A genomic-clinicopathologic Nomogram for the preoperative prediction of lymph node metastasis in gastric cancer.

BACKGROUND: Preoperative evaluation of lymph node (LN) state is of pivotal significance for informing therapeutic decisions in gastric cancer (GC) patients. However, there are no non-invasive methods that can be used to preoperatively identify such status. We aimed at developing a genomic biosignature based model to predict the possibility of LN metastasis in GC patients. METHODS: We used the RNA profile retrieving strategy and performed RNA expression profiling in a large GC cohort (GSE62254, n = 300) from Gene Expression Ominus (GEO). In the exploratory stage, 300 GC patients from GSE62254 were involved and the differentially expressed RNAs (DERs) for LN-status were determined using the R software. GC samples in GSE62254 were randomly allocated into a learning set (n = 210) and a verification set (n = 90). By using the Least absolute shrinkage and selection operator (LASSO) regression approach, a set of 23-RNA signatures were established and the signature based nomogram was subsequently built for distinguishing LN condition. The diagnostic efficiency, as well as the clinical performance of this model were assessed using the decision curve analysis (DCA). Metascape was used for bioinformatic analysis of the DERs. RESULTS: Based on the genomic signature, we established a nomogram that robustly distinguished LN status in the learning (AUC = 0.916, 95% CI 0.833-0.999) and verification sets (AUC = 0.775, 95% CI 0.647-0.903). DCA demonstrated the clinical value of this nomogram. Functional enrichment analysis of the DERs was performed using bioinformatics methods which revealed that these DERs were involved in several lymphangiogenesis-correlated cascades. CONCLUSIONS: In this study, we present a genomic signature based nomogram that integrates the 23-RNA biosignature based scores and Lauren classification. This model can be utilized to estimate the probability of LN metastasis with good performance in GC. The functional analysis of the DERs reveals the prospective biogenesis of LN metastasis in GC.

Preoperative Controlling Nutritional Status (CONUT) score predicts short-term outcomes of patients with gastric cancer after laparoscopy-assisted radical gastrectomy.

BACKGROUND: An emerging prediction tool, the Controlling Nutritional Status (CONUT) score, has shown good assessment ability of postoperative outcomes in cancer patients. This study evaluated the role of the preoperative CONUT score regarding the short-term outcomes of gastric cancer (GC) after laparoscopic gastrectomy. METHODS: Three hundred and nine GC patients undergoing laparoscopic gastrectomy from January 2016 to June 2019 were analysed, retrospectively. The patients were divided into two groups according to the CONUT optimal cut-off value. Clinical characteristics and postoperative complications in the two groups were analysed and evaluated. Risk factors for complications were identified by univariate and multivariate analyses. RESULTS: A total of 309 patients underwent laparoscopic gastrectomy; 91 (29.4%) patients experienced postoperative complications. The preoperative CONUT score showed a good predictive ability for postoperative complications (area under the curve (AUC) = 0.718, Youden index = 0.343) compared with other indices, with an optimal cut-off value of 2.5. Patients with high CONUT score had a significantly higher incidence of overall complications (P < 0.001). Age, haemoglobin, C-reactive protein, red blood cell levels, CONUT scores, surgical procedure type, T1, T4, N0 and N3 pathological TNM classification, and pathological stages of I and III were associated with postoperative complications (P < 0.05). Furthermore, the preoperative CONUT score was identified as an independent risk predictor of postoperative complications (P = 0.012; OR = 2.433; 95% CI, 1.218-4.862) after multivariate analysis. CONCLUSIONS: The preoperative CONUT score is a practical nutritional assessment for predicting short-term outcomes in GC patients after laparoscopy-assisted gastrectomy.

The relationship between the number of examined lymph nodes and the efficacy of chemotherapy for gastric cancer.

