Diagnostic accuracy of C-reactive protein for intraabdominal infections after colorectal resections

Role of Biomarkers in the Diagnosis of Anastomotic Leakage After Colorectal Surgery: A Systematic Review and Meta-Analysis

Due to its diverse presentation, anastomotic leakage (AL) following colorectal surgery is challenging to detect and frequently discovered when the patient becomes critically ill. When diagnosing AL in its early stages, biomarkers play a large role. This review was conducted to evaluate the diagnostic value of biomarkers in AL after colorectal surgeries. A literature search was undertaken electronically in major search engines such as Medline (PubMed), Google Scholar, ScienceDirect, EMBASE, and CENTRAL (Cochrane Library) databases. Observational studies of both retrospective and prospective nature were included. Origin Pro 2022 (Origin Labs) software was used to assess the prevalence of AL and generate the forest plot. A total of 13 articles fulfilled the eligibility criteria. A pooled prevalence of 9.19% was noted for AL in colorectal surgeries. In the present review, the observed sensitivity for C-reactive protein (CRP) was 80.5% and the specificity was 84% (postoperative day three). In contrast, these were 100% and 83.9% for procalcitonin on postoperative day five. CRP showed the highest diagnostic accuracy and excels at eliminating AL, but combining biomarkers can increase the diagnostic precision of early detection of AL.

Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis

Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.

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.

Validity of C-Reactive Protein as a Surrogate Marker for Infectious Complications After Surgery for Colorectal Cancer

Abstract Background: This study aimed to establish a threshold of C-reactive protein (CRP) level for early detection of post-operative infectious complications after surgery for colorectal cancer. Patients and Methods: In this single-center, retrospective analysis, we studied the data of 178 patients who underwent surgery for colorectal cancer between January 2018 and February 2022. Elective surgery with curative intent was performed, and serum CRP levels were measured on five consecutive days after surgery. Receiver operating characteristic curves were utilized to assess the cutoff point of the CRP level with maximum predictive value, Results: A total of 59 cases of early post-operative complications, including pneumonia, wound infection, intra-abdominal infection, and anastomotic leakage were evaluated. During the monitoring period, patients with complications had higher CRP level than those without complications. The cutoff points on the five post-operative days were estimated to be 6.50, 10.83, 11.44, 6.67, and 5.71 mg/dL, respectively, and they were correlated to the occurrence of infectious complications. Higher CRP levels were associated with greater blood loss during surgery (p = 0.003) and increased length of hospital stay (p < 0.001) than did lower CRP levels. Conclusions: C-reactive protein monitoring in the early post-operative period is a cost-effective test that can be easily performed to predict the occurrence of infectious complications. It may be helpful in improving surgical outcomes, shortening the length of hospital stay and appropriate antibiotic administration.

Surgical Site Infections in Gastroenterological Surgery

Surgical site infections (SSIs) remain one of the most common serious surgical complications and are the second most frequent healthcare-associated infection. Patients with SSIs have a significantly increased postoperative length of hospital stay, hospital expenses, and mortality risk compared with patients without SSIs. The prevention of SSI requires the integration of a range of perioperative measures, and approximately 50% of SSIs are preventable through the implementation of evidence-based preventative strategies. Several international guidelines for SSI prevention are currently available worldwide. However, there is an urgent need for SSI prevention guidelines specific to Japan because of the differences in the healthcare systems of Japan versus western countries. In 2018, the Japan Society for Surgical Infection published SSI prevention guidelines for gastroenterological surgery. Although evidence-based SSI prevention guidelines are now available, it is important to consider the appropriateness of these guidelines depending on the actual conditions in each facility. A systemic inflammatory host response is a hallmark of bacterial infection, including SSI. Therefore, blood inflammatory markers are potentially useful in SSI diagnosis, outcome prediction, and termination of therapeutic intervention. In this review, we describe the current guideline-based perioperative management strategies for SSI prevention, focusing on gastroenterological surgery and the supplemental utility of blood inflammatory markers.

Biomarkers as Prognostic Predictors and Therapeutic Guide in Critically Ill Patients: Clinical Evidence

A biomarker is a molecule that can be measured in a biological sample in an objective, systematic, and precise way, whose levels indicate whether a process is normal or pathological. Knowing the most important biomarkers and their characteristics is the key to precision medicine in intensive and perioperative care. Biomarkers can be used to diagnose, in assessment of disease severity, to stratify risk, to predict and guide clinical decisions, and to guide treatments and response to them. In this review, we will analyze what characteristics a biomarker should have and how to ensure its usefulness, and we will review the biomarkers that in our opinion can make their knowledge more useful to the reader in their clinical practice, with a future perspective. These biomarkers, in our opinion, are lactate, C-Reactive Protein, Troponins T and I, Brain Natriuretic Peptides, Procalcitonin, MR-ProAdrenomedullin and BioAdrenomedullin, Neutrophil/lymphocyte ratio and lymphopenia, Proenkephalin, NefroCheck, Neutrophil gelatinase-associated lipocalin (NGAL), Interleukin 6, Urokinase-type soluble plasminogen activator receptor (suPAR), Presepsin, Pancreatic Stone Protein (PSP), and Dipeptidyl peptidase 3 (DPP3). Finally, we propose an approach to the perioperative evaluation of high-risk patients and critically ill patients in the Intensive Care Unit (ICU) based on biomarkers.

C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis

BACKGROUND

Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery.

METHODS

Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD).

