Early prediction of anastomotic leakage after laparoscopic rectal surgery using creactive protein

Diagnostic Modalities for Early Detection of Anastomotic Leak After Colorectal Surgery

INTRODUCTION

Anastomotic leak (AL) remains a severe complication following colorectal surgery, leading to increased morbidity and mortality, particularly in cases of delayed diagnosis. Existing diagnostic methods, including computed tomography (CT) scans, contrast enemas, endoscopic examinations, and reoperations can confirm AL but lack strong predictive value. Early detection is crucial for improving patient outcomes, yet a definitive and reliable predictive test, or "gold standard," is still lacking.

METHODS

A comprehensive PubMed review was focused on CT imaging, serum levels of C-reactive protein (CRP), and procalcitonin (PCT) to assess their predictive utility in detecting AL after colorectal resection. Three independent reviewers evaluated eligibility, extracted data, and assessed the methodological quality of the studies.

RESULTS

Summarized in detailed tables, our analysis revealed the effectiveness of both CRP and PCT in the early detection of AL during the postoperative period. CT imaging, capable of identifying fluid collection, pneumoperitoneum, extraluminal contrast extravasation, abscess formation, and other early signs of leak, also proved valuable.

CONCLUSIONS

Considering the variability in findings and statistics across these modalities, our study suggests a personalized, multimodal approach to predicting AL. Integrating CRP and PCT assessments with the diagnostic capabilities of CT imaging provides a nuanced, patient-specific strategy that significantly enhances early detection and management. By tailoring interventions based on individual clinical characteristics, surgeons can optimize patient outcomes, reduce morbidity, and mitigate the consequences associated with AL after colorectal surgery. This approach emphasizes the importance of personalized medicine in surgical care, paving the way for improved patient health outcomes.

Early Predictors of Fistula Formation Following Head and Neck Reconstruction

BACKGROUND

 Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation.

METHODS

 We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula.

RESULTS

 In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value.

CONCLUSION

 CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.

Development and Validation of a Novel Nomogram Model for Early Diagnosis of Anastomotic Leakage After Laparoscopic Colorectal Cancer Surgery

Background: This study aimed to investigate the clinical value of inflammatory factors for predicting anastomotic leakage (AL) after laparoscopic colorectal cancer surgery and establish a nomogram model to assess the probability of its occurrence. Patients and Methods: Data of 637 patients who underwent laparoscopic colorectal cancer surgery between June 2019 and June 2022 were collected. Differences in procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) levels before surgery and on postoperative day (POD) 3 and 5 were compared between patients with and without AL (AL and non-AL groups, respectively). The diagnostic accuracy was determined using the area under the receiver operating characteristic curve (AUC), and a nomogram model was developed. Results: Post-operative AL occurred in 46 (7.2%) patients. Procalcitonin, CRP, and WBC levels on POD 3 and 5 were higher in the AL group than in the non-AL group. The AUCs of PCT, CRP, and WBC levels for predicting AL on POD 3 were 0.833, 0.757, and 0.756, respectively, which were better than those on POD 5 (AUC = 0.669, 0.581, and 0.588, respectively). The nomogram model for AL was developed based on five variables (PCT, CRP, WBC, American Society of Anesthesiologists [ASA] grade and comorbidities), and it had an AUC of 0.922. Calibration curves demonstrated that the nomogram had good fit. The Delong test showed that the AUC of the nomogram for predicting the probability of AL was higher than that of PCT alone (z = 2.311, p = 0.02). Conclusions: Procalcitonin measured on POD 3 seems to be a promising negative predictor of AL after laparoscopic colorectal cancer surgery. Furthermore, the nomogram model developed in our study, which utilizes a series of predictors that can be easily accessed, has demonstrated potential to further improve the prediction accuracy.

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.

Medium-term surgical outcomes and health-related quality of life after laparoscopic vs open colorectal cancer resection: SF-36 health survey questionnaire

BACKGROUND

Previous studies that compared the postoperative health-related quality of life (HRQoL) outcomes after receiving laparoscopic resection (LR) or open resection (OR) in patients with colorectal cancer (CRC) have different conclusions.

AIM

To explore the medium-term effect of postoperative HRQoL in such patients.

