 and 18.5 ≤ BMI < 25 or BMI ≥ 25); or COR-BMI (2) (RDW > 13.1 and BMI < 18.5). Cox regression models were used to investigate the association between COR-BMI and cancer-specific survival (CSS) rate among LSCC patients.

Results

The 5-y, 10-y, and 15-y CSS rates were 71.6%, 60.1%, and 55.4%, respectively. There were significant differences among the COR-BMI groups in age (< 60 versus ≥ 60 y; P = 0.005) and T stage (T1, T2, T3, or T4; P = 0.013). Based on the results, COR-BMI (1 versus 0: HR = 1.76; 95% CI = 0.98–3.15; 2 versus 0: HR = 2.91; 95% CI = 1.53–5.54, P = 0.001) was a significant independent predictor of CSS.

Conclusion

COR-BMI is a novel inflammation- and nutrition-based prognostic system, which could predict long-term survival in LSCC patients who underwent surgery.

Influence of high body mass index on mortality and infectious outcomes in patients who underwent open gastrointestinal surgery: A meta-analysis

BACKGROUND

The influence of high body mass index (BMI) on mortality and infectious outcomes of patients following open gastrointestinal surgery was unclear. This meta-analysis aimed to resolve this controversy.

METHODS

PubMed and EMBASE were searched by 2 researchers. High and normal BMIs were defined as ≥25 and 18.5-24.99, respectively. Odds ratios (ORs) were calculated to compare the pooled effect sizes. The primary outcome was mortality. The secondary outcome was infectious outcomes, including surgical site, pulmonary infections, and urinary tract infections.

RESULTS

Eleven eligible articles with 51,307 patients total were included. Compared with normal BMIs, high BMIs did not increase the risk of mortality (OR, 0.78; 95% confidence interval [CI], 0.58-1.06; P = .12). The secondary outcome indicated a significantly higher risk of infectious outcomes in high-BMI patients (OR, 1.34; 95% CI; 1.13-1.58; P = .0007). Among high-BMI patients, the risks of surgical site infections (OR, 1.75; 95% CI, 1.33-2.3; P < .0001) and pulmonary infections (OR, 1.2; 95% CI, 1.02-1.40; P = .03) increased significantly; urinary tract infections (OR, 1.10; 95% CI, 0.92-1.31; P = .30) did not show statistical difference.

CONCLUSIONS

High BMI was associated with higher risks of infectious outcomes, including surgical site infections and pulmonary infections after open gastrointestinal surgery, but no association was observed between high BMI and urinary tract infections.

Prognostic nutritional index predicts survival and correlates with systemic inflammatory response in advanced pancreatic cancer

BACKGROUND

Recent studies have implied a prognostic value of the prognostic nutritional index (PNI) in certain types of human cancers. However, the value of PNI for predicting survival in patients with pancreatic cancer remains unknown. The goal of this study was to investigate the predictive significance of PNI in patients with advanced pancreatic cancer.

METHODS

A total of 321 consecutive patients with pathologically-confirmed locally advanced or metastatic pancreatic ductal adenocarcinoma (PDAC) were retrospectively recruited between January 2011 and August 2013. The patients were divided into a test set (n = 110) and a validation set (n = 211). We evaluated the association between PNI and overall survival (OS). The relationship between PNI and systemic inflammatory response markers, including the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) was also assessed. In addition, the associations between PNI and the TNF-α were analyzed.

RESULTS

Kaplan-Meier analyses showed that a low PNI correlated significantly with a shorter OS in patients with advanced pancreatic cancer (190 days for patients with a low PNI vs. 290 days for patients with a high PNI, log-rank = 12.566, P < 0.001). Multivariate analysis identified PNI as an independent prognostic factor for OS (hazard ratio [HR]: 0.627, 95% confidence interval [CI]: 0.453-0.868, P = 0.003). PNI also correlated positively with NLR and PLR and negatively with LMR. Additionally, patients with a low PNI exhibited high levels of TNF-α.

CONCLUSIONS

Our results confirm that PNI is associated with the systemic inflammatory response and can be used to predict survival in advanced pancreatic cancer.

Total lymphocyte count and serum albumin as predictors of nutritional risk in surgical patients

BACKGROUND

Early detection of changes in nutritional status is important for a better approach to the surgical patient. There are several nutritional measures in clinical practice, but there is not a complete method for determining the nutritional status, so, health professionals should only choose the best method to use.

AIM

To evaluate the total lymphocyte count and albumin as predictors of identification of nutritional risk in surgical patients.

METHODS

Prospective longitudinal study was conducted with 69 patients undergoing surgery of the gastrointestinal tract. The assessment of nutritional status was evaluated by objective methods (anthropometry and biochemical tests) and subjective methods (subjective global assessment).

RESULTS

All parameters used in the nutritional assessment detected a high prevalence of malnutrition, with the exception of BMI which detected only 7.2% (n=5). The albumin (p=0.01), the total lymphocytes count (p=0.02), the percentage of adequacy of skinfolds (p<0.002) and the subjective global assessment (p<0.001) proved to be useful as predictors of risk of postoperative complications, since the smaller the values of albumin and lymphocyte count and higher the score the subjective global assessment were higher risks of surgical complications.

CONCLUSIONS

A high prevalence of malnutrition was found, except for BMI. The use of albumin and total lymphocyte count were good predictor for the risk of postoperative complications and when used with other methods of assessing the nutritional status, such as the subjective global assessment and the percentage of adequacy of skinfolds, can be useful for identification of nutritional risk and postoperative complications.

