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.

American vs. European Trauma Centers: A Comparison of Preventable Deaths. / Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo.

INTRODUCTION: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. METHODS: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. RESULTS: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001). CONCLUSIONS: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center.

Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability.

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture.

Genetic risk score based on obesity-related genes and progression in weight loss after bariatric surgery: a 60-month follow-up study.

BACKGROUND: Obesity is a polygenic multifactorial disease. Recent genome-wide association studies have identified several common loci associated with obesity-related phenotypes. Bariatric surgery (BS) is the most effective long-term treatment for patients with severe obesity. The huge variability in BS outcomes between patients suggests a moderating effect of several factors, including the genetic architecture of the patients. OBJECTIVE: To examine the role of a genetic risk score (GRS) based on 7 polymorphisms in 5 obesity-candidate genes (FTO, MC4R, SIRT1, LEP, and LEPR) on weight loss after BS. SETTING: University hospital in Spain. METHODS: We evaluated a cohort of 104 patients with severe obesity submitted to BS (Roux-en-Y gastric bypass or sleeve gastrectomy) followed up for >60 months (lost to follow-up, 19.23%). A GRS was calculated for each patient, considering the number of carried risk alleles for the analyzed genes. During the postoperative period, the percentage of excess weight loss total weight loss and changes in body mass index were evaluated. Generalized estimating equation models were used for the prospective analysis of the variation of these variables in relation to the GRS. RESULTS: The longitudinal model showed a significant effect of the GRS on the percentage of excess weight loss (P = 1.5 × 10-5), percentage of total weight loss (P = 3.1 × 10-8), and change in body mass index (P = 7.8 × 10-16) over time. Individuals with a low GRS seemed to experience better outcomes at 24 and 60 months after surgery than those with a higher GRS. CONCLUSION: The use of the GRS in considering the polygenic nature of obesity seems to be a useful tool to better understand the outcome of patients with obesity after BS.

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.

Psychopathological profile before and after bariatric surgery.

Presurgical psychopathological assessment usually focuses on detecting severe mental disorders. However, mild intensity psychopathology and eating behaviour pattern may also influence postsurgical outcomes. The aim was to identify psychopathology and eating behaviour pattern in candidates prepared for bariatric surgery compared to a normative population before and after surgery. A cohort of 32 patients seeking bariatric surgery in a university hospital between March 2016 and March 2017 were evaluated with Personality Assessment Inventory (PAI), 36-item EDE-Q and BES before and after surgery. Thirty-two patients before and 26 one year after surgery were included. The PAI presurgical psychometric profile suggested a mild mixed adjustment disorder focused on somatic complaints. After surgery, patients improved in somatic complaints (p < 0.001), and depression (p = 0.04). Related eating disorders were more common than those of the normative group and improved significantly after surgery in scores for compulsive intake (BES p < 0.001) and overall key behaviours of eating disorders and related cognitive symptoms (EDE-Q/G p < 0.001). In our cohort ready for bariatric surgery a mild psychopathological profile is still present and becomes closer to that of the normative group after surgery. Further studies are needed to evaluate the effects of mild psychopathology on outcomes after bariatric surgery.

Cost analysis of a patient blood management program for patients undergoing gastric cancer surgery.

Patient Blood Management (PBM) programs have probed to reduce blood transfusions and postoperative complications following gastric cancer resection, but evidence on their economic benefit is scarce. A recent prospective interventional study of our group described a reduction in transfusions, infectious complications and length of stay after implementation of a multicenter PBM program in patients undergoing elective gastric cancer resection with curative intent. The aim of the present study was to analyze the economic impact associated with these clinical benefits. The mean [and 95% CI] of total healthcare cost per patient was lower (-1955 [-3764, -119] €) after the PBM program implementation. The main drivers of this reduction were the hospital stay (-1847 [-3161, -553] €), blood transfusions (-100 [-145, -56] €), and post-operative complications (-162 [-718, 411] €). Total societal cost was reduced by -2243 [-4244, -210] € per patient. These findings highlight the potential economic benefit of PBM strategies.

