Prognostic Relevance of Preoperative Immune, Inflammatory, and Nutritional Biomarkers in Patients Undergoing Gastrectomy for Resectable Gastric Adenocarcinoma: An Observational Multicentre Study.

Background: The aim of this study was to evaluate different preoperative immune, inflammatory, and nutritional scores and their best cut-off values as predictors of poorer overall survival (OS) and disease-free survival (DFS) in patients who underwent curative gastric cancer resection. Methods: This was a retrospective observational multicentre study based on data of the Spanish EURECCA Esophagogastric Cancer Registry. Time-dependent Youden index and log-rank test were used to obtain the best cut-offs of 18 preoperative biomarkers for OS and DFS. An adjusted Cox model with variables selected by bootstrapping was used to identify the best preoperative biomarkers, which were also analysed for every TNM stage. Results: High neutrophil-to-lymphocyte ratio (NLR), high monocyte systemic inflammation index (moSII), and low prognostic nutritional index (PNI) were identified as independent predictors of poor outcome: NLR > 5.91 (HR:1.73; 95%CI [1.23-2.43]), moSII >2027.12 (HR:2.26; 95%CI [1.36-3.78]), and PNI >40.31 (HR:0.75; 95%CI [0.58-0.96]) for 5-year OS and NLR > 6.81 (HR:1.75; 95%CI [1.24-2.45]), moSII > 2027.12 (HR:2.46; 95%CI [1.49-4.04]), and PNI > 40.31 (HR:0.77; 95%CI [0.60,0.97]) for 5-year DFS. These outcomes were maintained in the whole cohort for NLR and moSII (p < 0.05) but not in stage II and for PNI in all tumoral stages. The associations of NLR-PNI and moSII-PNI were also a relevant prognostic factor for OS. Conclusions: High NLR, high moSII (for stages I and III), and low PNI (regardless of tumour stage) were the most promising preoperative biomarkers to predict poor OS and DFS in gastric cancer patients treated with curative intent.

Machine Learning Risk Prediction Model of 90-day Mortality After Gastrectomy for Cancer.

OBJECTIVE: To develop and validate a risk prediction model of 90-day mortality (90DM) using machine learning in a large multicenter cohort of patients undergoing gastric cancer resection with curative intent. BACKGROUND: The 90DM rate after gastrectomy for cancer is a quality of care indicator in surgical oncology. There is a lack of well-validated instruments for personalized prognosis of gastric cancer. METHODS: Consecutive patients with gastric adenocarcinoma who underwent potentially curative gastrectomy between 2014 and 2021 registered in the Spanish EURECCA Esophagogastric Cancer Registry database were included. The 90DM for all causes was the study outcome. Preoperative clinical characteristics were tested in four 90DM predictive models: Cross Validated Elastic regularized logistic regression method (cv-Enet), boosting linear regression (glmboost), random forest, and an ensemble model. Performance was evaluated using the area under the curve by 10-fold cross-validation. RESULTS: A total of 3182 and 260 patients from 39 institutions in 6 regions were included in the development and validation cohorts, respectively. The 90DM rate was 5.6% and 6.2%, respectively. The random forest model showed the best discrimination capacity with a validated area under the curve of 0.844 [95% confidence interval (CI): 0.841-0.848] as compared with cv-Enet (0.796, 95% CI: 0.784-0.808), glmboost (0.797, 95% CI: 0.785-0.809), and ensemble model (0.847, 95% CI: 0.836-0.858) in the development cohort. Similar discriminative capacity was observed in the validation cohort. CONCLUSIONS: A robust clinical model for predicting the risk of 90DM after surgery of gastric cancer was developed. Its use may aid patients and surgeons in making informed decisions.

Preoperative neutrophil-to-lymphocyte ratio behaves as an independent prognostic factor even in patients with postoperative complications after curative resection for gastric cancer.

PURPOSE: The aim of this study was to determine if the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) could be modified by the presence of postoperative complications (POC) and their severity in patients with gastric adenocarcinoma resected with curative intent. METHODS: A retrospective study based on a prospective database of patients with resectable gastric adenocarcinoma treated with radical intention (R0) between January 1998 and February 2012. The primary endpoint was overall survival according to preoperative peripheral blood NLR and postoperative complications. Clinicopathological variables, preoperative blood tests, POC and its severity (Clavien-Dindo classification), type of POC (infectious or not infectious) and mortality were registered. A univariate and multivariate analysis (step forward Cox regression) was performed. The Kaplan-Meier method was used to assess overall survival. RESULTS: The 147 patients with gastric cancer who had undergone radical resection were included from an initial cohort of 209 patients. Univariant analysis: type of surgery, pT, pN, postoperative complications (Clavien-Dindo ≥ 3) and preoperative NLR ≥ 2.4 were significantly associated with survival (p < 0.05). Patients with POC showed worse long-term survival (p = 0.000), with no difference (p = 0.867) between infectious or non-infectious POC. NLR ≥ 2.4 was associated with infectious POC (p < 0.001). Patients with preoperative NLR ≥ 2.4 (p = 0.02) had a worse prognosis. Multivariate analysis: pN (p < 0.001), postoperative complications (p < 0.001) (HR 3.04; 95% CI: 1.97-4.70) and NLR ≥ 2.4 (p = 0.04) (HR = 1.55; 95% CI: 1.02-2.3) were independent prognostic factors. CONCLUSION: The preoperative inflammatory state of patients with gastric cancer measured by NLR behaves as an independent prognostic factor, even in patients with POC.

