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Almutairi FM. Role of Biomarkers in the Diagnosis of Anastomotic Leakage After Colorectal Surgery: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e62432. [PMID: 39011204 PMCID: PMC11249052 DOI: 10.7759/cureus.62432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/11/2024] [Indexed: 07/17/2024] Open
Abstract
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.
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Affiliation(s)
- Farooq M Almutairi
- Clinical Laboratories Sciences, College of Applied Medical Sciences, University of Hafr Al-Batin, Hafr Al-Batin, SAU
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2
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Van Daele E, Vanommeslaeghe H, Peirsman L, Van Nieuwenhove Y, Ceelen W, Pattyn P. Early postoperative systemic inflammatory response as predictor of anastomotic leakage after esophagectomy: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:757-765. [PMID: 38704210 DOI: 10.1016/j.gassur.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/22/2024] [Accepted: 02/03/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Postesophagectomy anastomotic leakage occurs in up to 16% of patients and is the main cause of morbidity and mortality. The leak severity is determined by the extent of contamination and the degree of sepsis, both of which are related to the time from onset to treatment. Early prediction based on inflammatory biomarkers such as C-reactive protein (CRP) levels, white blood cell counts, albumin levels, and combined Noble-Underwood (NUn) scores can guide early management. This review aimed to determine the diagnostic accuracy of these biomarkers. METHODS This study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in the PROSPERO (International Prospective Register of Systematic Reviews) database. Two reviewers independently conducted searches across PubMed, MEDLINE, Web of Science, and Embase. Sources of bias were assessed, and a meta-analysis was performed. RESULTS Data from 5348 patients were analyzed, and 13% experienced leakage. The diagnostic accuracy of the serum biomarkers was analyzed, and pooled cutoff values were identified. CRP levels were found to have good diagnostic accuracy on days 2 to 5. The best discrimination was identified on day 2 for a cutoff value < 222 mg/L (area under the curve = 0.824, sensitivity = 81%, specificity = 88%, positive predictive value = 38.6%, and negative predictive value = 98%). A NUn score of >10 on day 4 correlated with poor diagnostic accuracy. CONCLUSION The NUn score failed to achieve adequate accuracy. CRP seems to be the only valuable biomarker and is a negative predictor of postesophagectomy leakage. Patients with a CRP concentration of <222 mg/L on day 2 are unlikely to develop a leak, and patients can safely proceed through their enhanced recovery after surgery protocol. Patients with a CRP concentration of <127 mg/L on day 5 can be safely discharged when clinically possible.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Louise Peirsman
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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3
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Van Daele E, Vanommeslaeghe H, Decostere F, Beckers Perletti L, Beel E, Van Nieuwenhove Y, Ceelen W, Pattyn P. Systemic Inflammatory Response and the Noble and Underwood (NUn) Score as Early Predictors of Anastomotic Leakage after Esophageal Reconstructive Surgery. J Clin Med 2024; 13:826. [PMID: 38337519 PMCID: PMC10856250 DOI: 10.3390/jcm13030826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Anastomotic leakage (AL) remains the main cause of post-esophagectomy morbidity and mortality. Early detection can avoid sepsis and reduce morbidity and mortality. This study evaluates the diagnostic accuracy of the Nun score and its components as early detectors of AL. This single-center observational cohort study included all esophagectomies from 2010 to 2020. C-reactive protein (CRP), albumin (Alb), and white cell count (WCC) were analyzed and NUn scores were calculated. The area under the curve statistic (AUC) was used to assess their predictive accuracy. A total of 74 of the 668 patients (11%) developed an AL. CRP and the NUn-score proved to be good diagnostic accuracy tests on postoperative day (POD) 2 (CRP AUC: 0.859; NUn score AUC: 0.869) and POD 4 (CRP AUC: 0.924; NUn score AUC: 0.948). A 182 mg/L CRP cut-off on POD 4 yielded a 87% sensitivity, 88% specificity, a negative predictive value (NPV) of 98%, and a positive predictive value (PPV) of 47.7%. A NUn score cut-off > 10 resulted in 92% sensitivity, 95% specificity, 99% NPV, and 68% PPV. Albumin and WCC have limited value in the detection of post-esophagectomy AL. Elevated CRP and a high NUn score on POD 4 provide high accuracy in predicting AL after esophageal cancer surgery. Their high negative predictive value allows to select patients who can safely proceed with enhanced recovery protocols.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