RESULTS

Twenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7-9%), and the median time to diagnosis was 6.9 days (range 3-10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23-0.85), 0.84 (95% CIs 0.18-0.86) and 0.84 (95% CIs 0.18-0.89) respectively. Negative likelihood ratios (LR-) showed moderate evidence to rule out AL on POD 3 (LR- 0.29), POD4 (LR- 0.24) and POD5 (LR- 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (-0.18) showed moderate evidence to rule out AL.

CONCLUSIONS

In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development.

Early detection of anastomotic leak with C-reactive protein increases the chances of anastomotic salvage

AIM

Anastomotic leak results in increased morbidity and affects functional and oncological outcomes after colectomy. Measurement of C-reactive protein (CRP) allows early detection of anastomotic leaks. The aim of this study was to evaluate the benefit to the patient of earlier diagnosis and management of anastomotic leaks, namely avoiding takedown of the anastomosis.

METHOD

Patients with an anastomotic fistula after elective colorectal surgery from 2010 to 2020 were included. Three periods were defined according to progressive adherence to the CRP protocol in our department. A comparison was made between the periods 'before' (2010-2013) and 'after' (2016-2020) in terms of morbidity, mortality, anastomotic salvage, days spent in hospital within the first postoperative month, timely adjuvant chemotherapy and anastomotic stenosis.

RESULTS

Out of 2655 elective colorectal operations, 171 patients presented with an anastomotic leak and 123 patients were included in the study. In univariate analysis, patients in the 'after' group had fewer severe complications (Clavien-Dindo Grade III to IV, 66.7% vs. 56.9; p = 0.017); the difference did not reach significance regarding timely postoperative chemotherapy (p = 0.058) and anastomotic stenosis (p = 0.682). In both, univariate and multivariate analysis, the 'after' period increased the chances of preserving the anastomosis (OR = 2.37 [1.08-5.17]) and increased the number of days out of hospital (p = 0.0002).

CONCLUSION

A CRP-based protocol for the screening of anastomotic leaks after colorectal surgery was related to increased anastomotic conservation, a decreased impact and severity of the leak and a shorter length of hospital stay.

THE ROLE OF INFLAMMATION MARKERS IN THE EARLY POSTOPERATIVE PERIOD FOR MANAGEMENT PATIENTS WITH COLORECTAL CANCER

Objective: To evaluate the role of inflammatory markers in the early diagnosis of complications of colorectal cancer surgical treatment.

Methods: the study was conducted in the Medical Research and Education Center of Moscow State University named after M.V. Lomonosov from 2019 to 2021. The study included all patients who underwent surgical treatment for colorectal cancer in the 1st surgical department of the Moscow Research and Educational Center, Lomonosov Moscow State University. M.V. Lomonosov. The study examined clinical and laboratory data based on case histories of patients with stage II-III colorectal cancer, who underwent elective colorectal cancer treatment with lymph node dissection with the formation of a primary anastomosis. All patients underwent routine proctography in the early postoperative period.

Results: The study included 80 patients with stage I-III colorectal cancer, of which 26 had septic complications, including clinically insignificant anastomosis leakage. Statistically significant differences was found between the groups of patient with and without septic complications on the 2nd day of the postoperative day in terms of the absolute level of leukocytes (p=0.01), hemoglobin (p=0.07), total protein (p=0.02) and C-reactive protein (p=0.03).

Conclusion: An increase in the level of markers of the inflammatory response, such as the number of leukocytes, the level of total protein and the level of C-reactive protein, can be observed already at a relatively early postoperative period in patients with infectious complications, including those with clinically insignificant intestinal anastomotic leaks.

The utility of serum osteopontin levels for predicting postoperative complications after colorectal cancer surgery

BACKGROUND/AIM

Osteopontin (OPN) is a secretory glycoprotein, which is expressed not only in osteoblasts, but immune cells including macrophages and activated T cells. Its pleiotropic immune functions, such as bone remodeling, cancer progression, immune response, and inflammation have been reported previously. However, the association between OPN and postoperative complications (POC) after colorectal cancer (CRC) surgery has not been studied, so far.

METHODS

Peripheral blood samples were collected before (pre) and immediately after surgery (post), and on postoperative days (POD) 1, 3, 5, and 7. Serum OPN levels were measured by ELISA. In total, 78 patients who underwent elective CRC surgery were divided into the No-POC (n = 54) and POC (n = 24) groups.

RESULTS

The POC group had significantly higher OPN levels than the No-POC group throughout the postoperative observation period. The maximum OPN levels from pre- to postsurgical samples showed the best predictive potential for POCs (cut off: 20.75 ng/mL, area under the curve: 0.724) and were correlated with length of postoperative stays. OPN values were significantly correlated with C-reactive protein on POD3 and were identified as an independent predictive marker for POCs (odds ratio: 3.88, 95% CI: 1.175-12.798, P = 0.026). The severity of POCs was reflected in increased OPN levels.

CONCLUSION

Increased postoperative OPN was associated with increased postoperative inflammatory host responses and POC after CRC surgery. Serum OPN level may be a useful biomarker for early prediction of POC and it may provide additional information for treatment decisions to prevent POC.

Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage: A prospective observational study

BACKGROUND

Colorectal anastomotic leakage (CAL) is one of the most dreaded complications after colorectal surgery, with an incidence that can be as high as 27%. This event is associated with increased morbidity and mortality; therefore, its early diagnosis is crucial to reduce clinical consequences and costs. Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL.

AIM

To assess the usefulness of plasma C-reactive protein (CRP) and calprotectin (CLP) as early predictors of CAL.

