Increased serum levels of C-reactive protein precede anastomotic leakage in colorectal surgery. World J Surg. 2010;34:140-146. [PMID: 19953248 DOI: 10.1007/s00268-009-0304-z]

Periprocedural Changes of Serum Biomarkers in Predicting Complications Following Bariatric Surgery for Obesity: Systematic Review and Meta-analysis

Bariatric surgery is an effective treatment for severe obesity, but complications and peri-operative monitoring are important considerations. We conducted a comprehensive review of studies assessing pre-operative biomarkers and complications in patients undergoing bariatric surgery. A total of 14 studies were included. Gastric leak, infections, bleeding, obstruction or stenosis, hypoglycemia, and hypoalbuminemia were the most common complications observed. Our analysis showed a significant association between lower pre-operative albumin levels and complications (SMD [95%CI] =  - 0.21 [- 0.38; - 0.04]). However, other biomarkers did not have a significant impact on complication occurrence. Changes in C-reactive protein, neutrophil-lymphocyte ratio, and white blood cell levels were observed in certain peri-operative time points and complication subgroups. These findings suggest the potential use of pre-operative biomarkers and peri-operative changes of biomarker's levels for predicting complications.

C‐reactive protein as an early predictor of anastomotic dehiscence in various types of reconstruction in elective abdominal surgery

Objective

The most important factor in abdominal surgery is the successful healing of the intestinal anastomosis performed. This study aims to evaluate the role of C‐reactive protein (CRP) in predicting anastomotic dehiscence in the first week following surgery.

Methods

The study included 100 patients surgically treated over a period of 1 year. Postoperative (p/o) values of CRP, leukocyte (white blood cells [WBCs]) and body temperature (BT) were measured in relation to the development of p/o complications.

Results

CRP p/o values were significantly higher in patients with complications and proved helpful in predicting p/o complications, while WBC and BT were not. For the development of anastomotic leakage, receiver operating characteristic curve shows the earliest diagnostic accuracy on the third p/o day with the cut‐off value of 115.1 mg/L; however, the largest area under the curve was on the fifth p/o day with a cut‐off value of 59.2 mg/L, a sensitivity of 89%, a specificity of 61%, a positive predictive value (PPV) of 21.9 and a negative predictive value (NPV) of 100.

Conclusions

Measurement of p/o CRP values may indicate problematic healing of digestive tract anastomosis before the appearance of clinical signs. High sensitivity and high NPV allow us to rule out p/o complications and anastomotic dehiscence with great certainty and safely discharge these patients from the hospital.

The association between inflammatory and immune system biomarkers and the dietary inflammatory index in patients with COVID-19

Background

Inflammation and cytokine storm have been reported to be the main cause of acute symptoms of coronavirus disease (COVID-19). Diet-induced inflammation may affect the condition of patients with COVID-19. Therefore, this study aimed to investigate the relationship between disease severity, inflammatory and immune system biomarkers, and the dietary inflammatory index (DII) in patients with COVID-19.

Methods

This cross-sectional study was conducted on 500 adult patients with COVID-19. Patients were divided into mild, moderate, and severe conditions based on clinical and laboratory evidence. A validated food frequency questionnaire (FFQ) was used to determine DII and energy-adjusted DII (E-DII) scores. The serum C-reactive protein (CRP) level and blood cell count were measured for all patients. Multiple linear regression was used to explore the association between DII and E-DII and CRP, blood cell counts, and hospitalization in patients with COVID-19.

Results

Coronavirus disease (COVID-19) patients with higher DII had higher consumption of fat and carbohydrate and lower intakes of protein, anti-inflammatory nutrients, garlic, caffeine, tea, onion, and fiber (P < 0.05). There was a positive association between DII and CRP (β = 1.024, P < 0.001), hospitalization (β = 1.062, P < 0.001), WBC count (β = 0.486, P < 0.009), neutrophil count (β = 0.565, P < 0.001), and neutrophil-to-lymphocyte ratio (β = 0.538, P < 0.001) and a negative association between DII and the lymphocyte count (β = −0.569, P < 0.001). There was a positive association between E-DII and hospitalization (β = 1.645, P < 0.001), WBC count (β = 0.417, P < 0.02), and neutrophil-to-lymphocyte ratio (β = 0.35, P < 0.03).

Conclusion

There is a positive correlation between DII and inflammation, immune hyperactivation, and length of hospital stay in patients with COVID-19. Further longitudinal studies are necessary.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Procalcitonin is one of the predictive factors of dehiscence of the colorectal anastomosis

Background/Aim: Dehiscence of the colorectal anastomosis is one of the most serious complications in digestive surgery that is still present in a large percentage today, which significantly increases the cost of treatment and can lead to death. Due to all the above, early detection of anastomotic dehiscence is very important, as well as the decision on surgical treatment. Procalcitonin (PCT) is thought to be an important marker of inflammation and sepsis. Aim of this paper was to confirm PCT as a marker of great sensitivity in early diagnosis of anastomotic leakage. Methods: The study included patients who underwent surgery for colorectal cancer in the period from 2016 to 2020. Patients were operated according to an elective protocol and with an open surgical approach. In patients, PCT values were measured on the 2nd and 4th postoperative day (POD) to determine the association between elevated PCT values and the onset of dehiscence of the colorectal anastomosis. Results: A study was conducted in 118 patients in whom a stapler colorectal anastomosis was created. Colorectal anastomosis dehiscence occurred in 10 patients. In 4 patients with dehiscence, no re-surgical intervention was required, but they were taken care of by conservative methods. Repeated surgery was performed in 6 patients. In all patients with dehiscence, there was a multiple increase in the value of PCT above normal. Conclusion: PCT has high sensitivity and specificity (85 and 74 % respectively) as a marker in dehiscence of colorectal anastomosis. In this study it was found that PCT values were significantly correlated with the dehiscence of anastomo-sis 2nd POD and especially 4th POD.

First day postoperative values of the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and C-reactive protein as complication predictors following gastric oncologic surgery

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) level are simple laboratory test parameters that can provide us with information on the inflammatory status of the organism. CRP has been shown to be a predictor of postoperative complications, whereas NLR and PLR have shown greater usefulness in the prognosis of oncologic pathologies.

AIM

To evaluate the associations of NLR and PLR with postoperative complications following gastric oncologic surgery and compare them with CRP.

MATERIALS AND METHODS

A prospective study was conducted on 66 patients that underwent oncologic gastric surgery, within the time frame of January 2014 and March 2019. The variables analyzed were sociodemographic data, surgical technique, tumor extension, and NLR, PLR, and CRP levels from the first day after surgery, as well as postoperative complications.

