Effect of Perioperative Transfusion on Recurrence and Survival after Gastric Cancer Resection: A 7-Institution Analysis of 765 Patients from the US Gastric Cancer Collaborative

Outpatient and Ambulatory Extended Recovery Robotic Hepatectomy: Multinational Study of 307 Cases

BACKGROUND

For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure.

STUDY DESIGN

We audited outpatient (less than 2 midnights) robotic hepatectomy at 6 hepatobiliary centers in 2 nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. Establishing early recovery after surgery programs were active at all sites, and home digital monitoring was available at 1 of the institutions.

RESULTS

A total of 307 outpatient (26 same-day and 281 next-day discharge) robotic hepatectomies were identified (2013 to 2023). Most were minor hepatectomies (194 single segments, 90 bi-segmentectomies, 14 three segments, and 8 four segments). Thirty-nine (13%) were for benign histology, whereas 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, and 208 metastatic disease). Patient characteristics were a median age of 60 years (18 to 93 years), 55% male, and a median BMI of 26 kg/m 2 (14 to 63 kg/m 2 ). Thirty (10%) patients had cirrhosis. One hundred eighty-seven (61%) had previous abdominal operation. Median operative time was 163 minutes (30 to 433 minutes), with a median blood loss of 50 mL (10 to 900 mL). There were no deaths and 6 complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Readmission was required in 5 (1.6%) patients. Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7, 8, 4A, 2, and 1), there were 12 positive margins (9%) and 2 readmissions for abscess.

CONCLUSIONS

Outpatient robotic hepatectomy in well-selected cases is safe (0 mortality, 2% complication, and 1.6% readmission), including resection in the superior or posterior portions of the liver that is challenging with nonarticulating laparoscopic instruments.

Preoperative visceral fat index predicts the survival outcomes of patients with gastric cancer after surgery

Visceral adipose tissue and skeletal muscle mass are associated with carcinogenesis and clinical outcomes in patients with cancer. The aim of the present study was to determine the influence of body composition parameters on postoperative survival in patients with gastric cancer. Demographic data and systemic inflammatory response data were obtained from patients with gastric cancer undergoing radical gastrectomy. The patient's skeletal muscle and visceral fat were assessed using computed tomography, and the corresponding skeletal muscle index (SMI) and visceral fat index (VFI) were calculated. Univariate and multivariate analyses were then performed. Of the 342 patients from whom information was collected, 125 of these patients eventually succumbed to the disease. A total of 271 (79.24%) of the patients were male and 71 (20.76%) were female. Regarding the entire cohort, the mean age was 64 years [interquartile range (IQR), 56-74 years], while the mean body mass index collected was 21.53 (IQR, 19.27-24.22). The median SMI and VFI of the patients were 47.73 (IQR, 41.67-55.51) and 41.28 (IQR, 36.62-45.36), respectively. It was concluded that a low SMI and VFI were associated with worse survival outcomes. However, the neutrophil-to-lymphocyte ratio and perioperative blood transfusion were not significantly associated with overall survival (OS). Among the indicators assessed, a low VFI was an independent risk factor associated with the worst OS time (hazard ratio 1.59; confidence interval, 1.03-2.45; P=0.038). Finally, a prognostic nomogram was constructed which included the VFI to assist clinicians in making more informed decisions. In conclusion, after data collection and analysis, it was found that there was a significant correlation between a low VFI and a shorter OS time in patients with gastric cancer following gastrectomy, suggesting that VFI may be a promising therapeutic target for postoperative interventions to improve patient survival further.

Effect of different acupuncture sequences of Huiyangjiuzhen acupoints on blood glucose and hemorheology in the anesthetized rabbits

Background and objective

Hemorheology and blood glucose are commonly used to estimate the risks of thrombosis and stress hyperglycemia after anaesthesia. The sequence of acupoint stimulation might influence the therapeutic effects of acupuncture. In the current study, we aimed at investigating the effect of different acupuncture sequences of "Huiyangjiuzhen" acupoints on the blood glucose and hemorheology in anesthetized rabbits.

Methods

Twenty-five rabbits were randomly divided into five groups, including the control group (CG), the positive-sequence group (PSG), the reverse-sequence group (RSG), the disorder-sequence group (DSG), and the random group (RG). Except for the CG and RG, the rabbits in other groups were acupunctured with different sequences of "Huiyangjiuzhen"acupoints when the rabbits were anesthetized. The acupoints in rabbits of the RG were chosen randomly. The levels of blood glucose and hemorheology indexes before and after anaesthesia was detected.

Results

In the PSG, Hηb 200/s, Mηb 30/s, Hηr 200/s, ERI, hematocrit and plasma viscosity levels were decreased, and the blood glucose level was not changed. In the DSG, the levels of Mηb 30/s and hematocrit were decreased, and the blood glucose was increased. In the CG, RSG and RG, no hemorheology indexes were changed and the blood glucose was increased.

Conclusion

"Huiyangjiuzhen" acupuncture could decrease the risks of post-operative thrombosis and stress hyperglycemia in anesthetized rabbits. This effectiveness depends on both acupuncture and acupuncture sequence at the "Huiyangjiuzhen" acupoints.

Effects of perioperative blood transfusion in gastric cancer patients undergoing gastrectomy: A systematic review and meta-analysis

Background

The short-term and long-term effects of perioperative blood transfusion (PBT) on patients with gastric cancer are still intriguing. This systematic review and meta-analysis aimed to investigate the effects of blood transfusion on clinical outcomes in patients with gastric cancer undergoing gastrectomy.

Methods

We searched PubMed, Web of Science, Embase, and The Cochrane Library on December 31th 2021. The main outcomes were overall survival (OS), disease-free survival (DFS), disease-specific survival (DFS), and postoperative complications. A fixed or random-effects model was used to calculate the hazard ratio (HR) with 95% confidence intervals (CIs).

Results

Fifty-one studies with a total of 41,864 patients were included for this review and meta-analysis. Compared with patients who did not receive blood transfusions (NPBT), PBT was associated with worse 5-year OS (HR = 2.39 [95%CI: 2.00, 2.84]; p < 0.001; Multivariate HR = 1.43 [95%CI: 1.24, 1.63]; p < 0. 001), worse 5-year DFS (HR = 2.26 [95%CI: 1.68, 3.05]; p < 0.001; Multivariate HR = 1.45 [95%CI: 1.16, 1.82]; p < 0. 001), and worse 5-year DSS (HR = 2. 23 [95%CI: 1.35, 3.70]; p < 0.001; Multivariate HR = 1.24 [95%CI: 0.96, 1.60]; p < 0.001). Moreover, The PBT group showed a higher incidence of postoperative complications [OR = 2.30 (95%CI:1.78, 2. 97); p < 0.001] than that in the NPBT group, especially grade III-V complications, according to the Clavien-Dindo classification. [OR = 2.50 (95%CI:1.71, 3.63); p < 0.001].

Conclusion

In patients who underwent gastrectomy, PBT was associated with negative survival effects (OS, DFS, DSS) and a higher incidence of perioperative complications. However, more research was expected to further explore the impact of PBT. Meanwhile, strict blood transfusion management should be implemented to minimize the use of PBT.

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

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

Impact of perioperative red blood cell transfusion, anemia of cancer and global health status on the prognosis of elderly patients with endometrial and ovarian cancer

Introduction

Perioperative red blood cell (RBC) transfusions have been associated with increased morbidity and worse oncological outcome in some solid neoplasms. In order to elucidate whether RBC transfusions themselves, the preoperative anemia of cancer (AOC), or the impaired global health status might explain this impact on patients with endometrial cancer (EC) or ovarian cancer (OC), we performed a retrospective, single-institution cohort study.

Materials and methods

Women older than 60 years with EC or OC were included. The influence of RBC transfusions, AOC, and frailty status determined by the G8 geriatric screening tool (G8 score), as well as the clinical-pathological cancer characteristics on progression-free survival (PFS) and overall survival (OS), was determined by using the Kaplan-Meier method and the Cox regression analyses.