METHODS

A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis, from March 2017 to August 2019. Patients were divided into three groups: G1 – no complications; G2 – complications not related to CAL; and G3 – CAL. Five biomarkers were measured and analyzed in the first 5 postoperative days (PODs), namely white blood cell (WBC) count, eosinophil cell count (ECC), CRP, CLP, and procalcitonin (PCT). Clinical criteria, such as abdominal pain and clinical condition, were also assessed. The correlation between biomarkers and CAL was evaluated. Receiver operating characteristic (ROC) curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL, and the area under the ROC curve (AUROC), specificity, sensitivity, positive predictive value, and negative predictive value (NPV) during this period were estimated.

RESULTS

In total, 25 of 396 patients developed CAL (6.3%), and the mean time for this diagnosis was 9.0 ± 6.8 d. Some operative characteristics, such as surgical approach, blood loss, intraoperative complications, and duration of the procedure, were notably related to the development of CAL. The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications (median of 21 d vs 13 d and 7 d respectively; P < 0.001). For abdominal pain, the best predictive performance was on POD4 and POD5, with the largest AUROC of 0.84 on POD4. Worsening of the clinical condition was associated with the diagnosis of CAL, presenting a higher predictive effect on POD5, with an AUROC of 0.9. WBC and ECC showed better predictive effects on POD5 (AUROC = 0.62 and 0.7, respectively). Those markers also presented a high NPV (94%-98%). PCT had the best predictive effect on POD5 (AUROC = 0.61), although it presented low accuracy. However, this biomarker revealed a high NPV on POD3, POD4, and POD5 (96%, 95%, and 96%, respectively). The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications (195.5 ± 139.9 mg/L vs 59.5 ± 43.4 mg/L; P < 0.00001). On POD5, CRP had a NPV of 98%. The mean CLP value on POD3 was significantly higher in G3 compared with G1 (5.26 ± 3.58 μg/mL vs 11.52 ± 6.81 μg/mL; P < 0.00005). On POD3, the combination of CLP and CRP values showed a high diagnostic accuracy (AUROC = 0.82), providing a 5.2 d reduction in the time to CAL diagnosis.

CONCLUSION

CRP and CLP are moderate predictors of CAL. However, the combination of these biomarkers presents an increased diagnostic accuracy, potentially decreasing the time to CAL diagnosis.

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.

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.

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.

Safe Discharge Criteria After Curative Gastrectomy for Gastric Cancer

Purpose

This study aimed to investigate the relationship between clinical and laboratory parameters and complication status to predict which patients can be safely discharged from the hospital on the third postoperative day (POD).

Materials and Methods

Data from a prospectively maintained database of 2,110 consecutive patients with gastric adenocarcinoma who underwent curative surgery were reviewed. The third POD vital signs, laboratory data, and details of the course after surgery were collected. Patients with grade II or higher complications after the third POD were considered unsuitable for early discharge. The performance metrics were calculated for all algorithm parameters. The proposed algorithm was tested using a validation dataset of consecutive patients from the same center.

Results

Of 1,438 patients in the study cohort, 142 (9.9%) were considered unsuitable for early discharge. C-reactive protein level, body temperature, pulse rate, and neutrophil count had good performance metrics and were determined to be independent prognostic factors. An algorithm consisting of these 4 parameters had a negative predictive value (NPV) of 95.9% (95% confidence interval [CI], 94.2–97.3), sensitivity of 80.3% (95% CI, 72.8–86.5), and specificity of 51.1% (95% CI, 48.3–53.8). Only 28 (1.9%) patients in the study cohort were classified as false negatives. In the validation dataset, the NPV was 93.7%, sensitivity was 66%, and 3.3% (17/512) of patients were classified as false negatives.

Conclusions

Simple clinical and laboratory parameters obtained on the third POD can be used when making decisions regarding the safe early discharge of patients who underwent gastrectomy.

Severity of early diagnosed organ/space surgical site infection in elective gastrointestinal and hepatopancreatobiliary surgery

Background

Organ/space surgical site infection (SSI) is a significant clinical problem. The postdiagnosis course of organ/space SSIs and the impact of its early diagnosis on clinical outcomes are yet to be clarified. Thus, we aimed to investigate the association between the timing of diagnosis and the clinical outcome of organ/space SSI.

Methods

This retrospective, single‐center cohort study evaluated patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery between 2016 and 2020. Clinical outcomes were compared between the early group (ie, SSI diagnosed until postoperative day [POD] 4) and normal‐late group (ie, SSI diagnosed after POD 5). The primary outcome was the final C‐reactive protein (CRP) level within 14 d after organ/space SSI diagnosis.

Results

In total, 110 patients were evaluated. The median time of diagnosis was 7 d postoperatively (interquartile range, 5–9 d postoperatively). Compared with the normal‐late group, the early group included a higher proportion of patients with Clavien–Dindo grade ≥IIIb (8/21 vs 11/89, P = .01), higher final CRP value within 14 d after SSI diagnosis (mean, 4.49 mg/dL vs 2.27 mg/dL, P = .01), longer postoperative length of hospitalization (median, 45.0 d vs 33.0 d; P = .028), and worse 1‐y overall survival rate (74.8% vs 89.3%, P = .08).