RESULTS

Seventeen patients (25.8%) presented with grade III-V complications, utilizing the Clavien-Dindo classification system. Mean NLR value was 11.30 and was associated with the appearance of major complications, with statistical significance (p = 0.009). Mean PLR was266.05 and was not significantly associated with complications (p = 0.149). Fifty-four patients had a mean CRP level of 143.24 and it was not related to the appearance of major complications (p = 0.164).

CONCLUSIONS

The NLR is a simple and inexpensive parameter, which measured on postoperative day one, predicted the appearance of major postoperative complications in our study sample and appears to be a better predictive parameter than CRP for said complications. Further studies to confirm that trend need to be carried out.

C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann–Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann–Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

C-reactive Protein for Predicting Early Postoperative Complications in Patients Undergoing Laparoscopic Shaving for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

To assess the accuracy of C-reactive protein (CRP) in predicting early postoperative complications in patients undergoing elective laparoscopic shaving for rectosigmoid deep infiltrating endometriosis (DIE).

DESIGN

A single-center observational retrospective cohort study.

SETTING

Third-level referral center for endometriosis.

PATIENTS

A total of 294 patients were included in the study. All of them underwent elective laparoscopic shaving for rectosigmoid DIE.

INTERVENTIONS

Postoperative CRP levels (assessed from day 3 onward, every 48 hours, until hospital discharge) and early postoperative complications were reviewed to assess CRP as a predictive marker of postoperative complications.

MEASUREMENTS AND MAIN RESULTS

The study outcomes were the association between early postoperative complications and CRP levels, the optimal CRP cutoff, and its predictive accuracy. Twenty-five patients (8.5%) experienced early postoperative complications. Five patients with postoperative complications within 2 days of surgery were excluded from the analysis. On postoperative day 3 the difference in the means of CRP levels between patients with and without complications was 2.5 mg/dL (95% CI, 1.0-4.1), whereas on day 5 the difference was 5.3 mg/dL (95% CI, 3.3-7.5), with a significant increase of 2.8 mg/dL (95% CI, 0.2-5.5). On postoperative day 7 the difference was 11.4 mg/dL (95% CI, 8.2-14.6), with an increase of 6.1 mg/dL (95% CI, 2.2-9.9) from day 5. The mean CRP level in the group with complications showed an increase of 1.2 mg/dL (95% CI, -1.3 to 3.8) from day 3 to day 5 and of 6.2 mg/dL (95% CI, 2.6-9.8) from day 5 to day 7. The optimal cutoff for the CRP level in predicting early postoperative complications was 3.1 mg/dL on postoperative day 3 and 5.2 mg/dL on postoperative day 5, with a sensitivity of 87.5% (95% CI, 52.9-97.8) and 80% (95% CI, 37.6-96.4), a specificity of 62.5% (95% CI, 52.1-71.9) and 91.2% (95% CI, 81.1-96.2), a positive predictive value of 17.5% (95% CI, 8.7-31.9) and 44.4% (95% CI, 18.9-73.3), a negative predictive value of 98.2% (95% CI, 90.6-99.7) and 98.1% (95% CI, 90.1-99.7), and an area under the receiver operating characteristic curve of 75.0% (95% CI, 61.9-80.1) and 85.6% (95% CI, 74.1-96.5), respectively.

CONCLUSION

CRP on postoperative day 5 seemed to be a moderately accurate predictive marker of early postoperative complications in the patients who had undergone elective laparoscopic shaving for rectosigmoid DIE.

The role of CRP in the diagnosis of postoperative complications in rectal surgery

Postoperative complications of rectal resections classified as grade III or higher according to Clavien-Dindo system, which also include anastomotic leaks, are usually life-threatening conditions. Delayed diagnosis may account for almost 18% of deaths. Due to nonspecific clinical signs in the early postoperative period, diagnosing these complications may truly be a challenge for clinicians. Nowadays, with the implementation of the ERAS protocol (enhanced recovery after surgery) and efforts concentrated on quickly delivered treatment to patients suffering from the above-mentioned complications, an appropriate marker with high specificity is required. Postoperative levels of C-reactive protein in blood serum seem promising in this aspect. The presented study aimed to determine the cut-off level of serum C-reactive protein as a possible predictive factor for early diagnosis of serious postoperative complications associated with rectal resections. This could also lead clinicians to the diagnosis of anastomotic leak after other possible options are ruled out. This study is a retrospective observational analysis of patients who underwent open resection of rectal cancer during a one-year period. Collected data included risk factors (age, gender, BMI, bowel preparation), record of complications and C Reactive Protein (CRP) serum levels. The study included 162 patients. Uncomplicated postoperative course was observed in 58 patients (35.8%). Complications were present in 104 cases (64.2%), including surgical site infections (16.7%) and anastomotic leak (9.9%). The mortality rate was 2.5%. Serum CRP threshold predicting relevant complications reached a sensitivity of 83.3% and specificity of 82.7% on POD 4, with a 175.4 mg/L cut-off value, burdened with a 95.7% negative predictive value. Postoperative serum C-reactive protein may be used as a good predictor of infectious complications, including anastomotic leaks. Measuring CRP levels in the early postoperative period may facilitate identification oflow-risk patients ensure early and safe discharges from hospital after rectal resections.

C-reactive protein can predict anastomotic leak in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

Anastomotic leakage (AL) is one of the most significant complications after colorectal surgery, affecting length of stay, patient morbidity, mortality, and long-term oncological outcome. Serum C-reactive protein (CRP) level rises in infective and inflammatory states. Elevated CRP has been shown to be associated with anastomotic leak.

OBJECTIVE

Perform a meta-analysis of current CRP data in AL after colorectal surgery.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, CENTRAL databases STUDY SELECTION: Comparative studies studying serum CRP levels in adult patients with and without AL after colorectal surgery.

INTERVENTION(S)

Elective and emergency open, laparoscopic or robotic colorectal excisions for cancer and benign pathology.

MAIN OUTCOME MEASURES

Mean serum CRP measurements between post-operative days (POD) 1 through 7 in patients with and without AL. Perform ROC analysis to determine cut-off CRP values to indicate AL.

