Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy.

OBJECTIVE: The current study used a composite outcome to investigate whether applying the ERAS protocol would enhance the recovery of patients undergoing laparoscopic total gastrectomy (LTG). EXPOSURES: Laparoscopic total gastrectomy and perioperative interventions were the exposure. An ERAS clinical pathway consisting of 14 items was implemented and assessed. Patients were divided into either ERAS-compliant or non-ERAS-compliant group according the adherence above 9/14 or not. MAIN OUTCOMES AND MEASURES: The primary study outcome was a composite outcome called 'optimal postoperative recovery' with the definition as below: discharge within 6 days with no sever complications and no unplanned re-operation or readmission within 30 days postoperatively. Univariate logistic regression analysis and multivariate logistic regression analysis were used to model optimal postoperative recovery and compliance, adjusting for patient-related and disease-related characteristics. RESULTS: A total of 252 patients were included in this retrospective study, 129 in the ERAS compliant group and 123 in the non-ERAS-compliant group. Of these, 79.07% of the patients in ERAS compliant group achieved optimal postoperative recovery, whereas 61.79% of patients in non-ERAS-compliant group did (P = 0.0026). The incidence of sever complications was lower in the ERAS-compliant group (1.55% vs. 6.5%, P = 0.0441). No patients in ERAS compliant group had unplanned re-operation, whereas 5.69% (7/123) of patients in non-ERAS-compliant group had (p = 0.006). The median length of the postoperative hospital stay was shorter in the in the ERAS compliant group (5.51 vs. 5.68 days, P = 0.01). Both logistic (OR 2.01, 95% CI 1.21-3.34) and stepwise regression (OR 2.07, 95% CI 1.25-3.41) analysis showed that high overall compliance with the ERAS protocol facilitated optimal recovery in such patients. In bivariate analysis of compliance for patients who had an optimal postoperative recovery, carbohydrate drinks (p = 0.0196), early oral feeding (P = 0.0043), early mobilization (P = 0.0340), and restrictive intravenous fluid administration (P < 0.0001) were significantly associated with optimal postoperative recovery. CONCLUSIONS AND RELEVANCE: Patients with higher ERAS compliance (almost 70% of the accomplishment) suffered less severe postoperative complications and were more likely to achieve optimal postoperative recovery.

Temperature measurements of a wearable and wireless axillary sensor iThermonitor but not a bladder probe represents the core temperature during laparoscopic rectal surgery.

OBJECTIVE: To investigate whether the temperature recorded by an iThermonitor has better concordance with the core temperature than the bladder temperature recorded by a Foley catheter sensor in laparoscopic rectal surgery. METHODS: Eighty-two adults undergoing laparoscopic rectal surgery were enrolled. Temperatures were continuously measured by a distal oesophageal probe (the reference core temperature), axillary iThermonitor and Foley catheter sensor (bladder temperature) in each patient during surgery. Pairs of axillary and core temperatures or pairs of bladder temperature and core temperatures were compared and summarized using linear regression and the repeated-measured Bland-Altman method during the whole surgical period and pneumoperitoneum period. RESULTS: There were 3303 pairs of temperature measurements during the whole surgical period. The mean difference between iThermonitor and oesophageal was 0.05 °C ; the limits of agreement were - 0.48 to 0.56 °C. The mean difference between the oesophagus and bladder was 0.28 °C; the limits of agreement were - 0.39 to 0.94 °C (P < 0.001, F-test vs. iThermonitor). Ninety -five% of all iThermonitor values were within 0.5 °C of oesophageal temperature, whereas the proportion for oesophageal and bladder differences within 0.5 °C was only 84% (95% confidence interval 80-88%). Lin's CCC for the iThermonitor and bladder measurements were 0.842 (95%CI: 0.831-0.851) and 0.688 (95%CI: 0.673-0.703) respectively. Similar results were found during the pneumoperitoneum period. CONCLUSIONS: The temperature recorded by iThermonitor has better concordance with the core temperature than the bladder temperature recorded by Foley catheter sensor in laparoscopic rectal surgery.

Efficacy of resistin and leptin in predicting persistent organ failure in patients with acute pancreatitis.