Results

In total, 263 patients with EC (n = 152) and OC (n = 111) were included in the study. Patients with EC receiving RBC transfusions were faced with a significantly shorter 5-year PFS (79.8% vs. 26.0%; p < 0.001) and 5-year OS (82.6% vs. 25.7%; p < 0.001). In multivariable analyses, besides established clinical-pathological cancer characteristics, the RBC transfusions remained the only significant prognostic parameter for PFS (HR: 1.76; 95%-CI [1.01–3.07]) and OS (HR: 2.38; 95%-CI [1.50–3.78]). In OC, the G8 score stratified the cohort in terms of PFS rates (G8-non-frail 53.4% vs. G8-frail 16.7%; p = 0.010) and AOC stratified the cohort for 5-year OS estimates (non-anemic: 36.7% vs. anemic: 10.6%; p = 0.008). Multivariable Cox regression analyses determined the G8 score and FIGO stage as independent prognostic factors in terms of PFS (HR: 2.23; 95%-CI [1.16–4.32] and HR: 6.52; 95%-CI [1.51–28.07], respectively). For OS, only the TNM tumor stage retained independent significance (HR: 3.75; 95%-CI [1.87–7.53]).

Discussion

The results of this trial demonstrate the negative impact of RBC transfusions on the prognosis of patients with EC. Contrastingly, the prognosis of OC is altered by the preoperative global health status rather than AOC or RBC transfusions. In summary, we suggested a cumulatively restrictive transfusion management in G8-non-frail EC patients and postulated a more moderate transfusion management based on the treatment of symptomatic anemia without survival deficits in OC patients.

Impact of allogeneic red blood cell transfusion on prognosis in soft tissue sarcoma patients. A single-centre study

BACKGROUND

Perioperatively administered (leukocyte reduced) allogeneic red blood cell transfusions (lrRBCTs) may lead to transfusion-related immunomodulation and reduced overall survival (OS) in cancer patients. Herein, the effect of lrRBCT on local recurrence (LR), distant metastasis (DM), and OS in soft tissue sarcoma (STS) patients was analysed.

METHODS

Retrospective study on 432 STS patients (mean age: 60.0 ± 17.8 years; 46.1% female), surgically treated at a tertiary tumour centre. Uni- and multivariate survival models were calculated to analyse impact of perioperative lrRBCTs on LR, DM, OS.

RESULTS

Perioperatively, 75 patients (17.4%) had received lrRBCTs. Older patients, deep, large, lower limb STS rather required lrRBCTs (all p < 0.05). No significant association between lrRBCT administration and LR- (p = 0.582) or DM-risk (p = 0.084) was observed. LrRBCT was associated with worse OS in univariate analysis (HR: 2.222; p < 0.001), with statistical significance lost upon multivariate analysis (HR: 1.658; p = 0.059; including age, histology, size, grading, amputation, depth). Adding preoperative haemoglobin in subgroup of 220 patients with laboratory parameters revealed significant negative impact of low haemoglobin on OS (p = 0.014), whilst effect of lrRBCT was further diminished (p = 0.167).

CONCLUSION

Unfavourable prognostic factors prevail in STS patients requiring lrRBCTs. Low haemoglobin levels rather than lrRBCT seem to reduce OS.

Does Intraoperative Blood Loss Affect the Short-Term Outcomes and Prognosis of Gastric Cancer Patients After Gastrectomy? A Meta-Analysis

Purpose

The purpose of the current meta-analysis was to analyze whether intraoperative blood loss (IBL) influenced the complications and prognosis of gastric cancer patients after gastrectomy.

Methods

We systematically searched the PubMed, Embase and Cochrane library databases on November 29, 2021. The Newcastle-Ottawa scale was used to evaluate the quality of included studies. This meta-analysis uses RevMan 5.3 for data analysis.

Results

A total of nine retrospective studies were included in this meta-analysis, involving 4653 patients. In terms of short-term outcomes, the Larger IBL group has a higher complication rate (OR = 1.94, 95% CI, 1.44 to 2.61, P < 0.0001) and a longer operation time (OR = 77.60, 95% CI, 41.95 to 113.25, P < 0.0001) compared with the smaller IBL group, but the Larger IBL group had higher total retrieved lymph nodes (OR = 3.68, 95% CI, 1.13 to 6.24, P = 0.005). After pooling up all the HRs, the Larger IBL group has worse overall survival (OS) (HR = 1.80, 95% CI, 1.27 to 2.56, P = 0.001) and disease-free survival (DFS) (HR = 1.48, 95% CI, 1.28 to 1.72, P < 0.00001).

Conclusion

Larger IBL increased operation time and postoperative complications, and decreased OS and DFS of gastric cancer patients. Therefore, surgeons should be cautious about IBL during operation.

A Machine Learning-Modified Novel Nomogram to Predict Perioperative Blood Transfusion of Total Gastrectomy for Gastric Cancer

Background

Perioperative blood transfusion reserves are limited, and the outcome of blood transfusion remains unclear. Therefore, it is important to prepare plans for perioperative blood transfusions. This study aimed to establish a risk assessment model to guide clinical patient management.

Methods

This retrospective comparative study involving 513 patients who had total gastrectomy (TG) between January 2018 and January 2021 was conducted using propensity score matching (PSM). The influencing factors were explored by logistic regression, correlation analysis, and machine learning; then, a nomogram was established.

Results

After assessment of the importance of factors through machine learning, blood loss, preoperative controlling nutritional status (CONUT), hemoglobin (Hb), and the triglyceride–glucose (TyG) index were considered as the modified transfusion-related factors. The modified model was not considered to be different from the original model in terms of performance, but is simpler. A nomogram was created, with a C-index of 0.834, and the decision curve analysis (DCA) demonstrated good clinical benefit.

Conclusions

A nomogram was established and modified with machine learning, which suggests the importance of the patient’s integral condition. This emphasizes that caution should be exercised regarding transfusions, and, if necessary, preoperative nutritional interventions or delayed surgery should be implemented for safety.

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

Background/objective

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

Methods

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

Results

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

Conclusions

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

Prognostic Value of Intraoperative Blood Transfusion in Patients with Adenocarcinoma of the Esophagogastric Junction

Background and objectives: Adenocarcinoma of the esophagogastric junction (AEG) has a complicated surgical anatomy, due to which it sometimes induces excessive intraoperative blood loss that necessitates intraoperative blood transfusion (BTF). However, few reports have focused on the impact of BTF on the survival outcomes of patients with AEG. We aimed to evaluate the impact of BTF on AEG prognosis. Materials andMethods: We included 63 patients who underwent surgical resection for AEG at our hospital between January 2010 and September 2020. Clinicopathological characteristics and survival outcomes were compared between patients with (n = 12) and without (n = 51) BTF. Multivariate analysis was performed to identify the independent prognostic factors for overall survival. Results: None of the patients who underwent minimally invasive surgery received BTF. Patients who received BTF had a significantly worse 5-year survival rate than those who did not (67.8% vs. 28.3%, p = 0.001). BTF was an independent risk factor for overall survival (hazard ratio: 3.90, 95% confidence interval 1.30–11.7), even after patients who underwent minimally invasive surgery were excluded. Conclusions: BTF adversely affected the survival outcomes of patients with AEG who underwent curative surgery. To avoid BTF, surgeons should strive to minimize intraoperative bleeding.

Blood transfusion has an adverse impact on the prognosis of patients receiving chemotherapy for advanced colorectal cancer: experience from a single institution with a patient blood management program

PURPOSE

Perioperative blood transfusion in early stage cancer patients had a negative effect on the prognosis of patients, but the prognostic impact of transfusion in advanced cancer patients remains unclear. To minimize and guide rational transfusion, an institutional patient blood management (PBM) program was launched, and we evaluated the new program that has changed the practice and impacted on the prognosis of advanced cancer patients.