Pre-operative assessment of muscle mass to predict surgical complications and prognosis in patients with endometrial cancer

BACKGROUND

Sarcopenia or loss of skeletal muscle mass is an objective measure of frailty associated with functional impairment and disability. This study aimed to examine the impact of sarcopenia on surgical complications and survival outcomes in patients with endometrial cancer.

METHODS

A retrospective review of endometrial cancer patients who underwent surgery between 2005 and 2009 was performed. Sarcopenia was assessed on preoperative computed tomography (CT) scan by measurement of the lumbar psoas muscle cross-sectional area and defined as any value below the median (<4.33 cm(2)). Sarcopenic obesity was defined as sarcopenia plus a body mass index (BMI) of 30 kg/m(2) or higher. Microsatellite instability (MSI) was analyzed using the National Cancer Institute (NCI) consensus markers and tumor from hysterectomy specimens.

RESULTS

Of 122 patients, 27 (22%) met the criteria for sarcopenic obesity. Sarcopenic patients were older than patients with normal muscle mass (mean age, 69.7 vs. 62.1 years; p < 0.001), had a lower BMI (31.1 vs. 39.4 kg/m(2); p < 0.001), and had more comorbidities (p = 0.048). Sarcopenia was not associated with tumor MSI, hospital stay, 90-day readmission rate, or early/late complications. Patients with sarcopenia had a shorter recurrence-free survival than nonsarcopenic patients (median 23.5 vs. 32.1 months; log-rank p = 0.02), but did not differ in terms of overall survival (log-rank p = 0.25). After adjustment for race, BMI, lymphocyte count, and tumor histology, sarcopenia was associated with a fourfold shorter recurrence-free survival (adjusted hazard ratio [HRadj], 3.99; 95% confidence interval [CI], 1.42-11.3).

CONCLUSIONS

Sarcopenia has an impact on recurrence-free survival, but does not appear to have a negative impact on surgical outcomes or overall survival among endometrial cancer patients who undergo preoperative CT scan.

Nutritional risk index is predictor of postoperative complications in operations of digestive system or abdominal wall?

BACKGROUND

Malnutrition can be considered the most common disease in hospitals due to its high prevalence.

AIM

To investigate the methods of evaluation of the nutritional status that better correlate with postoperative complications and the length of hospital stay in patients submitted to gastrointestinal or abdominal wall surgeries.

METHODS

This is a retrospective evaluation of 215 nutritional assessment records. All were submitted to traditional anthropometry (weight, height, BMI, arm circumference, triceps skinfold thickness and mid-arm muscle circumference), subjective global assessment, serum albumin and lymphocyte count. Nutritional risk index was also calculated.

RESULTS

A total of 125 patients were included. Malnutrition was diagnosed by mid-arm muscle circumference, nutritional risk index and subjective global assessment in 46%, 88% and 66%, respectively. Severe malnutrition was found in 17,6% if considered subjective global assessment and in 42% by the nutritional risk index. Oncologic patients had a worst nutritional status according to this index (5,42 less units). There was a negative correlation between occurrence the noninfectious postoperative complications with the nutritional risk index (p=0,0016). Similarly, lower serum albumin levels were associated with higher non infectious complications (p=0,0015). The length of hospital stay was, in average, 14,24 days less in patients without complications as compared with non infectious postoperative complications (p<0,05).

CONCLUSION

Nutritional risk index and serum albumin are the parameters with the best capacity to predict the occurrence of non infectious postoperative complications and the length of hospital stay was higher to this patients.

Improving the outcomes in gastric cancer surgery

Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk surgery and five-year survival rates are poor, therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately, in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-, intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index (e.g., Charlson comorbidity index), assessment of nutritional status (e.g., short nutritional assessment questionnaire, nutritional risk screening - 2002) and frailty assessment (Groningen frailty indicator, Edmonton frail scale, Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential. Implementation of fast-track or enhanced recovery after surgery programs is showing promising results, although future studies have to determine what the exact optimal strategy is. Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection. Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far. Advances in postoperative care include optimal timing of oral diet, which has been shown to reduce hospital stay. In general, hospital volume, i.e., centralization, and clinical audits might further improve the outcome in gastric cancer surgery. In conclusion, progress has been made in improving the surgical treatment of gastric cancer. However, gastric cancer treatment is high risk surgery and many areas for future research remain.

Trends in clinical features, postoperative outcomes, and long-term survival for gastric cancer: a Western experience with 1,278 patients over 30 years

BACKGROUND

The aim of the present study was to identify temporal trends in long-term survival and postoperative outcomes and to analyze prognostic factors influencing the prognosis of patients with gastric cancer (GC) treated in a 30-year interval in a tertiary referral Western institution.

METHODS

Between January 1980 and December 2010, 1,278 patients who were diagnosed with GC at the Digestive Surgery Department, Catholic University of Rome, Italy, were identified. Among them, 936 patients underwent surgical resection and were included in the analysis.

RESULTS

Over time there was a significant improvement in postoperative outcomes. Morbidity and mortality rates decreased to 19.4% and 1.6%, respectively, in the last decade. By contrast, the multivisceral resection rate steadily increased from 12.7% to 29.6%. The overall five-year survival rate steadily increased over time, reaching 51% in the last decade, and 64.5% for R0 resections. Multivariate analysis showed a higher probability of overall survival for early stages (I and II), extended lymphadenectomy, and R0 resections.

CONCLUSIONS

Over three decades there was a significant improvement in perioperative and postoperative care and a steady increase in overall survival.