C-reactive protein as an early predictor for anastomotic leakage in elective abdominal surgery

Systematic review of the significance of neutrophil to lymphocyte ratio in anastomotic leak after gastrointestinal surgeries

INTRODUCTION

The inflammatory response is thought to be a critical initiator of epigenetic alterations. The neutrophil to lymphocyte ratio (NLR), a biomarker of inflammation, is computed by dividing the number of neutrophils by the number of lymphocytes. The primary goal of this systematic review and meta-analysis was to evaluate the pre-operative NLR of gastrointestinal surgery patients who had an anastomotic leak (AL) in comparison to those who did not AL.

METHODS

We performed a comprehensive search for relevant papers published before May 4, 2022, using PubMed, Scopus, and Web of Science. Standardized mean difference (SMD) with a 95% confidence interval (CI) was pooled in meta-analysis to yield a summary estimate. We utilized the random-effects model to create pooled effects since we discovered a substantial heterogeneity level. For evaluating quality, the Newcastle-Ottawa scale (NOS) was implemented.

RESULTS

The research comprised 12 studies with a total of 2940 individuals who had GI operations, 353 of whom went on to develop AL. We discovered that patients who had GI surgeries and acquired AL had significantly higher NLR levels than those who did not (random-effects model: SMD = 0.75, 95% CI = 0.11-1.38, p = 0.02). Patients with AL showed significantly higher NLR levels than control group in retrospective studies (SMD = 0.93, 95% CI = 0.20-1.66, p=0.01) but not in prospective studies (SMD = - 0.11, 95% CI = - 0.65-0.43, p = 0.69), according to the subgroup analysis based on research design. Subgroup analysis based on ethnicity yielded that white patients with AL exhibited significantly higher NLR values than the control group (SMD = 1.35, 95% CI = 0.01-2.68, p = 0.04) but this result was not applied to East Asian patients (SMD = 0.14, 95% CI = -0.13-0.41, p = 0.29).

CONCLUSION

Our research suggests a potential association between preoperative NLR and postoperative AL. However, it is essential to acknowledge the variability in the findings, with significantly higher NLR levels observed in retrospective studies and among white patients, but not consistently replicated in prospective studies and among East Asian patients. Further investigations with larger and more diverse cohorts are warranted to validate these findings and explore potential factors contributing to the observed discrepancies.

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.

Diagnostic accuracy of C-reactive protein and procalcitonin in the early diagnosis of infections after laparoscopic rectal cancer surgery

BACKGROUND

We aimed to examine the diagnostic accuracy of postoperative procalcitonin (PCT) and C-reactive protein (CRP) in the detection of infectious complications in patients after laparoscopic rectal cancer surgery, as opposed to all colorectal surgery.

METHODS

Between December 2018 and December 2020, 204 patients who underwent laparoscopic rectal cancer surgery were enrolled retrospectively. The PCT, CRP and white blood cell (WBC) count were measured before surgery and on postoperative days (PODs) 3 and 5. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Net Reclassification Index (NRI) was used to calculate the ability to correct reclassification.

RESULTS

Infectious complications occurred in 36 patients (17.6%), including 17 cases of anastomotic leakage (AL) (8.3%). The AUCs of PCT and CRP in predicting infectious complications on POD 3 were 0.690 and 0.731, respectively, which were better than those on POD 5 (AUC 0.666 and 0.697, respectively). PCT with an optimal cutoff value of 1.10 ng/mL (AUC 0.792, specificity 78.6%, negative predictive value [NPV] 96.6%), CRP with an optimal cutoff value of 109.5 mg/L (AUC 0.760, specificity 78.6%, NPV 96.1%) on POD 3 had superior diagnostic accuracy in predicting AL, both better than WBC (AUC 0.627). The AUC of combining PCT and CRP on POD 3 in predicting AL was 0.851, with a specificity of 79.7% and NPV of 97.4%, and the NRI was estimated to be 7.0%.

CONCLUSIONS

Both PCT and CRP on POD 3 are excellent negative predictors for early monitoring of infectious complications, especially AL, in patients undergoing laparoscopic rectal cancer surgery.

