Surgical Apgar Score predictive value for early postoperative organ dysfunction in cancer patients.

BACKGROUND: Surgical APGAR Score (SAS) is based only on intraoperative data and has the advantage of being easy to calculate. Low SAS was associated with an increased risk for postoperative complications, but its utility for specific outcomes prediction, such as postoperative cardiovascular, renal, or metabolic dysfunction is less investigated. Our study aimed to investigate SAS predictive value for early postoperative organ dysfunction in a surgical oncological population. METHODS: This is a prospective observational study that enrolled all consecutive patients submitted to oncologic surgery over 20-days. Registered parameters included demographics, comorbidities, diagnosis and surgery data, SAS score, postoperative complications, organ dysfunction and in-hospital mortality. SAS predictive value for postoperative organ dysfunction was assessed using logistic regression and ROC curves. RESULTS: The study included 205 oncological patients with a mean age (standard deviation) of 60 (12.8) years. SAS was between 8 and 10 in 60% of patients and between 0 and 7 in 40% of patients. Postoperative complications developed in 33 patients (16.1%) and organ dysfunction in 26 patients (12.7%). The rates of postoperative complications, organ dysfunction and mortality, were significantly higher in patients with a low SAS (0-7) than high SAS (8-10). SAS had a low discrimination capacity to distinguish between patients who will develop postoperative complications and those who will not (AUROC 0.65) but was more accurate in identifying surgical oncological patients at risk for cardiovascular and metabolic dysfunction (AUROC 0.83 and 0.85 respectively). CONCLUSION: SAS may be a useful tool to identify cancer surgery patients at risk for postoperative cardiovascular and metabolic dysfunction.

TECHNICAL DIFFICULTIES AND PROCEDURAL COMPLICATIONS IN CLOSING MALIGNANT ESOPHAGEAL-RESPIRATORY FISTULAS.

The aim of the study was to outline technical difficulties and procedural complications of using partially covered esophageal self-expandable metal stents (SEMSs) in malignant esophageal respiratory fistulas (ERFs) as a palliative treatment option. In this study, 150 patients with malignant dysphagia underwent treatment with SEMSs. A total of 36 ERFs were detected through endoscopic or clinical assessment. Complete fistula sealing with SEMSs was possible in 35 of the 36 patients. The majority of fistulas were diagnosed in male patients with advanced esophageal cancer. All of them presented with prolonged dysphagia and cachexia. Stent migration or tumoral overgrowth was identified in 6 cases with recurrent dysphagia, and required a second stent insertion. SEMSs were highly efficient in 98% of the patients studied with ERFs, with successfully sealed ERFs after the first attempt, with an overall median survival rate of 92 days. The technique of esophageal SEMS placement is simple and can be rapidly mastered. Patients with ERFs have a respiratory shunt that makes intubation difficult and is often avoided. Restoring oral feeding increased the patient quality of life. SEMS placement is generally safe, but has few associated postoperative complications.

Outcome Predictive Value of Serum Ferritin in ICU Patients with Long ICU Stay.

Background and Objectives: The simplified interpretation of serum ferritin levels, according to which low ferritin levels indicate iron deficiency and high levels indicate hemochromatosis is obsolete, as in the presence of inflammation serum ferritin levels, no longer correlate with iron stores. However, further data are needed to interpret serum ferritin levels correctly in patients with ongoing inflammation. Our study aimed to assess serum iron and ferritin dynamics in patients with long ICU stay and the possible correlations with organ dysfunction progression and outcome. Materials and Methods: We conducted a prospective study in a university hospital intensive care unit (ICU) over six months. All patients with an ICU length-of-stay of more than seven days were enrolled. Collected data included: demographics, Sequential Organ Failure Assessment (SOFA) score, admission, weekly serum iron and ferritin levels, ICU length-of-stay and outcome. Interactions between organ dysfunction progression and serum iron and ferritin levels changes were investigated. Outcome predictive value of serum ferritin was assessed. Results: Seventy-two patients with a mean ICU length-of-stay of 15 (4.4) days were enrolled in the study. The average age of patients was 62 (16.8) years. There were no significant differences between survivors (39 patients, 54%) and nonsurvivors (33 patients, 46%) regarding demographics, serum iron and ferritin levels and SOFA score on ICU admission. Over time, serum iron levels remained normal or low, while serum ferritin levels statedly increased in all patients. Serum ferritin increase was higher in nonsurvivors than survivors. There was a significant positive correlation between SOFA score and serum ferritin (r = 0.7, 95%CI for r = 0.64 to 0.76, p < 0.01). The predictive outcome accuracy of serum ferritin was similar to the SOFA score. Conclusions: In patients with prolonged ICU stay, serum ferritin dynamics reflects organ dysfunction progression and parallels SOFA score in terms of outcome predictive accuracy.

Perioperative Anemia and Transfusion in Colorectal Cancer Patients.