BACKGROUND: The purpose of this research was to investigate the relationship between the number of examined lymph nodes (eLNs) and the prognosis. METHODS: A retrospective examination of reports and studies carried out at two institutions was conducted. According to TNM stages, the relationship between the number of eLNs and the prognosis was analyzed. RESULTS: The 5-year disease-specific survival (DSS) of all enrolled patients was 66.3%. A multivariate analysis showed the type of gastrectomy, histologic type, perineural invasion, pT stage, pN stage, chemotherapy and eLNs to be independent prognostic markers. Additionally, with the exception of patients with stage I disease, the 5-year DSS of patients who had < 25 eLNs removed had a higher risk of having a worst prognosis compared to patients who had ≥ 25 eLNs removed. Through this study, a hypothetical TNM staging system was obtained for predicting the prognosis according to the number of eLNs. Chemotherapy was able to improve the prognosis of patients with stage III and < 25 eLNs in stage II. CONCLUSIONS: Extended lymphadenectomy with a new goal of dissecting 25 LNs for the evaluation of stage II-III cancer cases is recommended. Our hypothetical TNM staging system may be able to stratify the risk more accurately compared to the current AJCC 8th system. Chemotherapy can improve the prognosis in advanced gastric cancer, but its benefit may be affected by the surgical quality.

The safety and tolerability of combined immune checkpoint inhibitors (anti-PD-1/PD-L1 plus anti-CTLA-4): a systematic review and meta-analysis.

BACKGROUND: The future of combined immunotherapy (a PD-1/PD-L1 plus a CTLA-4 antagonist) is very bright. However, besides improving efficacy, combined therapy increases treatment-related adverse events (TRAEs). Also, the clinical application is limited in some solid tumors. METHODS: This paper purports to investigate the TRAEs for the combined immunotherapy aiming for a more appropriate utilization of immune checkpoint inhibitors (ICIs) in clinical practice through a meta-analysis. RESULTS: A total of 17 eligible studies covering 2626 patients were selected for a meta-analysis based on specified inclusion and exclusion criteria. The incidence rates of any grade and grade 3 or higher TRAEs were 88% (95%CI, 84-92%) and 41% (95%CI, 35-47%), respectively. The overall incidence of any grade TRAEs leading to discontinuation of treatment was 20% (95%CI, 16-24%). The incidence rate of treatment related deaths was 4.3‰ (95%CI, 1.4‰-8.4‰). Analysis showed that NIVO1 + IPI3 cohort had higher incidences of grade 3 or higher TRAEs (RR = 1.77, 95%CI, 1.34-2.34, p < 0.0001) and any grade TRAEs leading to discontinuation of treatment (RR = 1.81, 95%CI, 1.08-3.04, P = 0.02), compared with NIVO3 + IPI1 regimen. CONCLUSIONS: The combined therapy had high TRAEs. The TRAEs, especially grade 3 or higher, led to discontinuation of the treatment. Furthermore, the incidence of treatment-related deaths was rare. Moreover, the NIVO3 + IPI1 regimen, regardless of efficacy, is more recommended because of better tolerance and lower adverse events.

Mesh-reinforced pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective study of 126 patients.

BACKGROUND: Pancreatic fistula is a major cause of morbidity and mortality after pancreaticoduodenectomy. The aim of this study is to compare the safety and efficacy of a newly developed technique, namely mesh-reinforced pancreaticojejunostomy, in comparison with the conventional use of pancreaticojejunostomy after undergoing a pancreaticoduodenectomy. METHODS: Data was collected from regarding 126 consecutive patients, who underwent the mesh-reinforced pancreaticojejunostomy or conventional pancreaticojejunostomy, after standard pancreaticoduodenectomy by one group of surgeons, between the time period of 2005 and 2016. This data was collected retrospectively. Surgical parameters and perioperative outcomes were compared between these two groups. RESULTS: A total of 65 patients received mesh-reinforced pancreaticojejunostomy and 61 underwent conventional pancreaticojejunostomy. There were no substantial differences in surgical parameters, mortality, biliary leakage, delayed gastric emptying, gastrojejunostomy leakage, intra-abdominal fluid collection, postpancreatectomy hemorrhage, reoperation, and the total hospital costs between the two groups. Pancreatic fistula rate (15 versus 34%; p = 0.013), overall surgical morbidity (25 versus 43%; p = 0.032), and length of hospital stay (18 ± 9 versus 23 ± 12 days; p = 0.016) were significantly reduced after mesh-reinforced pancreaticojejunostomy. Multivariate analysis of the postoperative pancreatic fistula revealed that the independent factors that were highly associated with pancreatic fistula were a soft pancreatic texture and the type of conventional pancreaticojejunostomy. CONCLUSIONS: This retrospective single-center study showed that mesh-reinforced pancreaticojejunostomy appears to be a safe technique for pancreaticojejunostomy. It may reduce pancreatic fistula rate and surgical complications after pancreaticoduodenectomy. TRIAL REGISTRATION: This research is waivered from trial registration because it is a retrospective analysis of medical records.

