Xian Shen

Sarcopenia is an Independent Predictor of Severe Postoperative Complications and Long-Term Survival After Radical Gastrectomy for Gastric Cancer: Analysis from a Large-Scale Cohort.

AbstractCurrently, the association between sarcopenia and long-term prognosis after gastric cancer surgery has not been investigated. Moreover, the association between sarcopenia and postoperative complications remains controversial. This large-scale retrospective study aims to ascertain the prevalence of sarcopenia and assess its impact on postoperative complications and long-term survival in patients undergoing radical gastrectomy for gastric cancer.From December 2008 to April 2013, the clinical data of all patients who underwent elective radical gastrectomy for gastric cancer were collected prospectively. Only patients with available preoperative abdominal CT scan within 30 days of surgery were considered for analysis. Skeletal muscle mass was determined by abdominal (computed tomography) CT scan, and sarcopenia was diagnosed by the cut-off values obtained by means of optimum stratification. Univariate and multivariate analyses evaluating risk factors of postoperative complications and long-term survival were performed.A total of 937 patients were included in this study, and 389 (41.5%) patients were sarcopenic based on the diagnostic cut-off values (34.9 cm2/m2 for women and 40.8 cm2/m2 for men). Sarcopenia was an independent risk factor for severe postoperative complications (OR = 3.010, P < 0.001), but not for total complications. However, sarcopenia did not show significant association with operative mortality. Moreover, sarcopenia was an independent predictor for poorer overall survival (HR = 1.653, P < 0.001) and disease-free survival (HR = 1.620, P < 0.001). Under the adjusted tumor-node-metastasis (TNM) stage, sarcopenia remained an independent risk factor for overall survival and disease-free survival in patients with TNM stage II and III, but not in patients with TNM stage I.Sarcopenia is an independent predictive factor of severe postoperative complications after radical gastrectomy for gastric cancer. Moreover, sarcopenia is independently associated with overall and disease-free survival in patients with TNM stage II and III, but not in patients with TNM stage I.

Sarcopenia, as defined by low muscle mass, strength and physical performance, predicts complications after surgery for colorectal cancer

Recent studies have shown that sarcopenia is associated with negative postoperative outcomes. However, none of these studies analysed muscle strength or physical performance, which are also important components of sarcopenia. The present study aimed to investigate whether sarcopenia itself, as defined by low muscle mass, strength and physical performance, would predict complications after surgery for colorectal cancer.

Ginsenoside Rb1 improves postoperative fatigue syndrome by reducing skeletal muscle oxidative stress through activation of the PI3K/Akt/Nrf2 pathway in aged rats

Ginsenoside Rb1 is reported to possess anti-fatigue activity, but the mechanisms remain unknown. The aim of this study was to investigate the molecular mechanisms responsible for the anti-fatigue effect of ginsenoside Rb1 on postoperative fatigue syndrome induced by major small intestinal resection (MSIR) in aged rat. Aged rats with MSIR were administrated with ginsenoside Rb1 (15 mg/kg) once a day from 3 days before surgery to the day of sacrifice, or with saline as corresponding controls. Rats without MSIR but going through the same surgery procedure were administrated with saline as blank controls. Anti-fatigue effect was assessed by an open field test; superoxide dismutase, reactive oxygen species and malondialdehyde in skeletal muscle were determined. The mRNA levels of Akt2 and Nrf2 in skeletal muscle were measured by real-time quantitative PCR. The activation of Akt and Nrf2 was examined by western blot and immunohistofluorescence. Our results revealed that ginsenoside Rb1 significantly increased the journey and the rearing frequency, decreased the time of rest in aged rats with MSIR. In addition, ginsenoside Rb1 significantly reduced reactive oxygen species and malondialdehyde release and increased the superoxide dismutase activity of skeletal muscle in aged rats with MSIR. Ginsenoside Rb1 also increased the expression of Akt2 and Nrf2 mRNA, up-regulated Akt phosphorylation and Nrf2 nuclear translocation. These findings indicate that ginsenoside Rb1 has an anti-fatigue effect on postoperative fatigue syndrome in aged rat, and the mechanism possibly involves activation of the PI3K/Akt pathway with subsequent Nrf2 nuclear translocation and induction of antioxidant enzymes.

Risk Factors for Hospital Readmission after Radical Gastrectomy for Gastric Cancer: A Prospective Study

Background Hospital readmission is gathering increasing attention as a measure of health care quality and a potential cost-saving target. The purpose of this prospective study was to determine risk factors for readmission within 30 days of discharge after gastrectomy for patients with gastric cancer. Methods We conducted a prospective study of patients undergoing radical gastrectomy for gastric cancer from October 2013 to November 2014 in our institution. The incidence, cause and risk factors for 30-day readmission were determined. Results A total of 376 patients were included in our analysis without loss in follow-up. The 30-day readmission rate after radical gastrectomy for gastric cancer was 7.2% (27of 376). The most common cause for readmission included gastrointestinal complications and postoperative infections. On the basis of multivariate logistic regression analysis, preoperative nutritional risk screening 2002 score ≥ 3 was an independent risk factor for 30-day readmission. Factors not associated with a higher readmission rate included a history of a major postoperative complication during the index hospitalization, prolonged primary length of hospital stay after surgery, a history of previous abdominal surgery, advanced age, body mass index, pre-existing cardiopulmonary comorbidities, American Society of Anesthesiology grade, type of resection, extent of node dissection and discharge disposition. Conclusions Readmission within 30 days of discharge after radical gastrectomy for gastric cancer is common. Patients with nutritional risk preoperatively are at high risk for 30-day readmission. Preoperative optimization of nutritional status of patients at nutritional risk may effectively decrease readmission rates.

