C-reactive protein, fibrinogen, and procalcitonin levels as early markers of staple line leak after laparoscopic sleeve gastrectomy in morbidly obese patients within an Enhanced Recovery After Surgery (ERAS) program

Can We Predict Gastric Leaks After Laparoscopic Sleeve Gastrectomy by Evaluating the Complete Blood Count on Postoperative Day 1?

INTRODUCTION

We assessed whether postoperative day-1 (POD-1) complete blood count (CBC) test parameters, including red cell distribution width (RDW), mean platelet volume (MPV), plateletcrit (PCT), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR), could identify patients with gastric leaks after laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients with postoperative gastric leaks (n=36) and patients with no complications who were selected by age-sex-BMI matching (n=254) were included in the study. The levels of RDW, MPW, PCT, PLR, and NLR were compared between groups in univariate analyses. Receiver operating characteristic (ROC) curve analysis was run for CBC parameters with a P-value<0.05 in univariate analyses. The area under the curve (AUC) was evaluated, and a cutoff value was determined. Sensitivity, specificity, likelihood ratio (LR), positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated.

RESULTS

The level of PCT was significantly lower, while levels of PLR and NLR were significantly higher in patients with postoperative gastric leaks as compared with those without (P<0.05). The AUC of both PCT and PLR was <0.750, while the AUC of NLR was 0.911. NLR cutoff at 3.6 yielded 80% sensitivity, 92% specificity, and an LR of 10. In the study cohort, PPV of 59%, NPV of 97%, and an accuracy of 90% were found.

CONCLUSIONS

Our results suggest that NLR at POD-1, with a cutoff value of 3.6, is a useful indicator of postoperative gastric leak who underwent LSG. We recommend the use of this easily calculated parameter in clinical practice.

Machine learning analysis of lab tests to predict bariatric readmissions

The purpose of this study was to develop a machine learning model for predicting 30-day readmission after bariatric surgery based on laboratory tests. Data were collected from patients who underwent bariatric surgery between 2018 and 2023. Laboratory test indicators from the preoperative stage, one day postoperatively, and three days postoperatively were analyzed. Least absolute shrinkage and selection operator regression was used to select the most relevant features. Models constructed included support vector machine (SVM), generalized linear model, multi-layer perceptron, random forest, and extreme gradient boosting. Model performance was evaluated and compared using the area under the receiver operating characteristic curve (AUROC). A total of 1262 patients were included, of which 7.69% of cases were readmitted. The SVM model achieved the highest AUROC (0.784; 95% CI 0.696-0.872), outperforming other models. This suggests that machine learning models based on laboratory test data can effectively identify patients at high risk of readmission after bariatric surgery.

Optimal Predictors of Postoperative Complications After Gastrectomy: Results from the Procalcitonin and C-reactive Protein for the Early Diagnosis of Anastomotic Leakage in Esophagogastric Surgery (PEDALES) Study

BACKGROUND

The aim of this study was to define whether procalcitonin (PCT) is an earlier and more accurate predictor than C-reactive protein (CRP) for anastomotic leakage (AL) and major infective complications (MICs).

METHODS

This was a prospective multicentric observational study conducted in three Italian centers, including all patients undergoing gastrectomy from May 2016 to April 2021. The endpoint was the assessment of the discrimination and accuracy achieved by the PCT and CRP values measured from POD1 to POD7 for predicting the occurrence of AL and MICs. Accuracy was assessed by calculating the area under the receiver operating curve (AUROC) values and Youden's statistics. Two charts were created for risk stratification during the postoperative course.

RESULTS

The rate of AL was 4.6%, with a median day of occurrence on POD5 (range 3-26). The overall rate of major infective complications was 19.9%, with a median day of occurrence on POD6 (range 2-30). PCT showed a significant association with AL on POD6 and POD7 and a significant association with MICs on POD2, while CRP values showed a significant association with AL on POD4 and a significant association with MICs on POD1. No difference in the prediction of AL was observed between PCT and CRP, while CRP was found to be a superior predictor of major infective complications on POD5 (p = 0.024) and POD7 (p = 0.035).