C-reactive protein monitoring after ileocecal resection and stoma closure reduces length of hospital stay: a prospective case-matched study in 410 patients with Crohn's disease

BACKGROUND

The aim of this study was to evaluate a C-reactive protein (CRP)-driven monitoring discharge strategy for patients with Crohn's disease (CD) undergoing laparoscopic ileo-cecal resection (ICR) and if needed, temporary stoma closure (SC).

METHODS

Four hundred and ten patients who underwent laparoscopic ICR for CD: 153 patients (CRP group) between June 2016 and June 2020 at our department, had a CRP-driven monitoring discharge on postoperative day (POD) 3 and were discharged on POD 4 if CRP < 100 mg/L. These patients were matched (according to age, sex, body mass index, type of CD (and stoma or not) to 257 patients who underwent laparoscopic ICR for CD between January 2009 and May 2016, without CRP monitoring (Control group). For SC, 79 patients with CRP monitoring were matched with 88 control patients. Primary outcome was overall length of hospital stay (LHS). Secondary outcomes were discharge on POD 4 for SC and POD 4 and POD 6 for ICR, 3-month postoperative overall morbidity and severe morbidity rates, surgical site infection, readmission rates, and CRP level in cases of morbidity at 3 months.

RESULTS

For ICR without stoma, mean LHS was significantly shorter in the CRP group than in the control group (6.9 ± 2 days vs 8.3 ± 6 days, p = 0.017). Discharge occurred on POD 6 (or before) in 73% of the patients (CRP group) vs 60% (Control group) (p = 0.027). For ICR with stoma, LHS was 8 days for both groups (p = 0.612). For SC, LHS was significantly shorter in the CRP group than in the control group (5.5 ± 3 days vs 7.1 ± 4 days; p = 0.002). Discharge occurred on POD 4 in 62% (CRP group) vs 30% (Control) (p = 0.003). Postoperative 3-month overall and severe morbidity, and rehospitalization rates were similar between groups.

CONCLUSIONS

CRP-driven monitoring discharge strategy after laparoscopic ICR for CD is associated with a significant reduction of LHS, without increasing morbidity, reoperation or rehospitalisation rates.

Research Progress on the Relationship Between Inflammation and Colorectal Cancer

Colorectal cancer is one of the common malignant tumors. Relevant epidemiology and a large number of experimental studies have proved that chronic inflammation is highly correlated with the occurrence and development of colorectal cancer. And inflammatory bowel disease has been proven to be an independent risk factor for colorectal cancer. Various inflammatory cells participate in the establishment of the chronic inflammatory intestinal microenvironment required for the onset of colorectal cancer. The abnormal signal pathways mediated by various inflammatory factors and inflammatory mediators promote the occurrence of tumors, which are related to colorectal cancer and pathogenesis-related inflammation mechanisms. At the gene level, miRNAs can also affect the pathogenesis of colorectal cancer by regulating mesenchymal epithelial transformation. This article reviews the relationship between inflammation and colorectal cancer as well as the related inflammatory mechanisms.

Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections

Purpose

The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery.

Method

Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation.

Results

This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively).

Conclusion

The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.

Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study

AIM

The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery.

METHODS

We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database.

RESULTS

The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy.

CONCLUSION

On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.

Lymphocyte C-reactive protein ratio: A new biomarker to predict early complications after gastrointestinal oncologic surgery

BACKGROUND

Lymphocyte-to-C-reactive protein ratio (LCR) has been used as a post-surgical prognostic biomarker in patients with gastric and colorectal cancer. However, its relationship with early postoperative complications in these patients is unknown. In this study, we aimed to reveal the relationship between LCR and postoperative complications.

METHODS

Eighty-one patients operated for stomach and colorectal cancer between January 2020 and August 2020 were prospectively analyzed. On preoperative and postoperative days 1, 3 and 5, other inflammatory parameters, mainly LCR, neutrophil lymphocyte ratio (NLR), were recorded. The patients were divided into two groups according to Clavien-Dindo classification as stage III and higher complications major, stage I-II/non-complication minor.