RESULTS

Twenty-three studies with 6647 patients (482 AL). Pooled mean time to diagnosis of AL was 7.70 days. AL associated with higher CRP on POD1 (mean difference (MD) 15.19, 95% CI 5.88-24.50, p = 0.001), POD2 (MD 51.98, 05% CI 37.36-66.60, p < 0.00001), POD3 (MD 96.92, 95% CI 67.96-125.89, p < 0.00001), POD4 (MD 93.15, 95% CI 69.47-116.84, p < 0.00001), POD5 (MD 112.10, 95% CI 89.74-134.45, p < 0.00001), POD6 (MD 98.38, 95% CI 80.29-116.46, p < 0.00001), and POD7 (MD 106.41, 95% CI 75.48-137.35, p < 0.00001) compared with no AL. ROC analysis identified a cut-off CRP of 148 mg/l on POD3 with sensitivity and specificity of 95%. On POD4 through POD7, cut-off levels were 123 mg/l, 115 mg/l, 105 mg/l, and 96 mg/l, respectively, with sensitivity and specificity of 100%.

LIMITATIONS

Study heterogeneity, some characteristics unreported, no RCT CONCLUSIONS: AL is associated with higher CRP levels on each post-operative day compared to no AL after colorectal surgery. The cut-off CRP values can be used to predict AL to expedite investigation and treatment.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.

Predictive value of 4th post-operative-day CRP in the early detection of complications after laparoscopic bowel resection for endometriosis

OBJECTIVE

Post-operative CRP on postoperative day 4 (POD) is used for the early detection of complications after colorectal surgery for cancer, but there is no evidence yet that justifies the use of this marker for bowel resection in case of endometriosis.

STUDY DESIGN

We retrospectively included 66 consecutive patients who underwent bowel resection for endometriosis (stage 4) in Lille university hospital, France, from August 1, 2015 until January 31, 2017. The composite endpoint of our study included anastomotic leakages, infectious or thrombo-embolic complications, hematomas, bowel stenosis, rectorrhagia, voiding dysfunction, and rehospitalization for related symptoms.

RESULTS

CRP on POD 4 presents a satisfying area under the curve of 0.85, for the composite endpoint. A CRP cut off value of 56 mg/L yielded a sensitivity of 0.61 (IC95%: 0.36 to 0.83) and a specificity of 0.98 (IC95%: 0.89 to 1). The negative and positive predictive values were 0.87 and 0.92.

CONCLUSION

The negative predictive value of the CRP on POD 4 after bowel resection for endometriosis is a useful early indicator for detecting a complication. Therefore, this biomarker might be safely used as an additional criterion for a safe discharge from hospital after colorectal resection in endometriosis.

Utility of Inflammatory Markers in Detection of Perioperative Morbidity After Laparoscopic Sleeve Gastrectomy, Laparoscopic Roux-en-Y Gastric Bypass, and One-Anastomosis Gastric Bypass-Multicenter Study

Background

The most commonly performed bariatric operations are laparoscopic sleeve gastrectomy (LSG) and bypass surgeries (laparoscopic one-anastomosis gastric bypass (OAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB)), and predicting perioperative morbidity is crucial for early, safe patient discharge. We aimed to determine whether C-reactive protein (CRP) and white blood count (WBC) measured on the first postoperative day predicts perioperative morbidity in the first 30-days after LSG and bypass surgeries.

Methods

We retrospectively analyzed data for 1400 patients who underwent bariatric surgery in seven bariatric centers from 2014 to 2018. Patients were divided into a complicated group (patients with postoperative complications) and a non-complicated group. We also performed separate analyses for LSG and bypass surgeries.

Results

Patients were 929 women (66%) and 471 men (34%) with a median age of 42 years (range, 35–51 years); 1192 patients underwent LSG (85%), 120 underwent LRYGB (9%), and 80 underwent OAGB (6%). We performed ROC analyses to set cut-off points, followed by multivariate logistic regressions. CRP > 33.32 mg/L increased the odds ratio (OR) of perioperative complications after LSG 2.27 times, while WBC > 12.15 × 10³/μL on postoperative day 1 was associated with a 3.34-times greater or of developing complications. WBC > 13.78 × 10³/μL was associated with a 13.34-times higher or of perioperative morbidity in patients undergoing bypass surgeries.

Conclusion

Even slightly elevated CRP and WBC on postoperative day 1 should alert surgeons to the potential risk of perioperative morbidity.

First day postoperative values of the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and C-reactive protein as complication predictors following gastric oncologic surgery

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) level are simple laboratory test parameters that can provide us with information on the inflammatory status of the organism. CRP has been shown to be a predictor of postoperative complications, whereas NLR and PLR have shown greater usefulness in the prognosis of oncologic pathologies.

AIM

To evaluate the associations of NLR and PLR with postoperative complications following gastric oncologic surgery and compare them with CRP.

MATERIALS AND METHODS

A prospective study was conducted on 66 patients that underwent oncologic gastric surgery, within the time frame of January 2014 and March 2019. The variables analyzed were sociodemographic data, surgical technique, tumor extension, and NLR, PLR, and CRP levels from the first day after surgery, as well as postoperative complications.

RESULTS

Seventeen patients (25.8%) presented with grade III-V complications, utilizing the Clavien-Dindo classification system. Mean NLR value was 11.30 and was associated with the appearance of major complications, with statistical significance (p = 0.009). Mean PLR was 266.05 and was not significantly associated with complications (p = 0.149). Fifty-four patients had a mean CRP level of 143.24 and it was not related to the appearance of major complications (p = 0.164).

CONCLUSIONS

The NLR is a simple and inexpensive parameter, which measured on postoperative day one, predicted the appearance of major postoperative complications in our study sample and appears to be a better predictive parameter than CRP for said complications. Further studies to confirm that trend need to be carried out.

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak

Setting:

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives:

This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients and Methods:

This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results:

GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions:

Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Drainage smell and peritonitis are efficient indicators of anastomotic leakage after laparoscopic rectal cancer resection

Objective

Anastomotic leakage (AL) is a frequent complication after laparoscopic rectal cancer resection (LRCR). The main objective of the present study was to identify accurate indicators of AL after LRCR.

Methods

A retrospective case-control study was performed of 185 patients who underwent laparoscopic surgery for rectal cancer between March 2012 and February 2017 at Beijing Friendship Hospital. Potential indicators of AL were examined via univariate and multivariate analyses. The performance of multivariate analysis was evaluated using receiver operating characteristic (ROC) curves.

Results

The overall AL rate was 17.84%. Multivariate analysis identified drainage smell (odds ratio [OR = 35.318, 95% confidence interval [CI] = 7.114 to 175.338) and peritonitis [OR = 17.475, 95% CI = 1.540 to 198.318) as independent indicators of AL. The area under the ROC curve was 0.720 (95% CI = 0.606 to 0.835).