BACKGROUND: To investigate the accuracy of resistin, leptin and adiponectin levels in predicting persistent organ failure in patients with acute pancreatitis (AP). METHODS: Data from 90 consecutive patients admitted to our hospital for AP were retrospectively collected from an ongoing prospective cohort study. The levels of adiponectin, leptin and resistin were measured and compared between patients with and without persistent organ failure. The accuracy of the adipokines in predicting persistent organ failure were compared with the patients' Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, and were separately investigated in overweight and non-overweight groups. RESULTS: Persistent organ failure occurred in 26.7% of the patients. The levels of resistin were significantly increased in AP patients with persistent organ failure, in both the overweight and the non-overweight subgroups. Resistin and APACHE-II score predicted persistent organ failure with comparable areas under the curve (AUC) of 0.72 and 0.75, respectively (p = 0.66). Resistin demonstrated similar accuracy with the APACHE-II score in predicting persistent organ failure in the overweight (0.69 vs. 0.66, p = 0.82) and non-overweight (0.76 vs. 0.87, p = 0.39) subgroups. There was no correlation between adiponectin and persistent organ failure, but a weak correlation between leptin and persistent organ failure was demonstrated. CONCLUSIONS: Resistin and leptin levels, rather than adiponectin, correlate with persistent organ failure in patients with AP.

Early classic hemofiltration exhibits no benefits in severe acute pancreatitis with early organ failure: a retrospective case-matched study.

Continuous venovenous hemofiltration (CVVH) is an important organ supportive technique. This study aimed to evaluate the impact of early classic CVVH on the outcomes of severe acute pancreatitis (SAP) patients with early organ failure (EOF). Between 2008 and 2012, a total of 44 SAP patients with EOF were admitted to our department. The 44 patients were classified into two groups according to whether they received early classic CVVH (2 L/h, initiated within 24 h after admission): 25 patients received early CVVH (ECVVH group), and 19 patients did not receive early CVVH (control group). The two groups were matched for age and Acute Physiology and Chronic Health Evaluation II scores. The severity of organ dysfunctions was evaluated by Sequential Organ Failure Assessment (SOFA) scores. Each group included 19 patients. The baseline characters between the two groups were balanced. The SOFA scores in the ECVVH group increased compared with those in the control group. The time to weaning from mechanical ventilation was significantly longer in the ECVVH group (log-rank test: χ(2) = 4.007, P = 0.045). Renal support was also significantly prolonged in the ECVVH group (the number of patients receiving CVVH 72 h after admission: 10 vs. 3, respectively, P = 0.038). Nine patients died in the ECVVH group versus six patients in the control group (P = 0.508). In conclusion, our study failed to prove that early classic CVVH had any benefits on the outcomes of SAP patients with EOF. Unexpectedly, early classic CVVH worsened organ functional capacity. However, it is possible that CVVH using advanced techniques may be beneficial in SAP patients with EOF.

Is continuous venovenous hemofiltration effective against severe acute pancreatitis?

Our aim was to investigate the efficacy of continuous venovenous hemofiltration (CVVH) in treating severe acute pancreatitis (SAP). A literature search was performed using PubMed (1992-present), and all studies investigating the efficacy of CVVH in treating SAP were included. Four comparative studies and seven case series comprising a total of 354 patients were included. The overall mortality rate of patients receiving CVVH was 20% (55/275). A decreased mortality rate and decreased serum cytokine levels were reported in the CVVH groups in only two studies. The starting time point, substitution fluid flow rate, filter membrane type, hemofilter change interval, anticoagulation, and sustaining times of CVVH varied among the studies, and the impact of these parameters on the efficacy of CVVH was poorly reported. High-volume CVVH, when started early, was demonstrated to be more effective in eliminating cytokines in only one study. After the application of CVVH, the patient conditions started to improve between the 6th and 72nd hours. In conclusion, no solid clinical evidence has proven the efficacy of CVVH in treating SAP. High-volume CVVH that is started early and sustained for at least 72 h may be adopted to investigate the efficacy of CVVH for treating SAP.

M1 macrophage predicted efficacy of neoadjuvant camrelizumab combined with chemotherapy vs chemotherapy alone for locally advanced ESCC: A pilot study.