METHODS

We investigated the medical records of colorectal cancer patients who received chemotherapy from 2015 to 2020. The amount and frequency of transfusion, iron replacement and laboratory findings, and overall survival were compared before and after implementation of PBM.

RESULTS

The rate of transfusion in colorectal cancer patients was significantly decreased from 23.5/100 person-quarter in 2015 to 1.2/100 person-quarter in 2020, but iron supplementation therapy was frequently used, and the proportion of patients who received transfusion under hemoglobin 7 g/dL significantly increased from 15.9% in 2015 to 55.3% in 2020. Multivariate analysis revealed that transfusion was a significant risk factor affecting the overall survival of patients (HR 2.70, 95% CI: 1.93-3.78, p<0.001). Kaplan-Meier analysis revealed that overall survival was significantly longer in non-transfused patients than in transfused patients (11.0 versus 22.4 months; HR 0.69, 95% CI: 0.56-0.86, p<0.001).

CONCLUSIONS

This study shows that minimized transfusion through an institutional PBM can positively affect the prognosis of patients who are receiving chemotherapy for advanced colorectal cancer.

Effects of Red Blood Cell Transfusions on Distant Metastases of Oral Squamous Cell Carcinomas

Simple Summary

Patients with distant metastasis of oral squamous cell carcinoma should be identified at an early stage of disease. In this study, we investigated if patients who received red blood cell transfusions are at risk for the development of distant metastasis. A positive correlation was found between RBC transfusion (HR = 2.42) and the occurrence of M+ in a multivariate regression model. Therefore, the administration of RBC can be considered as an independent prognostic factor and special attention should be paid to its detrimental effects in the perioperative management of OSCC patients.

Abstract

There is no consensus on the effect of red blood cell (RBC) transfusions on patients with oral squamous cell carcinoma (OSCC). The aim of this study was to investigate the association between RBC administration and the occurrence of distant metastases (M+) after surgical treatment of OSCC. All medical records of patients who underwent primary surgery for OSCC in our department (2003–2019) were analyzed retrospectively (n = 609). Chi and Cox regression models were used to analyze the influence of transfusion on the development of M+, and survival rates. Kaplan–Meier curves were used for graphical presentation. A multitude of patient-specific factors showed a statistical impact in univariate analysis (transfusion, age, gender, diabetes, pT, pN, L, V, Pn, G, UICC, adjuvant therapy, free microvascular transplant, preoperative hemoglobin level). Transfusion status and pN stage were the only variables that showed a significant correlation to M+ in the multivariate Cox model. The hazard ratios for the occurrence of M+ were 2.42 for RBC transfusions and 2.99 for pN+. Administration of RBC transfusions was identified as a significant prognostic parameter for the occurrence of distant metastases after surgical treatment of OSCC. Hence, the administration of RBC transfusions should be considered carefully in the perioperative management.

Blood transfusion had no influence on the 5-year biochemical recurrence after robot-assisted radical prostatectomy: a retrospective study

Background

Although red blood cells (RBC) transfusion is known to be significantly associated with biochemical recurrence in patients undergoing open prostatectomy, its influence on biochemical recurrence after robot-assisted laparoscopic radical prostatectomy remains unclear. Therefore, this study aimed to validate the effect of RBC transfusion on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Methods

This study retrospectively analyzed the medical records of patients who underwent robot-assisted laparoscopic radical prostatectomy at single tertiary academic hospital between October 2007 and December 2014. Univariate and multivariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with 5-year biochemical recurrence.

Results

A total of 1311 patients were included in the final analysis. Of these, 30 patients (2.3%) were transfused with RBC either during robot-assisted laparoscopic radical prostatectomy or during their hospital stay, which corresponded to 5-year biochemical recurrence of 15.7%. Multivariate Cox proportional hazard regression analysis showed that RBC transfusion had no influence on the 5-year biochemical recurrence. Variables including pathologic T stage (Hazard ratio [HR] 3.5, 95% confidence interval [CI] 2.4–5.1 p < 0.001), N stage (HR 2.3, 95% CI 1.5–3.7, p < 0.001), Gleason score (HR 2.4, 95% CI 1.8–3.2, p < 0.001), and surgical margin (HR 2.0, 95% CI 1.5–2.8, p < 0.001) were independently associated with the 5-year biochemical recurrence.

Conclusions

RBC transfusion had no significant influence on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy.

A Novel Nomogram for Prediction of Early Postoperative Complications of Total Gastrectomy for Gastric Cancer

Background

Accurate prediction of postoperative complications is especially important for the formulation of treatment plans for patients with total gastrectomy (TG) for gastric cancer (GC). The purpose of this study was to establish a risk assessment model for early postoperative complications.

Methods

This retrospective study involved 363 patients with GC who underwent TG from January 2019 to December 2020. The influencing factors were explored by univariate and multivariable logistic regression; then, a nomogram was established and verified by internal verification.

Results

Linear stapler (OR=2.501, P=0.030), age (OR=1.052, P =0.024), blood transfusion (yes) (OR=2.450, P =0.021), one-time consumables for surgery (or=1.000, P =0.022), number of total lymph nodes (OR=1.060, P =0.011) and number of positive lymph nodes (OR=1.054, P =0.029) were independent risk factors for early postoperative complications in TG, and nomogram model was constructed. The C-index of primary cohort, modeling cohort and validation cohort was 0.787, 0.754 and 0.912. The calibration curves showed good accuracy.

Conclusion

This study used the indicators available before and during surgery to establish a nomogram model for early postoperative complications of total gastrectomy for gastric cancer, which found that linear stapler (LS), blood transfusion, one-time consumables for surgery, number of total lymph nodes and number of positive lymph nodes were factors.

Do Red Blood Cell Transfusions Influence Long-Term Outcomes in Patients Undergoing Primary Surgery for Oral Squamous Cell Carcinoma?

PURPOSE

There is no consensus on the impact of red blood cell (RBC) transfusion on patients with oral squamous cell carcinoma (OSCC). The purpose of this study was to investigate the association between RBC transfusions and overall survival (OS) and tumor-free survival (TFS) after operative treatment of OSCC.

METHODS

In this retrospective cohort study, all patients treated with primary surgery between 2003 and 2017 because of OSCC were chart reviewed. The occurrence and amount of RBC transfusions (0; 1-3; >3 units) was correlated with OS and TFS by Kaplan-Meier survival and Cox regression analyses. Demographic, clinical, and pathological parameters were also evaluated in order to identify confounding factors.

RESULTS

Of 420 patients (243 [57.9%] male) with a mean age of 62.6 years, 67 (16.0%) received RBC transfusion. There were statistically significant (P < .01) differences in 5-year OS respectively TFS in transfused patients for the Kaplan-Meier survival analysis (0 units = 70.6%; [95% confidence interval {CI}: 65.0-75.4%] respectively 63.2% [95% CI: 57.4-68.4%], 1-3 units = 47.2% [95% CI: 29.4-63.1%] respectively 40.6% [95% CI: 24.6-55.95%] and >3 units = 48.9% [95% CI: 20.9-72.1%] respectively 30.5% [95% CI: 8.9-55.8%]). After multivariate adjustments for demographic, clinical, and pathological parameters, RBC transfusion could not be sustained as a significant prognostic factor in OS respectively TFS (1-3 units: hazard ratio = 1.5 [95% CI: 0.7-3.2] respectively 1.3 [95% CI: 0.7-2.6]; >3 units: hazard ratio = 1.2 [95% CI: 0.5 - 3.0] respectively 1.1 [95% CI: 0.5-2.4]).

CONCLUSIONS

Although RBC transfusion was not identified as a significant prognostic parameter in multivariate analysis, a clear trend for shorter OS and TFS for transfused patients in univariate and Kaplan-Meier survival analysis could be shown.