The indication and surgical results of local excision following radiotherapy for low rectal cancer

Aim  Radical surgery of rectal cancer is associated with significant morbidity, and some patients with low‐lying lesions must accept a permanent colostomy. The objective of this study was to evaluate the outcome of local excision followed by adjuvant radiotherapy for rectal cancer for curative purposes.

Prediction of Prolonged Postoperative Ileus After Radical Gastrectomy for Gastric Cancer: A Scoring System Obtained From a Prospective Study.

AbstractCurrently, there is a paucity of study investigating postoperative ileus in gastric cancer surgery. This prospective study aims to identify the risk factors for prolonged postoperative ileus (PPOI) and to use these risk factors to generate a risk stratification scoring system for the occurrence of PPOI.Patients who underwent radical gastrectomy for gastric cancer were included in this study. A multivariate logistic analysis was applied to identify independent risk factors for PPOI and to generate the scoring system. A receiver operating characteristic curve was generated and the area under the curve was calculated to demonstrate the predictive power of the scoring system.Finally, 296 patients were included and analyzed, of whom 96 (32.4%) developed PPOI. The multivariate analysis showed that age ≥65 years, operative duration ≥4 hours, tumor–node–metastasis (TNM) stage = III, open/converted operative technique, and total postoperative opiates dose (TOD) ≥0.3 mg/kg were independent risk factors for PPOI. Based on these factors, a risk stratification scoring system was generated, classified by low-risk (score 0–2), moderate-risk (score 3–4), and high-risk (score 5–6) groups. The incidence of PPOI increased by 7.5-fold from low-risk to high-risk group. The area under the curve of the scoring system was 0.841 (95% CI, 0.793–0.890), indicating a good predictive capability for the occurrence of PPOI.We have identified independent risk factors for the occurrence of PPOI and used these factors to construct a risk stratification scoring system.

Risk factors for postoperative fatigue after gastrointestinal surgery

BACKGROUND Postoperative fatigue (POF) is an important complication that is commonly observed postoperatively and is also one of the most serious obstacles to postoperative convalescence. However, the risk factors for POF have not been fully addressed, and there is no effective method to predict POF. The aim of the present study was to investigate the risk factors for POF and to explore prediction of the degree of POF. METHODS A prospective observational study was conducted of patients undergoing elective gastrointestinal surgery. Fatigue score, grip strength, length of postoperative hospital stay (LOS), as well as preoperative and intraoperative factors were collected. χ(2) was used to compare categorical variables, and multivariate logistic regression analysis was used to further analyze correlation between POF and preoperative and intraoperative factors. RESULTS A total of 155 patients were included in our analysis without loss in follow-up. Multivariate logistic regression analysis after adjustment for factors with severe POF in univariate analysis including preoperative fatigue, plasma albumin and hemoglobin level, and cardiopulmonary function demonstrated that old age, gastrectomy, and a nutritional risk screening 2002 score ≥ 3 were associated with a higher relative risk of severe POF. Moreover, laparoscopic-assisted surgery was associated with lower relative risk of severe POF. CONCLUSIONS Old age, nutritional risk screening 2002 score ≥ 3 and gastrectomy were risk factors for POF in patients undergoing elective gastrointestinal surgery. POF was reduced in laparoscopic-assisted surgery. Consideration of these factors could be important for the prevention and treatment of POF.

Laparoscopy or Open Surgery for Colorectal Cancer Within an Enhanced Recovery Program

TO THE EDITOR: Kennedy et al recently published an article examining the postoperative outcomes of laparoscopic surgery versus open resection of colorectal cancer within an enhanced recovery program (ERP). The main finding of their trial, called EnROL (Enhanced Recovery Open Versus Laparoscopic), was that laparoscopic surgery reduced the total postoperative hospital stay by 2 days. We congratulate the authors for their efforts because we know the difficulties of conducting such a trial. However, we think that some limitations of the study should be addressed. First, we noticed that compliance with the ERP components was low, especially with respect to early oral feeding, early mobilization, and optimized analgesia. Early oral feeding has been proven to reduce the length of hospital stay and the total postoperative complications. Failure to mobilize has been associated with prolonged length of hospital stay. In addition, Vlug et al found that hospital stay was reduced by 28% when early oral feeding and early mobilization were achieved. Optimized pain relief, allowing early mobilization and early return of gut function, is a prerequisite for enhanced recovery. Strict adherence to the ERP was associated with reduced length of hospital stay and improved outcome in colonic surgery for malignancy. Thus, the low compliance with the ERP components may have introduced a high risk of bias to the EnROL trial. Second, it was reported that the greater the number of evidencebased components included in the ERP, the better the outcome. However, some key ERP items were not included in the EnROL trial, such as prevention of postoperative nausea and vomiting. Postoperative nausea and vomiting lead to intolerance to oral feeding and is a leading cause of patient dissatisfaction and delayed hospital discharge. The absence of this ERP item probably explains the low compliance with early oral feeding. Above all, the low compliance and the absence of some key ERP components might make the EnROL trial underpowered, despite the substantial work of the authors. Therefore, the question regarding the benefits of laparoscopy within an ERP was not adequately answered by the EnROL trial. Additional large-scale randomized clinical trials are needed to examine the benefits of laparoscopic colorectal resection in the context of an even more optimized ERP than that applied in the EnROL trial.