Effect of Perioperative Blood Transfusions and Infectious Complications on Inflammatory Activation and Long-Term Survival Following Gastric Cancer Resection.

Background: The aim of this study was to evaluate the impact of perioperative blood transfusion and infectious complications on postoperative changes of inflammatory markers, as well as on disease-free survival (DFS) in patients undergoing curative gastric cancer resection. Methods: Multicenter cohort study in all patients undergoing gastric cancer resection with curative intent. Patients were classified into four groups based on their perioperative course: one, no blood transfusion and no infectious complication; two, blood transfusion; three, infectious complication; four, both transfusion and infectious complication. Neutrophil-to-lymphocyte ratio (NLR) was determined at diagnosis, immediately before surgery, and 10 days after surgery. A multivariate Cox regression model was used to analyze the relationship of perioperative group and dynamic changes of NLR with disease-free survival. Results: 282 patients were included, 181 in group one, 23 in group two, 55 in group three, and 23 in group four. Postoperative NLR changes showed progressive increase in the four groups. Univariate analysis showed that NLR change > 2.6 had a significant association with DFS (HR 1.55; 95% CI 1.06−2.26; p = 0.025), which was maintained in multivariate analysis (HR 1.67; 95% CI 1.14−2.46; p = 0.009). Perioperative classification was an independent predictor of DFS, with a progressive difference from group one: group two, HR 0.80 (95% CI: 0.40−1.61; p = 0.540); group three, HR 1.42 (95% CI: 0.88−2.30; p = 0.148), group four, HR 2.85 (95% CI: 1.64−4.95; p = 0.046). Conclusions: Combination of perioperative blood transfusion and infectious complications following gastric cancer surgery was related to greater NLR increase and poorer DFS. These findings suggest that perioperative blood transfusion and infectious complications may have a synergic effect creating a pro-inflammatory activation that favors tumor recurrence.

Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis.

BACKGROUND: The concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival. METHOD: All patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014-December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups. RESULTS: In total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, "macroscopically complete resection" had the highest compliance (96.5%) while "no serious complications" had the lowest compliance (63.7%). Age (OR 0.53 for the 65-74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34-0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08-0.70), multivisceral resection (OR 0.55, 95%CI 0.33-0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46-0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55-0.83). CONCLUSION: TO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.

[Adverse events in general surgery. A prospective analysis of 13,950 consecutive patients]. / Efectos adversos en cirugía general. Análisis prospectivo de 13.950 pacientes consecutivos.

INTRODUCTION: Adverse event (AE) rates in General Surgery vary, according to different authors and recording methods, between 2% and 30%. Six years ago we designed a prospective AE recording system to change patient safety culture in our Department. We present the results of this work after a 6 year follow-up. MATERIAL AND METHOD: The AE, sequelae and health care errors in a University Hospital surgery department were recorded. An analysis of each incident recorded was performed by a reviewer. The data was entered into data base for rapid access and consultation. The results were routinely presented in Departmental morbidity-mortality sessions. RESULTS: A total of 13,950 patients had suffered 11,254 AE, which affected 5142 of them (36.9% of admissions). A total of 920 patients were subjected to at least one health care error (6.6% of admissions). This meant that 6.6% of our patients suffered an avoidable AE. The overall mortality at 5 years in our department was 2.72% (380 deaths). An adverse event was implicated in the death of the patient in 180 cases (1.29% of admissions). In 49 cases (0.35% of admissions), mortality could be attributed to an avoidable AE. After 6 years there tends to be an increasingly lower incidence of errors. CONCLUSIONS: The exhaustive and prospective recording of AE leads to changes in patient safety culture in a Surgery Department and helps decrease the incidence of health care errors.