Comparison of clinical outcomes between mesh-reinforced pancreatojejunostomy and pancreatogastrostomy following pancreaticoduodenectomy: a cohort study.

BACKGROUND: Postoperative complications, especially postoperative pancreatic fistulas, remain the major concern following pancreaticoduodenectomy (PD). Mesh-reinforced pancreatic anastomoses, including pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), are a new effective technique in PD. This study was conducted to analyze the safety and efficacy of this new technique and to compare the results of mesh-reinforced PJ vs PG. METHODS: A total of 110 patients who underwent PD between August 2005 and January 2016 were eligible in this study. Perioperative and postoperative data of patients with a mesh-reinforced technique were analyzed. Data were also grouped according to the procedure performed: mesh-reinforced PJ and mesh-reinforced PG. RESULTS: Among patients undergoing PD with the mesh-reinforced technique, 42 had postoperative complications, and the comprehensive complication index (CCI) was 32.7 ± 2.5. Only 10% of patients had pancreatic fistula; three were grade A, six were grade B, and two were grade C. Biliary fistula occurred in only 8.2% of patients. Patients undergoing mesh-reinforced PG showed a significantly lower rate of CCI than did mesh-reinforced PJ patients (27.0 ± 2.1 vs 37.0 ± 3.9, p < 0.05). The mesh-reinforced PG was also favored over mesh-reinforced PJ because of significant differences in intra-abdominal fluid collection (5.9% vs 18.6%, p < 0.05) and delayed gastric emptying (3.9% vs 15.3%, p < 0.05). CONCLUSIONS: PD with the mesh-reinforced technique was a safe and effective method of decreasing postoperative pancreatic fistula. Compared with mesh-reinforced PJ, mesh-reinforced PG did not show significant differences in the rates of pancreatic fistula or biliary fistula. However, CCI, intra-abdominal fluid collection, and delayed gastric emptying were significantly reduced in patients with mesh-reinforced PG.

Short-term outcomes of laparoscopic total gastrectomy for gastric cancer: a comparative study with laparoscopic distal gastrectomy at a high-volume center.

BACKGROUND: Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, laparoscopic total gastrectomy (LTG) has been reported rarely when compared with LDG. This study was designed to evaluate the surgical outcomes as well as the morbidity and mortality of LTG compared with LDG to confirm the feasibility and safety of LTG. MATERIAL AND METHODS: We reviewed the data of patients at our institution undergoing LTG (n = 448) or LDG (n = 956) for gastric cancer between January 2008 and July 2016. Then the clinical characteristics and perioperative clinical outcomes of the two groups were compared. RESULTS: Except for tumor size and stage, there were no statistically significant differences in the clinicopathological parameters between the groups. LTG was associated with significantly longer operation time, late time to postoperative diet, and longer hospital stay compared with the LDG group. Overall complications developed in 60 patients (13.4%) and surgical complications in 48 patients (10.7%) after LTG. Postoperative complications were less frequent in the LDG group than in the LTG group (8.4% versus 13.4%, p < .01), and fewer surgical complications were observed with LDG than with LTG (7.5% versus 10.7%, p = .05). CONCLUSIONS: The results of LTG were favorable even though are not inferior to those of LDG. LTG for gastric cancer is technically feasible and safe. However, because of the limits of this study, other high-quality studies are needed for further evaluation.

