Effect of perioperative autologous versus allogeneic blood transfusion on the immune system in gastric cancer patients

Extracellular vesicles derived from stored red blood cell suspensions enhance invasion and migration of lung cancer cells by miR1246 and miR150-3p

BACKGROUND AND OBJECTIVES

Aged red blood cell (RBC) transfusions in lung cancer patients are often related to cancer recurrence and shorter lifespans. Extracellular vesicles (EVs) accumulated in stored RBC suspensions may be one of the important influential factors. This study aims to investigate how EVs derived from RBC suspensions affect the progress of lung cancer through the most enriched microRNAs (miRNAs) previously reported in our research.

STUDY DESIGN AND METHODS

EVs derived from stored RBC suspensions in Weeks 1, 3 and 5 were harvested via ultracentrifugation. Lung adenocarcinoma H1975 cells were co-cultured with EVs and transfected with miR1246 and miR150-3p mimics to evaluate alterations in their proliferation, invasion and migration abilities in vitro. Proteomics and bioinformatics were performed to predict the signalling pathway related to invasion and migration of H1975, which were verified by western blotting (WB) and flow cytometry.

RESULTS

EVs derived from stored RBC suspensions in Weeks 3 and 5 could significantly enhance the invasion and migration ability of H1975 cells and also increase the expression of miR1246 and miR150-3p. After transfection with miR1246 and miR150-3p mimics, invasion, migration and proliferation of H1975 cells were obviously enhanced. Proteomics analysis demonstrated that EVs co-cultivation and miRNA transfection groups were both enriched in cell adhesion molecules. WB and cytometry indicated that integrin beta-1 (ITGB1) and Rap1b were increased.

CONCLUSIONS

EVs derived from stored RBC suspensions can enhance invasion and migration ability of lung cancer cells via the most accumulated miR1246 and miR150-3p, which may increase the expression of ITGB1 through Rap1 signalling pathway.

[Influence of anesthesia on surgical site infections]

Surgical site infections (SSI) are the most frequent cause of impaired perioperative wound healing, lead to increased postoperative morbidity, mortality and length of hospital stay and are therefore a relevant perioperative complication. In addition to numerous measures taken by the surgical departments, there are anesthesiological options that can help to reduce the risk of SSI. In addition to heat, volume and transfusion management these include, for example, the use of antibiotics and the choice of the anesthesia procedure. This article is intended to provide fundamental knowledge on SSI, shows various options for reducing them in the context of anesthesia and evaluates their effectiveness and evidence based on the current state of knowledge.

THE USE OF AUTOLOGOUS BLOOD TRANSFUSION IN DIGESTIVE TRACT SURGERY: A LITERATURE REVIEW

BACKGROUND

The use of autologous blood transfusion in digestive tract surgeries, whether after preoperative blood collection or intraoperative blood salvage, is an alternative to allogeneic blood, which brings with it certain risks and shortage, due to the lack of donors. Studies have shown lower mortality and longer survival associated with autologous blood, however the theoretical possibility of spreading metastatic disease is still one of the limiting factors of its use.

OBJECTIVE

To evaluate the application of autologous transfusion in digestive tract surgeries, noting the benefits, damages and effects on the spread of metastatic disease.

METHODS

This is an integrative review of the literature available in the PubMed, Virtual Health Library and SciELO databases, by searching for "Autologous Blood Transfusion AND Gastrointestinal Surgical Procedures". Observational and experimental studies and guidelines published in the last five years in Portuguese, English or Spanish were included.

RESULTS

Not all patients benefit from blood collection before elective procedures, with the time of surgery and hemoglobin levels some of the factors that may indicate the need for preoperative storage. Regarding the intraoperative salvaged blood, it was observed that there is no increased risk of tumor recurrence, but the importance of using leukocyte filters and blood irradiation is highlighted. There was no consensus among the studies whether there is a maintenance or reduction of complication rates compared to allogeneic blood. The cost related to the use of autologous blood may be higher, and the less stringent selection criteria prevent it from being added to the general donation pool.

CONCLUSION

There were no objective and concordant answers among the studies, but the strong evidence of less recurrence of digestive tumors, the possibility of changes in morbidity and mortality, and the reduction of costs with patients suggest that the practice of autologous blood transfusion should be encouraged in digestive tract surgeries. It is necessary to note if the deleterious effects would stand out amidst the possible benefits to the patient and to health care systems.

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.

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.

Transfusion‑related immunomodulation in patients with cancer: Focus on the impact of extracellular vesicles from stored red blood cells (Review)

Red blood cell (RBC) transfusions may have a negative impact on the prognosis of patients with cancer, where transfusion‑related immunomodulation (TRIM) may be a significant contributing factor. A number of components have been indicated to be associated with TRIM. Among these, the impact of extracellular vesicles (EVs) has been garnering increasing attention from researchers. EVs are defined as nano‑scale, cell‑derived vesicles that carry a variety of bioactive molecules, including proteins, nucleic acids and lipids, to mediate cell‑to‑cell communication and exert immunoregulatory functions. RBCs in storage constitutively secrete EVs, which serve an important role in TRIM in patients with cancer receiving a blood transfusion. Therefore, the present review aimed to first summarize the available information on the biogenesis and characterization of EVs. Subsequently, the possible mechanisms of TRIM in patients with cancer and the impact of EVs on TRIM were discussed, aiming to provide an outlook for future studies, specifically for formulating recommendations for managing patients with cancer receiving RBC transfusions.