METHODS

This study randomized 567 patients undergoing non-metastatic CRC surgery managed by one surgeon to the LR or OR groups. HRQoL was assessed during the preoperative period and 3, 6, and 12 mo postoperative using a modified version of the 36-Item Short Form (SF-36) Health Survey questionnaire, emphasizing eight specific items.

RESULTS

This cohort randomly assigned 541 patients to receive LR (n = 296) or OR (n = 245) surgical procedures. More episodes of postoperative urinary tract infection (P < 0.001), wound infection (P < 0.001), and pneumonia (P = 0.048) were encountered in the OR group. The results demonstrated that the LR group subjectively gained mildly better general health (P = 0.045), moderately better physical activity (P = 0.006), and significantly better social function recovery (P = 0.0001) 3 mo postoperatively. Only the aspect of social function recovery was claimed at 6 mo, with a significant advantage in the LR group (P = 0.001). No clinical difference was found in HRQoL during the 12 mo.

CONCLUSION

Our results demonstrated that LR resulted in better outcomes, including intra-operative blood loss, surgery-related complications, course of recovery, and especially some health domains of HRQoL at least within 6 mo postoperatively. Patients should undergo LR if there is no contraindication.

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

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.

Anastomotic Rings and Inflammation Values as Biomarkers for Leakage of Stapled Circular Colorectal Anastomoses

Reliable markers to predict or diagnose anastomotic leakage (AL) of stapled circular anastomoses following colorectal resections are an important clinical need. Here, we aim to quantitatively investigate the morphology of anastomotic rings as an early available prognostic marker for AL and compare them to established inflammatory markers. We perform a prospective single-center cohort study, including patients undergoing stapled circular anastomosis between August 2020 and August 2021. The predictive value of the anastomotic ring configuration and the neutrophil-to-lymphocyte ratio (NLR) regarding anastomotic leakage is examined by ROC analyses and compared to the C-reactive protein (CRP) as an established marker. We included 204 patients, of which 19 suffered from anastomotic leakage (LEAK group), while in 185 patients the anastomoses healed well (HEAL group). The minimal height of the anastomotic rings as a binary classifier had a good ROC-AUC of 0.81 but was inferior to the NLR at postoperative day (POD) 5, with an excellent ROC-AUC of 0.93. Still, it was superior to the NLR at POD 3 (0.74) and the CRP at POD 3 (ROC-AUC 0.54) and 5 (ROC-AUC 0.70). The minimal height of the anastomotic rings as indicator for technically insufficient anastomoses is a good predictor of AL, while postoperatively the NLR was superior to the CRP in prediction of AL.

Evaluation of the use of inflammatory biomarkers in the early detection of anastomotic leakage after esophagectomy: A retrospective analysis

Background

Postoperative anastomotic leakage remains a major complication of esophagectomy. The development of a reliable method of early detection of anastomotic leakage can revolutionize the management of esophageal carcinoma.

Materials and Methods

This is a retrospective data analysis of 147 patients who underwent Ivor-Lewis esophagectomy as a curative attempt to treat distal esophageal carcinoma in our surgery department between 2010 and 2021. C-reactive protein and white blood cell count in postoperative days 1, 3, 5, and 8 were compared in patients with and without anastomotic leakage. The diagnostic accuracy of these tests was challenged against the clinical reference standard represented by computed tomography or upper gastrointestinal endoscopy.

Results

Twenty-eight patients (19%) developed anastomotic leakage. C-reactive protein values in postoperative day 8 were the only parameter to qualify as a potential clinically helpful test with an area under the receiver operating curve of 0.85 and a P value of less than .01. We calculated the cutoff value for C-reactive protein during postoperative day 8 to be 10.85 mg/dL with specificity and sensitivity of 73.1% and 89.3%, respectively. C-reactive protein showed a positive predictive value of 43.9% and a negative predictive value of 96.7% at this cutoff value.

Conclusion

An absolute diagnostic value of postoperative estimation of serum inflammatory biomarkers to detect anastomotic leakage could not be proved. Serum C-reactive protein on postoperative day 8 with a cutoff value of 10.85 mg/dL could be used to exclude anastomotic leakage after esophagectomy to serve as one of the discharge criteria of the patients.

Predictors That Identify Complications Such As Anastomotic Leak in Colorectal Surgery: A Systematic Review

Leakage of the anastomotic site is considered to be one of the most serious complications after colon and rectal surgery. It is associated with increased mortality, morbidity, and longer hospital stays. This systematic review examines the need for blood markers such as C-reactive protein (CRP), procalcitonin (PCT), albumin, and various other molecular markers that assist in their propensity to diagnose anastomotic leakage (AL) early after surgery.