Conclusion

Early diagnosed organ/space SSI are originally severe and may therefore be detected earlier. Importantly, early diagnosed organ/space SSI is likely to be severe and refractory.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

A probabilistic model for the prediction of intra-abdominal infection after colorectal surgery

AIM

Predicting intra-abdominal infections (IAI) after colorectal surgery by means of clinical signs is challenging. A naïve logistic regression modeling approach has some limitations, for which reason we study two potential alternatives: the use of Bayesian networks, and that of logistic regression model.

METHODS

Data from patients that had undergone colorectal procedures between 2010 and 2017 were used. The dataset was split into two subsets: (i) that for training the models and (ii) that for testing them. The predictive ability of the models proposed was tested (i) by comparing the ROC curves from days 1 and 3 with all the subjects in the test set and (ii) by studying the evolution of the abovementioned predictive ability from day 1 to day 5.

RESULTS

In day 3, the predictive ability of the logistic regression model achieved an AUC of 0.812, 95% CI = (0.746, 0.877), whereas that of the Bayesian network was 0.768, 95% CI = (0.695, 0.840), with a p-value for their comparison of 0.097. The ability of the Bayesian network model to predict IAI does present significant difference in predictive ability from days 3 to 5: AUC(Day 3) = 0.761, 95% CI = (0.680, 0.841) and AUC(Day 5) = 0.837, 95% CI = (0.769, 0.904), with a p-value for their comparison of 0.006.

CONCLUSIONS

Whereas at postoperative day 3, a logistic regression model with imputed data should be used to predict IAI; at day 5, when the predictive ability is almost identical, the Bayesian network model should be used.

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.

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.

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.

Procalcitonin as an Early Predictor of Intra-abdominal Infections Following Gastric Cancer Resection

BACKGROUND

The purpose of this study was to investigate the prognostic value of postoperative procalcitonin (PCT) and C-reactive protein (CRP) for their ability to detect Intra-abdominal infections (IAIs) in patients after GC surgery.

METHODS

Patients who underwent elective gastrectomy for primary GC were retrospectively enrolled between October 2018 and October 2019. The PCT and CRP levels and white blood cell (WBC) count were measured before surgery and on postoperative days (POD) 1, 3, 5, and 7. The differences in serum PCT, CRP, and WBC levels between IAIs and non-IAIs groups were compared. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve. Univariate and multivariate logistic regression analyses identified independent clinical factors that predicted postoperative IAIs.

RESULTS

A total of 155 patients who underwent GC surgery were enrolled. IAIs were observed in 12 patients (7.74%). The postoperative CRP and PCT values in the IAI group were higher than those in the non-IAI group. PCT had superior diagnostic accuracy on POD 3 (area under the curve 0.769) with an optimal cutoff value of 2.03 ng/mL, yielding 75% sensitivity, 87.4% specificity, and 97.6% negative predictive value. Multivariate analysis identified a PCT level of 2.03 mg/mL or greater on POD 3 as a significant predictive factor for IAIs after gastrectomy (odds ratio: 21.447, 95% confidence interval: 5.081-91.672).

CONCLUSIONS

PCT values less than 2.03 ng/mL on POD 3 is an excellent negative predictor of IAIs, which may ensure a safe early discharge after gastric cancer surgery.

[C-reactive protein as early predictor of anastomotic leakage after surgery for colorectal cancer. Systematic review and meta-analysis]

OBJECTIVE

Systematic review and meta-analysis of data on C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after surgery for colorectal cancer.

MATERIAL AND METHODS

Literature searching was performed in Medline, Elibrary, Scopus, Web of Science databases. Literature request consisted of keywords «CRP», «colorectal surgery», «anastomotic leakage» for the period 2008-2018. Meta-analysis included 2 manuscripts for the second postoperative day, 7 articles for the third postoperative day and 6 articles for the fourth postoperative day. ROC-analysis was made to determine optimal prognostic values.

RESULTS

ROC-curve for the second postoperative day - AUC 0.758; optimal CRP value - 154 mg/l (sensitivity 70.1%, specificity 55.6%), 95% confidence interval 0.698-0.819. ROC-curve for the third postoperative day - AUC 0.715; optimal CRP value - 144.5 mg/l (sensitivity 79.1% specificity 60.3%), 95% confidence interval 0.68-0.75. ROC-curve for the fourth postoperative day - AUC 0.767; optimal CRP value - 122.91 mg/l (sensitivity 72.3% specificity 60%), 95% confidence interval 0.73-0.804.

CONCLUSION

Increased CRP is an early predictor of AL after surgery for colorectal cancer. CRP level ≥144.5 mg/l on the third postoperative day can predict AL (sensitivity 79%, specificity 60%).

Early prediction model of organ/space surgical site infection after elective gastrointestinal or hepatopancreatobiliary cancer surgery

BACKGROUND

Organ/space SSI is a significant clinical problem. However, early detection of organ/space SSI is difficult, and previous predictive models are limited in their prognostic ability. We aimed to develop and validate a prediction model of organ/space surgical site infection (SSI) using postoperative day 3 laboratory data in patients who underwent gastrointestinal or hepatopancreatobiliary cancer resection.

METHODS

This retrospective cohort study using a single-center hospital data from April 2013 to September 2017 included all adult patients who underwent elective gastrointestinal or hepatopancreatobiliary cancer resection. The primary outcome was a presence of organ/space SSI including anastomotic leakage, pancreatic fistula, biliary fistula, or intra-abdominal abscess. We developed and validated a logistic regression model to predict organ/space SSI using laboratory data on postoperative day (POD) 3. Similar models using laboratory data on POD 1 or 5 were developed to compare the predictive ability of each model.