A Panel of Five-lncRNA Signature as a Potential Biomarker for Predicting Survival in Gastric and Thoracic Cancers

Dysfunctional long non-coding RNAs (lncRNAs) have been found to have carcinogenic and/or tumor inhibitory effects in the development and progression of cancer, suggesting their potential as new independent biomarkers for cancer diagnosis and prognosis. The exploration of the relationship between lncRNAs and the overall survival (OS) of different cancers opens up new prospects for tumor diagnosis and treatment. In this study, we established a five-lncRNA signature and explored its prognostic efficiency in gastric cancer (GC) and several thoracic malignancies, including breast invasive carcinoma (BRCA), esophageal carcinoma, lung adenocarcinoma, lung squamous cell carcinoma (LUSC), and thymoma (THYM). Cox regression analysis and lasso regression were used to evaluate the relationship between lncRNA expression and survival in different cancer datasets from GEO and TCGA. Kaplan-Meier survival curves indicated that risk scores characterized by a five-lncRNA signature were significantly associated with the OS of GC, BRCA, LUSC, and THYM patients. Functional enrichment analysis showed that these five lncRNAs are involved in known biological pathways related to cancer pathology. In conclusion, the five-lncRNA signature can be used as a prognostic marker to promote the diagnosis and treatment of GC and thymic malignancies.

Perioperative Allogeneic Blood Transfusion Does not Influence Patient Survival After Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis

BACKGROUND

Whether perioperative allogeneic blood transfusion (PABT) negatively influences patient survival after hepatectomy (HR) for hepatocellular carcinoma (HCC) remains controversial.

METHODS

Five hundred two patients who underwent HR for initial HCC between 1994 and 2015 were enrolled in this study. All patients were divided into two groups: the PABT group and the non-PABT group. Differences of clinicopathological factors, overall survival (OS), recurrence-free survival (RFS), and the recurrence pattern between the two groups were evaluated. Using propensity score matching for tumor-related factors, liver functions, and surgical factors (total 11 factors), the survival impact of PABT was also analyzed.

RESULTS

In the entire cohort, 78 patients (15.5%) received PABT such as red cell concentrate, fresh-frozen plasma, or platelets. OS (5-year OS: 55% vs. 76%; p = 0.0005) and RFS (2-year RFS: 47% vs. 56%; p = 0.0131) were significantly worse in the PABT group. The extrahepatic recurrence happened more frequently in the PABT group (15% vs. 5.4%; p = 0.0039). There were many significant clinicopathological differences between the two groups: more advanced tumor stage (tumor diameter, stage III or IV, microvascular invasion), worse liver functions (albumin, indocyanine green retention rate at 15 min), and more surgical stress (blood loss, operation time) in the PABT group. After propensity score matching, 43 pairs of patients were extracted. In this matched cohort, the survival curves of the PABT and non-PABT groups almost completely overlapped both in OS (5-year OS: 62% vs. 62%; p = 0.4384) and in RFS (2-year RFS: 49% vs. 47%; p = 0.8195). The significant difference of the extrahepatic recurrence rate disappeared in the matched cohort (p = 0.5789).

CONCLUSION

Using propensity score matching, we found that PABT does not influence patient survival after HR for HCC.

Nomograms for pre- and postoperative prediction of long-term survival among proximal gastric cancer patients: A large-scale, single-center retrospective study

BACKGROUND

The incidence of proximal gastric cancer (GC) is increasing, and methods for the prediction of the long-term survival of proximal GC patients have not been well established.

AIM

To develop nomograms for the prediction of long-term survival among proximal GC patients.

METHODS

Between January 2007 and June 2013, we prospectively collected and retrospectively analyzed the medical records of 746 patients with proximal GC, who were divided into a training set (n = 560, 75%) and a validation set (n = 186, 25%). A Cox regression analysis was used to identify the preoperative and postoperative risk factors for overall survival (OS).

RESULTS

Among the 746 patients examined, the 3- and 5-year OS rates were 66.1% and 58.4%, respectively. In the training set, preoperative T stage (cT), N stage (cN), CA19-9, tumor size, ASA core, and 3- to 6-mo weight loss were incorporated into the preoperative nomogram to predict the OS. In addition to these variables, lymphatic vascular infiltration (LVI), postoperative tumor size, T stage, N stage, blood transfusions, and complications were incorporated into the postoperative nomogram. All calibration curves used to determine the OS probability fit well. In the training set, the preoperative nomogram achieved a C-index of 0.751 [95% confidence interval (CI): 0.732-0.770] in predicting OS and accurately stratified the patients into four prognostic subgroups (5-year OS rates: 86.8%, 73.0%, 43.72%, and 20.9%, P < 0.001). The postoperative nomogram had a C-index of 0.758 in predicting OS and accurately stratified the patients into four prognostic subgroups (5-year OS rates: 82.6%, 74.3%, 45.9%, and 18.9%, P < 0.001).