Impact of Perioperative Blood Transfusions on Outcomes After Hyperthermic Intraperitoneal Chemotherapy: A Propensity-Matched Analysis

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major operation frequently necessitating red blood cell transfusion. Using multi-institutional data from the U.S. HIPEC Collaborative, this study sought to determine the association of perioperative allogenic blood transfusion (PABT) with perioperative outcomes after CRS/HIPEC.

METHODS

This retrospective cohort study analyzed patients who underwent CRS/HIPEC for peritoneal surface malignancy between 2000 and 2017. Propensity score-matching was performed to mitigate bias. Univariate analysis was used to compare demographic, preoperative, intraoperative, and postoperative variables. Factors independently associated with PABT were identified using multivariate analysis.

RESULTS

The inclusion criteria were met by 1717 patients, 510 (29.7%) of whom required PABT. The mean Peritoneal Cancer Index (PCI) of our cohort was 14.8 ± 9.3. Propensity score-matching showed an independent association between PABT and postoperative risk of pleural effusion, hemorrhage, pulmonary embolism, enteric fistula formation, Clavien-Dindo grades 3 and 4 morbidity, longer hospital stay, and reoperation (all P < 0.05 in the multivariate analysis). Compared with the patients who received 1 to 5 red blood cell (RBC) units, the patients who received more than 5 units had a greater risk of renal impairment, a longer intensive care unit (ICU) stay, and more postoperative infections. Finally, PABT was an independent predictor of worse survival for patients with appendiceal and colorectal primaries.

CONCLUSION

Even low levels of PABT for patients undergoing CRS/HIPEC are independently associated with a greater risk of infectious and non-infectious postoperative complications, and this risk is increased for patients receiving more than 5 RBC units. Worse survival was independently predicted by PABT for patients with peritoneal carcinomatosis of an appendiceal or colorectal origin.

Perioperative blood transfusion is not an independent predictor for worse outcomes in retroperitoneal sarcoma surgery

BACKGROUND

Surgery for retroperitoneal soft tissue sarcoma (RPS) is technically challenging, often requiring perioperative red blood cell transfusion (PBT). In other cancers, controversy exists regarding the association of PBT and oncologic outcomes. No study has assessed this association in primary RPS, or identified factors associated with PBT.

METHODS

Data was collected on all resected primary RPS between 2006 and 2020 at The Ottawa Hospital (Canada) and University Hospital Birmingham (United Kingdom). 'PBT' denotes transfusion given one week before surgery until discharge. Multivariable regression (MVA) identified clinicopathologic factors associated with PBT and assessed PBT association with oncologic outcomes. Surgical complexity was measured using resected organ score (ROS) and patterns of resection.

RESULTS

192 patients were included with 98 (50.8%) receiving PBT. Median follow-up was 38.2 months. High tumour grade (OR 2.20, P = 0.048), preoperative anemia (OR 2.78, P = 0.020), blood loss >1000 mL (OR 4.89, P = 0.004) and ROS >2 (OR 2.29, P = 0.026) were associated with PBT on MVA. A direct linear relationship was observed between higher ROS and increasing units of PBT (β = 0.586, P = 0.038). Increasingly complex patterns of resection were associated with increasing odds of PBT. PBT was associated with severe post-operative complications (P = 0.008) on MVA. Univariable association between PBT and 5-year disease-free or overall survival was lost upon MVA.

CONCLUSIONS

Surgical complexity and high tumour grade are potentially related to PBT. Oncologic outcomes are not predicted by PBT but are better explained by tumour grade which subsequently may increase surgical complexity. Strategies to reduce PBT should be considered in primary RPS patients.

Red blood cell transfusions and the survival in patients with cancer undergoing curative surgery: a systematic review and meta-analysis

Allogenic red blood cell transfusions exert a potential detrimental effect on the survival when delivered to cancer patients undergoing surgery with curative intent. We performed a systematic review and meta-analysis to assess the association between perioperative allogenic red blood cell transfusions and risk of death as well as relapse after surgery for localized solid tumors. PubMed, the Cochrane Library, and EMBASE were searched from inception to March 2019 for studies reporting the outcome of patients receiving transfusions during radical surgery for non-metastatic cancer. Risk of death and relapse were pooled to provide an adjusted hazard ratio with a 95% confidence interval [hazard ratio (HR) (95% confidence interval {CI})]. Mortality and relapse associated with perioperative transfusion due to cancer surgery were evaluated among participants (n = 123 studies). Overall, RBC transfusions were associated with an increased risk of death [HR = 1.50 (95% CI 1.42-1.57), p < 0.01] and relapse [HR = 1.36 (95% CI 1.26-1.46), p < 0.01]. The survival was reduced even in cancer at early stages [HR = 1.45 (1.36-1.55), p < 0.01]. In cancer patients undergoing surgery, red blood cell transfusions reduced the survival and increased the risk of relapse. Transfusions based on patients' blood management policy should be performed by applying a more restrictive policy, and the planned preoperative administration of iron, if necessary, should be pursued.

Perioperative Transfusions for Gastroesophageal Cancers: Risk Factors and Short- and Long-Term Outcomes

BACKGROUND

Perioperative blood transfusions have been associated with increased morbidity and poorer oncologic outcomes for numerous surgical procedures. However, this issue is understudied among patients with gastroesophageal malignancies. The objective was to clarify the risk factors and impact of perioperative transfusions on quality of life and surgical and oncologic outcomes among patients undergoing gastric and esophageal cancer surgery.

METHODS

Patients undergoing curative-intent resections for gastroesophageal cancers between 2010 and 2018 were included. Perioperative blood transfusion was defined as any transfusion within 24 h pre-operatively, during surgery, or the primary post-operative hospitalization period. Patient and tumor characteristics, surgical and oncological outcomes, and quality of life were compared.

RESULTS

A total of 435 patients were included. Perioperative transfusions occurred in 184 (42%). Anemia, blood loss, female sex, open surgical approach, and operative time emerged as independent risk factors for transfusions. Factors found to be independently associated with overall survival were neoadjuvant therapy, tumor size and stage, major complications, and mortality. Transfusions did not independently impact overall survival, disease-free survival, or quality of life.

CONCLUSIONS

Perioperative transfusions did not impact oncologic outcomes or quality of life among patients undergoing curative-intent surgery for gastroesophageal cancers.

Current perspectives on the safety and efficacy of robot-assisted surgery for gastric cancer

INTRODUCTION

Robotic gastrectomy is performed worldwide as part of the treatment for gastric cancer and is associated with good clinical outcome. This review aims to describe the current issues, debates, and future directions associated with the use of robotic gastrectomy for gastric cancer.

AREA COVERED

Here, we review the current evidence surrounding the safety and efficacy of robotic gastrectomy, including our institutional experience. Current issues associated with robotic gastrectomy, including feasibility, perioperative outcomes, and oncological outcomes, are described.

EXPERT OPINION

Sophisticated movements, articulating instruments, and the rapid introduction of fast-developing novel technology make robotic gastrectomy use more frequent. However, the need for well-designed prospective randomized trials is warranted.

Improved postoperative outcomes and reduced transfusion rates after implementation of a Patient Blood Management program in gastric cancer surgery

INTRODUCTION

Gastric cancer patients are often transfused with red blood cells, with negative impact on postoperative course. This multicenter prospective interventional cohort study aimed to determine whether implementation of a Patient Blood Management (PBM) program, was associated with a decrease in transfusion rate and improvements in clinical outcomes in gastric cancer surgery.

METHODS

We compared transfusion practices and clinical outcomes in patients undergoing elective gastric cancer resection before and after implementing a PBM program, including strategies to detect and treat anemia and restrictive transfusion practice (2014-2018). Primary outcome was transfusion rate (TR). Secondary outcomes were complications, reoperations, length of stay, readmissions, 90-day mortality and failure-to-rescue. Differences were adjusted by confounding factors.