Conclusion

Drainage smell and peritonitis could be reliable and accurate indicators of AL after LRCR.

Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery

Anastomotic leakage is a complication of colorectal surgery. C-reactive protein (CRP) is an acute-phase marker that can indicate surgical complications. We determined whether serum CRP levels in patients who had undergone colorectal surgery can be used to exclude the presence of anastomotic leakage and allow safe early discharge. We included 90 patients who underwent colorectal surgery with primary anastomosis. Serum CRP levels were measured retrospectively on postoperative days (PODs) 1 - 7. Patients with anastomotic leakage (n = 11) were compared to those without leakage (n = 79). We statistically analysed data and plotted receiver operating characteristic curves. The incidence of anastomotic leakage was 12.2%. Diagnoses were made on PODs 3 - 24. The overall mortality rate was 3.3% (18.2% in the leakage group, 1.3% in the non-leakage group; P < 0.045). CRP levels were most accurate on POD 4, with a cutoff level of 180 mg/L, showing an area under the curve of 0.821 and a negative predictive value of 97.2%. Lower CRP levels after POD 2 and levels <180 mg/L on POD 4 may indicate the absence of anastomotic leakage and may allow safe discharge of patients who had undergone colorectal surgery with primary anastomosis.

Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial

BACKGROUND

The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment.

PATIENTS AND METHODS

Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications.

RESULTS

Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur.

CONCLUSION

Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Drain fluid's pH predicts anastomotic leak in colorectal surgery: results of a prospective analysis of 173 patients

BACKGROUND

The early risk assessment of anastomotic leak (AL) after colorectal surgery is crucial. Several markers have been proposed, including peritoneal fluid's pH. Aim of the present study is to evaluate the role of drain fluid pH as predictor of AL.

METHODS

All patients undergoing colorectal surgery from January 2015 to December 2017 were considered eligible. Hartmann procedures, procedures including temporary ileostomy and emergency surgery were excluded. Drain fluid was submitted for pH and chemical-physical assessment on postoperative day 1 (POD1) and postoperative day 3 (POD3).

RESULTS

Out of 173 patients, those who developed AL showed a lower drain fluid's pH on POD1 and on POD3 compared to patients who did not (P<0.05). The plotted ROC curves identified 7.53 as pH cut-off on POD1 (AUC 0.80) and 7.21 on POD3 (AUC 0.86). With both the cut-offs, pH was an independent predictor of AL at multivariable analysis (P<0.001). pH<7.53 on POD1 and pH<7.21 on POD3 showed 93.75% sensitivity and 97% specificity respectively.

CONCLUSIONS

Drain fluid's pH on POD1 is useful to select patients who will not develop AL while on POD3 it might identify those requiring a more careful management.

Ghost Ileostomy in Advanced Ovarian Cancer: A Reliable Option

Objective

Diverting ileostomy (DI) has been proposed to reduce the incidence and consequences anastomotic leakage after bowel resection. In colorectal cancer treatment, ghost ileostomy (GI) has been proposed as an alternative to DI. Our objective was to report the results of GI associated with colorectal resection in the treatment of ovarian cancer.

Materials and Methods

This is an observational pilot study performed in a single institution. The main objective sought was to report the results of GI associated with colorectal resection in the treatment of ovarian cancer: 26 patients were included.

Results

Modified posterior exenteration was performed in 24 cases (92.3%) and rectum resection in the 2 cases of relapse (7.7%). After the main procedure GI was created, to check up the anastomosis status, a sequential postoperative rectoscopy was performed on postoperative day 5 ± 1 (range, 4–7). Serum levels were monitored in first and third postoperative days just with a descriptive intention to establish its relationship with the rectoscopy findings. In 2 cases, rectoscopy demonstrated a leakage. During postoperative course, no other complication related with the GI or DI was observed. No case of clinical anastomotic leakage was found.

Conclusions

To the extent of our knowledge, this is the first study in which GI has been performed for the treatment of patients with ovarian cancer. Ghost ileostomy represents a real option that may reduce the number of ileostomies performed in ovarian cancer without increasing the morbimortality. Ghost ileostomy presents the advantages of DI while avoiding its drawbacks. It also seems to be a safe, feasible, and reproducible technique that does not add significant costs to the surgery.

Identification of factors predictive of postoperative morbidity and short-term mortality in older patients after colorectal carcinoma resection: A single-center retrospective study

OBJECTIVES

The aim of this study is to investigate the effect of age on patient outcome after colorectal carcinoma (CRC) resection in patients over 65 years of age.

METHODS

This study included patients aged 65 years and older who underwent CRC resection between 2003 and 2013 at a single-center institution. Patients were divided into two groups: Group A (65-74 years old) and Group B (≥75 years old).

RESULTS

Multivariable logistic analysis of 415 patients revealed serum albumin levels on the third postoperative day (POD) (Odds Ratio (OR), 0.44; 95% CI, 0.21-0.94; P = 0.03) and C-reactive protein (CRP) levels (OR, 1.05; 95% CI, 1.00-1.01; P = 0.04) in patients with colon cancer as predictive factors for morbidity. In addition, the multivariable logistic analysis revealed serum albumin levels (OR, 0.27; 95% CI, 0.08-0.87; P = 0.03) in patients with rectal cancer as predictive factors for morbidity. The multivariate Cox Proportional Hazards Model identified re-intervention for colon cancer (Hazard Ratio (HR), 4.57; 95% CI, 1.36-15.4 P = 0.01) and for rectal cancer (HR, 11.8; 95% CI, 1.08-129 P = 0.04) as a predictive factor for 30-day mortality. Serum albumin level on the third POD was predictive of 30-day mortality (HR, 0.30; 95% CI, 0.13-0.71; P = 0.01) and of 1-year mortality (HR, 0.34; 95% CI, 0.17-0.66; P < 0.01) in patients with colon cancer.

CONCLUSION

Age is not predictive of postoperative morbidity and mortality in patients with CRC. Serum albumin levels on the third POD can predict morbidity and mortality for colon and rectal carcinoma in older patients undergoing colorectal resections.

Procalcitonin and C-reactive protein as early markers of anastomotic leak after laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) program

BACKGROUND

C-reactive protein (CRP) and procalcitonin (PCT) have been described as good predictors of anastomotic leak after colorectal surgery, obtaining the highest diagnostic accuracy on the 5th postoperative day. However, if an enhanced recovery after surgery (ERAS) program is performed, early predictors are needed in order to ensure a safe and early discharge. The aim of this study was to investigate the efficacy of CRP, PCT, and white blood cell (WBC) count determined on first postoperative days, in predicting septic complications, especially anastomotic leak, after laparoscopic colorectal surgery performed within an ERAS program.