Short-term outcomes of laparoscopic local resection for gastric submucosal tumors: a single-center experience of 266 patients.

BACKGROUND: Laparoscopic resections for submucosal tumors (SMTs) of the stomach have been developed rapidly over the past decade. Several types of laparoscopic methods for gastric SMTs have been created. We assessed the short-term outcomes of two commonly used types of laparoscopic local resection (LLR) for gastric SMTs and reported our findings. METHODS: We retrospectively analyzed the clinicopathological results of 266 patients with gastric SMTs whom underwent LLR between January 2006 and September 2016. 228 of these underwent laparoscopic exogastric wedge resection (LEWR), the remaining 38 patients with the tumors near the esophagogastric junction (EGJ) or antrum underwent laparoscopic transgastric resection (LTR). RESULTS: All the patients underwent laparoscopic resections successfully. The mean operation times of LEWR and LTR were 90.2 ± 37.2 min and 101.7 ± 38.5 min respectively. The postoperative length of hospital stays for LEWR and LTR were 5.1 ± 2.1 days and 5.3 ± 1.7 days respectively. There was a low complication rate (4.4%) and zero mortality in our series. CONCLUSION: ELWR is technically feasible therapy of gastric SMTs. LTR is secure and effective for gastric intraluminal SMTs located near the EGJ or antrum.

[Application of bio-mesh-reinforced pancreatico-gastrostomy after pancreaticoduodenectomy].

OBJECTIVE: To evaluate the clinical efficacy of bio-mesh-reinforced pancreaticogastrostomy. METHODS: A total of 23 patients undergoing bio-mesh-reinforced pancreaticogastrostomy from May 2011 to January 2013 were retrospectively analyzed. Their demographic data, operative parameters and post-operative outcomes were recorded. The severity of pancreatic leak was determined according to the criteria of International Study Group on Pancreatic Fistula (ISGPF). RESULTS: The mean anastomotic time was 24 (20-35) minutes. Intra-operative leak tests showed all pancreatic anastomoses were watertight. Six patients (26.1%) had pancreatic leakage of grade A. One patient (4.3%) had pancreatic leakage of grade B. No patient developed postoperative pancreatic leakage of class C. One case of abdominal infection was reported. No severe complications such as hemorrhage, bile leakage or gastrojejunostomy leakage were observed. All patients recovered well within Month 1 post-discharge. CONCLUSION: This novel technique may be a simple and feasible strategy for all types of pancreatic remnants.

Comprehensive multi-omics analysis of tryptophan metabolism-related gene expression signature to predict prognosis in gastric cancer.

Introduction: The 5-year survival of gastric cancer (GC) patients with advanced stage remains poor. Some evidence has indicated that tryptophan metabolism may induce cancer progression through immunosuppressive responses and promote the malignancy of cancer cells. The role of tryptophan and its metabolism should be explored for an in-depth understanding of molecular mechanisms during GC development. Material and methods: We utilized the Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) dataset to screen tryptophan metabolism-associated genes via single sample gene set enrichment analysis (ssGSEA) and correlation analysis. Consensus clustering analysis was employed to construct different molecular subtypes. Most common differentially expressed genes (DEGs) were determined from the molecular subtypes. Univariate cox analysis as well as lasso were performed to establish a tryptophan metabolism-associated gene signature. Gene Set Enrichment Analysis (GSEA) was utilized to evaluate signaling pathways. ESTIMATE, ssGSEA, and TIDE were used for the evaluation of the gastric tumor microenvironment. Results: Two tryptophan metabolism-associated gene molecular subtypes were constructed. Compared to the C2 subtype, the C1 subtype showed better prognosis with increased CD4 positive memory T cells as well as activated dendritic cells (DCs) infiltration and suppressed M2-phenotype macrophages inside the tumor microenvironment. The immune checkpoint was downregulated in the C1 subtype. A total of eight key genes, EFNA3, GPX3, RGS2, CXCR4, SGCE, ADH4, CST2, and GPC3, were screened for the establishment of a prognostic risk model. Conclusion: This study concluded that the tryptophan metabolism-associated genes can be applied in GC prognostic prediction. The risk model established in the current study was highly accurate in GC survival prediction.