Background: Both anemia and blood transfusion are now considered independent risk factors for poor outcome in colorectal cancer patients. Severe anemia can increase tumor aggressiveness and blood transfusion may induce immunosuppression and promote cancer recurrence. Specific Patient Blood Management (PBM) strategies for oncological surgical patients are insufficiently defined and recommended. Primary objectives: Evaluation of the perioperative anemia prevalence and transfusion rate in colorectal cancer patients. Secondary objectives: Sub-group analysis of anemic versus non-anemic patients and colon versus rectal cancer patients. Methods: We retrospectively reviewed records from all consecutive surgical oncological patients admitted between January and June 2017. We selected major lower abdominal surgical patients and then colorectal surgical patients. We evaluated the perioperative hemoglobin values dynamics (preoperative=Hb1, postoperative= Hb2, at discharge= Hb3), anemia prevalence and severity and transfusion rate. Statistical analysis used Student t test, Wilcoxon signed-rank and Chi-square tests from SPSS 17. Results: Of the 1284 patients screened, 546 patients were submitted to major lower abdominal surgery and 260 patients to colorectal cancer surgery. The mean age was 65.6 +- 11.1 years, 57.7% males. The perioperative dynamics of hemoglobin was Hb1/Hb2/Hb3 =12/10.6/10.4 g/dL. Anemia prevalence was 52.3/82.3/82.6% preoperatively/postoperatively/at hospital discharge. Global transfusion rate was 23.8%, with pre/intra/postoperative distribution of 2.3/11.9/10.8%. Anemic patients were older (p=0.005), with a higher transfusion rate (p 0.001) and a longer hospital LOS (p=0.04). Colon cancer patients had lower Hb values (p=0.001) and higher prevalence of preoperative anemia (p=0.001) comparing with rectal cancer patients. Conclusions: The analysis of this cohort of colorectal cancer patients identified an increased prevalence of anemia in all perioperative phases. There is an urgent need of PBM program implementation in this selected group of surgical patients.

Long-Term Deleterious Effects of Short-term Hyperoxia on Cancer Progression-Is Brain-Derived Neurotrophic Factor an Important Mediator? An Experimental Study.

Perioperative factors promoting cancer recurrence and metastasis are under scrutiny. While oxygen toxicity is documented in several acute circumstances, its implication in tumor evolution is poorly understood. We investigated hyperoxia long-term effects on cancer progression and some underlying mechanisms using both in vitro and in vivo models of triple negative breast cancer (TNBC). We hypothesized that high oxygen exposure, even of short duration, may have long-term effects on cancer growth. Considering that hyperoxic exposure results in reactive oxygen species (ROS) formation, increased oxidative stress and increased Brain-Derived Neurotrophic Factor (BDNF) expression, BDNF may mediate hyperoxia effects offering cancer cells a survival advantage by increased angiogenesis and epithelial mesenchymal transition (EMT). Human breast epithelial MCF10A, human MDA-MB-231 and murine 4T1 TNBC were investigated in 2D in vitro system. Cells were exposed to normoxia or hyperoxia (40%, 60%, 80% O2) for 6 h. We evaluated ROS levels, cell viability and the expression of BDNF, HIF-1α, VEGF-R2, Vimentin and E-Cadherin by immunofluorescence. The in vivo model consisted of 4T1 inoculation in Balb/c mice and tumor resection 2 weeks after and 6 h exposure to normoxia or hyperoxia (40%, 80% O2). We measured lung metastases and the same molecular markers, immediately and 4 weeks after surgery. The in vitro study showed that short-term hyperoxia exposure (80% O2) of TNBC cells increases ROS, increases BDNF expression and that promotes EMT and angiogenesis. The in vivo data indicates that perioperative hyperoxia enhances metastatic disease and this effect could be BDNF mediated.

Perioperative Immune Response Alternation. Can It Influence Cancer Recurrence?

The relationship between host immune response and tumor cells is currently defined by the immunoediting concept, including three phases: elimination, equilibrium and escape. Cancer cells are initially eliminated by the immune system, but progressively can develop escape mechanisms. The balance between elimination and escape depends on the prevailing activity of cytotoxic Th1 or immunosuppressive Th2 lymphocytes. Surgery has the potential to eradicate the disease, but, along with other perioperative circumstances, can induce a variable degree and period of immunosuppression. By modifying the Th1/Th2 ratio, these perioperative circumstances may favor the escaping mechanisms and, consequently, promote cancer recurrence and metastasis altering long term prognosis of cancer patients.

Laparoscopic-assisted percutaneous endoscopic transgastrostomy jejunostomy.

BACKGROUND AND OBJECTIVES: New therapeutic protocols for patients with end-stage Parkinson disease include a carbidopa/levodopa combination using continuous, modulated enteral administration via a portable pump. The typical approach involves a percutaneous endoscopic transgastrostomy jejunostomy (PEG-J), which requires a combination of procedures designed to ensure that no organ is interposed between the abdominal wall and the gastric surface. Lack of transillumination in maximal endoscopic light settings is a major contraindication for PEG-J, and we decided to use a different approach to establish enteric access for long-term medication delivery via pump, using a minimally invasive procedure. METHODS: In all patients, we performed a laparoscopic-assisted percutaneous transgastrostomy jejunostomy (LAPEG-J) after an unsuccessful endoscopic transillumination. RESULTS: Five patients with end-stage Parkinson disease were referred to our department after successful therapeutic testing with administration of levodopa/carbidopa via naso-jejunal tube. All patients failed the endoscopic transillumination during the endoscopic procedure and were considered for LAPEG-J. In all patients, the LAPEG-J procedure was uneventful. The most common reason identified for failed transillumination was a high position of the stomach, followed by interposition of the liver or colon between the stomach and anterior abdominal wall. There were no complications regarding the LAPEG-J procedure, and all patients were discharged during the second postprocedural day. CONCLUSIONS: LAPEG-J provides a simple and safe option for placing a jejunostomy after an unsuccessful PEG-J attempt.