RESULTS

A total of 1578 patients were included. Organ/space SSI was diagnosed in 107 patients, with median diagnosis days of 6 (interquartile range, 4-9 days) after surgery. A prediction model using five commonly measured variables on POD 3 was created with the area under the curve (AUC) of 0.883 (95%CI 0.819-0.946). The AUC of a model with POD 1 laboratory data was 0.751 (95%CI 0.655-0.848), while that of POD 5 laboratory data was 0.818 (95%CI 0.730-0.906).

CONCLUSIONS

Laboratory data on POD 3 could forecast organ/space SSI precisely. Further prospective studies are warranted to investigate the clinical impact of this model.

How can biomarkers be used to differentiate between infection and non-infectious causes of inflammation?

Diagnosis of sepsis is based on recognition of systemic inflammation and organ failure in the context of an inciting infection. Since none of the diagnostic criteria are specific to sepsis, it is easy to confound sepsis with noninfectious causes of systemic inflammation, including pancreatitis, cardiac ischemia, bowel perforation, vasculitis, and pulmonary embolism amongst others. Two widely used biomarkers, C-reactive protein and procalcitonin, have proven promising in sepsis diagnosis. Each has found varying success in the clinical context, with some centers relying heavily on these markers and others eschewing their use almost entirely. In this chapter, we present the evidence for their use in the diagnosis of sepsis and management of antibiotic therapy in the intensive care unit context.

Blood Galectin-3 Levels Predict Postoperative Complications after Colorectal Cancer Surgery

BACKGROUND

Recent studies suggested that galectin-3 may act as a pro-inflammatory damage-associated molecular pattern. The aim of this study is to investigate the association between blood galectin-3 and postoperative complications (POC) after colorectal cancer (CRC) surgery.

METHODS

Blood samples were taken from 35 patients with CRC before surgery, immediately after surgery, and on postoperative days (POD) 1, 3, 5, and 7. Blood galectin-3 and interleukin-6 levels were measured by commercially available ELISA. Patients were divided into those with (POC group) and without POC (no-POC group).

RESULTS

Significantly higher galectin-3 levels were observed pre- and postoperatively in the POC group (n=10) compared with those of the no-POC group (n=25). Galectin-3 levels on POD1 showed the best predictive potential for POC (cut-off: 3.18 pg/mL, area under the curve: 0.868).

CONCLUSIONS

These results indicate that increased perioperative blood galectin-3 levels may be associated with POC after CRC surgery.

Leukocytosis after distal pancreatectomy and splenectomy as a marker of major complication

BACKGROUND

The aim of this study was to analyze the associations between the degree of postoperative leukocytosis and major morbidity after elective distal pancreatectomy with splenectomy (DPS).

METHODS

Retrospective review of patients undergoing DPS for pancreatic diseases (2013-2016). Receiver operating characteristic curves, Youden's index, and area under the curve were used to identify ideal lab cut-off values and discriminatory ability of postoperative white blood cell count to detect complications.

RESULTS

158 patients underwent DPS. Median age was 57 years (range, 22-90) and 53% of patients were male. POD3 absolute WBC count ≥16 × 10⁹/L or an increase in WBC count ≥9 × 10⁹/L from preoperative baseline was associated with major morbidity after DPS (AUC 0.7 and 0.7, respectively).

CONCLUSION

Postoperative day three leukocytosis ≥16 × 10⁹/L or an increase in WBC of ≥9 × 10⁹/L from preoperative baseline should raise clinical awareness for major postoperative complication after DPS.

Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery

Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL.

Reduction rate of C-reactive protein as an early predictor of postoperative complications and a reliable discharge indicator after gastrectomy for gastric cancer

Purpose

Postoperative complications (PCs) after gastrectomy are associated with readmission and longer hospital stay. This study aimed to determine the role of CRP as an early predictor of PCs and a reliable discharge indicator after gastrectomy.

Methods

Clinicopathologic data and PCs of 613 patients who underwent gastrectomy for gastric cancer in 2015–2016 were retrospectively analyzed, including consecutive blood samples for CRP obtained preoperatively, at the operative day, and postoperatively. Following the Clavien-Dindo classification, the patients were divided into a group with major PCs and a group with minor/no PCs. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Clinical factors related to major PCs were identified using univariate and multivariate logistic regression analyses.

Results

PCs occurred in 89 patients (14.5%). The most significant predictive factor for major PCs was a CRP concentration reduction rate of ≤38.1% (AUC, 0.82; sensitivity, 76.4%; specificity, 76.1%) between postoperative day (POD) 3 and 5 (R5), followed by ≤11.1% (AUC, 0.75; sensitivity, 73%; specificity, 76%) between POD 2 and 3 (R4). When both factors were applied (R4 ≤ 11.1% and R5 ≤ 38.1%), the specificity was 91.6%; when only one condition was satisfied (R4 ≤ 11.1% or R5 ≤ 38.1%), the sensitivity was 91%.

Conclusion

CRP concentration reduction rates between POD 3 and 5 and between POD 2 and 3 were the best combination factors to predict PCs and indicate a safe discharge after gastrectomy for gastric cancer.

Nomogram for Predicting Risk of Intestinal Complications After Colorectal Cancer Surgery

Background

Intestinal complications are a major cause of morbidity after colorectal cancer surgery. This study aimed to develop an effective nomogram for predicting risk of intestinal complications following colorectal cancer surgery.