CONCLUSIONS

PCT was not superior to CRP as an early predictor of AL and major infective complications after gastrectomy. CRP should be used as the reference screening postoperative marker.

Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy

Background and Objectives:

Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure.

Methods:

A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019.

Results:

A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15–95 days).

Conclusion:

Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.

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.

Clinical predictive efficacy of C-reactive protein for diagnosing infectious complications after gastric surgery

BACKGROUND

With the popularization of Enhanced Recovery After Surgery (ERAS), identifying patients with complications before discharging becomes important. This study aimed to explore the efficacy of C-reactive protein (CRP) in predicting infectious complications after gastrectomy.

METHODS

Patients with gastric cancer who underwent gastrectomy at Beijing Cancer Hospital from March 2017 to April 2018 were enrolled in the training set. Complications were prospectively registered. Receiver operating characteristic analysis was performed to assess the diagnostic accuracy of CRP via evaluating the area under the curve (AUC). Patients who had CRP tested on postoperative day (POD) 5 and accepted gastrectomy from April to December 2018 were included in the validation set to validate the cut-off value of CRP obtained from the training set.

RESULTS

A total of 350 patients were included (263 patients in the training set and 87 patients in the validation set). Out of these, 24 patients were diagnosed with infectious complications and 17 patients had anastomotic leakage in the training set. The CRP level on POD5 had superior diagnostic accuracy for infectious complications with an AUC of 0.81. The cut-off value of CRP on POD5 at 166.65 mg/L yielded 93% specificity and 97.2% negative predict value (NPV); For anastomotic leakage, the AUC of CRP on POD5 was 0.81. Using the cut-off value of CRP at 166.65 mg/L on POD5 achieved 92% specificity and 98.6% NPV. The optimal cut-off value (CRP 166.65 mg/L on POD5) was validated in the validation set. It achieved 97.5% specificity and 94.0% NPV for infectious complications, and 97.6% specificity and 96.4% NPV for anastomotic leakage.

CONCLUSION

CRP is a reliable predictive marker for the diagnosis of inflammatory complications following gastric surgery. However, this study was based on preliminary data. The validity of this data needs confirmation by a larger number of cases.

The independent risks and specific biomarker of breast cancer-related ischemic stroke

AIM

This retrospective study was designed to investigate the independent risks and specific biomarker for breast cancer-related ischemic stroke (BCRS).

METHODS

Clinical features and laboratory findings were compared between BCRS group and breast cancer group without stroke, and further multivariate analyses were performed to predict independent risks factors for BCRS patients. A receiver operator characteristic (ROC) curve analysis was configured to estimate the diagnostic efficacy of each independent risk and the product of these risks and to obtain the optimal cut-off value of diagnosis, which was termed the BCRS Index.

RESULTS

BCRS patients had elevated plasma D-dimer and CA153 levels and platelet-to-lymphocyte ratio (PLR), as well as more patients received endocrine therapy (all p ＜ 0.05). Moreover, multivariate analysis revealed that D-dimer levels (odds ratio [OR]: 1.002; 95% confidence interval [CI]: 1.001-1.003; p = 0.000), CA153 levels (OR: 1.005; 95% CI: 1.001-1.008; p = 0.007), PLR (OR: 1.010; 95% CI: 1.004-1.015; p = 0.001), and endocrine therapy (OR: 1.268; 95% CI: 1.087-1.479; p = 0.003) were identified as independent risks of BCRS. Furthermore, ROC analysis displayed that the product of risks had the best diagnostic efficacy, of which the area under the curve was 0.846 ± 0.28. The optimum cut-off point was 2.37 × 10⁶/mL, which was termed the BCRS Index with higher diagnostic accuracy and validity.

CONCLUSIONS

Endocrine therapy, as well as elevated plasma D-dimer and CA153 levels and PLR values may be independent risks for BCRS. Furthermore, BCRS Index should be served as a novel specific biomarker for BCRS, which is useful to distinguish BCRS for clinicians.