| | - Flo Decostere
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Louise Beckers Perletti
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Esther Beel
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
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C-Reactive Protein as Predictor for Infectious Complications after Robotic and Open Esophagectomies. J Clin Med 2022; 11:jcm11195654. [PMID: 36233522 PMCID: PMC9571314 DOI: 10.3390/jcm11195654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction: The value of C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after esophagectomy has been addressed by numerous studies. Despite its increasing application, robotic esophagectomy (RAMIE) has not been considered separately yet in this context. We, therefore, aimed to evaluate the predictive value of CRP in RAMIE. Material and Methods: Patients undergoing RAMIE or completely open esophagectomy (OE) at our University Center were included. Clinical data, CRP- and Procalcitonin (PCT)-values were retrieved from a prospectively maintained database and evaluated for their predictive value for subsequent postoperative infectious complications (PIC) (AL, gastric conduit leakage or necrosis, pneumonia, empyema). Results: Three hundred and five patients (RAMIE: 160, OE: 145) were analyzed. PIC were noted in 91 patients on postoperative day (POD) 10 and 123 patients on POD 30, respectively. Median POD of diagnosis of PIC was POD 8. Post-operative CRP-values in the robotic-group peaked one and two days later, respectively, and converged from POD 5 onward compared to the open-group. In the group with PIC, CRP-levels in the robotic-group were initially lower and started to differ significantly from POD 3 onward. In the open-group, increases were already noticed from POD 3 on. Procalcitonin levels did not differ. Best Receiver operating curve (ROC)-results were on POD 4, highest negative predictive values at POD 5 (RAMIE) and POD 4 (OE) with cut-off values of 70 mg/L and 88.3 mg/L, respectively. Conclusion: Post-operative CRP is a good negative predictor for PIC, after both RAMIE and OE. After RAMIE, CRP peaks later with a lower cut-off value.
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Evaluation of the Use of Inflammatory Biomarkers in the Early Detection of Anastomotic Leakage after Oesophagectomy. Surg Open Sci 2022; 10:12-18. [PMID: 35800711 PMCID: PMC9253454 DOI: 10.1016/j.sopen.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/28/2022] [Accepted: 05/14/2022] [Indexed: 11/21/2022] Open
Abstract
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. Anastomotic leakage is a serious and quite common complication after esophagectomy. Early detection of anastomotic leakage is crucial to successful management. Increased inflammatory biomarkers suggest the presence of anastomotic leakage. Increased serum C-reactive protein is a potential detector of anastomotic leakage.
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Gong SC, Ryu H, Jang JY. Usefulness of delta neutrophil index as a biomarker to predict postoperative complication in patients who underwent esophagectomy: A case-control study. Medicine (Baltimore) 2021; 100:e28311. [PMID: 34941124 PMCID: PMC8702068 DOI: 10.1097/md.0000000000028311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 11/23/2021] [Indexed: 01/05/2023] Open
Abstract
Esophagectomy demonstrates a high incidence of complications owing to its complexity and invasiveness; hence, early detection of complications is important. We aimed to evaluate the predictive value of the delta neutrophil index (DNI) for complications after esophagectomy.We retrospectively analyzed patients who underwent esophagectomy in the department of general surgery at a single institution between January 2011 and October 2020. Patient characteristics, laboratory findings, and clinical outcomes were assessed.Fifty-seven patients were enrolled in this study, of whom 31 (54.4%) had complications. The complication group had significantly longer mean mechanical ventilation, hospital stay and intensive care unit stay periods, and higher acute physiology, age, chronic health evaluation score and mortality rate than the noncomplication group. DNI on postoperative day (POD) 2 was also significantly higher in the complication group. Logistic regression analysis showed that DNI on POD 2 was an independent risk factor associated with the complications. Receiver operating characteristic curve analysis showed that the area under curve of DNI on POD 2 was 0.712 (cutoff value: 2.15%, sensitivity 61.5%, and specificity 70.8%).Our study indicated that postoperative DNI can be useful as an early predictive biomarker of the complications after esophagectomy.