RESULTS

Fifty seven patients were operated for colorectal cancer, 24 patients for gastric cancer. The mean age of the patients was 65.6 ± 12.6, 34.6% of them was women. Age, operation time and hospital stay were significantly different between the groups (p= 0.004, p= 0.002, p< 0.001). Major complications developed in 18 patients. On postoperative day 5, LCR found superior diagnostic accuracy in predicting major postoperative complications compared to other inflammatory markers. On the postoperative 5th day, the cut-off value of LCR was 0.0034, 88.8% (71.9-94.8) sensitivity, and 85.7% (73.6-95.4) selectivity.

CONCLUSION

Among different inflammatory markers, postoperative LCR is a safe and effective predictor of postoperative complications, especially after gastric and colorectal cancer surgery on day 5.

Procalcitonin Levels in Post TACE Infection

Purpose

This study aimed to evaluate the value of serum procalcitonin (PCT) levels in the diagnosis of abscess and sepsis following transarterial chemoembolization (TACE) therapy among patients with hepatocellular carcinoma (HCC).

Patients and Methods

In this study, a retrospective review of patient charts was performed in 2221 patients who suffered from hepatocellular carcinoma and had undergone 8656 TACE procedures from January 2012 to January 2018. According to the diagnosis of infection and abscess after TACE, these participants were divided into infection group (group A, n=48) and abscess group (group B, n=35). Group B included subgroup B1 (suffered from liver abscess but no sepsis, n=16) and subgroup B2 (suffered from liver abscess and sepsis, n=19). The main observational indexes included sociodemographic characteristics and laboratory and clinical parameters.

Results

The results showed that the mean PCT and C-reactive protein (CRP) levels were higher in group B, but receiver-operating characteristic (ROC) analysis showed low sensitivity and specificity. Only the mean PCT level was higher in subgroup B2 than in subgroup B1 (P<0.001); the ROC analysis had high sensitivity and specificity. However, all other data such as NEUT (neutrophil count) and NEUTP (neutrophil percentage) showed no significant differences.

Conclusion

Serum PCT level was a promising inexpensive marker for the diagnosis of liver abscess and sepsis following TACE therapy among patients with primary liver cancer. A cutoff level of 5.1 ng/mL for PCT had high sensitivity and specificity in predicting liver abscess with sepsis.

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 Biologic Material Reinforcement on Surgical Anastomosis After Gastrectomy-A Pilot Study

Background: Acellular dermal matrix is a biologic material derived from the skin of human cadaveric donors. It has been used successfully in the past to reduce complications in breast surgery and hernia repair. This investigation was aimed at assessing the feasibility of using acellular dermal matrix to support the anastomosis after gastrectomy with the aim of reducing anastomotic site leakage complications. Methods: Patients were randomly assigned to standard anastomotic reconstruction (control arm) or anastomotic reconstruction with acellular dermal matrix reinforcement (intervention arm). Surgical outcomes related to anastomotic complications were collected. Because actual anastomotic leaks found on imaging studies are infrequent and thus require a very high number of patient recruitment to detect statistically significant difference between the two groups, in this pilot investigation other clinical and laboratory measures that have been shown to correlate to or predict anastomotic leaks were also collected. Each surgical outcome was compared. Results: A total of 94 patients (intervention arm: 50, control arm: 44), were included in the analysis. Two patients in the control arm (4.55%) and one patient in the intervention arm (2.00%) experienced anastomotic leakage (p = 0.598), a difference without statistical significance. However, average postoperative C-reactive protein (CRP) levels and NUn scores, both of which have been shown to reflect likelihood of progressing to anastomotic leakage, were significantly lower for the intervention arm. The control arm showed an average CRP level of 128.77 mg/dL (SD: 97.08) while the intervention arm showed 77.38 mg/dL (SD: 49.08, p = 0.049). Conclusions: Leakage rate reduction with acellular dermal matrix reinforcement of anastomotic site was not detected in this investigation. However, postoperative inflammation levels and numerical predictors of anastomotic leakage development were significantly lower with acellular dermal matrix reinforcement of surgical anastomosis. This finding is worthy of further investigation, as reduction of inflammation with anastomotic site reinforcement is a novel finding, and more in-depth research may lead to discoveries on the physiologic role of the surgical anastomosis in post-gastrectomy patients. In addition, lower CRP and NUn scores for the intervention arm suggest potential for larger studies to detect reduction in clinical leak rates after acellular dermal matrix reinforcement.