Introduction: The efficacy and safety of immunotherapy have been widely recognized in gastrointestinal-related cancers. However, the efficacy of neoadjuvant camrelizumab for locally advanced esophageal squamous cell carcinoma (ESCC) has not been firmly established. This study compared the efficacy of camrelizumab in combination with neoadjuvant DCF (docetaxel, cisplatin and fluorouracil), with DCF alone for ESCC, and exploring biomarkers related to immune infiltration of the ESCC immunotherapy response. Methods: We enrolled and randomly assigned patients with stage II-IVa ESCC to two study treatments: camrelizumab combined with docetaxel, cisplatin and fluorouracil (DCF) regimen and DCF regimen alone. The tissue for multiplex immunofluorescence (mIF) was obtained before and after neoadjuvant therapy. The Response Evaluation Criteria in Solid Tumors RECIST Version 1.1 (RECIST 1.1) and Tumor Regression Grade (TRG) was used to evaluate efficacy. Results: A total of 30 patients were enrolled in the study. Following neoadjuvant camrelizumab, the objective response rate (ORR) and the disease control rate (DCR) were 46.7% (7/15) and 95.7% (14/15), respectively. No patients reported complete remission, while ORR and DCR in the chemotherapy group were 26.7% (4/15) and 86.7% (13/15), respectively. R0 resection after neoadjuvant treatment was achieved in 3 out of 15 patients in the combined group and in all patients (15/15) in the chemotherapy group. In the combined group, M1-type tumor-associated macrophages and CD56dim NK cells were more abundant in responders than in non-responders (p < 0.05). A higher M1/M2 ratio was observed in responders (p < 0.05). With respect to the NGS, among the copy number amplified genes, the 11q13 amplicon (CCND1/FGF19/FGF4/FGF3) showed the highest frequency (47%, 7/15). Conclusions: Neoadjuvant camrelizumab combined with chemotherapy improved ORR in locally advanced ESCC. M1-type tumor-associated macrophages and CD56dim NK cells might be utilized to predict camrelizumab efficacy.

Effects of hydromorphone-based intravenous patient-controlled analgesia with and without a low basal infusion on postoperative hypoxaemia: study protocol for a randomised controlled clinical trial.

INTRODUCTION: When patients receive patient-controlled intravenous analgesia (PCIA), no basal infusion is always recommended, as the addition of a basal infusion increases the occurrence of postoperative opioid-induced respiratory depression. However, few studies have investigated whether low basal infusions increase the incidence of postoperative hypoxaemia relative to no basal infusion. We intend to conduct a clinical trial to test the hypothesis that PCIA with a low basal infusion does not increase the occurrence of postoperative hypoxaemia relative to PCIA with no basal infusion. METHODS AND ANALYSIS: This single-centre parallel randomised controlled clinical trial will be conducted with 160 patients undergoing gastrointestinal tumour surgery. The assigned nurse will set analgesic pumps (low or no basal infusion PCIA) according to block-based randomisation sequence. Other investigators and all participants will be blinded to intervention allocation. All patients will be monitored continuously with the ep pod, a wireless wearable device, recording of oxygen saturation (SpO2) and daily ambulation duration for 48 hours postoperatively. Three follow-up evaluations will be conducted to assess the analgesic effect (Numeric Rating Scale (NRS) pain score) and opioid-related side effects (Overall Benefit of Analgesic Score (OBAS)). The primary outcome will be the area under the curve for hypoxaemia (defined as SpO2<95%) per hour. The secondary outcomes will be the areas under the curve for hypoxaemia defined as SpO2<90% and <85% per hour, hydromorphone consumption, OBASs at 24 and 48 hours postoperatively, NRS scores at 4, 24 and 48 hours postoperatively, and the ambulation time per hour over 48 hours. ETHICS AND DISSEMINATION: The study has been approved by the Xijing Hospital Ethics Committee (KY20212163-F-1). Written informed consent will be obtained from all patients or their authorised surrogates. All data will be managed with confidentiality. Findings will be disseminated at international conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ChiCTR2100054317.

Postoperative short-term use of the nonsteroidal anti-inflammatory drug flurbiprofen did not increase the anastomotic leakage rate in patients undergoing elective gastrointestinal surgery-a retrospective cohort study.