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Affiliation(s)
- Seong Chan Gong
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hoon Ryu
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Young Jang
- Department of Surgery, National Health Insurance Service, Goyang, Korea
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7
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Barbaro A, Eldredge TA, Shenfine J. Diagnosing anastomotic leak post-esophagectomy: a systematic review. Dis Esophagus 2021; 34:5889927. [PMID: 33565590 DOI: 10.1093/dote/doaa076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/13/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
Esophagectomy is the gold-standard treatment for esophageal cancer; however, postoperative anastomotic leakage remains the primary concern for surgeons. No consensus exists on the optimal investigations to predict an anastomotic leak. This systematic review aims to identify a single test or combination of tests with acceptable sensitivity and specificity to identify anastomotic leak after esophagectomy and to formulate a diagnostic algorithm to facilitate surgical decision-making. A systematic review of PubMed and EMBASE databases was undertaken to evaluate diagnostic investigations for anastomotic leak post-esophagectomy. Each study was reviewed and where possible, the sensitivity, specificity, positive predictive value, and negative predictive value were extracted. The review identified 3,204 articles, of which 49 met the inclusion criteria. Investigations most commonly used for diagnosis of anastomotic leak were: C-reactive protein (CRP), oral contrast imaging, computed tomography (CT), pleural drain amylase concentration, and the 'NUn score'. The sensitivity of CRP for detecting anastomotic leak varied from 69.2% to 100%. Oral contrast studies sensitivities varied between 16% and 87.5% and specificity varied from 20% to 100%. Pleural drain amylase sensitivities ranged between 75% and 100% and specificity ranged from 52% to 95.5%. The NUn score sensitivities ranged from 0% to 95% and specificity from 49% to 94.4%. No single investigation was identified to rule out anastomotic leak in asymptomatic patients. However, the authors propose a diagnostic algorithm incorporating CRP, pleural drain amylase concentration, and CT with oral contrast to aid clinicians in predicting anastomotic leak to facilitate safe, timely discharge post-esophagectomy.
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Affiliation(s)
- Antonio Barbaro
- Department of Surgery, The Royal Adelaide Hospital, Adelaide, Australia
| | - Thomas A Eldredge
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Department of Surgery, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jonathan Shenfine
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Division of Surgery, Flinders Medical Centre, Bedford Park, Australia
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8
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Liesenfeld LF, Sauer P, Diener MK, Hinz U, Schmidt T, Müller-Stich BP, Hackert T, Büchler MW, Schaible A. Prognostic value of inflammatory markers for detecting anastomotic leakage after esophageal resection. BMC Surg 2020; 20:324. [PMID: 33298038 PMCID: PMC7726907 DOI: 10.1186/s12893-020-00995-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/01/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Early diagnosis of anastomotic leakage (AL) after esophageal resection is crucial for the successful management of this complication. Inflammatory serological markers are indicators of complications during the postoperative course. The aim of the present study was to evaluate the prognostic value of routine inflammatory markers to predict anastomotic leakage after transthoracic esophageal resection. METHODS Data from all consecutive patients undergoing transthoracic esophageal resection between January 2010 and December 2016 were analyzed from a prospective database. Besides clinicodemographic parameters, C-reactive protein, white blood cell count and albumin were analyzed and the Noble/Underwood (NUn) score was calculated to evaluate their predictive value for postoperative anastomotic leakage. Diagnostic accuracy was measured by sensitivity, specificity, and negative and positive predictive values using area under the receiver operator characteristics curve. RESULTS Overall, 233 patients with transthoracic esophageal resection were analyzed, 30-day mortality in this group was 3.4%. 57 patients (24.5%) suffered from AL, 176 patients were in the AL negative group. We found significant differences in WBCC, CRP and NUn scores between patients with and without AL, but the analyzed markers did not show an independent relevant prognostic value. For CRP levels below 155 mg/dl from POD3 to POD 7 the negative predictive value for absence of AI was > 80%. Highest diagnostic accuracy was detected for CRP levels on 4th POD with a cut-off value of 145 mg/l reaching negative predictive value of 87%. CONCLUSIONS In contrast to their prognostic value in other surgical procedures, CRP, WBCC and NUn score cannot be recommended as independent markers for the prediction of anastomotic leakage after transthoracic esophageal resection. CRP is an accurate negative predictive marker and discrimination of AL and no-AL may be helpful for postoperative clinical management. Trial registration The study was approved by the local ethical committee (S635-2013).