Systematic use of the serum C-reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks

BACKGROUND

This study aimed to characterize the time-dependent relationship between serum C-reactive protein (CRP) and anastomotic integrity in the early post-operative period and to develop a systematic use of CRP and computed tomography.

METHODS

Patients aged 18 years or over who had the formation of a left-sided colonic or a colorectal anastomosis, in Royal Sussex County Hospital, were included. The post-operative day (POD) CRP cut-off values were calculated according to receiver operating characteristic analysis to evaluate the sensitivities and specificities of the proposed cut-off parameters.

RESULTS

A total of 125 left-sided colonic and colorectal anastomoses were recruited and analysed. When comparing to POD1 CRP cut-off, the calculated CRP ratio cut-off values of all the rest of PODs (2-5) were highly significant in the laparoscopic group and the overall group (P < 0.001). This statistically significant ratio was also demonstrated in the open group at POD2 (P < 0.0001).

CONCLUSION

CRP and CRP ratios cut-off values were sensitive to detect an anastomotic leak in the early post-operative period. The cut-off values could facilitate the development of systematic use of CRP and computed tomography.

Correlation between invasive microbiota in margin-surrounding mucosa and anastomotic healing in patients with colorectal cancer

BACKGROUND

Impaired anastomotic healing is one of the major complications resulting from radical resection in colorectal cancer (CRC). Accumulating evidence suggests that intestinal microbiota is correlated with anastomotic healing.

AIM

To explore the microbiota structural shift in margin-surrounding mucosa and evaluate the predictive ability of selected bacterial taxa for impaired anastomotic healing.

METHODS

Margin-surrounding mucosa samples derived from 37 patients were collected to characterize the microbial community structure by 16s rRNA gene sequencing. The patients were divided into two groups according to the healing status of anastomoses: well-healing group (n = 30) and impaired-healing group (n = 7). Statistic differences in bacteria taxa were compared by Wilcoxon test and chi-squared test. The predictive ability of the selected bacterial taxa for the healing status of anastomoses was evaluated by the area under the receiver operator characteristic curve.

RESULTS

Community structure shifts were observed in the impaired-healing group and well-healing group. Six bacterial species were found to be significantly correlated with anastomotic healing, and among these species, Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis were considered as the predictive factors. Taking the known risk factor age into consideration, Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis improved predictive ability for the healing status of anastomoses.

CONCLUSION

These data show that Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis could be considered as supplementary factors in the prediction of anastomosis healing status in patients after CRC radical resection.

Secondary peritonitis: principles of diagnosis and intervention

Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.

Results after Definitive Surgical Treatment in Patients with Enteroatmospheric Fistula

As enteroatmospheric fistulas (EAF) lack healthy overlying tissue, spontaneous healing is very unlikely. Our aim was to identify risk factors for recurrence and mortality after definitive surgical treatment for EAF. Sixty-two consecutive patients with a diagnosis of EAF were submitted to definitive surgical repair (fistula resection and primary anastomosis) during a 6-year period. Several patient, disease, and operative variables were assessed as risk factors associated to our endpoints: recurrence and mortality. All patients were followed-up until hospital discharge or death. Univariate and multivariate analysis were performed. There were 24 females and 38 males with a median age of 53 years (interquartile ranges 43–63). EAF recurred in 23 patients. Univariate analysis identified several risk factors for recurrence which included performing more than one anastomosis (20 vs 52%, P = 0.013), failure of achieving total abdominal closure (16 vs 47%, P = 0.025), intraoperative hemorrhage >400 cc (28 vs 65%, P = 0.007), presence of multiple fistulas (25 vs 61%, P = 0.008), and preoperative C-reactive protein >0.5 mg/dL (54 vs 82%, P = 0.029). The latter two remained significant after multivariate analysis. Final EAF closure was attained in 47 patients (76%) and 8 more (13%) had a low-output (<50 mL/day) enterocutaneous fistula. Timing of surgery was not related to fistula recurrence. Eight patients died (13%), and fistula recurrence was the only risk factor found related to mortality both through univariate (26 vs 5%, P = 0.043) and after multivariate analysis. EAF management represents a rather challenging problem. Timing for surgical treatment is controversial and is based mostly on patient status and surgeon's criteria. Recurrence is associated to EAF characteristics and an inflammatory state; it was also the only factor associated to mortality.