METHODS

We conducted a prospective study including 134 patients who underwent laparoscopic colorectal surgery within an ERAS program between 2015 and 2017. The primary endpoint investigated was anastomotic leak. CRP, PCT, and WBC count were determined in the blood sample extracted on postoperative day 1 (POD 1), POD 2 and POD 3.

RESULTS

Anastomotic leak (AL) was detected in 6 patients (4.5%). Serum levels of CRP and PCT, but not WBC, determined on POD 1, POD 2, and POD 3 were significantly higher in patients who had AL in the postoperative course. Using ROC analysis, the best AUC of the CRP and PCT levels was on POD 3 (0.837 and 0.947, respectively). A CRP cutoff level at 163 mg/l yielded 85% sensitivity, 80% specificity, and 99% negative predictive value (NPV). A PCT cutoff level at 2.5 ng/ml achieved 85% sensitivity, 95% specificity, 44% positive predictive value, and 99% NPV.

CONCLUSIONS

CRP and PCT are relevant markers for detecting postoperative AL after laparoscopic colorectal surgery. Furthermore, they can ensure an early discharge with a low probability of AL when an ERAS program is performed.

[Postoperative C-reactive protein is a reliable marker to detect complications after radical cystectomy]

PURPOSE

Postoperative serum C-reactive protein (CRP) can be measured after major abdominal surgery to predict of complications at postoperative day (POD) 4. However, in urology, no studies have been conduced to analyze the role of CRP after radical cystectomy. The present study aims to analyze the relationship between a high postoperative level of CRP and the presence of complications after radical cystectomy for cancer.

MATERIALS AND METHODS

This multicenter retrospective study included 313 patients treated with radical cystectomy for cancer between January 2013 and July 2016. Among the patients, 57.5% of patients received urinary diversion using a Bricker ileal conduit, 30.5% an orthotropic ileal neobladder, and 11.5% had an ureterocutaneostomy.

RESULTS

Three hundred and thirteen patients were included (mean age 68.1±9.2 years). Among the patients, 26.5% had grade≥2 complications, according to the Clavien-Dindo classification. In multivariate analysis, only CRP level at POD 4 predicted the risk of a complication (P<0.001). CRP>150mg/L at POD 4 was strongly associated with a risk of a postoperative complication after a cystectomy (OR=81.42, 95% CI [25.6-258.3], P<0.001). CRP assessed on POD4 was reliable at ruling out the existence of an infectious complications with a negative predictive value of 0.94. The main limitation of our study was it observational design.

CONCLUSIONS

CRP at POD4 with a threshold of 150mg/L would reliably predict the risk of postoperative complications after cystectomy. Monitoring postoperative CRP could help adapt rehabilitation protocols after radical cystectomy and also the early management of complications.

Attitudes of surgeons to the use of postoperative markers of the systemic inflammatory response following elective surgery

Background

Cancer is responsible for 7.6 million deaths worldwide and surgery is the primary modality of a curative outcome. Postoperative care is of considerable importance and it is against this backdrop that a questionnaire based study assessing the attitudes of surgeons to monitoring postoperative systemic inflammation was carried out.

Method

A Web based survey including 10 questions on the “attitudes of surgeons to the use of postoperative markers of the systemic inflammatory response following elective surgery” was distributed via email. Two cohorts were approached to participate in the survey. Cohort 1 consisted of 1092 surgeons on the “Association of Coloproctology of Great Britain and Ireland (ACPGBI)” membership list. Cohort 2 consisted of 270 surgeons who had published in this field in the past as identified by two recent reviews. A reminder email was sent out 21 days after the initial email in both cases and the survey was closed after 42 days in both cases.

Result

In total 29 surgeons (2.7%) from cohort 1 and 40 surgeons (14.8%) from cohort 2 responded to the survey. The majority of responders were from Europe (77%), were colorectal specialists (64%) and were consultants (84%) and worked in teaching hospitals (54%) and used minimally invasive techniques (87%). The majority of responders measured CRP routinely in the post-operative period (85%) and used CRP to guide their decision making (91%) and believed that CRP monitoring should be incorporated into postoperative guidelines (81%).

Conclusion

Although there was a limited response the majority of surgeons surveyed measure the systemic inflammatory response following elective surgery and use CRP measurements together with clinical findings to guide postoperative care. The present results provide a baseline against which future surveys can be compared.

•

Shows that there is a widespread interest in the use of markers of the systemic inflammatory response in managing patients.

•

This is particularly true when managing complications post operatively.

•

There would seem to be scope for incorporation of markers of the SIR into formal post operative guidelines.

Diagnostic Accuracy of Procalcitonin and C-reactive Protein for the Early Diagnosis of Intra-abdominal Infection After Elective Colorectal Surgery: A Meta-analysis

OBJECTIVE

Intra-abdominal infections (IAIs) after elective colorectal surgery impact significantly the short- and long-term outcomes. In the era of fast-track surgery, they often come to light after discharge from hospital. Early diagnosis is therefore essential. C-reactive protein levels have proved to be accurate in this setting. Procalcitonin has been evaluated in several studies with conflicting results. This meta-analysis aimed to compare the predictive abilities of C-reactive protein and procalcitonin in the occurrence of IAIs after elective colorectal surgery.

METHODS

This meta-analysis included studies analyzing C-reactive protein and/or procalcitonin levels at postoperative days 2, 3, 4, and/or 5 as markers of intra-abdominal infection after elective colorectal surgery. Methodological quality was assessed by the QUADAS2 tool. The area under the curve summary receiver-operating characteristic was calculated for each day and each biomarker, using a random-effects model in cases of heterogeneity.

RESULTS

The meta-analysis included 11 studies (2692 patients). An IAI occurred in 8.9% of the patients. On postoperative day 3, area under the curve was 0.80 (95% CI, 0.76-0.85) for C-reactive protein and 0.78 (95% CI, 0.68-0.87) for procalcitonin. On postoperative day 5, their predictive accuracies were 0.87 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.82-0.98), respectively. The accuracy of C-reactive protein and procalcitonin did not differ at any postoperative day.

CONCLUSIONS

Levels of inflammatory markers under the cutoff value between postoperative days 3 and 5 ensure safe early discharge after elective colorectal surgery. Procalcitonin seems not to have added value as compared to C-reactive protein in this setting.