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Affiliation(s)
- Lukas F Liesenfeld
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ulf Hinz
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Anja Schaible
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
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9
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Barrie J, Cockbain A, Tsachiridi M, Surendrakumar V, Maxwell M, Tamhankar AP. Predicting Delayed Complications After Esophagectomy in the Current Era of Early Discharge and Enhanced Recovery. Am Surg 2020; 86:615-620. [PMID: 32683954 DOI: 10.1177/0003134820923314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Enhanced recovery protocols after esophagectomy aim to discharge patients by day 7. A small risk of delayed complications exists. We aimed to assess whether C-reactive protein (CRP) levels on day 7 could help predict delayed complications and assist safe discharge. METHODS All consecutive esophagectomies over 3 years were retrospectively reviewed. Patients were categorized on day 7 into (1) those clinically unsafe for discharge; (2) those clinically safe for discharge; and (3) those considered safe for discharge but develop a delayed complication. CRP level on day 7 and the trend in CRP levels between days 3 and 7 were compared. RESULTS A total of 140 patients underwent esophagectomy, of which 64 patients (46%) had at least one complication. On day 7, 62 (44%) patients were considered clinically unsafe for discharge; 74 (53%) were considered safe for discharge; and 4 (3%) were safe but developed a delayed complication. No patient with delayed complication had a day 7 CRP level < 84 mg/L. CRP trend did not help predict delayed complications. CONCLUSIONS The actual CRP level on day 7 after esophagectomy, rather than the trend, can predict delayed complications. Early discharge after esophagectomy should be desisted if the clinical picture is better than the actual blood results.
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Affiliation(s)
- J Barrie
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - A Cockbain
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - M Tsachiridi
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - V Surendrakumar
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - M Maxwell
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - A P Tamhankar
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
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Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5709700. [PMID: 31957798 DOI: 10.1093/dote/doz089] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/07/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, UK
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thahesh Tharmaraja
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yashvi Bharwada
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Department of Academic Surgery and College of Medical and Dental Sciences, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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11
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Bundred J, Hollis AC, Hodson J, Hallissey MT, Whiting JL, Griffiths EA. Validation of the NUn score as a predictor of anastomotic leak and major complications after Esophagectomy. Dis Esophagus 2020; 33:5487967. [PMID: 31076741 DOI: 10.1093/dote/doz041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/27/2019] [Indexed: 12/11/2022]
Abstract
Predicting major anastomotic leak (AL) and major complications (Clavien-Dindo 3-5) following esophagectomy improves postoperative management of patients. The role of the NUn score in their prediction is controversial. This study aims to evaluate the predictive ability of this simple score. Data were retrospectively collected for consecutive esophagectomies over a 10-year period, and NUn scores were retrospectively calculated for each patient from informatics data. A standardized definition of major AL was used, excluding minor asymptomatic, radiologically detected leaks. The predictive accuracy of the NUn score and its constituent parts, for major AL and major complications, was assessed using area under receiver operating characteristics curves (AUROCs). Of 382 patients, 48 (13%) developed major AL and 123 (32%) developed major complications. The NUn score calculated on postoperative day 4 was significantly predictive of both outcomes, with AUROCs of 0.77 and 0.71, respectively (both P < 0.001). A NUn score cut-off of 10 had a negative predictive value of 95% for major AL. The NUn score was predictive of major complications on multivariable analysis. The NUn score was found to be a significant predictor of major AL, suggesting that this is a useful early warning score for major AL. The score may also be useful in identifying patients that are the most likely to benefit from enhanced recovery protocols.
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Affiliation(s)
- James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alexander C Hollis
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Mike T Hallissey
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John L Whiting
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham
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de Mooij CM, Maassen van den Brink M, Merry A, Tweed T, Stoot J. Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery. J Clin Med 2019; 8:E2005. [PMID: 31744186 PMCID: PMC6912692 DOI: 10.3390/jcm8112005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Cornelius Maarten de Mooij
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Martijn Maassen van den Brink
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Audrey Merry
- Department of Epidemiology, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands;
| | - Thais Tweed
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Jan Stoot
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
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Abstract
Anastomotic leakage (AL) is one of the most critical and detrimental complications in esophageal surgery. Early diagnosis and timely therapeutic action are necessary if patients are to avoid AL-related problems. However, there is no gold standard or consensus for early diagnosis. In this review, we focus on summarizing the definition and types of AL and modalities for early diagnosis of AL after esophagectomy.