Improved postoperative outcomes and reduced transfusion rates after implementation of a Patient Blood Management program in gastric cancer surgery.

INTRODUCTION: Gastric cancer patients are often transfused with red blood cells, with negative impact on postoperative course. This multicenter prospective interventional cohort study aimed to determine whether implementation of a Patient Blood Management (PBM) program, was associated with a decrease in transfusion rate and improvements in clinical outcomes in gastric cancer surgery. METHODS: We compared transfusion practices and clinical outcomes in patients undergoing elective gastric cancer resection before and after implementing a PBM program, including strategies to detect and treat anemia and restrictive transfusion practice (2014-2018). Primary outcome was transfusion rate (TR). Secondary outcomes were complications, reoperations, length of stay, readmissions, 90-day mortality and failure-to-rescue. Differences were adjusted by confounding factors. RESULTS: Some 789 patients were included (496 pre- and 293 post-PBM). TR decreased from 39.1% to 27.0% (adjusted difference -9.1, 95% CI -15.2 to -2.9), being reduction particularly significant in patients with anemia, ASA score 3-4, locally advanced tumors, undergoing open surgery and total gastrectomy. Infectious complications diminished from 25% to 16.4% (-6.1, 95%CI -11.5 to -0.7), reoperations from 8.1% to 6.1% (-2.2, 95%CI -5.1 to +0.6), median length of stay from 11 [IQR 8-18] to 8 [7-12] days (p < 0.001), hospital readmission from 14.1% to 8.9% (-5.4, 95%CI -9.6 to -1.1), mortality from 7.9% to 4.8% (-2.4, 95%CI -4.7 to -0.01), and failure-to rescue from 62.7% to 32.7% (-23.1, 95%CI -37.7 to -8.5). CONCLUSION: Implementation of a PBM program was associated with a reduction in transfusion rate and improvement in postoperative outcomes in gastric cancer patients undergoing curative resection.

A Clinical-Genetic Score for Predicting Weight Loss after Bariatric Surgery: The OBEGEN Study.

Around 30% of the patients that undergo bariatric surgery (BS) do not reach an appropriate weight loss. The OBEGEN study aimed to assess the added value of genetic testing to clinical variables in predicting weight loss after BS. A multicenter, retrospective, longitudinal, and observational study including 416 patients who underwent BS was conducted (Clinical.Trials.gov- NCT02405949). 50 single nucleotide polymorphisms (SNPs) from 39 genes were examined. Receiver Operating Characteristic (ROC) curve analysis were used to calculate sensitivity and specificity. Satisfactory response to BS was defined as at nadir excess weight loss >50%. A good predictive model of response [area under ROC of 0.845 (95% CI 0.805-0.880), p < 0.001; sensitivity 90.1%, specificity 65.5%] was obtained by combining three clinical variables (age, type of surgery, presence diabetes) and nine SNPs located in ADIPOQ, MC4R, IL6, PPARG, INSIG2, CNR1, ELOVL6, PLIN1 and BDNF genes. This predictive model showed a significant higher area under ROC than the clinical score (p = 0.0186). The OBEGEN study shows the key role of combining clinical variables with genetic testing to increase the predictability of the weight loss response after BS. This finding will permit us to implement a personalized medicine which will be associated with a more cost-effective clinical practice.

Correction to: Esogastro-Pleuro-Bronchial Fistula: An Unusual Complication After Sleeve Gastrectomy.

Due to a Production error Figs. 1 and 2 were omitted from the original article.

Longitudinal changes in telomere length in a cohort of obese patients submitted to bariatric surgery: a 2-year follow-up.