Aberrant DNA Methylation Patterns of Deleted in Liver Cancer 1 Isoforms in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC), a common primary liver cancer, is the third leading cause of death worldwide. DNA methylation changes are common in HCC and have been studied to be associated with hepatocarcinogenesis. In our study, we used the MassARRAY® EpiTYPER technology to investigate the methylation differences of deleted in liver cancer 1 (DLC1) (isoform 1 and 3) promoter between HCC tissues and corresponding adjacent noncancerous tissues and the association between methylation levels and clinicopathological features. In addition, the modified CRISPR-Cas9 system and the DNA methyltransferase inhibitor (DNMTi) were utilized to explore the functional correlation of epigenetic modifications and DLC1 gene regulation. The methylation levels of the DLC1 isoforms in HCC samples were found significantly lower than those in the adjacent noncancerous tissues (all p < 0.0001). Also, we found that the expression of DLC1 could be bidirectionally regulated by the modified CRISPR-Cas9 system and the DNMTi. Moreover, the hypomethylation of DLC1 in HCC samples was connected with the presence of satellite lesions (p = 0.0305) and incomplete tumor capsule (p = 0.0204). Receiver operator characteristic curve analysis demonstrated that the methylation levels of DLC1 could be applied to discriminate HCC patients (area under the curve = 0.728, p < 0.0001). The hypomethylation status was a key regulatory mechanism of DLC1 expression and might serve as a potential biomarker for HCC.

A new feasible technique of mesh-reinforced pancreatojejunostomy and pancreatogastrostomy: retrospective analysis of 61 cases.

BACKGROUND: Pancreatic leak was the major concern after pancreatoduodenectomy. METHODS: A total of 61 patients who underwent mesh-reinforced pancreatojejunostomy or pancreatogastrostomy from August 2005 to November 2011 were retrospectively analyzed. RESULTS: The mean anastomosis time of mesh-reinforced pancreatojejunostomy was 25 minutes ranging from 22 to 35 minutes. In mesh-reinforced pancreatogastrostomy, the mean anastomosis time ranged from 20 to 38 minutes with an average of 30 minutes. Blood loss was 200 to 4,000 ml with an average of 710 ml in all patients. There was one case of pancreatic leak of Class A, three cases of pancreatic leak of Class B, one case of pancreatic leak of Class C, one case of choledochojejunostomy leakage, one case of gastrojejunostomy leakage, and three cases of abdominal bleeding. CONCLUSION: As a new technique, mesh-reinforced pancreatojejunostomy and pancreatogastrostomy might be a safe and feasible procedure to prevent postoperative pancreatic leak. TRIAL REGISTRATION: This research is waivered from trial registration because it was a retrospective analysis of medical records.

Hypomethylation status of miR-657 promoter region as biomarker for diagnosis of hepatocellular carcinoma: a retrospective study.

Background: The purpose of our study was to evaluate whether the methylation status of the miR-657 promoter region could be used as a biomarker for diagnosis of hepatocellular carcinoma (HCC), so as to find alternative biomarkers of early HCC detection. Methods: Cancerous and paired adjacent noncancerous tissues were collected from 160 patients who had been diagnosed with HCC by histopathology and received surgery. The methylation status of the miR-657 promoter region was measured using a MassARRAY Analyzer 4. Receiver operator characteristic (ROC) curve analysis was used to assess the effectiveness of miR-657 promoter region methylation status as a biomarker for diagnosis of HCC. Results: The mean methylation level of the miR-657 promoter region was significantly lower in cancerous tissues than in normal tissues of HCC patients (48.91%:67.04%, P<0.0001). ROC curve analysis revealed that the mean methylation level of the miR-657 promoter region could distinguish cancerous tissues from paired normal tissues of HCC patients (area under the curve: 0.847, P<0.001). Using 59.50% as the optimal cut-off, the sensitivity was 95.50% and the specificity was 70.01%. Conclusions: Methylation levels of the miR-657 promoter region were decreased in HCC patients and could be used as alternative and supplementary biomarkers for diagnosis of HCC.