Low Postoperative Levels of C-Reactive Protein Are an Early Predictor for an Uncomplicated Course After Bariatric Surgery: A Retrospective, Validated Cohort Study

BACKGROUND

Bariatric surgery is popularly used to treat or prevent morbidity in severely obese patients. Severe complications are rare, but their early detection has a significant impact on clinical outcomes. We aimed to determine whether blood tests in the first few postoperative days are reliable predictors for complications.

METHODS

We retrospectively analyzed 1073 patients who underwent laparoscopic bariatric surgery between 2009 and 2018 at our center. Clinical outcome was correlated with postoperative serum C-reactive protein (CRP), white blood cell count, and vital signs, analyzed using a receiver operating characteristic (ROC) curve. A total of 570 procedures between 2009 and 2015 were used to calculate the best cutoff values (calculation group), which were validated with 330 different patients operated upon between 2016 and 2018 (validation group).

RESULTS

Twenty-four patients (4.2%) developed anastomotic or staple-line leakages in the calculation group. The ROC curve showed a good reliability for CRP levels on day 2 (area under the ROC curve=0.86); the highest Youden index existed for a cutoff of 119 mg/L. White blood cell count and heart rate were poor predictors. Even though several characteristics differed in the validation cohort, test quality of the cutoff was high (sensitivity, 71.4%; specificity, 94.9%; positive predictive value, 23.8%; negative predictive value, 99.3%). The prediction was excellent especially for leakages appearing on days 2 to 9 (sensitivity 100.0%, negative predictive value 100%). Leakages from day 10 were rare and prediction poor (sensitivity 0%).

CONCLUSIONS

A CRP level on day 2 <120 mg/L is a good predictor of a postoperative course without leakage, even though the predictive value goes down for late-appearing events. An earlier CRP measurement added no predictive benefit. The cutoff value was validated in an internal cohort and could be applied to different populations.

Diagnostic accuracy of procalcitonin as an early predictor of infection after radical gastrectomy for gastric cancer: A prospective bicenter cohort study

OBJECTIVE

To investigate the diagnostic accuracy of procalcitonin (PCT) as an early predictor of infection following radical gastrectomy to treat gastric cancer (GC).

METHODS

A prospective, observational, cohort study was conducted in two high-volume tertiary centers (registered under ClinicalTrials.gov). A total of 552 consecutive adult patients undergoing radical gastrectomy for GC from June 2018 to July 2019 were included. Routine blood tests (white blood cell count (WBC); neutrophil count; the neutrophil:WBC ratio, N%) and PCT were measured on post-operative day (POD) 3 and 5. Post-operative infection was recorded based on the criteria of the Center for Disease Control. The area under the curve (AUC) summarizing receiver-operating characteristic was calculated and compared for each biomarker measured.

RESULTS

Ninety three adverse events occurred in 70 patients (12.7%), with infections being the most common (n = 37, 6.7%). With cutoff values of 0.695 ng/mL at POD 3 and 0.515 ng/mL at POD 5, specificity and negative predictive value for infections were 0.656 and 96.3%, 0.816 and 96.1%, respectively. PCT had a better AUC than the WBC and neutrophil count to detect post-operative complications, especially infections (AUC: 0.678, 0.600, 0.592, P = 0.028 and 0.017, respectively) at POD 3, but which were comparable at POD 5. Additionally, 4 of the 8 patients with PCT levels ≥3 ng/mL on POD 5 were confirmed to have an infection.

CONCLUSION

PCT is a more reliable predictor than WBC and neutrophil count to detect infections following radical gastrectomy for GC. PCT levels <0.695 ng/mL at POD 3 and < 0.515 ng/mL at POD 5 makes post-operative infections very unlikely but extreme high PCT levels should alert the surgeon to the possibility of infections.