Material/Methods

We retrospectively analyzed 1876 patients who underwent colorectal cancer surgery at Yangpu and Zhuji hospitals from January 2013 to October 2018. Intestinal complications were defined as intestinal obstruction, leakage or bleeding, or peritonitis within 30 days after surgery. A logistic regression model was used to identify the risk factors associated with postoperative intestinal complications, and a nomogram for intestinal complications was established. The predictive accuracy of the nomogram was assessed using area under the receiver operating characteristic curve (AUC) and calibration plot.

Results

A total of 164 patients (8.7%) developed intestinal complications after colorectal cancer surgery; 35 (21.3%) of whom died in the postoperative period. Multivariate logistic analysis showed that male gender, history of abdominal surgery, preoperative intestinal obstruction/perforation, metastatic cancer, and lower level of hemoglobin and prognostic nutrition index were independent risk factors (P<0.05 for all). A nomogram was then constructed, and it displayed good accuracy in predicting postoperative intestinal complications with an AUC of 0.76. The calibration plot also showed an excellent agreement between the predicted and observed probabilities.

Conclusions

We constructed a nomogram based on clinical variables, which could provide individual prediction of postoperative intestinal complications with good accuracy.

Should They Stay or Should They Go? The Utility of C-Reactive Protein in Predicting Readmission and Anastomotic Leak After Colorectal Resection

BACKGROUND

Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission.

OBJECTIVE

This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection.

DESIGN

This is a retrospective review of a prospectively compiled single-institution database.

PATIENTS

From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included.

MAIN OUTCOME MEASURES

The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection.

RESULTS

Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value.

LIMITATIONS

This study was limited by its retrospective design and because all patients were treated at a single center.

CONCLUSIONS

Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.

Mechanical Bowel Preparation (MBP) Prior to Elective Colorectal Resections in Crohn's Disease Patients

BACKGROUND

Studies addressing the role of mechanical bowel preparation (MBP) in Crohn's disease (CD) patients are lacking.

METHODS

Consecutive elective colorectal resections for CD have been included in the present analysis. Exclusion criteria were small bowel resections not including colon, urgent surgeries, surgeries for cancer, and abdominoperineal resections for perianal disease. MBP was performed routinely between 1992 and 2004, omitted between 2005 and 2015, and reintroduced in 2016.Intraabdominal septic complications (IASC) were anastomotic leakage, intraabdominal abscess, intestinal fistula, and peritonitis.

RESULTS

Overall, 680 bowel resections for CD have been performed between 1992 and 2017. After exclusion of the abovementioned patients, 549 patients were included in the present analysis. The IASC rate was 12% in patients undergoing surgery after MPB as opposed to 24% when MBP was omitted (P < 0.001). By the multivariate analysis, preoperative MBP significantly reduced the risk of IASC (Hazard ratio 0.45; 95% CI, 0.23 - 0.86; P = 0.016). Preoperative weight loss (HR 2.0; 95% CI, 1.1 - 3.6; P = 0.024), penetrating disease (HR 2.6; 95% CI, 1.3 - 5.4; P = 0.01), and stapled as opposed to hand-sewn ileocolic anastomosis (HR 3.3; 95% CI, 1.4 - 7.7; P = 0.006) were associated with an increased risk of IASC. The positive impact of MBP was strongest on anastomotic complication rate in patients undergoing ileocolic resections for penetrating disease (11% vs 36%, P < 0.001).

CONCLUSION

Preoperative MPB should be strongly considered before colorectal surgery in patients with CD, especially in patients undergoing ileocolic resections for penetrating disease.

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.

Systemic Inflammatory Cytokines Predict the Infectious Complications but Not Prolonged Postoperative Ileus after Colorectal Surgery

Aim

Postoperative ileus (POI) is common after surgery. Animal studies indicate that the POI mechanism involves an inflammatory response, which is also activated during postoperative complications. This study aimed to determine whether inflammatory biomarkers might facilitate an early detection of prolonged POI (PPOI) or infectious complications.

Methods

Forty-seven adult patients who underwent oncological colorectal surgery were included. They filled out a perioperative diary to report their gastrointestinal symptoms. Blood samples were collected preoperatively, and on postoperative day (POD) 1 and 3. Levels of leucocytes, C-reactive protein (CRP), interleukin (IL)-6, TNF-α, and IL-1β were analyzed.

Results

Patients with PPOI had significantly longer stay in hospital than patients without (13.6 ± 10.5 versus 7.4 ± 3.2 days, p < 0.001); they also had higher levels of IL-6 ratios, leucocytes, and CRP levels, but did not reach significance. Higher levels of postoperative IL-6 and CRP levels (p < 0.05, resp.) were found in patients with infectious complications. The receiver operating characteristic (ROC) analysis found better diagnostic values of IL-6 ratio on both POD 1 and 3 than that of CRP (POD 1: ROC 0.825, p < 0.001).

Conclusion

Blood levels of inflammatory cytokines cannot predict PPOI after colorectal surgery. Instead, postoperative IL-6 changes may predict the infectious complications with a better diagnostic value than the current leukocytes or CRP tests.

Systematic review and meta-analysis of the use of serum procalcitonin levels to predict intra-abdominal infections after colorectal surgery

PURPOSE

There has been much recent interest in the use of procalcitonin (PCT) as a marker of intra-abdominal infection (IAI) following colorectal surgery. However, the literature remains divided on the value of PCT in this setting. This meta-analysis aims to evaluate the value of PCT in predicting IAI after colorectal surgery.