BACKGROUND: Flurbiprofen has been one of the most commonly used nonsteroidal anti-inflammatory drugs (NSAIDs) in China and other Asian countries for perioperative multimodal analgesia in recent years, yet its association with anastomotic leakage in gastrointestinal anastomoses is unknown. The current study was designed to investigate whether short-term administration of flurbiprofen would increase the risk of anastomotic leakage in patients undergoing gastrointestinal surgery for cancer resection. METHODS: A total of 3653 patients (2487 (66.1%) men) undergoing elective operation for gastrointestinal cancer between 18 July 2017 and 30 Oct 2020 were included. The median age was 61 years (interquartile range 53-67 years). The exposure was the short-term postoperative use of flurbiprofen (defined as flurbiprofen treatment within the first week after surgery). The primary outcome was the frequency of clinical anastomotic leakage. RESULTS: Of 3653 patients with available data who were included in the final analysis, 2282 received flurbiprofen administration, and 1371 did not. Anastomotic leakage was not significantly increased among the patients receiving flurbiprofen compared with those who did not (1.62% v 1.46%; P=0.70). In-hospital mortality was comparable between the two groups (0.04% v 0.07%; P=0.72). After adjusted analysis, male sex (OR 3.51, 95% CI 1.80-6.85), ASA score of 3-4 (OR 2.69, 95% CI 1.62-4.48), and intraoperative infusion (OR 2.24, 95% CI 1.19-4.21) were identified as risk factors for anastomotic leakage. CONCLUSIONS: Postoperative short-term use of flurbiprofen did not increase the risk of anastomotic leakage in gastrointestinal anastomoses.

Overweight is an additional prognostic factor in acute pancreatitis: a meta-analysis.

BACKGROUND/AIMS: It is generally accepted that there is a correlation between obesity and poor outcome in acute pancreatitis (AP); however, the relationship between overweight and the prognosis of AP is unknown. The aim of this study was to determine the correlation between overweight and the prognosis of AP. METHODS: MEDLINE and PubMed were searched using the terms 'acute pancreatitis', 'obesity', 'overweight', and 'body mass index' ('BMI'). All prospective clinical studies correlating BMI and AP were included. Obesity and overweight were defined as BMI ≥30 and from 25 to 30, respectively. A meta-analysis was performed with the endpoints severe AP (SAP), local complications, systemic complications, and mortality. RESULTS: Eight studies including 939 patients were found. The incidence rates of SAP (OR 2.48, 95% CI 1.34-4.60), local complications (OR 2.58, 95% CI 1.20-5.57), and mortality (OR 3.81, 95% CI 1.22-11.83) were increased in overweight patients with AP. No difference was detected in the incidence of systemic complications between the normal-weight and overweight patients (OR 1.62, 95% CI 0.76-3.43). In addition, the correlation between obesity and poor prognosis was again confirmed. CONCLUSION: Overweight is an additional prognostic factor of severity, local complications, and mortality in AP. and IAP.

Maximal voluntary ventilation and forced vital capacity of pulmonary function are independent prognostic factors in colorectal cancer patients: A retrospective study of 2323 cases in a single-center of China.

ABSTRACT: Preoperative pulmonary function assessment is applied to select surgical candidates and predict the occurrence of postoperative complications. This present study enrolled 2323 colorectal cancer patients. Forced vital capacity (FVC) and maximal voluntary ventilation (MVV) were measured as predicted values. Associations between patient pulmonary function and both prognosis and postoperative complications was analyzed. The value of FVC and MVV optimal cutoff was 98.1 (P < .001) and 92.5 (P < .001), respectively. Low FVC and low MVV were associated with higher rates of postoperative fever (23.8% vs 13.9%, P < .001; 17.8% vs 13.3%, P = .049, respectively) and with higher rates of pneumonia (3.75% vs 1.73%, P = .002; 3.00% vs 1.71%, P = .009, respectively), pleural effusion (3.00% vs 1.57%, P = .033; 3.18% vs 1.42%, P = .006, respectively), and poor patient prognosis (5-year overall survival: 80.0% vs 90.3%, P < .001; 71.7% vs 91.9%, P < .001, respectively). In addition, low FVC was closely related to the higher rate of anastomosis leak (4.31% vs 2.29%, P = .013), low MVV was correlated with the higher rate of uroschesis (2.38% vs 0.65%, P < .001). In subgroup analyses, the predictive value of FVC and MVV in patients with different tumor stage was analyzed. Both low FVC and MVV were independent risk factors for poor prognosis in stage II and III, indicating that low FVC and MVV are predictive of poorer prognosis and higher risk of postoperative complications in colorectal cancer patients.