BACKGROUND: Telomere length (TL) is one biomarker of cell aging used to explore the effects of the environment on age-related pathologies. Obesity and high body mass index have been identified as a risk factors for shortened TL. OBJECTIVE: To evaluate TL in different subtypes of obese patients, and to examine changes in TL in relation to weight loss after bariatric surgery. SETTING: University Hospital in Spain. METHODS: A cohort of 94 patients submitted to bariatric surgery were followed-up during 24 months (t24m: lost to follow-up = 0%). All patients were evaluated before surgery (t0) and during the postoperative period (t6m, t12m, and t24m) for body mass index and metabolic variables. We assessed TL at each timepoint using quantitative polymerase chain reactions and the telomere sequence to single-copy gene sequence ratio method. RESULTS: Patients with class III obesity showed significantly shorter TL at baseline than those patients with class II obesity (P = .027). No differences in TL were found between patients with or without type 2 diabetes or metabolic syndrome. Longitudinal analysis did not show an effect of time, type of surgery, age, or sex on TL. However, a generalized estimating equation model showed that TL was shorter amongst class III obesity patients across the time course (P = .008). Comparison between patients with obesity class II and class III showed differences in TL at t6m (adjusted P = .024), whereby class II patients had longer TL. However, no difference was observed at the other evaluated times. CONCLUSION: Obesity severity may have negative effects on TL independently of type 2 diabetes or metabolic syndrome. Although TL is significantly longer in class II obesity patients relative to class III 6 months after bariatric surgery. This difference is not apparent after 24 months.

Endoscopic Ultrasound (EUS)-Guided Drainage of a Postsleeve Gastrectomy Subphrenic Collection Using a Lumen Apposition Stent.

Sleeve gastrectomy is currently the most frequently performed bariatric surgery. Postoperative leaks represent the main cause of morbidity in up to 8% of patients with a mortality rate ranging between 0.1 and 5%. However, management of these leaks remains controversial. We report the case of a patient presenting with sepsis 2 weeks after surgery. A subphrenic collection and a leak were found on CT. Despite medical treatment, the patient did not show clinical improvement. Hence, we considered a transgastric endosonographic-guided drainage of the collection using an electrocautery-enhanced lumen-apposing metal stent (LAMS). The procedure underwent uneventfully, and the patient status improved rapidly. Two weeks later, the stent was withdrawn. A follow-up endoscopy 6 weeks later showed closure of the gastric wall defect.

An evaluation of morbidity and mortality in oncologic gastric surgery with the application of POSSUM, P-POSSUM, and O-POSSUM.

OBJECTIVE: Evaluation of surgical results observed in oncologic gastric surgery with reference to estimation of risks through POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity), P-POSSUM (Portsmouth POSSUM), and O-POSSUM (regression model based on the POSSUM and P-POSSUM, especially designed for gastric and esophagus surgery). METHODS: A prospective follow-up of a cohort of 106 consecutive patients, gastrectomized because of gastric cancer. The variables studied were: age, sex, technical surgery, American Society of Anesthesiologists (ASA) score, the Charlson comorbidity index, morbidity, and mortality. RESULTS: From January 2004 to April 2008, 131 patients were operated on for gastric neoplasia. Of these, 28 patients were excluded: 5 because of nonstandard gastrectomy, 17 because of staging laparoscopy or unresectable cancer after laparotomy, and 3 because of palliative gastroenteroanastomosis; 106 patients were included. We performed 38 total gastrectomies, 65 distal gastrectomies, 2 esophagogastrectomies, and 1 proximal gastrectomy. The mean age was 68 years (standard deviation (SD) = 12.1; range, 34-85 years). Associated comorbidity (Charlson) was 5.4 (SD = 2.7; range, 2-16); ASA 1 at 1.9%; ASA 2 at 36.8%; ASA 3 at 43.4%; and ASA 4 at 17.9%. Expected morbidity, according to POSSUM was 46.7%; observed morbidity was 50.5%. Morbidity ratio observed/expected was 1.08. Expected mortality, according to POSSUM = 13%, according to P-POSSUM = 4.9%, and according to O-POSSUM = 12.1%. Observed mortality was 7.8%. Mortality ratio observed/expected according to POSSUM, P-POSSUM, O-POSSUM was 0.6, 1.6, and 0.6, respectively. Morbidity results were within the confidence interval of the POSSUM estimation. Our results show lower mortality than the POSSUM and the O-POSSUM estimation (P < 0.001) and higher mortality regarding P-POSSUM estimation (P < 0.001). CONCLUSIONS: The control systems of risk allow us continuous evaluation of our results and objective comparison to other teams. Compared with the POSSUM scoring systems, our series showed quality improvement (morbidity and mortality) over time.