Primary malignant melanoma in gastroesophageal junction with 36 months' recurrence-free: a case report.

Background: Melanoma is a sinister malignant tumor originates from melanocytes and is characterized by the presence of black pigmentation in the tissue. The vast majority of melanomas are cutaneous melanomas, and primary mucosal melanomas originating from the esophagus are extremely rare. Primary malignant melanoma of esophagus (PMME) accounts for 0.1% to 0.2% of all primary esophageal malignancies. PMME possess high invasiveness but are insensitive to various treatments, so the prognosis is disappointing. Most literature reported that patients are prone to death from complications of tumor metastasis soon, even they undergo radical surgery. Case Description: In this case report, we admitted a 67-year-old female patient with recurrent chest tightness for 2 years and chest pain for 15 days on October 4, 2017. Preoperative imaging examinations, including computerized tomography (CT) and upper gastrointestinal examination by barium revealed stenosis of the lower esophagus and the fundus of the stomach, with mucosa destruction and lymph node metastasis in the hepatic-gastric space. A laparoscope assisted total gastrectomy with D2 lymph node resection and Roux-en-Y anastomosis was performed without adjuvant immunotherapy or targeted therapies. Postoperative pathological examination and immunohistochemical staining indicated malignant melanoma. Meanwhile we did not find a cutaneous lesion, this patient was therefore diagnosed with a rare PMME. There was no sign of recurrence or metastasis during the latest follow-up of 36 months after the operation, which also exceeded the median recurrence-free survival time in the existing cases worldwide. Conclusions: Therefore, we recommend early radical surgery, which may be beneficial to the PMME patient.

Usefulness of the estimation of physiologic ability and surgical stress (E-PASS) system for prediction of complication and prognosis in hepatocellular carcinoma patients after hepatectomy.

Background: Estimation of physiologic ability and surgical stress (E-PASS) system was verified in predicting postoperative complications or mortality in many surgical operations. This research aimed to investigate whether the E-PASS system could predict postoperative complications and was related with long-term prognosis in primary hepatocellular carcinoma (HCC) patients. Methods: A total of 236 HCC patients who underwent liver resection were collected in this study. We performed univariate analyses to determine the potential risk factors for complications after hepatectomy. The potential independent risk factors were then included in the logistic regression for multivariable analysis. The optimal cutoff value of Comprehensive Risk Score (CRS) was identified by a receiver operating characteristic (ROC) curve. Based on this value, the patients were divided into two groups to investigate the relation between CRS with postoperative complications. The relation between CRS and overall survival (OS) or recurrence-free survival (RFS) was analyzed further in these two groups. Results: Postoperative complications occurred in 79 patients. Multivariable analysis suggested that CRS was independent factor for predicting postoperative complications (P<0.001). The optimal CRS cutoff value in our study was 0.126. Patients with high Preoperative Risk Score (PRS) had a higher rate of postoperative complications occurrence, both major and mild complications (P<0.001). Our study showed that HCC patients with higher CRS had poorer survival prognosis [hazard ratio (HR): 3.735, 95% confidence interval (CI): 1.200-11.631, P=0.023]. The 3-year OS rate of high CRS group (CRS ≥0.126) and low CRS group (CRS <0.126) were 66.2% vs. 84.8% (P<0.001), respectively. Conclusions: For HCC patients after liver resection, E-PASS was an effective predictive system for evaluating the risks of postoperative complications and may can predict prognosis in long term.

C8orf76 Modulates Ferroptosis in Liver Cancer via Transcriptionally Up-Regulating SLC7A11.