Clinical evaluation of C-reactive protein and procalcitonin for the early detection of postoperative complications after laparoscopic sleeve gastrectomy

INTRODUCTION

Among the most common early complications after bariatric surgery are anastomosis leak and bleeding. In order to react quickly and perform accurate treatment before the clinical signs appear, early predictors should be found. In the study C-reactive protein (CRP) and procalcitonin (PCT) levels were investigated. Characterized by a relatively short half-life, they can predict surgical complications.

AIM

To develop and implement certain standards for early detection of complications.

MATERIAL AND METHODS

The study involved 319 adults who underwent laparoscopic sleeve gastrectomy (LSG) as a surgical intervention for morbid obesity at the Department of General Surgery of Ceynowa Hospital in Wejherowo. Every patient had CRP and PCT levels measured before the surgery and on the 1^st and 2^nd postoperative day (POD).

RESULTS

Early postoperative complications occurred in 19 (5.96%) patients. Septic and non-septic complications occurred in 3 and 16 patients respectively. Among the patients with septic postoperative complications CRP level increased significantly on the 2^nd POD compared to the remainder (p = 0.0221). Among the patients with non-septic postoperative complications CRP level increased significantly on the 1^st and 2^nd POD compared to the remainder. Among the patients with septic and non-septic postoperative complications PCT level increased significantly on the 2^nd POD compared to the remainder.

CONCLUSIONS

The CRP and PCT level are supposed to be relevant diagnostic markers to predict non-septic and septic complications after LSG.

Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference

This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.

Prediction of procalcitonin for postoperative intraabdominal infections after definitive operation of intestinal fistulae

BACKGROUND

Inflammatory biomarkers usually start to rise earlier before the infection becomes clinically evident. This study was designed to evaluate the predictive performance of procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) counts in postoperative intraabdominal infections (IAIs) after definitive operation of intestinal fistulae.

MATERIAL AND METHODS

We prospectively enrolled a total of 356 consecutive patients who underwent elective digestive tract reconstruction for gastrointestinal fistulae without existing clinical infection. Plasma PCT levels, serum CRP concentration, and WBC counts were assessed preoperatively and on postoperative days (PODs) 1, 3, 5, and 7. The predictive value of each laboratory marker for IAIs was calculated.

RESULTS

The occurrence rate of IAIs after elective digestive tract reconstruction for gastrointestinal fistulae in our study was 7.3%. Both PCT levels and WBC counts were significantly higher in patients with IAIs than those in patients without IAIs on POD 1, POD 3, and POD 5, whereas CRP levels differed significantly on POD 3 and POD 5. Receiver-operating characteristics demonstrated that PCT on POD 3 had the highest diagnostic accuracy for IAIs, and the area under the curve reached 0.86, with a sensitivity of 92.0% and specificity of 74.0%.

CONCLUSIONS

The value of PCT above 0.98 ng/L on POD 3 and 0.83 ng/L on POD 5 could predict the occurrence of IAIs after definitive operations for intestinal fistulae.

Procalcitonin Reveals Early Dehiscence in Colorectal Surgery: The PREDICS Study

OBJECTIVES

We designed a multicentric, observational study to test if Procalcitonin (PCT) might be an early and reliable marker of anastomotic leak (AL) after colorectal surgery (ClinicalTrials.govIdentifier:NCT01817647).

BACKGROUND

Procalcitonin is a biomarker used to monitor bacterial infections and guide antibiotic therapy. Anastomotic leak after colorectal surgery is a severe complication associated with relevant short and long-term sequelae.

METHODS

Between January 2013 and September 2014, 504 patients underwent colorectal surgery, for malignant colorectal diseases, in elective setting. White blood count (WBC), C-reactive protein (CRP) and PCT levels were measured in 3rd and 5th postoperative day (POD). AL and all postoperative complications were recorded.