Expression of NDRG2 in esophageal squamous cell carcinoma.

N-Myc downstream-regulated gene 2 (NDRG2), a new member of the N-Myc downstream-regulated gene family, has been found to be a differentially expressed gene involved in a variety of cancers. The present study aimed to investigate the expression of NDRG2 in esophageal squamous cell carcinoma (ESCC). Immunohistochemistry was performed in 154 samples from patients with ESCC to detect the expression level of NDRG2 and C-MYC. Results indicated that the expression level of NDRG2 in the cancer samples was significantly lower than that in normal tissues; the trend of C-MYC was the reverse. The Wilcoxon-Mann-Whitney test showed significant difference in the expression of NDRG2 in patients with different T stage, TNM stage, and differentiation degree of cancers (P = 0.036, 0.031, 0.001, respectively). Patients in stages I and II were followed up for 5 consecutive years and Kaplan-Meier survival analysis demonstrated that the survival time of ESCC patients with high expression of NDRG2 was longer than those with low expression during the 5-year follow-up period (P = 0.0018). Cox regression analysis indicated that low expression of NDRG2, cancer stage of pT1, and distant organ metastasis (pM1) were the independent poor prognostic factors of ESCC (P = 0.004, 0.019, 0.0013, respectively). Furthermore, up-regulation of NDRG2 was introduced to ESCC cell lines (EC9706 and EC109) by plasmid transfection. In vivo and in vitro studies indicated that overexpression of NDRG2 markedly reduced proliferation and promoted the apoptosis of EC9706 and EC109 cells. In summary, our results demonstrated that NDRG2 played an important role in the proliferation of ESCC cells and the expression of NDRG2 in ESCC was closely related with the prognosis.

The human lung cancer drug resistance-related gene BC006151 regulates chemosensitivity in H446/CDDP cells.

This study aimed to investigate the mechanism by which the human lung cancer drug resistance-related gene BC006151 regulates chemosensitivity by down-regulating BC006151 expression via antisense gene transfer in H446/(C)DDP cells. A retroviral vector containing the antisense BC006151 sequence was constructed and transfected into H446/(C)DDP cells. Transfection of the empty vector served as a negative control. The two groups of transfected cells were treated with various chemotherapeutic agents, after which morphological changes in cell ultrastructure were compared by transmission electron microscopy, cell proliferation and chemosensitivity to particular chemotherapeutic agents were compared by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide method, the effects of chemotherapy on cell cycle and apoptosis were compared by flow cytometry, and Bcl-2 was evaluated by immunohistochemistry and Western blot analysis. Results showed that apoptotic body-like structures were identified by transmission electron microscopy in the antisense gene-transfected cells. MTT founded that these cells exhibited a significantly lower level of proliferation than the control cells (p<0.01), together with a markedly increased sensitivity to various chemotherapeutic agents (p<0.01). Flow cytometry analysis revealed that a G1 phase arrest accounted for the reduction in proliferation in the antisense gene-transfected cells; increased apoptosis was also detected (p<0.01). Both immunohistochemistry and western blot analysis confirmed that Bcl-2 expression was significantly down-regulated in the antisense gene-transfected cells compared to controls. In a word, down-regulation of BC006151 can significantly inhibit proliferation and increase apoptosis of H446/(C)DDP cells after chemotherapy, and this gene may play an important role in the development of multidrug resistance in lung cancer.

Prognostic value of ABO blood group in a Chinese population in Northwest China region with curatively resected rectal cancer.