Systematic review of the role of biomarkers in diagnosing anastomotic leakage following colorectal surgery

BACKGROUND

Anastomotic leakage (AL) following colorectal surgery can be difficult to diagnose owing to varying clinical presentations. This systematic review aimed to assess biomarkers as potential diagnostic tests for preclinical detection of AL.

METHODS

A comprehensive literature review was conducted according to PRISMA guidelines. All published studies evaluating biomarkers, both systemic and peritoneal, in the context of AL following colorectal surgery were included. Studies were sought in three electronic databases (MEDLINE, PubMed and Embase) from January 1990 to June 2016.

RESULTS

Thirty-six studies evaluated 51 different biomarkers in the context of AL after colorectal surgery. Biomarkers included markers of ischaemia and inflammation, and microbiological markers, and were measured in both peritoneal drain fluid and the systemic circulation. The most commonly evaluated peritoneal drain fluid biomarkers were interleukin (IL) 6, IL-10 and tumour necrosis factor. Significantly raised drain levels in the early postoperative period were reported to be associated with the development of AL. C-reactive protein, procalcitonin and leucocytes were the most commonly evaluated systemic biomarkers with significant negative and positive predictive values. Associated area under the curve values ranged from 0·508 to 0·960.

CONCLUSION

Peritoneal drain fluid and systemic biomarkers are poor predictors of AL after colorectal surgery. Combinations of these biomarkers showed improvement in predictive accuracy.

Biomarkers and anastomotic leakage in colorectal surgery: C-reactive protein trajectory is the gold standard

BACKGROUND

Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak.

METHODS

C-reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma-glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post-operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers.

RESULTS

A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma-glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961.

CONCLUSION

This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study.

Post-Operative Infection Is an Independent Risk Factor for Worse Long-Term Survival after Colorectal Cancer Surgery

BACKGROUND

Colorectal cancer surgery is associated with a high incidence of post-operative infections, the outcome of which may be improved if diagnosed and treated early enough. We compared white blood cell (WBC) count, C-reactive protein (CRP), and procalcitonin (PCT) as predictors of post-operative infections and analyzed their impact on long-term survival.

METHODS

This retrospective study included 186 patients undergoing colorectal surgery. Post-operative values of WBC, CRP, and PCT were analyzed by the receiver operating characteristic (ROC) analysis. We followed infections 30 d after the surgery. A five-year survival was analyzed by Kaplan-Meier method and prognostic factors by Cox regression model.

RESULTS

Fifty-five patients (29.5%) developed post-operative infection, the most frequent of which was surgical site infection (SSI). C-reactive protein on post-operative day three and PCT on post-operative day two demonstrated the highest diagnostic accuracy for infection (area under the curve [AUC] 0.739 and 0.735). C-reactive protein on post-operative day three was an independent predictor of infection. Five-year survival was higher in the non-infected group (70.8%), compared with the infected group (52.1%). The worst survival (40.9%) was identified in patients with organ/space SSI. Post-operative infection and tumor stage III-IV were independent predictors of a worse five-year survival.

CONCLUSIONS

C-reactive protein on post-operative day three and PCT on post-operative day two may be early predictors of infection after colorectal cancer surgery. Post-operative infections in particular organ/space SSI have a negative impact on long-term survival.

Association Between Nutritional Status, Inflammatory Condition, and Prognostic Indexes with Postoperative Complications and Clinical Outcome of Patients with Gastrointestinal Neoplasia

The aim of this study is to describe and relate nutritional and inflammatory status and prognostic indexes with postoperative complications and clinical outcome of patients with gastrointestinal malignancies. Twenty-nine patients were evaluated; nutritional assessment was carried out by subjective and objective parameters; albumin, pre-albumin, C-reactive protein (CRP), and alpha-1-acid glycoprotein (AGP) were determined. To assess prognosis, the Glasgow scale, the Prognostic Inflammatory Nutritional Index (PINI), and CRP/albumin ratio were used; the clinical outcomes considered were hospital discharge and death. A high Subjective Global Assessment (SGA) score was associated with the occurrence of postoperative complications: 73% of the patients with postoperative complications had the highest SGA score, but only 6% of those without postoperative complications had the highest SGA score (P < 0.001). Greater occurrence of death was observed in patients with a high SGA score, low serum albumin, increased CRP, PINI > 1, and Glasgow score 2. There was a positive correlation between weight loss percentage with serum CRP levels (P = 0.002), CRP/albumin (P = 0.002), PINI (P = 0.002), and Glasgow score (P = 0.000). This study provides evidence that the assessment of the nutritional status and the use of prognostic indexes are good tools for predicting postoperative complications and clinical outcome in patients with gastrointestinal neoplasia.

Predictive value of preoperative serum C-reactive protein for recurrence after definitive surgical repair of enterocutaneous fistula

BACKGROUND

Recurrence rates after surgical repair of enterocutaneous fistula (ECF) have not changed substantially. Serum C-reactive protein (s-CRP) has been used as an indicator of postoperative complications in abdominal surgery. ​ The aim of this study was to determine the predictive value of preoperative s-CRP for recurrence after definitive surgical repair of ECF.

METHODS

Fifty consecutive patients with ECF persistence submitted electively to definitive surgical repair (ECF resection with primary anastomosis) were included. Among several variables, preoperative s-CRP (primary independent variable) was assessed as a factor related to recurrence (dependent variable). Univariate and multivariate analyses were performed.

RESULTS

ECF recurred in 19 patients (38%). Univariate and multivariate analyses disclosed operative blood loss greater than 325 mL (P < .05) and preoperative s-CRP greater than .5 mg/dL (P < .01) as the only risk factors for recurrence. ECF recurrence rates were significantly higher for patients with preoperative s-CRP above this level (53% vs 11%, P < .01). After conservative and surgical management, overall ECF closure was attained in 40 patients (80%).

CONCLUSIONS

Our results suggest that s-CRP may serve as a useful parameter to predict potential failure (recurrence) in patients submitted to definitive closure of ECF.

Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution on Post-Operative Pain and Analytic Acute-Phase Reactants after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Peritoneal lavage has been proposed to remove bacterial contamination and other materials promoting bacterial proliferation and pro-inflammatory cytokines that may enhance local inflammation. The aims of this study were to evaluate the effects of peritoneal lavage with physiologic saline or an antibiotic solution (clindamycin-gentamicin) on post-operative pain and analytic acute-phase reactants and to determine the microbiologic impact of both irrigations on peritoneal contamination in patients undergoing laparoscopic sleeve gastrectomy (LSG) as a bariatric procedure.