METHODS

Systemic literature search was performed using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews to identify studies evaluating the diagnostic accuracy of PCT as a predictor for detecting IAI on postoperative days (POD) 3 to 5 following colorectal surgery. A meta-analysis was performed using random effect model and pooled predictive parameters as well as cut-off values for POD 3 to 5 were derived.

RESULTS

Eight studies consisting 1629 patients were included. The pooled prevalence of IAI was 5.7% on POD 3, 9.7% on POD 4, and 6.3% on POD 5. The pooled AUC for POD 3 to 5 were 0.83 (95% CI 0.78-0.88), 0.79 (95% CI 0.64-0.93), and 0.94 (95% CI 0.91-0.97), respectively. The derived PCT cut-off values were 1.45 ng/ml on POD 3, 1.28 ng/ml on POD 4, and 1.26 ng/ml on POD 5. PCT had the highest diagnostic capability on POD 5 with diagnostic odds ratio of 32.9 (95% CI 15.01-69.88), sensitivity of 0.78 (95% CI 0.65-0.89), and specificity of 0.88 (95% CI 0.85-0.90).

CONCLUSIONS

PCT is a useful diagnostic predictor of IAI after colorectal surgery. It has the greatest diagnostic accuracy on POD 5 and can help guide safe discharge of patients after colorectal surgery.

[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.

Impact of angiotensin-converting enzyme 2 levels on postoperative pneumonia after esophagectomy

BACKGROUND

Pulmonary complications after esophagectomy are often fatal. The prediction of postoperative pulmonary complications remains a challenge. Accumulating evidence demonstrates a physiological and pathological role for angiotensin-converting enzyme 2 (ACE2) in the respiratory system. The purpose of this study was to evaluate the predictive value of ACE2 levels for the development of postoperative pneumonia.

METHODS

To evaluate the association between serum ACE2 levels and pneumonia after esophagectomy, we retrospectively reviewed the medical records of 80 patients who underwent thoracoscopic esophagectomy for esophageal cancer from 2009 to 2014.

RESULTS

Nineteen patients (23.8%) developed pneumonia after esophagectomy. Patients with pneumonia had significantly higher levels of ACE2 from the preoperative day to postoperative day (POD) 3, white blood cell count (POD7), and C-reactive protein (POD3, POD5, and POD7) than patients without pneumonia. Patients with postoperative pneumonia had higher serum ACE2 levels on POD3 than patients without pneumonia.

CONCLUSIONS

The elevation of ACE2 levels on POD3 may predict the incidence of pneumonia.

C-reactive protein in predicting major postoperative complications are there differences in open and minimally invasive colorectal surgery? Substudy from a randomized clinical trial

BACKGROUND

In search of improvement of patient assessment in the postoperative phase, C-reactive protein (CRP) is increasingly being studied as an early marker for postoperative complications following major abdominal surgery. Several studies reported an attenuated immune response in minimally invasive surgery, which might affect interpretation of postoperative CRP levels. The aim of the present study was to compare the value of CRP as a predictor for major postoperative complications in patients undergoing open versus laparoscopic colorectal surgery.

METHODS

A subgroup analysis from a randomized clinical trial (LAFA-trial) was performed, including all patients with non-metastasized colorectal cancer. In the LAFA trial, patients were randomized to open or laparoscopic segmental colectomy. In a subgroup of 79 patients of the LAFA trial, postoperative assessment of CRP levels was conducted routinely preoperatively and 1, 2, 24 and 72 h after surgery.

RESULTS

Thirty-seven patients were randomized to the open group and 42 patients to the laparoscopic group. Major complications occurred in 19% of laparoscopic procedures and 13.5% of open procedures (p = 0.776). CRP levels rise following surgical procedures. In uncomplicated cases, the rise in CRP levels was significantly lower at 24 and 72 h following laparoscopic resection in comparison to open resection. No differences in CRP levels were observed when comparing open and laparoscopic resection in patients with major complications.

CONCLUSION

In patients with an uncomplicated postoperative course, CRP levels were lower following minimally invasive resection, possibly due to decreased operative trauma. No differences in CRP were observed stratified for surgical technique in patients with major complications. These results suggest that CRP may be applied as a marker for major postoperative complications in both open and minimally invasive colorectal surgery. Future research should aim to assess the role of standardized postoperative CRP measurements.

Intra-abdominal infection after radical gastrectomy for gastric cancer: Incidence, pathogens, risk factors and outcomes

BACKGROUND

Surgical site infection, particularly intra-abdominal infection (IAI), remains a clinically important event after gastrectomy for gastric cancer. The aim of this retrospective study was to clarify the incidence, pathogens, risk factors and outcomes of IAI following gastrectomy for gastric cancer.

METHODS

The study cohort was 1835 patients who underwent gastrectomy for gastric cancer from January 2011 through December 2016. The incidence, pathogens, and treatment outcomes of IAI were examined, and the risk factors were identified using univariate and multivariate analyses.

RESULTS

In total, 73 patients (4.0%) developed IAI after radical gastrectomy. Bacterial culture in these patients showed that Gram-negative bacilli, such as Escherichia coli and Klebsiella pneumonia were the most common pathogens. Multivariate analysis identified that combined multi-organ resection (Odds Ratio [OR] = 2.262, 95% confidence interval [CI]: 1.114-4.596, P = 0.024), and body mass index (BMI) ≥ 25 kg/m² (OR = 1.968, 95% CI: 1.107-3.500, P = 0.021) were independent risk factors. Three patients (4.1%) developed IAI who died from sepsis and/or multiple-organ failure, which was significantly higher than in the remaining 1762 patients without IAI (5 cases, 0.3%, P = 0.003). Moreover, IAI required more re-operations (5.5% vs 0.8%, P = 0.005) and longer post-operative hospital stays (23.3 days vs 11.2 days, P < 0.001) compared without IAI.

