Although radical gastrectomy is the best chance for a cure in patients with gastric cancer, PCs remain clinically relevant. Among them, infectious complications are the most common problem associated with postoperative morbidity and mortality [16]. Therefore, prediction or early detection of these complications through clinical research helps to lower the mortality and morbidity rate of gastrectomy to treat gastric cancer.
Some studies have demonstrated that inflammation or nutrition-based scores including perioperative CRP, mGPS, prognostic nutritional index (PNI) and CAR are associated with PCs after various types of surgeries [4, 5, 7, 8, 11, 13]. Abnormal elevation of preoperative CRP reflects compromised cell-mediated immunity [17] and patients with a high preoperative CRP may be more prone to infectious complications after surgery. Also, hypoalbuminemia is a well-known factor associated with PCs due to decreased tissue healing and impaired immune response [8, 18]. Thus, the CAR can reflect both inflammatory and immune-nutritional status.
One of the most common diagnostic indicators of malnutrition is serum albumin level. Some authors insisted that a serum albumin level below 3.5 g/dL is an independent risk factor of PCs after abdominal surgery [19]. However, the half-life of albumin is relatively long and non-nutritive conditions such as water and disease can influence the albumin level in addition to nutritional factors. Although malnutrition is associated with PCs, the albumin level cannot solely predict PCs. In our series, preoperative albumin level was significantly associated with PCs (p = 0.028) on univariate analysis, but multivariate analysis did not show a statistically significant predictive value of PCs after gastrectomy.
The CAR is a simple and easy marker to predict PCs after many types of surgery. Our results provided information regarding PCs in patients with a high CAR. Based on our results, patients with elevated CAR may require close observation and more intensive care after gastrectomy. These patients may also benefit from anti-inflammatory therapy or nutritional support [20, 21]. Moreover, some studies have demonstrated that PCs after gastrectomy for gastric cancer are associated with long term prognosis predictors such as disease-free or overall survival rates [11]. Plus, some studies have used inflammatory mediators such as vasoactive amines and cytokines to demonstrate that inflammation is associated with tumorigenesis and metastasis [11]. Therefore, prevention of PCs based on preoperative CAR is a very important positive predictor of success.
It is possible to reverse inflammation and poor nutritional status, both of which affect PCs and hospital stay duration. The incidence of PCs can be reduced using nutritional support and anti-inflammatory therapy before and after gastrectomy for gastric cancer.
The present study has several limitations that should be considered. First, it was a retrospective, single-center study. Additionally, the optimal cutoff value for the preoperative CAR is unknown. Therefore, further large-scale and prospective multicenter studies are needed.