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Affiliation(s)
- Seok Whan Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Deog Gon Cho
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, The Catholic University of Korea, College of Medicine, Suwon, Republic of Korea
| | - Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
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Hagens ERC, Anderegg MCJ, van Berge Henegouwen MI, Gisbertz SS. International Survey on the Management of Anastomotic Leakage After Esophageal Resection. Ann Thorac Surg 2018; 106:1702-1708. [PMID: 29883644 DOI: 10.1016/j.athoracsur.2018.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anastomotic leakage is one of the most severe complications following esophageal surgery, leading to significant morbidity, prolonged hospital stay, considerable costs, decreased quality of life, and increased mortality. Management of anastomotic leakage is complicated and has currently not been standardized. The objective of this research is to gain insight into the different opinions on anastomotic leakage management among upper gastrointestinal surgeons and verify the need for diagnostic and treatment guidelines. METHODS Surgeons with interest in esophageal surgery were invited to participate in an international online questionnaire. The survey consisted of questions pertaining to the surgeons' experience, operation techniques, management routine, and opinion on future international guidelines on the treatment of anastomotic leakage. RESULTS Of the 331 invited surgeons, 40% participated in the survey. Among the 129 responders, 90.7% use laboratory diagnostics and 62.8% use imaging or endoscopy postoperatively on a routine basis to detect anastomotic leakage. In case of suspected anastomotic leakage, the most chosen diagnostic imaging modalities were computed tomography scan (35.7%) or dynamic swallow investigation (33.3%). Independent from the clinical manifestations, participants of this survey treat patients very differently. More than 70% of the responders agreed that there is a need for diagnostic and therapeutic international guidelines on anastomotic leakage management. CONCLUSIONS This survey shows that there is no standardized guideline for diagnostic workup or management of anastomotic leakage and that there is a need for an international guideline regarding the optimal management of anastomotic leakage.
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Affiliation(s)
- Eliza R C Hagens
- Department of Surgery, Academic Medical Center and Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Maarten C J Anderegg
- Department of Surgery, Academic Medical Center and Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Center and Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Utility of C-reactive protein as predictive biomarker of anastomotic leak after minimally invasive esophagectomy. Langenbecks Arch Surg 2018. [PMID: 29516256 DOI: 10.1007/s00423-018-1663-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Early detection of anastomotic leakage after esophagectomy has the potential to reduce morbidity and mortality. Prompt suspicion of leak may help to exclude patients from fast-track protocols, thereby avoiding early oral feeding and early hospital discharge which could aggravate the prognosis of a clinically occult leak. PATIENTS AND METHODS Observational retrospective cohort study. Patients with diagnosis of esophageal cancer who underwent elective minimally invasive esophagectomy were included. The following data were collected: age, gender, BMI, comorbidities, ASA score, tumor histology, TNM staging, use of neo-adjuvant therapy, type of operation, operative time, morbidity, and 90-day mortality. A panel of biomarkers including C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC), and percentage of neutrophils (PN) were measured at baseline and on postoperative days 3, 5, and 7. RESULTS Two hundred forty-three patients operated between 2012 and 2017 were included in the study. Anastomotic leakage occurred in 29 patients. There was a statistical association over time between anastomotic leakage and CRP (p < 0.001), PCT (p < 0.001), WBC (p = 0.019), and PN (p = 0.007). The cut-off value of CRP on POD 5 was 8.3 mg/dL, AUC = 0.818, negative LR = 0.176. CONCLUSIONS Increased serum CRP, PCT, WBC, and PN after minimally invasive esophagectomy are associated with anastomotic leakage. A CRP value lower than 8.3 mg/dL, combined with reassuring clinical and radiological signs, may be useful to exclude leakage on postoperative day 5.