RESULTS

Some 789 patients were included (496 pre- and 293 post-PBM). TR decreased from 39.1% to 27.0% (adjusted difference -9.1, 95% CI -15.2 to -2.9), being reduction particularly significant in patients with anemia, ASA score 3-4, locally advanced tumors, undergoing open surgery and total gastrectomy. Infectious complications diminished from 25% to 16.4% (-6.1, 95%CI -11.5 to -0.7), reoperations from 8.1% to 6.1% (-2.2, 95%CI -5.1 to +0.6), median length of stay from 11 [IQR 8-18] to 8 [7-12] days (p < 0.001), hospital readmission from 14.1% to 8.9% (-5.4, 95%CI -9.6 to -1.1), mortality from 7.9% to 4.8% (-2.4, 95%CI -4.7 to -0.01), and failure-to rescue from 62.7% to 32.7% (-23.1, 95%CI -37.7 to -8.5).

CONCLUSION

Implementation of a PBM program was associated with a reduction in transfusion rate and improvement in postoperative outcomes in gastric cancer patients undergoing curative resection.

Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

BACKGROUND

Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published over the past 10 years supports restrictive transfusion practices and blood conservation programs. Whether transfusion practices have changed remains unclear. We describe temporal RBC transfusion trends in a large North American population who underwent gastrointestinal cancer surgery.

METHODS

We conducted a population-based retrospective cohort study of patients who underwent gastrointestinal cancer resection between 2007 and 2018 using health administrative datasets. The outcome was RBC transfusion during hospitalization. Temporal transfusion trends were analyzed with Cochran-Armitage tests. Multivariable regression assessed the association between year of diagnosis and likelihood of RBC transfusion while controlling for confounding.

RESULTS

Of 79,764 patients undergoing gastrointestinal cancer resection, the median age was 69 years old (interquartile range (IQR) 60-78 years) and 55.5% were male. The most frequent procedures were colectomy (52.8%) and proctectomy (23.0%). A total of 18,175 patients (23%) received RBC transfusion. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p < 0.001). After adjusting for patient, procedure, and hospital factors, the most recent time period (2015-2018) was associated with a reduced likelihood of receiving RBC transfusion [relative risk 0.86 (95% confidence interval: 0.83-0.89)] relative to the intermediate time period (2011-2014).

CONCLUSION

Over 11 years, we observed decreased RBC transfusion use and reduced likelihood of transfusion in patients undergoing gastrointestinal cancer resection. This information provides a foundation to further examine transfusion appropriateness or explore if additional transfusion minimization in surgical patients can be achieved.

Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy

BACKGROUND

At present, the enhanced recovery after surgery (ERAS) protocol is widely implemented in the field of gastric surgery. However, the effect of the ERAS protocol on the long-term prognosis of gastric cancer has not been reported.

AIM

To compare the effects of ERAS and conventional protocols on short-term outcomes and long-term prognosis after laparoscopic gastrectomy.

METHODS

We retrospectively analyzed the data of 1026 consecutive patients who underwent laparoscopic gastrectomy between 2012 and 2015. The patients were divided into either an ERAS group or a conventional group. The groups were matched in a 1:1 ratio using propensity scores based on covariates that affect cancer survival. The primary outcomes were the 5-year overall and cancer-specific survival rates. The secondary outcomes were the postoperative short-term outcomes and inflammatory indexes.

RESULTS

The patient demographics and baseline characteristics were similar between the two groups after matching. Compared to the conventional group, the ERAS group had a significantly shorter postoperative hospital day (7.09 d vs 8.67 d, P < 0.001), shorter time to first flatus, liquid intake, and ambulation (2.50 d vs 3.40 d, P < 0.001; 1.02 d vs 3.64 d, P < 0.001; 1.47 d vs 2.99 d, P < 0.001, respectively), and lower medical costs ($7621.75 vs $7814.16, P = 0.009). There was a significantly higher rate of postoperative complications among patients in the conventional group than among those in the ERAS group (18.1 vs 12.3, P = 0.030). Regarding inflammatory indexes, the C-reactive protein and procalcitonin levels on postoperative day 3/4 were significantly different between the two groups (P < 0.001 and P = 0.025, respectively). The ERAS protocol was associated with significantly improved 5-year overall survival and cancer-specific survival rates compared with conventional protocol (P = 0.013 and 0.032, respectively). When stratified by tumour stage, only the survival of patients with stage III disease was significantly different between the two groups (P = 0.044).

CONCLUSION

Adherence to the ERAS protocol improves both the short-term outcomes and the 5-year overall survival and cancer-specific survival of patients after laparoscopic gastrectomy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Extracellular ubiquitin promotes hepatoma metastasis by mediating M2 macrophage polarization via the activation of the CXCR4/ERK signaling pathway

Background

Stored red blood cell (RBC) transfusion has been shown to enhance the risk of cancer recurrence. However, the underlying mechanism remains unknown. At our lab, we have demonstrated that the extracellular ubiquitin (eUb) released by aged RBCs could promote tumor metastasis in a melanoma mouse model. This study aimed to confirm the pro-tumor effect of eUb on hepatocellular carcinoma (HCC) and explore the related immunoregulatory mechanisms.

Methods

Forty HCC tissue specimens and the corresponding adjacent nontumor and normal liver tissues were collected. Two human hepatoma cell lines (MHCC-97H and HepG2.2.15), one murine hepatoma cell line (Hepa1-6), and one human monocyte cell line (THP-1) were adopted in this study. The coculture of hepatoma cells with macrophages was initiated with Transwell inserts. Cell migration in vitro was detected by Transwell and wound-healing assays, while in vivo tumor metastasis was measured by luciferase assay and H&E staining. Macrophage polarization was measured by flow cytometry, immunofluorescence, ELISA, qPCR, and Western blot. Protein expression was detected by Western blot, and immunoprecipitation was used to confirm the interaction between Ub and CXCR4 (CXC chemokine receptor type 4).

Results

Ub and CXCR4 were significantly upregulated in HCC tissues, and a positive correlation existed between them. In vitro, the migration of hepatoma cells was not affected by eUb directly, but their metastatic abilities were enhanced after coculture with the macrophages pretreated with eUb. Meanwhile, eUb promoted hepatoma cell metastasis in the lung in vivo and increased the ratio of M2 macrophages in the lung tissues and peripheral blood of tumor-bearing mice. Furthermore, the eUb-induced M2 macrophage polarization was related to the activation of the CXCR4/ERK (extracellular regulated protein kinase) signaling pathway.

Conclusions

Extracellular ubiquitin promoted hepatoma metastasis through M2 macrophage polarization via the activation of the CXCR4/ERK signaling pathway, indicating that a personalized transfusion strategy is needed for the treatment of HCC patients. Neutralizing Ub in stored RBC units could lessen the detrimental clinical outcomes induced by the transfusion of stored RBCs.

Impact of postoperative complications on long-term outcomes of patients following surgery for gastric cancer: A systematic review and meta-analysis of 64 follow-up studies

Gastrectomy for cancer is a technically demanding procedure, with postoperative complications (POCs) reported to be in the range of 20%-46%. However, the effect of POCs on long-term survival of gastric cancer patients following surgery is far from conclusive. This systemic review aimed to determine the impact of postoperative complications (POCs) on the long-term survival of patients following surgery for gastric cancer. A systematic electronic search of PubMed and Scopus was performed from inception to June 26, 2018 to identify studies that described the relationship between POCs and long-term survival. Hazard ratios (HRs) for overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) from each study were combined using a random-effects model. Sixty-four eligible studies with reported results for 46198 gastric cancer patients were included. A meta-analysis found a statistically significant difference in OS, CSS and RFS between gastric patients with unspecific POCs and no POCs, POCs ≥ Clavien-Dindo grade (CD) 2 and < CD2, major POCs and minor POCs, infectious and non-infectious complications, anastomotic and non-anastomotic complications, and cardiopulmonary and non-cardiopulmonary complications. Subgroup and sensitivity analyses did not significantly change the summary of OS risk estimates between patients with POCs and without POCs. No significant publication bias was observed for the same outcome. The meta-analysis revealed that POCs were associated with worse survival among patients with resected gastric cancer, suggesting that treatment strategies aimed at minimizing POCs may improve oncological outcomes.