METHODS

The patients were randomized into two groups: Those undergoing an intra-abdominal lavage with physiologic saline (Group 1; n = 40) and those undergoing a similar lavage with a gentamicin-clindamycin solution (Group 2; n = 40). Peritoneal contamination, post-operative pain, and analytic acute-phase reactants 24 h after surgery were investigated.

RESULTS

The median pain score 24 h after surgery was 3.5 in Group 1 and 1.5 in Group 2 (p = 0.021). The glucose concentration (mean difference 33.1 mg/dL; p = 0.004), aspartate aminotransferase (AST) concentration (mean difference 41.8 U/L; p = 0.009), alanine aminotransferase (ALT) concentration (mean difference 34.2 U/L; p = 0.029), white blood cell count (mean difference 1930/mm(3); p = 0.029); C-reactive protein concentration (mean difference 27.3 mg/L; p = 0.036), and serum lactic acid concentration (mean difference 0.34 mg/L; p = 0.049) were significantly higher in Group 1. Peritoneal contamination also was significantly higher in Group 1 (17.5% vs 0; p = 0.006).

CONCLUSIONS

Intra-peritoneal irrigation with a gentamicin and clindamycin solution in patients undergoing LSG leads to a reduction in post-operative pain and peritoneal contamination, less alteration of acute-phase reactants, lower blood glucose concentration, a smaller increase in liver enzymes, and a shorter hospital stay.

Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors

PURPOSE

To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage.

METHODS

The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution.

RESULTS

The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator.

CONCLUSIONS

The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.

The effect of a postoperative quality improvement program on outcomes in colorectal surgery in a community hospital

PURPOSE

The aim of this study was to evaluate whether implementation of a comprehensive quality improvement program was associated with improved outcomes in patients undergoing oncological colorectal surgery in a non-academic, non-referral community hospital.

METHODS

The quality improvement program (QIP) was introduced in January 2011 and consisted of the following interventions: (1) avoidance of postoperative nonsteriodal anti-inflammatory drugs; (2) normovolemia was pursued pre- and postoperatively; (3) non-resectional surgery if possible, in patients over 80 with ASA 3 or 4 classification; and (4) a standardized, postoperative surveillance protocol was introduced, with CRP determination day 2 and 4, and if necessary subsequent abdominal CT with rectal contrast to reduce delay in diagnosis of complications. From a prospectively maintained database of 488 patients undergoing colorectal surgery between 2009 and 2014, postoperative outcomes of patients operated before and after implementation of the program were compared.

RESULTS

The severe complication rate (Clavien-Dindo >3b) decreased significantly (25.0 vs. 13.7 %; p < .001) after implementation of the QIP program. The mortality rate dropped from 8.7 to 2.6 % (p = .003). The percentage of anastomotic leakage was 9.6% before QIP implementation and 4.2% after (p = .013). Median length of hospital stay decreased from 9 (IQR 5-19) to 7 days (IQR 4-12) (p < .001). Multivariate analyses showed that surgery after implementation of the program was a strong independent predictor for less major complications (OR 0.54, 95 % CI 0.32-0.88).

CONCLUSIONS

A significant decrease in major complications and mortality was observed after introduction of a relative simple quality improvement program.

C-REACTIVE PROTEIN IN DIABETIC PATIENTS BEFORE GASTRIC BYPASS AS A POSSIBLE MARKER FOR POSTOPERATIVE COMPLICATION

Background

: Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can be set off by the adipose tissue, once it is a metabolically active organ that can cause a chronic mild inflammatory state.

Aim

: To evaluate the correlation between preoperative C-reactive protein and postoperative complications risk in obese patients (grades II and III) after Roux-en-Y gastric bypass, with and without type 2 diabetes mellitus.

Methods :

Between 2008 and 2013 were analysed 209 patients (107 with diabetes), presenting body mass index >40 kg/m²or >35 kg/m²with comorbidities. During the postoperative period, two groups were evaluated: with and without complications. Preoperative ultra-sensitive C-reactive protein was measured by immunonephelometry method.

Results

: Complications occurred in seven patients (pulmonary thromboembolism, fistula, two cases of suture leak, pancreatitis, evisceration and upper digestive hemorrhage). No statistical significance was found regarding lipid profile and C-reactive protein between patients with and without type 2 diabetes mellitus. When compared to each other, both groups (with and without complications) presented with statistical significance regarding C-reactive protein level (7,2 mg/dl vs 3,7 mg/dl, p=0,016) and had similar weight loss percentage after 3, 6 and 12 months follow-up.

Conclusions

: Preoperative C-reactive protein serum level was higher in the group which presented complications after Roux-en-Y gastric bypass when compared to the group without postoperative complications.

Factors affecting serum albumin in the perioperative period of colorectal surgery: a retrospective study

Background

Albumin is considered a negative acute-phase protein because its concentration decreases during injury and sepsis. Hypoalbuminemia is a risk factor for mortality, postoperative complications, and prolonged hospital stay. The magnitude of the systemic inflammatory response during the perioperative period, as indicated by the acute-phase proteins—C-reactive protein (CRP) in particular—, may help identify the risk of postoperative infectious complication. The correlation between serum albumin and CRP with gastrointestinal cancer has been reported. However, it is unclear whether antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period in colorectal surgery. The primary endpoint of this study was to reveal that antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period of colorectal surgery.

Methods

Thirty-seven patients who underwent elective open colorectal surgery were included in this study. Correlations between preoperative CRP and serum albumin on postoperative day (POD) 3, between preoperative CRP and serum albumin on POD 7 and between CRP on POD 3 and serum albumin on POD 7 were examined. Relationships between preoperative CRP and hypoalbuminemia on POD 3, between preoperative CRP and hypoalbuminemia on POD 7 and between CRP on POD 3 and hypoalbuminemia on POD 7 were examined by receiver operating characteristic analysis.

Results

Three-quarters of patients were older than 65 years of age. Significant correlations were observed between preoperative CRP and serum albumin on POD 3 (p = 0.023), between preoperative CRP and serum albumin on POD 7 (p = 0.023) and between CRP on POD 3 and serum albumin on POD 7 (p < 0.001). The area under the receiver operating characteristic curve of CRP on POD 3 to development of hypoalbuminemia on POD 7 was 0.833 (95 % CI 0.679–0.987) with an optimal threshold of 12.43 mg/dL, sensitivity 75 % and specificity 80 %.