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Paireder M, Jomrich G, Asari R, Kristo I, Gleiss A, Preusser M, Schoppmann SF. External validation of the NUn score for predicting anastomotic leakage after oesophageal resection. Sci Rep 2017; 7:9725. [PMID: 28852063 PMCID: PMC5575338 DOI: 10.1038/s41598-017-10084-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/02/2017] [Indexed: 01/13/2023] Open
Abstract
Early detection of anastomotic leakage (AL) after oesophageal resection for malignancy is crucial. This retrospective study validates a risk score, predicting AL, which includes C-reactive protein, albumin and white cell count in patients undergoing oesophageal resection between 2003 and 2014. For validation of the NUn score a receiver operating characteristic (ROC) curve is estimated. Area under the ROC curve (AUC) is reported with 95% confidence interval (CI). Among 258 patients (79.5% male) 32 patients showed signs of anastomotic leakage (12.4%). NUn score in our data has a median of 9.3 (range 6.2–17.6). The odds ratio for AL was 1.31 (CI 1.03–1.67; p = 0.028). AUC for AL was 0.59 (CI 0.47–0.72). Using the original cutoff value of 10, the sensitivity was 45.2% an the specificity was 73.8%. This results in a positive predictive value of 19.4% and a negative predictive value of 90.6%. The proportion of variation in AL occurrence, which is explained by the NUn score, was 2.5% (PEV = 0.025). This study provides evidence for an external validation of a simple risk score for AL after oesophageal resection. In this cohort, the NUn score is not useful due to its poor discrimination.
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Affiliation(s)
- Matthias Paireder
- Department of Surgery, Upper GI Service, Comprehensive Cancer Center GET-Unit, Medical University of Vienna, Vienna, Austria
| | - Gerd Jomrich
- Department of Surgery, Upper GI Service, Comprehensive Cancer Center GET-Unit, Medical University of Vienna, Vienna, Austria
| | - Reza Asari
- Department of Surgery, Upper GI Service, Comprehensive Cancer Center GET-Unit, Medical University of Vienna, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Upper GI Service, Comprehensive Cancer Center GET-Unit, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Clinical Division of Oncology, Department of Medicine I and Comprehensive Cancer Center, GET-Unit, Medical University of Vienna, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Upper GI Service, Comprehensive Cancer Center GET-Unit, Medical University of Vienna, Vienna, Austria.
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Wang W, Zhao G, Wu L, Dong Y, Zhang C, Sun L. Risk factors for anastomotic leakage following esophagectomy: Impact of thoracic epidural analgesia. J Surg Oncol 2017; 116:164-171. [PMID: 28384375 DOI: 10.1002/jso.24621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/04/2017] [Indexed: 01/29/2023]
Affiliation(s)
- Wen Wang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Gefei Zhao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Linxin Wu
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Yanpeng Dong
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Chaobin Zhang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Li Sun
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
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Scarpa M, Cavallin F, Saadeh LM, Pinto E, Alfieri R, Cagol M, Da Roit A, Pizzolato E, Noaro G, Pozza G, Castoro C. Hybrid minimally invasive esophagectomy for cancer: impact on postoperative inflammatory and nutritional status. Dis Esophagus 2016; 29:1064-1070. [PMID: 26401634 DOI: 10.1111/dote.12418] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose of this case-control study was to evaluate the impact of hybrid minimally invasive esophagectomy for cancer on surgical stress response and nutritional status. All 34 consecutive patients undergoing hybrid minimally invasive esophagectomy for cancer at our surgical unit between 2008 and 2013 were retrospectively compared with 34 patients undergoing esophagectomy with open gastric tubulization (open), matched for neoadjuvant therapy, pathological stage, gender and age. Demographic data, tumor features and postoperative course (including quality of life and systemic inflammatory and nutritional status) were compared. Postoperative course was similar in terms of complication rate. Length of stay in intensive care unit was shorter in patients undergoing hybrid minimally invasive esophagectomy (P = 0.002). In the first postoperative day, patients undergoing hybrid minimally invasive esophagectomy had lower C-reactive protein levels (P = 0.001) and white cell blood count (P = 0.05), and higher albumin serum level (P = 0.001). In this group, albumin remained higher also at third (P = 0.06) and seventh (P = 0.008) postoperative day, and C-reactive protein resulted lower at third post day (P = 0.04). Hybrid minimally invasive esophagectomy significantly improved the systemic inflammatory and catabolic response to surgical trauma, contributing to a shorter length of stay in intensive care unit.