CONCLUSIONS

IAI is a major complication after radical gastrectomy for gastric cancer, and associated with combined multi-organ resection and a BMI ≥ 25 kg/m²; thus, meticulous surgical procedures need to be performed in patients with these specific risk factors.

Perioperative Increase in Neutrophil CD64 Expression is an Indicator for Intra-abdominal Infection after Colorectal Cancer Surgery

BACKGROUND

Colorectal surgery is associated with a high incidence of postoperative infections. Early clinical signs are difficult to distinguish from the systemic inflammatory response related to surgical trauma. Timely diagnosis may significantly improve the outcome. The objective of this study was to compare a new biomarker index CD64 for neutrophils (iCD64n) with standard biomarkers, white blood cell (WBC) count, neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP) and procalcitonin (PCT) for the early detection of postoperative infection.

METHODS

The prospective study included 200 consecutive patients with elective colorectal cancer surgery. Postoperative values of biomarkers from the postoperative day (POD) 1 to POD5 were analysed by the receiver operating characteristic (ROC) analysis to predict infection. The Cox regression model and the Kaplan-Meier method were used to assess prognostic factors and survival.

RESULTS

The increase of index CD64n (iCD64n) after surgery, expressed as the ratio iCD64n after/before surgery was a better predictor of infection than its absolute value. The best 30-day predictors of all infections were CRP on POD4 (AUC 0.72, 99% CI 0.61-0.83) and NLR on POD5 (AUC 0.69, 99% CI 0.57-0.80). The best 15-day predictors of organ/space surgical site infection (SSI) were the ratio iCD64n on POD1 (AUC 0.72, 99% CI 0.58-0.86), POD3 (AUC 0.73, 99% CI 0.59-0.87) and CRP on POD3 (AUC 0.72, 99% CI 0.57-0.86), POD4 (AUC 0.79, 99% CI 0.64-0.93). In a multivariate analysis independent risk factors for infections were duration of surgery and perioperative transfusion while the infection itself was identified as a risk factor for a worse long-term survival.

CONCLUSIONS

The ratio iCD64n on POD1 is the best early predictor of intra-abdominal infection after colorectal cancer surgery. CRP predicts the infection with the same predictive value on POD3.

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.

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.

C-Reactive Protein Was an Early Predictor of Postoperative Infectious Complications After Pancreaticoduodenectomy for Pancreatic Cancer

Objective

The study objective was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications (PICs) after pancreaticoduodenectomy.

Summary of Background Data

The incidence of PICs after pancreaticoduodenectomy still remains high and a clinically relevant problem, despite improvements in the surgical procedure.

Methods

We examined 110 consecutive patients who underwent pancreaticoduodenectomy for primary pancreatic cancer between 2006 and 2014. The predictive value was assessed by estimating the area under the receiver operating characteristic curve (AUC). Clinical and laboratory data, including CRP, were analyzed with univariate and multivariate logistic regression analyses to identify predictors of PICs of grade III or higher according to the Clavien-Dindo classification.

Results

PICs of grade III or higher occurred in 13 patients [11.8%; 95% confidence interval (CI), 6.45%–19.36%]. CRP level on postoperative day 3 (POD 3) was a good predictor of PICs (AUC, 0.815; 95% CI, 0.651–0.980), showing the highest accuracy among clinical and laboratory data. A cutoff value of 13.2 mg/dL yielded a sensitivity of 0.846 and a specificity of 0.794. On multivariate analysis, a POD 3 CRP level of 13.2 mg/dL or higher (odds ratio, 20.0; 95% CI, 4.07–97.9; P = 0.002) was a significant predictor of PICs after pancreaticoduodenectomy.

Conclusions

CRP elevation above 13.2 mg/dL on POD 3 is a significant predictive factor for PICs and should prompt an intense clinical search and therapeutic approach for PICs.

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.

Value of procalcitonin as a biomarker for postoperative hospital-acquired pneumonia after abdominal surgery

Background

Hospital-acquired pneumonia (HAP) is a common complication after abdominal surgery. The aim of this study was to evaluate the role of procalcitonin (PCT) and C-reactive protein (CRP) as early biomarkers for the diagnosis of postoperative HAP after abdominal surgery.

Methods

This study was conducted on 100 patients undergoing abdominal surgery. White blood cell counts, highest body temperature, and serum levels of CRP and PCT were recorded preoperatively and daily postoperatively until postoperative day (POD) 5. Chest radiography was performed preoperatively and daily postoperatively until POD 5.

Results

HAP was diagnosed in 14% of patients. Regarding the biomarkers studied after POD 1, CRP and PCT were significantly higher in patients with HAP than in those without HAP (P < 0.05). On POD 2, PCT had higher sensitivity and specificity (84% and 72%, respectively) than those for CPR (70% and 60%, respectively). The cut-off value of PCT on POD 2 was 1.4 ng/ml. On POD 3, 4, and 5, the sensitivity and specificity of PCT and CRP were not significantly different.

Conclusions

PCT and CRP are accurate biomarkers for early prediction of postoperative HAP after abdominal surgery. The diagnostic ability of PCT was significantly better than that of CRP on POD 2. After POD 2, the diagnostic ability was not significantly different between the biomarkers.

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.