CONCLUSION

The nomograms accurately predicted the pre- and postoperative long-term survival of proximal GC patients.

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.

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial

BACKGROUND

It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation.

OBJECTIVE

The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients.

DESIGN

Prospective observational study.

SETTING

Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand.

PATIENTS

Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy.

INTERVENTIONS

Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5).

MAIN OUTCOME MEASURES

Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA.

RESULTS

From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically.

CONCLUSION

Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass.

TRIAL REGISTRATION

The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216.

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 transfusion and the prognosis of colorectal cancer surgery: a systematic review and meta-analysis

Background

Perioperative transfusion can reduce the survival rate in colorectal cancer patients. The effects of transfusion on the short- and long-term prognoses are becoming intriguing.

Objective

This systematic review and meta-analysis aimed to define the effects of perioperative transfusion on the short- and long-term prognoses of colorectal cancer surgery.

Results

Thirty-six clinical observational studies, with a total of 174,036 patients, were included. Perioperative transfusion decreased overall survival (OS) (hazard ratio (HR), 0.33; 95% confidence interval (CI), 0.24 to 0.41; P < 0.0001) and cancer-specific survival (CSS) (HR, 0.34; 95% CI, 0.21 to 0.47; P < 0.0001), but had no effect on disease-free survival (DFS) (HR, 0.17; 95% CI, − 0.12 to 0.47; P = 0.248). Transfusion could increase postoperative infectious complications (RR, 1.89, 95% CI, 1.56 to 2.28; P < 0.0001), pulmonary complications (RR, 2.01; 95% CI, 1.54 to 2.63; P < 0.0001), cardiac complications (RR, 2.20; 95% CI, 1.75 to 2.76; P < 0.0001), anastomotic complications (RR, 1.51; 95% CI, 1.29 to 1.79; P < 0.0001), reoperation(RR, 2.88; 95% CI, 2.05 to 4.05; P < 0.0001), and general complications (RR, 1.86; 95% CI, 1.66 to 2.07; P < 0.0001).

Conclusion

Perioperative transfusion causes a dramatically negative effect on long-term prognosis and increases short-term complications after colorectal cancer surgery.

The prognostic role of perioperative allogeneic blood transfusions in gastric cancer patients undergoing curative resection: A systematic review and meta-analysis of non-randomized, adjusted studies

The impact of allogeneic perioperative blood transfusions (APTs) on the prognosis of gastric cancer patients undergoing curative-intent gastrectomy is still a highly debated topic. Two meta-analyses were published in 2015, and new studies report conflicting results. A literature review was conducted using PubMed, Scopus, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews, updated to March 1, 2016. Thirty-eight non-randomized studies reporting data on overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS) and postoperative complications (PCs) were included. An inverse variance random-effects meta-analysis was conducted. APTs showed an association with worse OS, DFS, DSS and an increased number of PCs. The hazard ratio (HR) for OS was 1.49, with a 95% confidence interval (95% CI) of 1.32-1.69 (p < .00001; Q-test p = .001, I-squared = 56%). After outlier exclusion, the HR for OS was 1.34 (95% CI = 1.23-1.45, p < .00001; Q-test p = .64, I-squared = 0%). The HR for DFS was 1.48 (95% CI = 1.18-1.86, p = .0007; Q-test p = .31, I-squared = 16%), and the HR for DSS was 1.66 (95% CI = 1.5-2.19, p = .0004; Q-test p = .96, I-squared = 0%). The odds ratio for PCs was 3.33 (95% CI = 2.10-5.29, p < .00001; Q-test p = .14, I-squared = 42%). This meta-analysis showed a significant association between transfusions and OS, DFS, DSS and PCs. The quality of the evidence was low. Aggregation, selection and selective reporting bias were detected. The biases shifted the results towards significance. Further studies using accurate adjustment methods are needed. Until such additional studies are performed, caution in administering transfusions and optimization of cancer patient blood management are warranted.

Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group

Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) 51.0–2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7–5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5–4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1–3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1–12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9–6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Peri-operative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.

Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group

Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) =1.0-2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7-5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5-4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1-3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1-12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9-6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Perioperative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.

Adverse prognostic impact of perioperative allogeneic transfusion on patients with stage II/III gastric cancer

BACKGROUND

Allogeneic blood transfusions (BTFs) are sometimes required for radical gastrectomy with regional lymph node dissection for advanced gastric cancer (GC). The prognostic impact of perioperative BTF in GC is controversial.

METHODS

Clinical data were collected retrospectively from 250 consecutive patients who underwent curative gastric resection for stage II/III GC. The prognostic impact of BTF on patient survival was evaluated. Subgroup analysis was performed according to units of blood transfused, timing of BTF, type of gastrectomy, splenectomy, intraoperative estimated blood loss, and year of surgery.