Standardizing the treatment of oesophagogastric junction tumours: Centralization, registries and surgical training. / Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación.

Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams' training curves without affecting morbidity, mortality or oncologic radicality.

Perioperative transfusion management in gastric cancer surgery: Analysis of the Spanish subset of the EURECCA oesophago-gastric cancer registry. / Conducta transfusional perioperatoria en la cirugía del cáncer gástrico: análisis del registro del grupo español EURECCA de cáncer esófago-gástrico.

INTRODUCTION: This study evaluated allogenic packed red blood cell (aPRBC) transfusion rates in patients undergoing resection for gastric cancer and the implementation of blood-saving protocols (BSP). METHODS: Retrospective study of all gastric cancer patients operated on with curative intent in Catalonia and Navarra (2011-2013) and included in the Spanish subset of the EURECCA Oesophago-Gastric Cancer Registry. Hospitals with BSP were defined as those with a preoperative haemoglobin (Hb) optimisation circuit associated with restrictive transfusion strategies. Predictors of aPRBC transfusion were identified by multinomial logistic regression analysis. RESULTS: A total of 652 patients were included, 274 (42.0%) of which received aPRBC transfusion. Six of the 19 participating hospitals had BSP and treated 145 (22.2%) patients. Low Hb level at diagnosis (10 vs 12.4g/dL), ASA score III/IV, pT3-4, open surgery, associated visceral resection, and having being operated on in a hospital without BSP were predictors of aPRBC transfusion, while low Hb level, associated visceral resection, and non-BSP hospital remained predictors in the multivariate analysis. In case of comparable risk factors for aPRBC transfusion, there was a higher use of preoperative intravenous iron treatment (26.2% vs 13.2%) and a lower percentage of transfusions (31.7% vs 45%) in hospitals with BSP. CONCLUSIONS: The perioperative transfusion rate in gastric cancer was 42%. Hospitals with BSP showed a significant reduction of blood transfusions but treated only 22% of patients. Main predictors of aPRBC were low Hb level, associated visceral resection, and undergoing surgery at a hospital without BSP.

Wernicke's encephalopathy after sleeve gastrectomy: Literature review.

OBJECTIVE: To describe a case of Wernicke's encephalopathy after laparoscopic sleeve gastrectomy. SETTING: Emergency Department and gastrointestinal surgery department. CASE REPORT: A 20-year-old man class III obesity (BMI 50.17kg/m(2)) underwent laparoscopic sleeve gastrectomy with uneventful recovery. Five weeks after surgery he was admitted in the Emergency Department because of persistent vomiting and dysphagia to solids. Esophagogastroduodenal transit and upper gastrointestinal endoscopy were requested but no relevant findings were shown. Laboratory analyses showed vitamin B1 12.2ng/mL and 48h following admission the patient experienced generalized weakness, sialorrhea and restrictions of actions such as reading a book. Neurological evaluation found confusion, motor ataxia, diplopy and nystagmus. A brain magnetic resonance was normal. According to low level of vitamin B1 and symptoms found in the patient a presumed diagnosis of Wernicke encephalopathy was made and parenteral thiamine 100mg/day was started. The patient was discharged asymptomatic with oral intake of vitamin B1 600mg per day. CONCLUSION: Nutritional deficiencies after restrictive procedures are uncommon but easily preventable and can result in life threatening. With the upswing of bariatric surgery, surgeons and emergency physicians should be able to diagnose and treat those complications. Prophylactic thiamine should be administered to patients with predisposing factors.

[Gastric cancer and laparoscopy: analysis of data from the national register of laparoscopic gastric surgery]. / Cáncer gástrico por laparoscopia: análisis de los datos del Registro Nacional de Cirugía Gástrica por Laparoscopia.

OBJECTIVE: To study the data from the Laparoscopic Gastric Surgery Spanish National Register of laparoscopic Gastric Surgery and to analyse the type of surgery, the conversion to laparotomy, postoperative complications and mortality. PATIENTS AND METHOD: From March 2005 to July 2008, details of 302 laparoscopic gastric surgical interventions were sent to the Association of Spanish Surgeons web-site. Details of surgical technique, reconversion, clinical and pathological data, morbidity and mortality were collected and analysed. RESULTS: A total of 245 patients had gastric adenocarcinoma, 35 of them stromal tumours and 22 other gastric pathologies. In gastric adenocarcinoma patients, resection was performed in 232 cases (95%). The most frequent histology was intestinal, mainly located in the distal third of the stomach, with 34% of the tumours being locally advanced. D2 lymphadenectomy was performed in 117 cases, D1 in 105, and D0 in 6. Reconversion was needed in 21 cases (9%), with technical difficulty being the most frequent cause. Postoperative complications were reported in 72 patients (31%), with anastomotic leak being one of the most significant. Postoperative mortality was 6%, with sepsis due to anastomotic leak and cardiac or respiratory complications the most frequent causes. The mean hospital stay of patients without complications was 9.2 +/- 3 days. CONCLUSIONS: Laparoscopic gastrectomy for gastric cancer is a feasible but technically demanding procedure. Potential benefits of minimal invasive surgery can be reduced due to a high rate of postoperative complications.