The utility of fibrinogen level as a predictor of complications after laparoscopic gynecologic surgery: a prospective observational study

Background

Complications after laparoscopic gynecological surgery may increase patients’ morbidity and mortality; therefore, their timely diagnosis and early treatment would help clinicians to avoid life-threatening situations. We aimed to evaluate the predictive role of fibrinogen for diagnosing complications after laparoscopic gynecologic surgery for benign and malignant conditions.

Patients and methods

All patients who underwent elective laparoscopic gynecologic surgery between June 2013 and December 2017 at the Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, Cagliari, were prospectively included. Post-operative complications were assessed and graded according to the Clavien-Dindo classification. Fibrinogen and white blood cell level were determined preoperatively, on the first post-operative day and at the appearance of symptoms indicative of an irregular post-operative course or at the time of re-hospitalization for persistent symptoms. The postoperative changes (calculated from the first postoperative day) were correlated with the occurrence and severity of complications and their predictive role was assessed.

Results

We enrolled 1016 patients: 36% underwent surgery for benign pathologies (mainly voluminous fibromatous uteri and severe deep endometriosis) and 64% for gynecologic malignancies. The overall complication rate was of 3.45%, the rate of major postoperative complications was 2.85%. A postoperative fibrinogen increase ≥ 20% had a high diagnostic accuracy to identify postoperative complications early (AUC 0.931, sensitivity 89%, and specificity 99%). The magnitude of postoperative fibrinogen change was associated with complication severity.

Conclusions

Our findings demonstrated that fibrinogen increase can enable the early detection of postoperative complications after laparoscopic gynecological surgery. Further prospective and multi-center studies are warranted to confirm these results.

The role of C-reactive protein after surgery for obesity and metabolic disorders

BACKGROUND

C-reactive protein (CRP) rise might be different in patients with obesity due to chronic inflammation.

OBJECTIVES

The aim was to analyze postoperative CRP rise and its role as an early prognostic marker of infectious complications.

SETTING

Center of maximum care in Germany.

METHODS

Patients who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic one-anastomosis gastric bypass as primary treatment for severe obesity were included. Serum CRP and leukocyte count were measured preoperatively, on postoperative days (POD) 1 and 4 and were analyzed regarding sex, body mass index, waist circumference, obesity-associated diseases, laboratory measurements (glycosylated hemoglobin, triglycerides, cholesterol), surgical procedure, infectious complications, and infectious with anastomotic leakage.

RESULTS

Four hundred seventy-one patients underwent surgery. Postoperative CRP rise was similar across sexes but lower in the super-super obese group (P < .05) and higher in the gastric bypass groups (P < .05). Linear regression model showed, that the higher preoperative value of waist circumference, the higher the preoperative CRP (beta value: .159, P = .006) and the lower the postoperative CRP rise on POD1 (beta value: -.171, P = .004) and 4 (beta value: -.170, P = .003). Only in the laparoscopic one-anastomosis gastric bypass group did a higher glycosylated hemoglobin predict a higher postoperative CRP rise (POD1: beta value: .434, P = .012; POD4: beta value: .513, P = .006). Fourteen patients (3%) developed infections, 7 of whom (1.5%) had anastomotic leakage. Leukocyte count was no predictor of infectious complications. The cut-off for CRP was 80.5 mg/L (POD1) and 164 mg/L (POD4), with 57.1% and 85.7% sensitivity and 97.9% and 99.6% specificity for anastomotic leakage.

CONCLUSION

Standard postoperative CRP rises less in patients with higher waist circumference and super-super obesity, but more after gastric bypass procedures. CRP but not leukocyte count predicts early anastomotic healing after obesity surgery. These findings should be considered when interpreting CRP values in the routine clinical setting.

Preoperative albumin-to-fibrinogen ratio predicts severe postoperative complications in elderly gastric cancer subjects after radical laparoscopic gastrectomy

BACKGROUND

A high prevalence of postoperative complications is closely associated with a worse short- and long-term outcome. This current study aimed to investigate potential risk factors including albumin-to-fibrinogen ratio (AFR) for severe postoperative complications (SPCs) in surgical gastric cancer (GC) patients.