RESULTS

Fifty-seven (22.8%) patients underwent perioperative BTF. Patients who received BTF experienced a significantly shorter disease-specific survival after curative surgery, and multivariable analysis identified perioperative BTF as an independent prognostic factor for cancer-related death (hazard ratio, 1.80; 95% confidence interval, 1.05-3.02; p = 0.032). The BTF group experienced significantly lower recurrence-free survival rate and a higher rate of initial peritoneal recurrence. The amount of blood cells transfused had less impact on prognosis. Pre- or postoperative BTF without intraoperative BTF had limited influence on postoperative prognosis. Prognosis of patients was affected by splenectomy. Even when intraoperative blood loss exceeded 800 ml, the prognosis of the non-BTF group was more favorable. The prognostic impact of BTF became less clear after introduction of adjuvant chemotherapy with S-1.

CONCLUSIONS

BTF was an independent prognostic factor in patients with stage II/III GC after curative gastrectomy. To improve prognosis, BTF should be avoided when possible, particularly during surgery.

Risk factors for postoperative severe complications in elderly patients after radical surgery for gastric cancer

AIM: To identify the risk factors for postoperative severe complications (PSC) in elderly patients after radical surgery for gastric cancer.

METHODS: Altogether 113 elderly patients (70-79 years old) with gastric cancer who received surgical treatment between January 2004 and December 2014 at the Second Affiliated Hospital of Anhui Medical University were retrospectively. On the basis of the presence of complications, the patients were divided into a group with PSC and a group without. The relevant clinical data were evaluated and compared by statistical analysis.

RESULTS: PSC occurred in 16 of 113 elderly patients with gastric cancer who received surgical treatment, and the incidence rate of PSC was 14.2% (16/113). The incidence of PSC was significantly associated with history of drinking (P = 0.045 < 0.05), lower serum albumin (P = 0.007 < 0.05), longer operative time (P = 0.039 < 0.05), and intraoperative blood loss > 800 mL (P = 0.006 < 0.05), but not with gender (P = 0.388 > 0.05), body mass index (P = 0.297 > 0.05), smoking history (P = 0.146 > 0.05), hypertension (P = 0.152 > 0.05), coronary heart disease (P = 0.099 > 0.05), chronic obstructive pulmonary disease (COPD) (P = 0.139 > 0.05), diabetes (P = 0.873 > 0.05), or surgical method (P = 0.913 > 0.05).

CONCLUSION: History of drinking, lower serum albumin, longer operation time, and intraoperative blood loss > 800 mL were risk factors for PSC in elderly patients after radical surgery for gastric cancer.

Perioperative Allogenenic Blood Transfusion is Associated With Worse Clinical Outcome for Patients Undergoing Gastric Carcinoma Surgery: A Meta-Analysis

Whether perioperative allogenic blood transfusion (ABT) has adverse effect on patients with gastric carcinoma (GC) surgery or not, that is controversial. Our study evaluated the association between ABT and some clinical outcomes of GC surgery patients. Data of relevant studies were based on PubMed, EMBASE, and the Cochrane Library search. The relative risk (RR) of 5-year survival rates, tumor recurrence, and postoperative complications were performed; subgroup analyses included district, transfusion rates, age, participants, sex, and tumor stage. The study was approved by the ethics committee of the First People's Hospital of Shunde. In total, 9189 participants from 16 studies were included in the meta-analysis. The 5-year survival rate was decreased for the GC patients with ABT (RR = 0.74, 95% confidence interval [CI] = 0.69-0.79), the risk of tumor recurrence was significantly higher for ABT patients (RR = 1.82, 95% CI = 1.32-2.51), and postoperative complications increased in ABT patients (RR = 1.36, 95% CI = 1.02-1.81), respectively; in subgroup analyses, 5-year survival rates were not associated with the transfusion rates (χ2 = 0.37, P = 0.54). Transfusion for patients undergoing GC surgery, even low transfusion rates, would reduce the 5-year survival rates, and elevated the risk of tumor recurrence and postoperative complication.

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

BACKGROUND

The prognostic effect of perioperative blood transfusion on recurrence and survival in patients undergoing resection of gastric adenocarcinoma (GAC) remains controversial.

STUDY DESIGN

All patients who underwent resection for GAC from 2000 to 2012 at the 7 institutions of the US Gastric Cancer Collaborative were identified. The effect of transfusion on recurrence-free (RFS) and overall survival (OS) in the context of adverse clinicopathologic variables was examined by univariate and multivariate regression analyses.

RESULTS

Of 965 patients, 765 underwent curative intent R0 resection. Median follow-up was 44 months; 30-day mortalities were excluded. Median estimated blood loss (EBL) was 200 mL, and 168 patients (22%) received perioperative allogeneic blood transfusions. Transfused patients were less likely to receive adjuvant therapy (44% vs 56%; p = 0.01). Transfusion was associated with significantly decreased median RFS (13.5 vs 37.2 months, p < 0.001). Median OS was similarly decreased in patients receiving transfusions (18.6 vs 49.8 months, p < 0.001). On multivariate analysis, transfusion remained an independent risk factor for decreased RFS (hazard ratio [HR] 1.63; 95% CI 1.13 to 2.37; p = 0.010) and decreased OS (HR 1.79; 95% CI 1.21 to 2.67; p = 0.004), regardless of EBL or need for splenectomy. Timing (intraoperative vs postoperative) and volume of transfusion did not alter the negative prognostic effect of transfusion on survival.