Conclusions

The present study revealed that antecedent CRP was associated with future serum albumin. Additionally, CRP on POD 3 could be useful in predicting the development of hypoalbuminemia on POD 7. This result suggests that CRP on POD 3 may be a valuable indicator for early nutritional intervention.

Searching for predictors of surgical complications in critically ill surgery patients in the intensive care unit: a review

We reviewed the use of the levels of C-reactive protein, lactate and procalcitonin and/or the Sequential Organ Failure Assessment score to determine their diagnostic accuracy for predicting surgical complications in critically ill general post-surgery patients. Included were all studies published in PubMed from inception to July 2013 that met the following inclusion criteria: evaluation of the above parameters, describing their diagnostic accuracy and the risk stratification for surgical complications in surgical patients admitted to an intensive care unit. No difference in the Sequential Organ Failure Assessment scores was seen between patients with or without complications. The D-lactate levels were significantly higher in those who developed colonic ischemic complications after a ruptured abdominal aortic aneurysm. After gastro-intestinal surgery, contradictory data were reported, with both positive and negative use of C-reactive protein and procalcitonin in the diagnosis of septic complications. However, in trauma patients, the C-reactive protein levels may help to discriminate between those with and without infectious causes. We conclude that the Sequential Organ Failure Assessment score, lactate concentration and C-reactive protein level have no significant predictive value for early postoperative complications in critically ill post-surgery patients. However, procalcitonin seems to be a useful parameter for diagnosing complications in specific patient populations after surgery and/or after trauma.

Diagnostic value of C-reactive protein to rule out infectious complications after major abdominal surgery: a systematic review and meta-analysis

PURPOSE

Infectious complications occur frequently after major abdominal surgery and have a major influence on patient outcome and hospital costs. A marker that can rule out postoperative infectious complications (PICs) could aid patient selection for safe and early hospital discharge. C-reactive protein (CRP) is a widely available, fast, and cheap marker that might be of value in detecting PIC. Present meta-analysis evaluates the diagnostic value of CRP to rule out PIC following major abdominal surgery, aiding patient selection for early discharge.

METHODS

A systematic literature search of Medline, PubMed, and Cochrane was performed identifying all prospective studies evaluating the diagnostic value of CRP after abdominal surgery. Meta-analysis was performed according to the PRISMA statement.

RESULTS

Twenty-two studies were included for qualitative analysis of which 16 studies were eligible for meta-analysis, representing 2215 patients. Most studies analyzed the value of CRP in colorectal surgery (eight studies). The pooled negative predictive value (NPV) improved each day after surgery up to 90% at postoperative day (POD) 3 for a pooled CRP cutoff of 159 mg/L (range 92-200). Maximum predictive values for PICs were reached on POD 5 for a pooled CRP cutoff of 114 mg/L (range 48-150): a pooled sensitivity of 86% (95% confidence interval (CI) 79-91%), specificity of 86% (95% CI 75-92%), and a positive predictive value of 64% (95% CI 49-77%). The pooled sensitivity and specificity were significantly higher on POD 5 than on other PODs (p < 0.001).

CONCLUSION

Infectious complications after major abdominal surgery are very unlikely in patients with a CRP below 159 mg/L on POD 3. This can aid patient selection for safe and early hospital discharge and prevent overuse of imaging.

Diagnostic accuracy of C-reactive protein and procalcitonin in the early detection of infection after elective colorectal surgery - a pilot study

Background

Colorectal surgery is associated with postoperative infectious complications in up to 40% of cases, but the diagnosis of these complications is frequently misleading, delaying its resolution. Several biomarkers have been shown to be useful in infection diagnosis.

Methods

We conducted a single-centre, prospective, observational study segregating patients submitted to elective colorectal surgery with primary anastomosis, CRP and PCT were measured daily. We compared infected and non-infected patients.

Results

From October 2009 to June 2011, a total of 50 patients were included. Twenty-one patients developed infection. PCT and CRP before surgery were equally low in patients with or without postoperative infectious complications. After surgery, both PCT and CRP increased markedly. CRP time-course from the day of surgery onwards was significantly different in infected and non-infected patients (P = 0.001) whereas, PCT time-course was almost parallel in both groups (P = 0.866). Multiple comparisons between infected and non-infected patients from 5^th to 9^th postoperative days (POD) were performed and CRP concentration was significantly different (P < 0.01, Bonferroni correction), on the 6^th, 7^th and 8^th POD. A CRP concentration > 5.0 mg/dl at the D6 was predictive of infection with a sensitivity of 85% and a specificity of 62% (positive likelihood ratio 2.2, negative likelihood ratio 0.2).

Conclusions

After a major elective surgical insult both CRP and PCT serum levels increased independently of the presence of infection. Besides serum CRP time-course showed to be useful in the early detection of an infectious complication whereas PCT was unhelpful.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-444) contains supplementary material, which is available to authorized users.

Usefulness of drain amylase, serum C-reactive protein levels and body temperature to predict postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal.

METHODS

From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF.

RESULTS

Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m(2) to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively.

CONCLUSIONS

Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.

Prediction and diagnosis of colorectal anastomotic leakage: A systematic review of literature

Although many studies have focused on the preoperative risk factors of anastomotic leakage after colorectal surgery (CAL), postoperative delay in diagnosis is common and harmful. This review provides a systematic overview of all available literature on diagnostic tools used for CAL. A systematic search of literature was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. Articles were selected when a diagnostic or prediction tool for CAL was described and tested. Two reviewers separately assessed the eligibility and level of evidence of the papers. Sixty-nine articles were selected (clinical methods: 11, laboratory tests: 12, drain fluid analysis: 12, intraoperative techniques: 22, radiology: 16). Clinical scoring leads to early awareness of probability of CAL and reduces delay of diagnosis. C-reactive protein measurement at postoperative day 3-4 is helpful. CAL patients are characterized by elevated cytokine levels in drain fluid in the very early postoperative phase in CAL patients. Intraoperative testing using the air leak test allows intraoperative repair of the anastomosis. Routine contrast enema is not recommended. If CAL is clinically suspected, rectal contrast-computer tomography is recommended by a few studies. In many studies a “no-test” control group was lacking, furthermore no golden standard for CAL is available. These two factors contributed to a relatively low level of evidence in the majority of the papers. This paper provides a systematic overview of literature on the available tools for diagnosing CAL. The study shows that colorectal surgery patients could benefit from some diagnostic interventions that can easily be performed in daily postoperative care.