Hepatocellular carcinoma (HCC) is a common malignant tumor worldwide. Chromosome 8 open reading frame 76 (C8orf76), a novel gene located in the nucleus, is highly expressed in many tumor types. However, the specific mechanisms and functions of C8orf76 in HCC remain unclear. Here, we reported for the first time that C8orf76 gene expression levels were frequently upregulated in liver cancer and significantly correlated with HCC development. C8orf76 downregulation induced G1-S arrest and inhibited cell proliferation. Intriguingly, C8orf76 deficiency could accelerate erastin or sorafenib-induced ferroptosis through increasing lipid reactive oxygen species (ROS) levels. Moreover, although C8orf76 overexpression did not affect tumorigenesis under normal conditions, it increased resistance to lipid disturbance and ferroptosis triggered by erastin or sorafenib, which further facilitated HCC cell growth and tumor progression. Mechanistically, C8orf76 bound to the promoter region of the solute carrier family 7 member 11 (SLC7A11) gene and upregulated SLC7A11 transcriptionally. SLC7A11-dependent cystine import led to sufficient GSH synthesis and lipid peroxidation inhibition, thus accelerating tumor growth. Our study indicated that C8orf76 could be a novel marker for HCC diagnosis. In addition, a better comprehensive understanding of the potential role of C8orf76 in HCC helped us develop novel therapeutic strategies for this intractable cancer.

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) model as a predictor of postoperative complications and mortality after digestive surgeries: a meta-analysis and systematic review.

BACKGROUND: Conflicting results exist about the usefulness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) model in patients undergoing digestive surgeries. Thus, this study aims to analyze and evaluate the E-PASS model for predicting postoperative complications and mortality. METHODS: A literature search strategy for "E-PASS" was carried out in PubMed, Embase, Google Scholar, Ovid, and Cochrane databases for studies published before November 2020. "E-PASS" or "Estimation of Physiologic Ability and Surgical Stress" were used as the search terms in all databases, and a total of 20 published English language studies with available data relating to digestive surgery were selected for this study. Clinical data and indices including preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, mortality, and overall survival (OS) were collected. Meta-analyses of heterogeneity were performed using Review Manager version 5.3 and STATA 14.0. RESULTS: Twenty studies with 9,136 patients were included in our meta-analysis. Using a random-effects model, the indices of the E-PASS model in patients with postoperative complications were significantly greater than those in patients without complications [PRS: 95% confidence interval (CI): 0.14-1.50; SSS: 95% CI: 0.28-1.06; CRS: 95% CI: 048-1.49]. Moreover, patient morbidity and mortality were associated with a higher CRS (morbidity: 95% CI: 2.17-6.29; mortality: 95% CI: 1.57-4.78), while subgroup analyses showed that a high CRS in the elderly was related to increased morbidity (95% CI: 1.57-4.78) without heterogeneity. In addition, we found that a high E-PASS CRS was significantly associated with shorter OS after digestive surgery (95% CI: 1.24-5.41). DISCUSSION: The higher CRS score in the E-PASS model accompanies with many postoperative complications, increased mortality and shorter OS. Collectively, the E-PASS model is a convenient and effective risk assessment for patients undergoing digestive surgeries. More stringently designed studies are expected to develop better estimates of the application value of this model in digestive surgeries.

Creatinine-to-cystatin C ratio as a marker of skeletal muscle mass for predicting postoperative complications in patients undergoing gastric cancer surgery.