CONCLUSIONS

Perioperative allogeneic blood transfusion is associated with decreased RFS and OS after resection of gastric cancer, independent of adverse clinicopathologic factors. This supports the judicious use of perioperative transfusion during resection of gastric cancer.

Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*

The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Blood Management presents an updated report of the Practice Guidelines for Perioperative Blood Management.

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Allogeneic blood transfusion and the prognosis of gastric cancer patients: systematic review and meta-analysis

BACKGROUND

Perioperative allogeneic blood transfusion (ABT) may be a deleterious predictor on the prognosis of gastric cancer (GC) for subjects who had undergone curative surgeries. In this article we proposed to figure out the effect of ABT with a systematic review and meta-analysis.

METHODS

Relevant articles were identified by searching Pubmed and Embase to March 2014. A random-effects model or fixed-effects model was used to calculate pooled odds ratios (ORs). Sensitivity analysis, meta-regression, stratified analysis, dose-response meta-analysis were conducted, and publication bias tested.

RESULTS

Eighteen studies (9120 GC patients) were included, of which 36.3% received transfusions. ABT was associated with increased all-cause mortality (OR, 2.17; 95% confidence interval [CI], 1.72-2.74; p<0.001; I2=75%). Sensitivity analysis showed significant changes in ORs while meta-regression had little influence on ORs. Galbraith plot revealed the OR reduced to 2.10 (95% CI, 1.86-2.37; p<0.001) with tau2 reduced to 0.00 and I2 reduced to 0%. RESULTS of stratified analysis were robust and consistent. Dose-response meta-analysis revealed that all-cause mortality was significantly lower in patients transfused with ≤800 mL of blood than those transfused with >800 mL (OR, 0.58; 95% CI, 0.37-0.92; p=0.02; I2=54%). ABT was also associated with increased cancer-related mortality (OR, 2.57, p=0.011) and recurrence (OR, 1.52, p=0.017).

CONCLUSIONS

In GC patients undergoing curative surgeries, ABTs are associated with a worse prognosis, including all-cause mortality, cancer-related mortality and recurrence. Patient blood management should be investigated further to minimize use of ABT.

Post-traumatic immunosuppression is reversed by anti-coagulated salvaged blood transfusion: deductions from studying immune status after knee arthroplasty

Major trauma increases vulnerability to systemic infections due to poorly defined immunosuppressive mechanisms. It confers no evolutionary advantage. Our objective was to develop better biomarkers of post-traumatic immunosuppression (PTI) and to extend our observation that PTI was reversed by anti-coagulated salvaged blood transfusion, in the knowledge that others have shown that non-anti-coagulated (fibrinolysed) salvaged blood was immunosuppressive. A prospective non-randomized cohort study of patients undergoing primary total knee arthroplasty included 25 who received salvaged blood transfusions collected post-operatively into acid-citrate-dextrose anti-coagulant (ASBT cohort), and 18 non-transfused patients (NSBT cohort). Biomarkers of sterile trauma included haematological values, damage-associated molecular patterns (DAMPs), cytokines and chemokines. Salvaged blood was analysed within 1 and 6 h after commencing collection. Biomarkers were expressed as fold-changes over preoperative values. Certain biomarkers of sterile trauma were common to all 43 patients, including supranormal levels of: interleukin (IL)-6, IL-1-receptor-antagonist, IL-8, heat shock protein-70 and calgranulin-S100-A8/9. Other proinflammatory biomarkers which were subnormal in NSBT became supranormal in ASBT patients, including IL-1β, IL-2, IL-17A, interferon (IFN)-γ, tumour necrosis factor (TNF)-α and annexin-A2. Furthermore, ASBT exhibited subnormal levels of anti-inflammatory biomarkers: IL-4, IL-5, IL-10 and IL-13. Salvaged blood analyses revealed sustained high levels of IL-9, IL-10 and certain DAMPs, including calgranulin-S100-A8/9, alpha-defensin and heat shock proteins 27, 60 and 70. Active synthesis during salvaged blood collection yielded increasingly elevated levels of annexin-A2, IL-1β, Il-1-receptor-antagonist, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IFN-γ, TNF-α, transforming growth factor (TGF)-β1, monocyte chemotactic protein-1 and macrophage inflammatory protein-1α. Elevated levels of high-mobility group-box protein-1 decreased. In conclusion, we demonstrated that anti-coagulated salvaged blood reversed PTI, and was attributed to immune stimulants generated during salvaged blood collection.