Role of the initial degree of anaemia and treatment model in the prognosis of gastric cancer patients treated by chemotherapy: a retrospective analysis

Background

Anaemia is highly prevalent in gastric cancer (GC) patients. The role of initial haemoglobin levels in predicting the prognosis of GC patients treated by chemotherapy has not been well determined. Our present study aims to evaluate the relationship between the degree of anaemia and the overall survival (OS) and progression-free survival (PFS) of patients with GC.

Methods

Our retrospective study enrolled 598 patients who were treated with chemotherapy when the recurrent or metastatic GCs were unsuitable for surgical resection. Univariate and multivariate analyses were performed to identify risk factors that had the potential to affect patient prognosis. Additionally, the relationship between clinicopathological characteristics, including treatment method, and degree of cancer-related reduction in haemoglobin was further analysed.

Results

Our results revealed that patients with HB_ini level ≤ 80 g/L had a trend toward a shortened median OS and PFS (p = 0.009 and p = 0.049, respectively). Interestingly, we also found that HB_dec ≥ 30 g/L was associated with a significantly shortened median OS and PFS (p = 0.039 and p = 0.001, respectively). Multivariate analysis showed that HB_ini levels ≤80 g/L could be used as an independent prognostic factor for recurrent and metastatic GC. More importantly, HB_dec ≥ 30 g/L and treatment response were also significantly associated with OS and PFS. Furthermore, the degree of haemoglobin decrease was associated with chemotherapy including platinum and the number of chemotherapy cycles.

Conclusion

Our study concludes that the initial degree of anaemia and a decrease in haemoglobin of ≥30 g/L can serve as biomarkers to predict prognosis in recurrent or metastatic GC patients, while chemotherapy treatment rather than red blood cell (RBC) transfusion can improve their prognosis. Additionally, platinum should not be recommended for treating severely anaemic GC patients.

Postoperative Outcomes Within an Enhanced Recovery after surgery protocol in gastric surgery for cancer (POWER.4): Study protocol for a prospective, multicentre, observational cohort study

BACKGROUND AND OBJECTIVE

Enhanced recovery pathways or ERAS have been applied in gastric cancer surgery extrapolated from colorectal surgery. The objective of the study is to assess postoperative complications 30 days after gastric surgery for cancer, with any level of compliance with the ERAS protocol. The secondary objectives are to assess 30-day mortality, the relationship between adherence to the ERAS protocol and complications, the impact of each of the items of the protocol on postoperative complications and hospital stay, and to describe the impact of complications on length of hospital stay.

MATERIALS AND METHODS

Multicenter, observational, prospective study including all consecutive patients undergoing scheduled gastric cancer surgery, over a period of 3 months, with a 30-day follow-up at participating centers, with any level of compliance with the protocol.

RESULTS

The approval of the Comité Autonómico de Ética de la Investigación de Aragón has been obtained (C.P. - C.I. PI19 / 106, 27 th March 2019). POWER.4 was registered at www.clinicaltrials.gov on March 7, 2019 (NCT03865810).

CONCLUSIONS

The data as a whole will be published in peer-reviewed journals. The data will not be made public by identifying each participating center. It is expected that the results of this study will identify potential areas for improvement in which more targeted research is needed.

Predicting overall and major postoperative morbidity in gastric cancer patients

BACKGROUND

Postoperative complications after gastric cancer resection vary in different series and they might have a significant impact in long-term outcomes. Our aim was to build a prediction rule on gastric cancer patients' overall and major morbidity risks.

METHODS

This retrospective study included 1223 patients from a single center who were resected between 1992 and 2016. Overall and major morbidity predictors were identified through multiple logistic regression. Models' performances were assessed through discrimination, calibration, and cross-validation, and nomograms were constructed.

RESULTS

The mean age was 61.3-year old and the male gender was more frequent (60%). The most common comorbidities were hypertension (HTN), diabetes, and chronic obstructive pulmonary disease (COPD). A D2-distal gastrectomy was the most frequent procedure and 87% of all lesions were located in the middle or distal third. Age, COPD, coronary heart disease, chronic liver disease, pancreatic resection, and operative time were independent predictors of overall and major morbidity. The extent of resection and splenectomy was associated with overall events and HTN with major ones. Both models were very effective in predicting events among patients at higher risk.

CONCLUSIONS

The overall and major morbidity models and nomograms included clinical- and surgical-related data that were very effective in predicting events, especially for high-risk patients.

Preoperative Plasma Fibrinogen and Serum Albumin Score Is an Independent Prognostic Factor for Resectable Stage II-III Gastric Cancer

Background

Radical gastrectomy with D2 lymphadenectomy is recognized as the standard treatment for resectable advanced gastric cancer. Preoperative fibrinogen and albumin measurements may bring clinical benefits in terms of providing advanced notice of a poor prognosis or recurrence in patients undergoing radical resection. The aim of this study was to identify markers that are predictive of a poor prognosis prior to surgery.

Methods

Eight hundred forty-two consecutive patients who underwent curative radical gastrectomy at our hospital between 2008 and 2012 were retrospectively reviewed. Based on plasma fibrinogen and serum albumin levels, preoperative fibrinogen and albumin scores (Fib-Alb scores) were investigated, and the prognostic significance was determined.

Results

The patients were classified according to a Fib-Alb score of 0 (n = 376), 1 (n = 327), or 2 (n = 139). When the correlation between the response rate and the change in the Fib-Alb score was investigated, the response rate was significantly lower in patients with an increased Fib-Alb score than in the other patients. In the survival analysis, patients in the Fib-Alb high-score group exhibited significantly worse recurrence-free survival (RFS) (P = 0.030) than patients in the other groups. A multivariate analysis using clinical stage and the change in the Fib-Alb score as covariates revealed that a change in the Fib-Alb score (Fib-Alb score 1, HR: 1.31, 95% CI: 1.03-1.66, P = 0.028; Fib-Alb score 2, HR: 1.61, 95% CI: 1.20-2.17, P = 0.001) was a significant independent predictive factor for RFS.

Conclusions

The prognosis of patients with high fibrinogen and low albumin levels is poor. The Fib-Alb score was shown to be an independent prognostic factor for postoperative recurrence in gastric cancer patients who underwent radical gastrectomy.

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

Background

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

Methods

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

Results

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

Conclusions

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

Intraoperative Blood Loss is Associated with Shortened Postoperative Survival of Patients with Stage II/III Gastric Cancer: Analysis of a Multi-institutional Dataset

BACKGROUND

The influence of intraoperative blood loss (IBL) on postoperative long-term outcomes of patients with gastric cancer is controversial. Here, we used a large multicenter dataset from nine institutes to evaluate the prognostic impact of IBL on patients with stage II/III gastric cancer.

METHODS

The study analyzed 1013 patients with stage II/III gastric cancer who underwent gastrectomy without preoperative treatment and intraoperative transfusion. Patients were equally divided into learning and validation cohorts using a table of random numbers. The optimal cutoff value of IBL to predict recurrence was determined using the learning cohort, and the prognostic significance of the proposed cutoff was validated using the second cohort.

RESULTS

The optimal cutoff value of IBL determined with the learning cohort using the receiver operating characteristic curve analysis was 330 ml. In the validation cohort, IBL > 330 ml was significantly associated with high body mass index, total gastrectomy, and postoperative complications, but not disease stage and the frequency of adjuvant chemotherapy. The disease-free and disease-specific survival rates of patients in the IBL > 330 ml (IBL-high) group were significantly shorter compared with those in the IBL ≤ 330 ml group. IBL-high was identified as an independent prognostic factor of disease recurrence (hazard ratio 1.45, 95% confidence interval 1.01-2.09, P = 0.0420). The hazard ratio of the IBL-high group was greater in the surgery-alone subgroup compared with that of the postoperative adjuvant-chemotherapy subgroup.