METHODS

Elderly patients (≥65 years) with primary GC who underwent elective radical laparoscopic gastrectomy under general anesthesia were included. According to the Clavien-Dindo classification system, the severity of complications was assessed from Grade I to V and SPCs were defined as C-D Grade ≥ IIIa. The clinicopathological features, operative-associated characteristics, postoperative recovery and laboratory tests were compared between patients with or without SPCs. Receiver operating characteristic (ROC) curve analysis using Youden's Index was established for determining the predictive value and cut-off threshold of AFR for SPCs. Binary univariate and multivariate logistic regression models were used to assess factors influencing SPCs.

RESULTS

A total of 365 elderly GC patients were finally included in the analysis, of which 52 (52/365, 14.2%) patients had developed SPCs within postoperative 30 days. Preoperative AFR level predicted SPCs in surgical GC patients with an AUC of 0.841, a sensitivity of 76.36% and a specificity of 80.77%, respectively (P < 0.001). The multivariate analysis revealed that a lower AFR level (OR: 1.94, 95% CI: 1.09-3.36, P = 0.017) and an older age (OR: 1.81, 95% CI: 1.06-3.04, P = 0.023) were two independent predictive factors for SPCs in surgical GC patients.

CONCLUSIONS

Preoperative AFR level is a useful predictor for SPCs in elderly GC subjects after radical laparoscopic gastrectomy.

Enhanced recovery after surgery protocols in functional endoscopic sinus surgery for patients with chronic rhinosinusitis with nasal polyps: a randomized clinical trial

Background:

Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speed up recovery. This study aimed to assess the impact of ERAS protocols for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

Methods:

One hundred and two patients with CRSwNP undergoing FESS were randomly divided into the ERAS group and the control group. The outcomes of the Self-Rating Anxiety Scale (SAS), Visual Analogue Scale (VAS), Medical Outcomes Study Sleep Scale (MOS-SS) and Kolcaba Comfort Scale Questionnaire (GCQ) were determined in both groups. The serum levels of C-reactive protein (CRP) were compared preoperatively and 24 hours postoperatively.

Results:

The ERAS group had a significantly better SAS scores than did the control group (28 [24, 35] vs. 43 [42, 47], Z = 5.968, P < 0.001). The rhinalgia and headache scores at 2, 24 and 48 hours postoperatively were lower in the ERAS group than that in the control group (all P < 0.001). The outcomes of the MOS-SS (43 [42, 39] vs. 28 [22, 35], Z = 7.071, P < 0.001) and GCQ (76 [68, 87] vs. 64 [50, 75], Z = 4.806, P < 0.001) were significantly different between the two groups. No significant difference was found in the preoperative CRP levels between the two groups (1.3 [0.6, 2.8] vs. 0.5 [0.5, 1.2], Z = 3.049, P > 0.05); However, the CRP level in 24 hours postoperatively was significantly lower in the ERAS group than that in the control group (2.5 [1.4, 3.9] vs. 6.6 [3.8, 9.0], Z = 5.027, P < 0.001). The incidence rates of complications, such as nausea/emesis (χ² = 0.343, P > 0.05), hemorrhage, aspiration and tumble, were not increased in the ERAS group compared with those in the control group. The ERAS group had a significantly shorter length of hospital stay (5 [4, 5] days vs. 8 [8,9] days, Z = 8.939, P < 0.001) and hospitalization expenses ($ 2670 [2375, 2740] vs. $3129 [3116, 3456], Z = 8.514, P < 0.001).

Conclusions:

ERAS protocols might optimize FESS for patients with CRSwNP by reducing psychological and physical stress, shortening the length of hospital stay and lowering hospitalization expenses without increasing postoperative complications.

Trial registration:

Chinese Clinical Trial Registry, No. ChiCTR1800015791; http://www.chictr.org.cn/showproj.aspx?proj=26872