Transoperative refusion: a simple and safe method in emergency surgery

The objective is to reinforce the importance of blood reinfusion as a cheap, safe and simple method, which can be used in small hospitals, especially those in which there is no blood bank. Moreover, even with the use of devices that perform the collection and filtration of blood, more recent studies show that the cost-benefit ratio is much better when autologous transfusion is compared with blood transfusions, even when there is injury to hollow viscera and blood contamination. It is known that the allogeneic blood transfusion carries a number of risks to patients, among them are the coagulation disorders mediated by excess enzymes in the conserved blood, and deficiency in clotting factors, mainly the Factor V, the proacelerin. Another factor would be the risk of contamination with still unknown pathogens or that are not investigated during screening for selection of donors, such as the West Nile Fever and Creutzfeldt-Jacob, better known as "Mad Cow" disease. Comparing both methods, we conclude that blood autotransfusion has numerous advantages over heterologous transfusion, even in large hospitals. We are not against blood transfusions, just do not agree that the patient's own blood is discarded without making sure there will be enough blood in stock to get him out of the hemorrhagic shock.

Semi-imprinting quercetin into poly[N,N-dimethylacrylamide-co-3, 9-divinyl-2, 4, 8, 10-tetraoxaspiro (5.5) undecane] network: evaluation of the antioxidant character

A responsive antioxidant system constituted from quercetin inserted into poly[N,N-dimethylacrylamide-co-3, 9-divinyl-2, 4, 8, 10-tetraoxaspiro (5.5) undecane] through a semi-imprinted procedure was evaluated. A continuous magnetic field (MF) was used during supramolecular structure preparation. The strength of coupling quercetin was evaluated based on the template release from the polymeric matrices, as well as to what extent quercetin reloaded into the polymer matrix in prescribed conditions--with or without the MF presence--shows antioxidant properties. The antioxidant activity of the complex was investigated by radical inhibitor activity method using 2, 2-diphenyl-l-picrylhydrazyl. The evaluation of the homogeneity distribution of the quercetin inside the polymeric network was made by near-infrared chemical imaging and correspondingly statistical analysis. For in vivo biocompatibility investigation, granuloma test in rats was performed correlated with the activity of enzymes involved in oxidative stress as well as immunologic effects of tested supramolecular complexes that include quercetin as therapeutic agent.

Perioperative care and cancer recurrence: Is there a connection?

Cancer is the second most common cause of death in the United States. Metastatic disease is a more important cause of cancer-related death relative to primary tumor progression. Surgical excision is the primary treatment for most malignant tumors. However, surgery itself can inhibit important host defenses and promote the development of metastases. An altered balance between the metastatic potential of the tumor and the anti-metastatic host defenses, including cell-mediated immunity and natural killer cell function, is a plausible mechanism of increased cancer metastasis. This article reviews the increasingly recognized concept of anesthetic technique along with perioperative factors and their potential to affect long-term outcome after cancer surgery. The potential effect of intravenous anesthetics, volatile agents, local anesthetic drugs, opiates, and non-steroidal anti-inflammatory drugs are reviewed along with recent literature and ongoing clinical trials in this area. Regional anesthesia is increasingly emerging as a safer option with less cancer recurrence potential as compared to general anesthesia. Blood transfusion, pain, stress, use of beta-blockers, and hypothermia are other potentially important perioperative factors to consider.

Effect of opiates, anesthetic techniques, and other perioperative factors on surgical cancer patients

BACKGROUND

Opioid pharmacotherapy is often used to treat cancer pain. However, morphine and other opioid-like substance use in patients with cancer may have significant adverse consequences, including the suppression of both innate and acquired immune responses. Although studies have examined the possibility that regional anesthesia attenuates the immunosuppressive response of surgery, the effects of morphine and other opioid-related substances on tumor progression remain unknown.

METHODS

This article presents an evidence-based review of the influence of opioids and anesthetic technique on the immune system in the context of cancer recurrence. The review focuses on the field of regional anesthesia and the setting of surgical oncologic procedures. The method for perioperative pain management and the technique of anesthesia chosen for patients in cancer surgery were explored.

RESULTS

General anesthetics have been indicated to suppress both cell-mediated immunity and humoral immunity. Evidence suggests that intravenous opioids suppress the immune system. However, the mechanisms by which anesthetics and analgesics inhibit the immune system are not understood. Compared with the alternatives, regional analgesia offers reduced blood loss and superior postoperative analgesia. Because of these advantages, the use of regional analgesia has increased in oncologic surgeries.

CONCLUSION

Immune responses from all components of the immune system, including both the humoral and cell-mediated components, appear to be suppressed by anesthetics and analgesics. The clinical anesthesiologist should consider these factors in the application of technique, especially in cancer surgery.

Perioperative allogenenic blood transfusion is associated with worse clinical outcomes for hepatocellular carcinoma: a meta-analysis

Background and Objective

The impact of perioperative allogenenic blood transfusion (ABT) on clinical outcomes for hepatocellular carcinoma (HCC) is conflicting and unclear. The aim of this meta-analysis is to evaluate the association between ABT and HCC clinical outcomes. Outcomes evaluated were all-cause death, tumor recurrence and postoperative complications.

Methods

Relevant articles were identified through MEDLINE search (up to November 2012). Meta-analyses were performed by using the fixed or random effect models. Study heterogeneity was assessed by Q-test and I² test. Publication bias was evaluated by funnel plots, Egger′s and Begg’s test.