CONCLUSIONS

Our analysis of a multicenter dataset indicates that IBL adversely influenced long-term outcomes of patients with stage II/III gastric cancer.

Long-lasting discussion: Adverse effects of intraoperative blood loss and allogeneic transfusion on prognosis of patients with gastric cancer

Gastrectomy with radical lymph node dissection is the most promising treatment avenue for patients with gastric cancer. However, this procedure sometimes induces excessive intraoperative blood loss and requires perioperative allogeneic blood transfusion. There are lasting discussions and controversies about whether intraoperative blood loss or perioperative blood transfusion has adverse effects on the prognosis in patients with gastric cancer. We reviewed laboratory and clinical evidence of these associations in patients with gastric cancer. A large amount of clinical evidence supports the correlation between excessive intraoperative blood loss and adverse effects on the prognosis. The laboratory evidence revealed three possible causes of such adverse effects: anti-tumor immunosuppression, unfavorable postoperative conditions, and peritoneal recurrence by spillage of cancer cells into the pelvis. Several systematic reviews and meta-analyses have suggested the adverse effects of perioperative blood transfusions on prognostic parameters such as all-cause mortality, recurrence, and postoperative complications. There are two possible causes of adverse effects of blood transfusions on the prognosis: Anti-tumor immunosuppression and patient-related confounding factors (e.g., preoperative anemia). These factors are associated with a worse prognosis and higher requirement for perioperative blood transfusions. Surgeons should make efforts to minimize intraoperative blood loss and transfusions during gastric cancer surgery to improve patients’ prognosis.

Preoperative Immune Response is Associated with Perioperative Transfusion Requirements in Glioma Surgery

Immunosuppression induced by transfusion causes postoperative adverse events including poor prognosis in cancer, but data on influence of the immune response on blood transfusion requirements during perioperative period are limited. The aim of this study was to investigate whether the preoperative immune response is associated with perioperative blood cell transfusion in a glioma surgical patient population. The authors identified 321 cases of surgery for treatment of glioma. Patient variables, preoperative laboratory variables (hemoglobin, platelet count, activated partial thromboplastin time, prothrombin time, hematocrit, red and white blood cell count), and transfusions were registered. Plasma concentration of Th-associated cytokines was measured by flow cytometry. Multivariable regression analysis and receiver operating characteristic curve were undertaken to identify predictors of transfusion. Of 321 patients, 157 (48.90%) received red blood cells transfusion. The mean age is significantly higher in transfusion group compared to no transfusion group, while postoperative hospital stay, preoperative hemoglobin, prothrombin time, activated partial thromboplastin time, platelet count, red and white blood cell count and hematocrit of patients did not differ significantly between the two groups. No significant differences of IL-2, -4, -6, -10 and INF-γ concentration were observed between transfusion and no transfusion group. The concentration of TNF and IL-17A was significantly lower in transfusion patients than in the no transfusion subjects. Low plasma TNF and IL-17A levels predicted high perioperative transfusion rate, the combination of them enlarged the prognostic accuracy of testing. Our study demonstrates that the preoperative immune response influences transfusion requirements, and TNF and IL-17 are important predictive risk factors for perioperative use of blood components in glioma patients.

Extracellular Ubiquitin is the Causal Link between Stored Blood Transfusion Therapy and Tumor Progression in a Melanoma Mouse Model

Background: The transfusion of blood that has been stored for some time was found to be associated with transfusion-related immune modulation (TRIM) responses in cancer patients, which could result in poor clinical outcomes, such as tumor recurrence, metastasis and reduced survival rate. Given the prior observation of the positive correlation between ubiquitin content in whole blood and storage duration by the investigators of the present study, it was hypothesized that this could be the causal link behind the association between the transfusion of stored blood and poor cancer prognosis.

Methods: In the present study, a melanoma mouse model was used to study the potential clinical impact of ubiquitin present in stored blood on cancer prognosis through a variety of cell biology methods, such as flow cytometry and immunohistochemistry.

Results: Both extracellular ubiquitin and the infusion of stored mice blood that comprised of ubiquitin reduced the apoptotic rate of melanoma cells, promoted lung tumor metastasis and tumor progression, and reduced the long-term survival rate of melanoma mice. In addition, the upregulation of tumor markers and tumorigenic TH2 cytokine generation, as well as reduced immune cell numbers, were observed in the presence of ubiquitin.

Conclusions: The present findings provide novel insights into the role of ubiquitin in immune regulation in a melanoma mouse model, and suggest ubiquitin as the causal link between allogeneic blood transfusion therapy and poor cancer prognosis.

Patient blood management for liver resection: consensus statements using Delphi methodology

BACKGROUND

Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology.

METHODS

An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement.

RESULTS

The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended.

CONCLUSIONS

PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

Association of Perioperative Transfusion with Recurrence and Survival After Resection of Distal Cholangiocarcinoma: A 10-Institution Study from the US Extrahepatic Biliary Malignancy Consortium

BACKGROUND

Perioperative allogeneic blood transfusion is associated with poor oncologic outcomes in multiple malignancies. The effect of blood transfusion on recurrence and survival in distal cholangiocarcinoma (DCC) is not known.

METHODS

All patients with DCC who underwent curative-intent pancreaticoduodenectomy at 10 institutions from 2000 to 2015 were included. Primary outcomes were recurrence-free (RFS) and overall survival (OS).

RESULTS

Among 314 patients with DCC, 191 (61%) underwent curative-intent pancreaticoduodenectomy. Fifty-three patients (28%) received perioperative blood transfusions, with a median of 2 units. There were no differences in baseline demographics or operative data between transfusion and no-transfusion groups. Compared with no-transfusion, patients who received a transfusion were more likely to have (+) margins (28 vs 14%; p = 0.034) and major complications (46 vs 16%; p < 0.001). Transfusion was associated with worse median RFS (19 vs 32 months; p = 0.006) and OS (15 vs 29 months; p = 0.003), which persisted on multivariable (MV) analysis for both RFS [hazard ratio (HR) 1.8; 95% confidence interval (CI) 1.1-3.0; p = 0.031] and OS (HR 1.9; 95% CI 1.1-3.3; p = 0.018), after controlling for portal vein resection, estimated blood loss (EBL), grade, lymphovascular invasion (LVI), and major complications. Similarly, transfusion of ≥ 2 pRBCs was associated with lower RFS (17 vs 32 months; p < 0.001) and OS (14 vs 29 months; p < 0.001), which again persisted on MV analysis for both RFS (HR 2.6; 95% CI 1.4-4.5; p = 0.001) and OS (HR 4.0; 95% CI 2.2-7.5; p < 0.001). The RFS and OS of patients transfused 1 unit was comparable to patients who were not transfused.

CONCLUSION

Perioperative blood transfusion is associated with decreased RFS and OS after resection for distal cholangiocarcinoma, after accounting for known adverse pathologic factors. Volume of transfusion seems to exert an independent effect, as 1 unit was not associated with the same adverse effects as ≥ 2 units.

Gastric cancer surgery: clinical outcomes and prognosis are influenced by perioperative blood transfusions

Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient's clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a total or a subtotal gastrectomy accompanied by D2 lymphectomy for gastric cancer. The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87-5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87-5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70-10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73-83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.

Perioperative Single-Donor Platelet Apheresis and Red Blood Cell Transfusion Impact on 90-Day and Overall Survival in Living Donor Liver Transplantation

Background:

Although many previous studies have confirmed that perioperative blood transfusion is associated with poor outcomes after liver transplantation (LT), few studies described the influence of single-donor platelet apheresis transfusion in living donor LT (LDLT). This study aimed to assess the effect of blood products on outcomes for LDLT recipients, focusing on apheresis platelets.