RESULTS

We registered 28 (5.6%) anastomotic leaks. Specificity and negative predictive value for AL with PCT less than 2.7 and 2.3 ng/mL were, respectively, 91.7% and 96.9% in 3rd POD and 93% and 98.3% in 5th POD. Receiver operating characteristic curve for biomarkers shows that in 3rd POD, PCT and CRP have similar area under the curve (AUC) (0.775 vs 0.772), both better than WBC (0.601); in 5th POD, PCT has a better AUC than CRP and WBC (0.862 vs 0.806 vs 0.611). Measuring together PCT and CRP significantly improves AL diagnosis in 5th POD (AUC: 0.901).

CONCLUSIONS

PCT and CRP demonstrated to have a good negative predictive value for AL, both in 3rd and in 5th POD. Low levels of PCT, together with low CRP values, seem to be early and reliable markers of AL after colorectal surgery. These biomarkers might be safely added as additional criteria of discharge protocols after colorectal surgery.

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.

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.

Using CRP to predict anastomotic leakage after open and laparoscopic colorectal surgery: is there a difference?

AIM

C-reactive protein (CRP) has proven to be a useful adjunct in early diagnosis of anastomotic leak (AL) after colorectal surgery. It would be of considerable value to examine whether modality of surgery has influence upon postoperative CRP serum levels and their predictive value in the diagnosis of AL.

METHODS

All patients undergoing elective colorectal surgery with anastomosis were enrolled into a prospective database between 2011 and 2014. AL was defined with strict operative and radiological criteria. Outcomes between open and laparoscopic resections were assessed statistically and Receiver Operating Characteristic (ROC) curve analysis performed.

RESULTS

Seven hundred twenty-seven patients with an intestinal anastomosis were identified including 468 laparoscopic procedures (468/727; 64 %). There were 58 anastomotic leaks (58/727; 7.9 %) of which 29 (6.2 %) were laparoscopic and 29 (11.2 %) were open. Mean CRP levels were significantly higher in patients after open surgery compared with laparoscopic both with AL (p = 0.013), and without (p = 0.02). ROC curve analysis revealed postoperative day 3 (cut-off CRP 209) and day 4 (cut-off CRP 123.5) to be most predictive of leak in the open group with an area under the curve (AUC) 0.794 (sensitivity 80 %, specificity 80 %) and AUC 0.806 (sensitivity 94 %, specificity 60 %), respectively. In the laparoscopic group, day 2 proved to be the most accurate day for detection of leak with a cut-off CRP of 146.5 showing 75 % sensitivity and a 70 % specificity (AUC 0.766).

CONCLUSION

CRP levels are higher after open surgery compared with laparoscopic surgery, both with and without AL. AL generates a significant detectable increase in CRP within 2-4 days after surgery.

C-Reactive Protein as a Marker for Postoperative Complications. Are There Differences in Emergency and Elective Colorectal Surgery?

BACKGROUND

C-reactive protein levels are frequently raised in patients with major complications following elective colorectal surgery and used as a predictor for complications. The significance of raised C-reactive protein levels to predict outcome in emergency colorectal surgery is unclear, because preoperative C-reactive protein levels are often raised.

OBJECTIVE

The aim of this study was to determine whether serum C-reactive protein is an adequate predictive marker for major postoperative complications after colorectal surgery in an acute setting.

DESIGN

This is an observational cohort study of all patients undergoing colorectal surgery.

PATIENTS

Consecutive patients undergoing colorectal surgery with reconstruction via anastomosis and/or stoma from January 2009 to March 2014 were included.

SETTING

This study was conducted at VU University Medical Center, Amsterdam.

MAIN OUTCOME MEASURES

Postoperative C-reactive protein levels, operative details, and postoperative complications were recorded to determine the differences in C-reactive protein as a marker for complications in emergency and elective colorectal surgery.

RESULTS

A total of 724 patients underwent colorectal resection, 559 elective cases and 165 emergency cases. A major complication was observed in 176 of 724 patients (24.3%). Major complications were observed more often in patients who underwent emergency surgery, 37% versus 20.9% after elective resections. C-reactive protein levels were significantly higher preoperatively in patients operated on in an acute care setting and on the first two postoperative days; from the third postoperative day, no statistically significant differences were found in C-reactive protein levels.

LIMITATIONS

This study was limited by its observational nature.