Results

A total of 5635 cases from 22 studies finally met our inclusion criteria. Meta-analysis indicated HCC patients with ABT had an increased risk of all-cause death at 3 and 5 years after surgery (respectively: OR = 1.92, 95% CI, 1.61–2.29,P<0.001; OR = 1.60, 95% CI, 1.47–1.73,P<0.001 ) compared with those without ABT. The risk of tumor recurrence was significantly higher for ABT cases at 1, 3 and 5 years (respectively: OR = 1.70, 95% CI, 1.38–2.10, P<0.001; OR = 1.22, 95% CI, 1.08–1.38, P<0.001; OR = 1.16, 95% CI, 1.08–1.24, P<0.001). The HCC cases with ABT significantly increased postoperative complications occurrence compared with non-ABT cases (OR = 1.78,95% CI, 1.34–2.37, P<0.001).

Conclusions

The findings from the current meta-analysis demonstrated that ABT was associated with adverse clinical outcomes for HCC patients undergoing surgery, including increased death, recurrence and complications. Therefore, ABT should not be performed if possible.

Contemporary perioperative care strategies

Background

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.

Methods

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.

Results

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion

Multidisciplinary management of perioperative patient care has improved outcomes.

A clinical study of weining granules in the treatment of gastric precancerous lesions

OBJECTIVE

To investigate the clinical effects of Weining granules on gastric precancerous lesions (GPLs).

METHODS

120 patients with GPLs were randomly assigned in a 1:1 ratio to receive Weining granules (trial group) or the comparator Weifuchun tablets (control group) for 6 months. Outcomes were compared between the two groups including: overall response; gastroscopically-determined response; pathologically-confirmed response; eradication of Helicobacter pylori (HP); microvessel density (MVD) in the gastric mucosa; expression of vascular endothelial growth factor (VEGF); interleukin 2 (IL-2); interleukin 6 (IL-6); T lymphocyte subsets; immunoglobulins; symptom scores; quality of life (QOL); and adverse reactions.

RESULTS

Patients in the trial group had a significantly higher (P < 0.05) overall response rate (81.7%) as compared with those in the control group (63.3%). Relative to treatment with Weifuchun tablets treatment with Weining granules resulted in a significant improvement (P < 0.05) in the scores for gastric pain, distension and stuffiness in the hypochondrium, and anorexia. As compared with the tablets the granules were associated with a significantly higher overall gastroscopically-determined response rate (78.3%; P < 0.05). Pathological examination of tissue samples indicated that 61.7% of patients receiving the granules were cured with an overall response rate of 75.5%; these rates were significantly higher than in the control group (P < 0.05). In comparison with patients receiving the tablets, those given the granules were significantly more likely to have their HP eradicated (75.0% vs. 51.4%; P < 0.05). Improvements in MVD, VEGF, CD4+, CD4+/ CD8+, IL-2, IL-6 and IgG were significantly greater with the Weining Granules than with the Weifuchun tablets (P < 0.05 or P < 0.01). After follow-up of 1 year, 17.5% of patients in the trial group relapsed as compared with 39.5% in the control group (P < 0.05). Relative to the control group, the trial group showed significantly greater improvements in physical, psychological and social relationships, and in environmental domains (P < 0.05 or P < 0.01). No significant adverse reactions were observed during treatment.

CONCLUSION

The Weining granules appear to be effective in improving the gastric precancerous state and the main symptoms, in inhibiting angiogenesis, enhancing immune function and QOL, and in reducing 1-year relapses. In addition, this preparation seems to be associated with a low risk of adverse events, making it a safe and efficacious option for the treatment of GPLs.

Roles of inflammatory cytokines in the progression of gastric cancer: friends or foes?

Increasing evidence is being reported regarding the hypothesis that several proinflammatory and anti-inflammatory cytokines may promote tumor progression and affect the host antitumor response. However, the manner in which a local cytokine network operates in tumor development remains unclear. We reviewed the literature to examine the consequences of novel insights into inflammatory cytokines associated with gastric cancer progression. The Medline and EMBASE databases were searched for publications regarding the role of inflammatory cytokines in the development of gastric cancer. A number of studies have suggested that several proinflammatory and anti-inflammatory cytokines promote tumor progression through the direct activation of nuclear factor-κB (NF-κB) and the upregulation of angiogenesis and adhesion molecules. Furthermore, these processes suppress host antitumor immunity, leading to tumor progression and metastasis. In patients with advanced gastric cancer, most cytokines that enhance or suppress host antitumor immunity appear to have elevated serum and local expression levels. The net cytokine environment fluctuates at various stages of tumor development. In conclusion, a more detailed understanding of the differential roles of malignant cell-derived and hostderived cytokines at different stages of the malignant process could, consequently, open new avenues for the manipulation of cytokine expression and function in cancer immunotherapy for gastric cancer.

Roles of inflammatory cytokines in the progression of gastric cancer: friends or foes?