Utilizing PubMed and Google Scholar as resources and including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the articles, and studies over the last five years were included. A total of 12 studies have been discussed, and most articles suggest CRP as an excellent indicator. CRP compared to Dutch leakage scores (DLS) and PCT studies suggest that the three combinations improve the predictable outcome of AL. In addition, CRP and PCT have been shown to diagnose AL early in the postoperative period. Other studies include the role of markers of oxidative stress markers, Interleukin-6, Interleukin-10, and other molecular markers in the peritoneal drain which are predictive for identifying AL after three days postoperatively (POD-3).

Overall, CRP has proven to be a reliable standard indicator of diagnosis. This is because the postoperative elevation of this protein indicates a problem of leakage with clinical symptoms. Other blood parameters are useful for diagnosis as well, but the limitations are the lack of appropriate studies and the number of randomized controlled trials in this area of ​​study.

Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study

PURPOSE

Anastomotic leakage (AL) poses the most serious problem following low anterior resection in patients with rectal cancer independent of surgical approach or technique. The aim of this study was to evaluate risk factors for the occurrence of AL and how they affect the oncological long-term outcome of patients who received neoadjuvant therapy.

METHODS

A single centre cohort study of 163 consecutive locally advanced rectal cancer patients (cT3, cT4, N +) that received neoadjuvant therapy followed by resection with primary anastomosis between January 1998 and December 2020 were included in this study. Short- and long-term findings were compared between patients with AL (Leakage +) and without AL (Leakage -).

RESULTS

A complete follow-up was obtained from 163 patients; thereby, 33 patients (20%) developed an AL. We observed more patients with comorbidities (38% vs. 61%, p = 0.049) which developed a leakage in the course. Permanent stoma rate (36% vs. 18%, p = 0.03) was higher, and time between primary operation and stoma reversal was longer (219 days [172-309] vs. 93 days [50-182], p < 0.001) in this leakage group as well. Tumour distance lower than 6 cm from the anal verge (OR: 2.81 [95%CI: 1.08-7.29], p = 0.04) and comorbidities (OR: 2.22 [95%CI: 1.01-4.90], p = 0.049) was evaluated to be independent risk factors for developing an AL after rectal cancer surgery. Oncological outcome was not influenced by AL nor by other associated risk factors.

CONCLUSION

We could clearly detect the distance of tumour from the anal verge and comorbidities independent risk factors for the occurrence of AL. Oncological findings and long-term outcome were not influenced by these particular risk factors.

Machine Learning-based Correlation Study between Perioperative Immunonutritional Index and Postoperative Anastomotic Leakage in Patients with Gastric Cancer

Backgrounds: The immunonutritional index showed great potential for predicting postoperative complications in various malignant diseases, while risk assessment based on machine learning (ML) methods is becoming popular in clinical practice. Early detection and prevention for postoperative anastomotic leakage (AL) play an important role in prognosis improvement among patients with gastric cancer (GC). Methods: This retrospective study included 297 patients with gastric cancer receiving gastrectomy between 2018 and 2021 in general surgery department of Xinhua Hospital. Perioperative clinical variables were collected to evaluate the predictive value for postoperative AL with 5 ML models. Then, AUROC was applied to identify the optimal perioperative clinical index and ML model for predicting postoperative AL. Results: The incidence of postoperative AL was 6.1% (n=18). After the training of 5 ML classification models, we found that immunonutritional index had significantly better classification ability than inflammatory or nutritional index alone separately (AUROC=0.87 vs. 0.83, P=0.01; AUROC=0.87 vs. 0.68, P<0.01). Next, we found that support vector machine (SVM), one of the ML methods, with selected immunonutritional index showed significantly greater classification ability than optimal univariant parameter [CRP on postoperative day 4 (AUROC=0.89 vs.0.86, P=0.02)]. Also, statistical analysis revealed multiple variables with significant relevance to postoperative AL, including serum CRP and albumin on postoperative day 4, NLR and SII etc. Conclusion: This study showed that perioperative immunonutritional index could act as an indicator for postoperative AL. Also, ML methods could significantly enhance the classification ability, and therefore, could be applied as a powerful tool for postoperative risk assessment for patients with GC.