CONCLUSIONS

Although acute colorectal surgery is associated with higher C-reactive protein levels in the first 2 postoperative days, this study shows that postoperative C-reactive protein levels may be used as a predictor for complications in both acute and elective surgery from the third postoperative day onward. It is hypothesized that the stimulus for C-reactive protein production is removed during surgery, and, with a short-half-life of 19 hours, C-reactive protein levels drop to similar levels as seen in patients undergoing elective surgery.

Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review

Introduction

Inflammatory and protein mediators (cytokine, chemokine, acute phase proteins) play an important, but still not completely understood, role in the morbidity and mortality of intra-abdominal sepsis/injury. We therefore systematically reviewed preclinical and clinical studies of mediators in intra-abdominal sepsis/injury in order to evaluate their ability to: (1) function as diagnostic/prognostic biomarkers; (2) serve as therapeutic targets; and (3) illuminate the pathogenesis mechanisms of sepsis or injury-related organ dysfunction.

Methods

We searched MEDLINE, PubMed, EMBASE and the Cochrane Library. Two investigators independently reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intra-abdominal sepsis/injury.

Results

Among 2437 citations, we selected 182 studies in the scoping review, including 79 preclinical and 103 clinical studies. Serum procalcitonin and C-reactive protein appear to be useful to rule out infection or monitor therapy; however, the diagnostic and prognostic value of mediators for complications/outcomes of sepsis or injury remains to be established. Peritoneal mediator levels are substantially higher than systemic levels after intra-abdominal infection/trauma. Common limitations of current studies included small sample sizes and lack of uniformity in study design and outcome measures. To date, targeted therapies against mediators remain experimental.

Conclusions

Whereas preclinical data suggests mediators play a critical role in intra-abdominal sepsis or injury, there is no consensus on the clinical use of mediators in diagnosing or managing intra-abdominal sepsis or injury. Measurement of peritoneal mediators should be further investigated as a more sensitive determinant of intra-abdominal inflammatory response. High-quality clinical trials are needed to better understand the role of inflammatory mediators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1093-4) contains supplementary material, which is available to authorized users.

Predictive Value of C-Reactive Protein for Major Complications after Major Abdominal Surgery: A Systematic Review and Pooled-Analysis

Background

Early diagnosis and treatment of complications after major abdominal surgery can decrease associated morbidity and mortality. Postoperative CRP levels have shown a strong correlation with complications. Aim of this systematic review and pooled-analysis was to assess postoperative values of CRP as a marker for major complications and construct a prediction model.

Study design

A systematic review was performed for CRP levels as a predictor for complications after major abdominal surgery (MAS). Raw data was obtained from seven studies, including 1427 patients. A logit regression model assessed the probability of major complications as a function of CRP levels on the third postoperative day. Two practical cut-offs are proposed: an optimal cut-off for safe discharge in a fast track protocol and another for early identification of patients with increased risk for major complications.

Results

A prediction model was calculated for major complications as a function of CRP levels on the third postoperative day. Based on the model several cut-offs for CRP are proposed. For instance, a two cut-off system may be applied, consisting of a safe discharge criterion with CRP levels below 75 mg/L, with a negative predictive value of 97.2%. A second cut-off is set at 215 mg/L (probability 20%) and serves as a predictor of complications, indicating additional CT-scan imaging.

Conclusions

The present study provides insight in the interpretation of CRP levels after major abdominal surgery, proposing a prediction model for major complications as a function of CRP on postoperative day 3. Cut-offs for CRP may be implemented for safe early-discharge in a fast-track protocol and, secondly as a threshold for additional examinations, such as CT-scan imaging, even in absence of clinical signs, to confirm or exclude major complications. The prediction model allows for setting a cut-off at the discretion of individual surgeons or surgical departments.

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.

Meta-analysis of the predictive value of C-reactive protein for infectious complications in abdominal surgery

BACKGROUND

The aim of this analysis was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications after a variety of abdominal operations.