Increasing evidence is being reported regarding the hypothesis that several proinflammatory and anti-inflammatory cytokines may promote tumor progression and affect the host antitumor response. However, the manner in which a local cytokine network operates in tumor development remains unclear. We reviewed the literature to examine the consequences of novel insights into inflammatory cytokines associated with gastric cancer progression. The Medline and EMBASE databases were searched for publications regarding the role of inflammatory cytokines in the development of gastric cancer. A number of studies have suggested that several proinflammatory and anti-inflammatory cytokines promote tumor progression through the direct activation of nuclear factor-κB (NF-κB) and the upregulation of angiogenesis and adhesion molecules. Furthermore, these processes suppress host antitumor immunity, leading to tumor progression and metastasis. In patients with advanced gastric cancer, most cytokines that enhance or suppress host antitumor immunity appear to have elevated serum and local expression levels. The net cytokine environment fluctuates at various stages of tumor development. In conclusion, a more detailed understanding of the differential roles of malignant cell-derived and hostderived cytokines at different stages of the malignant process could, consequently, open new avenues for the manipulation of cytokine expression and function in cancer immunotherapy for gastric cancer.

Association between red blood cell transfusions and development of non-Hodgkin lymphoma: a meta-analysis of observational studies

The incidence of non-Hodgkin lymphoma (NHL) has increased steadily for the past few decades. Previous studies have suggested an association between blood transfusions and NHL. The main objective of this study was to evaluate this relationship with a meta-analysis of observational studies. A literature search was undertaken, looking for case-control and cohort studies evaluating the risk of developing NHL in persons who received allogeneic blood transfusions; 14 studies were included. Outcome was calculated and reported as relative risk (RR). Heterogeneity was assessed with Cochrane Q and I2 statistics. Dissemination bias was evaluated by funnel plot visualization and trim-and-fill analysis. Quality assessment was performed with the Newcastle-Ottawa scale. Our analysis showed a RR of developing NHL of 1.05 (95% CI, 0.89-1.25; P = .42) and 1.34 (95% CI, 1.15-1.55; P < .01) in case-control and cohort studies, respectively. When pooling all studies, RR was 1.2 (95% CI, 1.07-1.35; P < .01). In subset analysis, RR of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) was 1.66 (95% CI, 1.08-2.56; P = .02). The RR of NHL was elevated in both men and women and in persons receiving transfusions either before or after 1992. Blood transfusions appear to increase the risk of developing NHL; however, the risk of CLL/SLL appears higher than for other NHL subtypes.

Effect of anaesthetic technique and other perioperative factors on cancer recurrence

Surgical excision is the mainstay of treatment for potentially curable solid tumours. Metastatic disease is the most important cause of cancer-related death in these patients. The likelihood of tumour metastases depends on the balance between the metastatic potential of the tumour and the anti-metastatic host defences, of which cell-mediated immunity, and natural killer cell function in particular, is a critical component. It is increasingly recognized that anaesthetic technique and other perioperative factors have the potential to effect long-term outcome after cancer surgery. Surgery can inhibit important host defences and promote the development of metastases. Anaesthetic technique and drug choice can interact with the cellular immune system and effect long-term outcome. The potential effect of i.v. anaesthetics, volatile agents, local anaesthetic drugs, opiates, and non-steroidal anti-inflammatory drugs are reviewed here. There is particular interest at present in the effect of regional anaesthesia, which appears to be beneficial. Retrospective analyses have shown an outcome benefit for paravertebral analgesia for breast cancer surgery and epidural analgesia for prostatectomy. Blood transfusion, pain, stress, and hypothermia are other potentially important perioperative factors to consider.

Association of allogeneic blood transfusions and long-term survival of patients with gastric cancer after curative gastrectomy

INTRODUCTION

The relationship between perioperative allogeneic blood transfusions and poor prognosis in patients with gastric cancer remains controversial. The aim of this study is to examine the effect of perioperative blood transfusions on long-term survival of patients undergoing curative gastric resection for gastric cancer.

METHODS

Eight hundred fifty-six consecutive patients with gastric cancer who underwent curative gastrectomy (R0) from January 1, 1991 through December 31, 2002 were enrolled in this retrospective study.

RESULTS

A multivariate overall survival analysis using Cox proportional hazard regression model revealed macroscopically infiltrative tumor, tumor infiltration of serosa, lymph node metastasis, blood transfusions (hazard ratio, 2.69), pulmonary disease, and liver dysfunction as prognostic factors for long-term survival. Blood transfusion was an independent prognostic factor at all stages of disease. Disease-specific and overall survival showed significant differences between the transfused and nontransfused groups (log-rank, P < 0.0001). Based on multivariate logistic regression analysis, the need for blood transfusion was significantly associated with advanced age (>or=65 years), long duration of operation (>or=300 min), massive blood loss (>or=1,000 ml), and anemia (Hb < 10 g/dl).

CONCLUSIONS

Allogeneic blood transfusion is an independent prognostic factor for long-term survival in gastric cancer patients.

Blood loss in surgical oncology: neglected quality indicator?

Quality indicators can be defined as "specific and measurable elements of practice that can be used to assess the quality of care". Surgical blood loss is one of the most significant perioperative predictors of patient outcome. Blood loss is a modifiable quality indicator for oncologic cancer surgery. Surgical oncologists need to alter their surgical technique to promote bloodless surgery and decrease the variability in reported blood loss and rates of blood transfusion.