BACKGROUND: Gastric cancer patients usually suffer from skeletal muscle depletion. The serum creatinine/cystatin C ratio (CCR) is a new, simple tool that could serve as a biomarker of skeletal muscle mass. This study explored the ability of the preoperative CCR to predict postoperative complications in patients with gastric cancer. METHODS: A total of 309 patients with gastric cancer who were undergoing surgery were enrolled in this study. Univariate analyses were conducted to determine the potential risk factors for postoperative complications, and multivariate analyses were used to determine the independent influencing factors of postoperative complications. A receiver operating characteristic curve was conducted to identify the optimal cutoff value of the CCR. Patients were divided into two groups according to the critical value to investigate the relationship between the CCR and postoperative complications. RESULTS: Postoperative complications occurred in 87 patients. Multivariate analysis suggested that age, red blood cell level, lymphocyte count, cystatin C, CCR, and N factor were independent risk or protective factors for postoperative complications (P<0.001). The optimal cutoff value of the preoperative CCR was 7.117. Compared with the high preoperative CCR group, patients with a low preoperative CCR were more likely to have both mild complications (P<0.001) and major complications (P<0.001). CONCLUSIONS: The preoperative CCR can effectively predict postoperative complications in gastric cancer patients after surgery.

Risk Factors for Duodenal Stump Leakage after Laparoscopic Gastrectomy for Gastric Cancer.

PURPOSE: Duodenal stump leakage (DSL) is a potentially fatal complication that can occur after gastrectomy, but its underlying risk factors are unclear. This study aimed to investigate the risk factors and management of DSL after laparoscopic radical gastrectomy for gastric cancer (GC). MATERIALS AND METHODS: Relevant data were collected from several prospective databases to retrospectively analyze the data of GC patients who underwent Billroth II (B-II) or Roux-en-Y (R-Y) reconstruction after laparoscopic gastrectomy from 2 institutions (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, and HwaMei Hospital, University of Chinese Academy of Sciences). The DSL risk factors were analyzed using univariate and multivariate analysis regression. RESULTS: A total of 810 patients were eligible for our analysis (426 with R-Y, 384 with B-II with Braun). Eleven patients had DSL (1.36%). Body mass index (BMI), elevated preoperative C-reactive protein (CRP) level, and unreinforced duodenal stump were the independent risk factors for DSL. DSL was diagnosed in 2-12 days, with a median of 8 days. Seven patients received conservative treatment, 3 patients received puncture treatment, and only 1 patient required reoperation. All patients recovered successfully after treatment. CONCLUSIONS: The risk factors of DSL were BMI ≥24 kg/m2, elevated preoperative CRP level, and unreinforced duodenal stump. Nonsurgical treatments for DSL are preferred.

Comparison of Long-Term Outcomes of Endoscopic Submucosal Dissection and Surgery for Early Gastric Cancer: a Systematic Review and Meta-analysis.

BACKGROUND: Endoscopic submucosal dissection (ESD) is an endoscopic alternative to surgical resection of early gastric cancer (EGC). Besides offering both diagnostic and therapeutic capability, it has the benefits of reducing post-operative complications and provides fast recovery and better quality of life compared to surgical resection of neoplastic lesions. However, due to limitations of the procedure, its long-term outcomes are rather controversial. METHODS: This study has been carried out to investigate the long-term outcomes of ESD which includes the overall survival (OS), disease-free survival (DFS), and recurrence rate. The following databases were used to search for articles published until February 2018: Medline, Cochrane Library, PubMed, Web of Science, and EBSCO. RESULTS: A total of 13 eligible studies covering 4986 patients were selected for a meta-analysis based on specified inclusion and exclusion criteria. The difference of OS and disease-specific survival (DSS) between ESD and surgical treatment was not statistically significant (RR = 0.90, 95% CI = 0.68-1.19, p = 0.46; RR = 0.40, 95% CI = 0.15-1.03, p = 0.06, respectively). However, DFS in the ESD group was much lower than that in the surgery group (RR = 3.40, 95% CI = 2.39-4.84, p < 0.001). In terms of the treatment after recurrence, the proportion of patients who could receive radical treatment was significantly higher in the ESD than that in the gastrectomy (OR = 5.27, 95% CI = 2.35-11.79, p < 0.001). CONCLUSIONS: This meta-analysis showed that ESD might be an alternative treatment option to surgery for patients with EGC in Asian countries. But a close surveillance program after ESD is of necessity, considering the higher possibility of tumor recurrence after ESD.