Human Subcutaneous Tissue Response to Glucose Sensors: Macrophages Accumulation Impact on Sensor Accuracy.

BACKGROUND: Subcutaneous (s.c.) glucose sensors have become a key component in type 1 diabetes management. However, their usability is limited by the impact of foreign body response (FBR) on their duration, reliability, and accuracy. Our study gives the first description of human acute and subacute s.c. response to glucose sensors, showing the changes observed in the sensor surface, the inflammatory cells involved in the FBR and their relationship with sensor performance. METHODS: Twelve obese patients (seven type 2 diabetes) underwent two abdominal biopsies comprising the surrounding area where they had worn two glucose sensors: the first one inserted 7 days before and the second one 24 h before biopsy procedure. Samples were processed and studied to describe tissue changes by two independent pathologists (blind regarding sensor duration). Macrophages quantification was studied by immunohistochemistry methods in the area surrounding the sensor (CD68, CD163). Sensor surface changes were studied by scanning electron microscopy. Seven-day continuous glucose monitoring records were considered inaccurate when mean absolute relative difference was higher than 10%. RESULTS: Pathologists were able to correctly classify all the biopsies regarding sensor duration. Acute response (24 h) was characterized by the presence of neutrophils while macrophages were the main cell involved in subacute inflammation. The number of macrophages around the insertion hole was higher for less accurate sensors compared with those performing more accurately (32.6 ± 14 vs. 10.6 ± 1 cells/0.01 mm2; P < 0.05). CONCLUSION: The accumulation of macrophages at the sensor-tissue interface is related with decrease in accuracy of the glucose measure.

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.

Impact of Bariatric Surgery on Heme Oxygenase-1, Inflammation, and Insulin Resistance in Morbid Obesity with Obstructive Sleep Apnea.

INTRODUCTION: Morbid obesity and obstructive sleep apnea (OSA) interact at an inflammatory level. Bariatric surgery reduces inflammatory responses associated with obesity. Heme oxygenase-1 (HO-1) is an enzyme with anti-inflammatory properties, which might be increased in morbid obesity or OSA. We studied morbidly obese patients with OSA to determine: (a) HO-1 plasma concentrations according to OSA severity and their relationship with insulin resistance and inflammation and (b) the impact of bariatric surgery on HO-1 and parameters of insulin resistance and inflammation. MATERIAL AND METHODS: We analyzed the homeostasis model insulin resistance index (HOMA) and plasma concentrations of HO-1, tumor necrosis factor alpha, interleukin-6, interleukin-1-beta, C reactive protein (CRP), and adiponectin according to polysomnography findings in 66 morbidly obese patients before bariatric surgery and 12 months after surgery. RESULTS: Before surgery, HO-1 plasma concentrations were similar in three groups of patients with mild, moderate, and severe OSA, and correlated with HOMA (r = 0.27, p = 0.02). Twelve months after surgery, low-grade inflammation and insulin resistance had decreased in all the groups, but HO-1 plasma concentration had decreased only in the severe OSA group (p = 0.02). In this group, the reduction in HO-1 correlated with a reduction in CRP concentrations (r = 0.43, p = 0.04) and with improved HOMA score (r = 0.37, p = 0.03). CONCLUSIONS: Bariatric surgery decreases HO-1 concentrations in morbid obesity with severe OSA, and this decrease is associated with decreases in insulin resistance and in inflammation.