A positive association between the ABO blood types and survival has been suggested in several malignancies. However, little is known about the relationship between ABO blood group and survival in rectal cancer patients. The aim of this study was to assess the role of the ABO blood types in predicting the prognosis of a Chinese population in Northwest China region with curatively resected rectal cancer. We retrospectively analyzed 1613 consecutive patients who underwent curative surgery for rectal cancer between June, 2011 and December, 2016. The relationship between the ABO blood types and overall survival (OS) was analyzed. The median follow-up period of the 1613 rectal cancer patients was 69.6 months with 1427 alive. There was a significance difference of survival among ABO blood groups (P=0.007). The mean overall survival (OS) of the blood type B patients was 70.8 months, O was 64.3, whereas the mean OS of the AB and A blood type patients was significantly lower, 58.4 months and 59.7 months respectively (P=0.007, log-rank test). Compared with patients with A and AB blood types, patients with blood type B and O were more likely to have better survival(P=0.001). A blood groups were associated with significantly decreased overall survival in rectal cancer patients (hazard ratio = 1.263; 95% confidence interval = 0.776-2.054, P =0.010). In order to confirm our above results, we performed the same investigation in an independent cohort from another hospital of 505 Chinese patients and get the similar results. Our study showed that ABO blood group is associated with survival in Northwest Chinese patients with rectal cancer and the blood type B and O were favourable prognostic factors for patients with rectal cancer.

No associations between fruit and vegetable consumption and pancreatic cancer risk: a meta-analysis of prospective studies.

The associations between fruit and vegetable consumption and pancreatic cancer risk are inconclusive. We conducted a meta-analysis of prospective studies to investigate the associations. The search was conducted systemically using the PubMed and EMBASE databases up to March 2017. Relative risks and 95% confidence intervals for the highest versus lowest consumption and dose-response analyses were assessed. Subtype and subgroup analyses were performed. Twelve studies were eligible. The summary relative risks of the highest versus lowest consumption were 0.95 (0.80-1.12) for total fruits and vegetables without heterogeneity (I2 = 0%, P = 0.44), 0.96 (0.82-1.12) for fruits without low heterogeneity (I2 = 37%, P = 0.12) and 0.94 (0.84-1.06) for vegetables with low heterogeneity (I2 = 9%, P= 0.36). Dose-response analyses also showed no significantly inverse associations for each 100 g/day increase; the summary relative risks were 1.00 (0.98-1.02) for total fruits and vegetables, 1.01 (0.97-1.05) for fruits and 1.00 (0.97-1.03) for vegetables. The results of subtype analyses were consistent with the fruit and vegetable analyses; the relative risks were 0.97 (0.80-1.17) for citrus fruit without low heterogeneity (I2 = 39%, P = 0.15) and 0.89 (0.76-1.05) for cruciferous vegetables without low heterogeneity (I2 = 14%, P= 0.32). In conclusion, this meta-analysis does not support significant associations between fruit and vegetable consumption and pancreatic cancer risk.

The ability of current scoring systems in differentiating transient and persistent organ failure in patients with acute pancreatitis.

PURPOSE: The purpose of this study is to investigate the accuracy of currently used scoring systems in differentiating transient and persistent organ failure in patients with acute pancreatitis (AP). MATERIALS AND METHODS: In this retrospective study, 127 consecutive patients with AP and organ failure were included. Patients were divided into transient and persistent organ failure groups. The Acute Physiology and Chronic Health Examination II score, bedside index of severity in acute pancreatitis, harmless acute pancreatitis score, and modified Marshall scores within the first 24 hours of organ failure were collected, and their accuracy in predicting transient organ failure was assessed. RESULTS: Transient organ failure occurred in 46 patients (36.2%). Fewer patients with transient organ failure initiated with multiple organ failure (13.0% vs 37.0%, P=.004) and renal failure (17.4% vs 44.4%, P=.002). In predicting transient organ failure, the area under the curves of the 4 scoring systems is from 0.66 to 0.71. The area under the curve of serum amylase was 0.78, which was slightly better than that of the modified Marshall and Acute Physiology and Chronic Health Examination II score and was significantly better than that of the bedside index of severity in acute pancreatitis and harmless acute pancreatitis score (P<.05). CONCLUSIONS: Current scoring systems are not accurate enough in differentiating transient and persistent organ failure in patients with AP.