METHODS

A meta-analysis of seven cohort studies from a single institution was performed. Laparoscopic gastric bypass and colectomies, as well as open resections of cancer of the colon, rectum, pancreas, stomach and oesophagus, were included. The predictive value of CRP was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

Of 1986 patients, 577 (29·1 (95 per cent c.i. 27·1 to 31·3) per cent) had at least one postoperative infectious complication. Patients undergoing laparoscopic gastric bypass (383 patients) or colectomy (285), and those having open gastric (97) or colorectal (934) resections were combined in a meta-analysis. Patients who had resection for cancer of the oesophagus (41) or pancreas (246) were analysed separately owing to heterogeneity. CRP levels 4 days after surgery had the highest diagnostic accuracy (AUC 0·76, 95 per cent c.i. 0·73 to 0·78). Sensitivity and specificity were 68·5 (60·6 to 75·5) and 71·6 (66·6 to 76·0) per cent respectively. Positive and negative predictive values were 50·4 (46·0 to 54·8) and 84·3 (80·8 to 87·3) per cent. The threshold CRP varied according to the procedure performed.

CONCLUSION

The negative predictive value of serum CRP concentration on day 4 after surgery facilitates reliable exclusion of postoperative infectious complications.

C-reactive protein is a predictive factor of anastomotic leakage after laparoscopic colorectal cancer surgery

AIM: To evaluate the potential predictive role of C-reactive protein (CRP) in assessing anastomotic leakage after laparoscopic colorectal cancer surgery.

METHODS: We reviewed pre- and postoperative serum CRP in 124 patients who underwent laparoscopic surgery for colorectal cancer between January 2013 and January 2014. Patients with anastomotic leakage (group A, n = 17) were compared to those without (group B, n = 107). Patients with ongoing infections before surgery or with acquired infections other than leakage were excluded. Mean pre- and postoperative values of CRP were compared.

RESULTS: The average values of serum CRP were significantly higher in group A than in group B starting from the 2nd postoperative day (POD) until the diagnosis of leakage (P < 0.001). The cut-off value of 80 mg/L on the 3rd POD maximized the sensitivity (77%) and specificity (98%) of serum CRP in assessing the risk of leakage.

CONCLUSION: According to these results, an early and persistent elevation of CRP after laparoscopic surgery for colorectal cancer is a marker of anastomotic leakage. A cut-off value > 80 mg/L on POD3 maximizes sensitivity and specificity.

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.

Accurate prediction of anastomotic leakage after colorectal surgery using plasma markers for intestinal damage and inflammation

BACKGROUND

Anastomotic leakage is a frequent and life-threatening complication after colorectal surgery. Early recognition of anastomotic leakage is critical to reduce mortality. Because early clinical and radiologic signs of anastomotic leakage are often nonspecific, there is an urgent need for accurate biomarkers. Markers of inflammation and gut damage might be suitable, as these are hallmarks of anastomotic leakage.

STUDY DESIGN

In 84 patients undergoing scheduled colorectal surgery with primary anastomosis, plasma samples were collected preoperatively and daily after surgery. Inflammatory markers, C-reactive protein; calprotectin; and interleukin-6, and intestinal damage markers, intestinal fatty acid binding protein; liver fatty acid binding protein; and ileal bile acid binding protein, were measured. Diagnostic accuracy of single markers or combinations of markers was analyzed by receiver operating characteristic curve analysis.

RESULTS

Anastomotic leakage developed in 8 patients, clinically diagnosed at median day 6. Calprotectin had best diagnostic accuracy to detect anastomotic leakage postoperatively. Highest diagnostic accuracy was obtained when C-reactive protein and calprotectin were combined at postoperative day 3, yielding sensitivity of 100%, specificity of 89%, positive likelihood ratio = 9.09 (95% CI, 4.34-16), and negative likelihood ratio = 0.00 (95% CI, 0.00-0.89) (p < 0.001). Interestingly, preoperative intestinal fatty acid binding protein levels predicted anastomotic leakage at a cutoff level of 882 pg/mL with sensitivity of 50%, specificity of 100%, positive likelihood ratio = infinite (95% CI, 4.01-infinite), and negative likelihood ratio = 0.50 (95% CI, 0.26-0.98) (p < 0.0001).

CONCLUSIONS

Preoperative intestinal fatty acid binding protein measurement can be used for anastomotic leakage risk assessment. In addition, the combination of C-reactive protein and calprotectin has high diagnostic accuracy. Implementation of these markers in daily practice deserves additional investigation.