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Affiliation(s)
- M Scarpa
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - F Cavallin
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - L M Saadeh
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - E Pinto
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - R Alfieri
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - M Cagol
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - A Da Roit
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - E Pizzolato
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - G Noaro
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - G Pozza
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
| | - C Castoro
- Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy
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Baker EH, Hill JS, Reames MK, Symanowski J, Hurley SC, Salo JC. Drain amylase aids detection of anastomotic leak after esophagectomy. J Gastrointest Oncol 2016; 7:181-8. [PMID: 27034784 DOI: 10.3978/j.issn.2078-6891.2015.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. As hospital length of stay decreases, the timely diagnosis of leak becomes more important. We evaluated CT esophagram, white blood count (WBC), and drain amylase levels in the early detection of anastomotic leak. METHODS The diagnostic performance of CT esophagram, drain amylase >800 IU/L, and WBC >12,000/µL within the first 10 days after surgery in predicting leak at any time after esophagectomy was calculated. RESULTS Anastomotic leak occurred in 13 patients (13%). CT esophagram performed within 10 days of surgery diagnosed six of these leaks with a sensitivity of 0.54. Elevation in drain amylase level within 10 days of surgery diagnosed anastomotic leak with a sensitivity of 0.38. When the CT esophagram and drain amylase were combined, the sensitivity rose to 0.69 with a specificity of 0.98. WBC elevation had a sensitivity of 0.92, with a specificity of 0.34. Among 30 patients with normal drain amylase and a normal WBC, one developed an anastomotic leak. CONCLUSIONS Drain amylase adds to the sensitivity of CT esophagram in the early detection of anastomotic leak. Selected patients with normal drain amylase levels and normal WBC may be able to safely forgo CT esophagram.
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Affiliation(s)
- Erin H Baker
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Joshua S Hill
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Mark K Reames
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - James Symanowski
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Susie C Hurley
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Jonathan C Salo
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
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Van Veer H, Moons J, Darling G, Lerut T, Coosemans W, Waddell T, De Leyn P, Nafteux P. Validation of a new approach for mortality risk assessment in oesophagectomy for cancer based on age- and gender-corrected body mass index. Eur J Cardiothorac Surg 2015; 48:600-7. [PMID: 25564215 DOI: 10.1093/ejcts/ezu503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 11/11/2014] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES We developed a new algorithm to identify high-risk patients for underweight after oesophagectomy for cancer. Patients were assigned to an age-gender-specific body mass index percentile (AG-BMI) which is then used in a survival analysis. This model was able to identify patients more at risk for being underweight in comparison with the classically used BMI. It shows a worse overall survival (OS) in patients with a preoperative AG-BMI < 10th percentile. The aim of this study is to validate this new model based on a cohort of patients from an external high-volume institution specialized in oesophageal cancer surgery. METHODS The validation cohort consists of 407 patients operated on between 1999 and 2012 with the prerequisite data to calculate AG-BMI and OS. The base cohort consisted of 642 consecutive patients, operated on in our institution between 2005 and 2010. Age, gender, height and weight on the day before surgery were used to calculate the BMI and the AG-BMI. OS was analysed and a multivariate analysis was performed. RESULTS Incidence rates of the AG-BMI < 10th percentile risk-patients in the validation cohort showed similar results to our original results (17.8 vs 17.2% for the base cohort) with a similar significant OS difference between at-risk patients and not-at-risk patients (P < 0.001). Multivariate analysis found the same five independent prognosticators for OS in both datasets: age, early versus advanced disease, resection status, number of positive lymph nodes and the AG-BMI 10th percentile, but not BMI itself. In the validation cohort, gender was identified as an additional independent prognosticator. The worse OS survival in AG-BMI < 10th percentile in both patient populations was related to a significantly higher number of deaths without oesophageal cancer recurrence. CONCLUSIONS This study validates the newly developed AG-BMI model to predict more accurately a subgroup of patients at risk for worse survival after oesophagectomy. Improved perioperative identification of risk factors for poorer OS could help to develop perioperative strategies to reduce these risks.
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Affiliation(s)
- Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Gail Darling
- Department of Thoracic Surgery, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Waddell
- Department of Thoracic Surgery, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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