Methods:

This retrospective study included 126 recipients who underwent their first adult-to-adult LDLT. Twenty-four variables including consumption of blood products of 126 LDLT recipients were assessed for their link to short-term outcomes and overall survival. Kaplan-Meier survival curve and the log-rank test were used for recipient survival analysis. A multivariate Cox proportional-hazard model and a propensity score analysis were applied to adjust confounders after potential risk factors were identified by a univariate Cox analysis.

Results:

Patients who received apheresis platelet transfusion had a lower 90-day cumulative survival (78.9% vs. 94.2%, P = 0.009), but had no significant difference in overall survival in the Cox model, compared with those without apheresis platelet transfusion. Units of apheresis platelet transfusion (hazard ratio [HR] = 3.103, 95% confidence interval [CI]: 1.720–5.600, P < 0.001) and preoperative platelet count (HR = 0.170, 95% CI: 0.040–0.730, P = 0.017) impacted 90-day survival independently. Multivariate Cox regression analysis also found that units of red blood cell (RBC) transfusion (HR = 1.036, 95% CI: 1.006–1.067, P = 0.018), recipient's age (HR = 1.045, 95% CI: 1.005–1.086, P = 0.025), and ABO blood group comparison (HR = 2.990, 95% CI: 1.341–6.669, P = 0.007) were independent risk factors for overall survival after LDLT.

Conclusions:

This study suggested that apheresis platelets were only associated with early mortality but had no impact on overall survival in LDLT. Units of RBC, recipient's age, and ABO group comparison were independent predictors of long-term outcomes.

Clinical trends and effects on quality metrics for surgical gastroesophageal cancer care

Background

Surgical therapy of mid-stage gastric cancer (GC) and other neoplastic conditions requiring gastric resection remains at the center of curative outcomes, while epidemiologic changes and multimodality treatment options have evolved rapidly. Putative quality metrics for gastrectomy such as R0 rate, total lymph node (LN) count or postoperative morbidity may depend partly on changing disease and treatment patterns, and deserve evaluation under various practice conditions.

Methods

Data within a U.S.-based single surgical oncologist's practice over 15 years were prospectively recorded and retrospectively analyzed for clinicopathologic factors, operative treatment aspects and outcomes. Trends and spectrum changes over three time intervals were analyzed with contingency analysis and continuous data comparative statistics.

Results

Of 179 patients undergoing gastric resection, 119 were male and 60 female, with a median age of 63 years (range, 24-98 years). Resections included 56 total, 56 subtotal/distal, 30 proximal and 37 segmental gastrectomies. Diagnoses included 96 GCs, 31 gastroesophageal (GE) junction (GEJ) cancers, 21 GI stromal tumors (GISTs), and 31 other conditions. Significant trends from first towards last time interval were observed for resection type (16% to 32% proximal, 9% to 30% segmental, P=0.0003), curative intent (76% to 98%, P=0.002), diagnosis (5% to 42% GEJ cancer, P<0.0001) and preoperative therapy use (0% to 58%, P<0.0001), among others. Intraoperative aspects showed significantly reduced blood loss (median: 500 to 150 mL) and transfusion requirements (39% to 4%), and an increased use of minimally invasive techniques over time (all at P<0.001). Among patients undergoing curative intent GC resection with LN dissection, total LN counts remained steady (mean: 26), while the number of involved LNs decreased (9.0 to 3.7, P=0.0003) and the R0 resection rate increased from 74% to 85% (P=0.05). The number of specimens with >15 LNs examined increased from 69.0% to 92.5% (P=0.022). At the same time, spleen preservation rate (91% overall) and major morbidity (16%) remained unchanged throughout. Postoperative length of stay decreased from a median of 12 to 8 days (P<0.0001).

Conclusions

This experience represents some variable practice patterns within a clinicopathologic spectrum of GE diseases. Postoperative or oncologic quality metrics have been sustained or did improve, which would support their utility for various practice settings; they compare favorably to other published U.S. experiences during the same time period.

Association of perioperative transfusion with survival and recurrence after resection of gallbladder cancer: A 10-institution study from the US Extrahepatic Biliary Malignancy Consortium

BACKGROUND AND OBJECTIVES

Perioperative blood transfusion is associated with poor outcomes in several malignancies. Its effect in gallbladder cancer (GBC) is unknown.

METHODS

All patients with GBC who underwent curative-intent resection at 10-institutions from 2000 to 2015 were included. The effect of blood transfusion on overall survival (OS) and recurrence-free (RFS) was evaluated.

RESULTS

Of 262 patients with curative-intent resection for GBC, 61 patients (23%) received blood transfusions. Radical cholecystectomy was the most common procedure (80%), but major hepatectomy was more frequent in the transfusion versus no-transfusion group (13% vs 4%; P = 0.02). The transfusion group was less likely to have incidentally discovered disease (57% vs 74%) and receive adjuvant therapy (29% vs 48%), but more likely to have preoperative jaundice (23% vs 11%), T3/T4 tumors (60% vs 39%), LVI (71% vs 40%), PNI (71% vs 48%), and major complications (39% vs 12%) (all P < 0.05). Transfusion was associated with lower median OS compared to no-transfusion (20 vs 32 mos; P < 0.001), which persisted on multivariable (MV) analysis (HR:1.9; 95%CI 1.1-3.5; P = 0.035), controlling for comorbidities, serum albumin, INR, preoperative jaundice, major hepatectomy, incidental discovery, margin status, T-Stage, LN status, and major complications. Median RFS of transfused patients was 13mo compared to 49mo for non-transfused patients (P = 0.1). Transfusion, however, was an independent predictor of decreased RFS on MV analysis (HR:2.3; 95%CI 1.1-5.1; P = 0.035).

CONCLUSIONS

Perioperative blood transfusion is associated with decreased OS and RFS after resection for GCC, accounting for other adverse factors. Transfusions should thus be administered with well-defined protocols.

Total iron-binding capacity is a novel prognostic marker after curative gastrectomy for gastric cancer

BACKGROUND

Patients with gastric cancer (GC) are affected by changes in iron status. Before surgery, GC patients are likely to have iron-deficiency anemia; and after gastrectomy, patients suffer from low nutritional status and low iron. This study investigated preoperative iron status associated with prognosis after curative gastrectomy for gastric cancer.

METHODS

We evaluated preoperative serum hemoglobin (Hgb), Fe and total iron-binding capacity (TIBC) in 298 patients who underwent curative gastrectomy for GC without preoperative chemotherapy, and analyzed these factors' associations with prognosis after surgery.

RESULTS

Of the 298 patients, 129 (43.2%) had low Hgb levels, and 33 (11.1%) had low TIBC (< 260 µg/dl) that was not associated with Hgb or Fe level. Patients with low TIBC were significantly associated with older age (≥ 65 years old; P = 0.0085), low albumin (< 3.9 g/dl; P = 0.0388) and high CRP (≥ 0.15 mg/dl; P = 0.0018) in multivariate analysis. Low Fe (< 60 µg/dl) was not associated with disease-free survival (DFS) or overall survival (OS); however, low Fe was associated with longer cancer-specific survival in Stage III GC patients (P = 0.0333). Both low Hgb and low TIBC were significantly associated with shorter DFS (Hgb: P = 0.0433; TIBC: P < 0.0001) and shorter OS (Hgb: P = 0.0352; TIBC: P < 0.0001). Low TIBC were significantly associated with shorter DFS (HR 2.167, 95% CI 1.231-3.639, P = 0.0086) and shorter OS (HR 2.065, 95% CI 1.144-3.570, P = 0.0173) in multivariate Cox hazard regression analysis.

CONCLUSIONS

Preoperative serum TIBC level of GC patients who undergo curative gastrectomy is a novel prognostic marker in univariate and multivariate analyses.