The Role of C-Reactive Protein in the Early Prediction of Serious Pancreatic Fistula Development after Pancreaticoduodenectomy

The Role of C-reactive Protein and Procalcitonin in Predicting the Occurrence of Pancreatic Fistula in Patients who Underwent Laparoscopic Pancreaticoduodenectomy: a Retrospective Study

The occurrence of postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD) is a significant concern, yet there is currently a lack of consensus on reliable predictive methods for this complication. Therefore, the aim of this study was to assess the clinical significance of C-reactive protein (CRP) and procalcitonin (PCT) values and their reliability in early predicting the development of clinically relevant pancreatic fistula (CRPF) following LPD.A retrospective analysis was conducted using data from 120 patients who had LPD between September 2019 and December 2021. Preoperative assessment data, standard patients' demographic and clinicopathological characteristics, intra- and postoperative evaluation, as well as postoperative laboratory values on postoperative days (PODs) 1, 3, and 7, including white blood cells (WBCs), CRP, and PCT, were prospectively recorded on a dedicated database. Two clinicians separately collected and cross-checked all of the data.Among 120 patients [77 men (64%), 43 women (36%], CRPF occurred in 15 patients (11 grade B and 4 grade C fistulas). The incidence rate of CRPF was 12.3%. A comparison of the median values of WBCs, PCT, and CRP across the two groups revealed that the CRPF group had higher values on most PODs than the non-CRPF group. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and cutoff values. It was discovered that POD 3 has the most accurate and significant values for WBCs, CRP, and PCT. According to the ROC plots, the AUC for WBCs was 0.842, whereas the AUC for PCT was 0.909. As for CRP, the AUC was 0.941 (95% CI 0.899-0.983, p < 0.01) with a cutoff value of 203.45, indicating a sensitivity of 93.3% and specificity of 91.4%.Both CRP and PCT can be used to predict the early onset of CRPF following LPD, with CRP being slightly superior on POD 3.

C-reactive protein postoperative values to predict clinically relevant postoperative pancreatic fistula after distal pancreatectomy

INTRODUCTION

despite significant medical and technological advances, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is reported to be between 3-45 %. The main objective of this study was to analyze the early post-surgical risk factors for developing POPF after DP.

MATERIAL AND METHODS

a retrospective observational study was performed on a prospective basis of patients undergoing DP in a tertiary hospital from January 2011 to December 2021. Sociodemographic, preoperative analytical, tumor-related and postoperative complications variables were analyzed.

RESULTS

of the 52 patients analyzed, 71.8 % of the sample had postoperative drains amylase elevation. However, 25.7 % of the total had grade-B and/or grade-C POPF. Univariate logistic regression with the variables studied showed the following as risk factors for B-C or clinically relevant POPF: amylase values in drainage at the 5th postoperative day (POD) (p = 0.097; 1.01 [1-1.01]), preoperative BMI (p = 0.015; 1.27 [1.04-1.55]) and C-reactive protein (CRP) value at the 3rd POD (p = 0.034; 1.01 [1.01-1.02]). The ROC curve of CRP value at the 3rd POD showed an area under the curve of 0.764 (95 % CI: 0.6-0.93) and the best cut-off point was 190 mg/l (sensitivity 89 % and specificity 67 %).

CONCLUSIONS

CRP value at the 3rd POD is a predictive factor for POPF after DP. Early detection of patients at risk of POPF based on these characteristics could have an impact on their postoperative management.

Diagnostic value of C-reactive protein and procalcitonin for postoperative pancreatic fistula following pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

C-reactive protein (CRP) and procalcitonin (PCT) have recently been used to diagnose and screen for postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD), but their reliability is still unclear. Our study aims to assess the efficacy of CRP and PCT in the diagnosis of POPF after PD.

METHODS

Electronic databases such as PubMed, Excerpta Medica (EMBASE), the Web of Science (WOS) and the China National Knowledge Infrastructure (CNKI) were used to search for studies and full-text articles that assessed the diagnostic efficacy of CRP and PCT for POPF. Review Manager 5.4 and STATA 14.0 were used to estimate the pooled diagnostic value of CRP and PCT. Sensitivity analyses and Deeks' funnel plot tests were conducted on the selected studies.

RESULTS

Twenty studies that satisfied the established selection criteria were chosen. Both CRP and PCT were shown to be highly effective in diagnosing POPF, each with a high area under the curve (AUC). The AUC of CRP on postoperative day (POD) 4 had a value of 0.86, with a sensitivity and specificity of 0.85 and 0.69, respectively. The AUC of PCT on POD 5 had a value of 0.87, with a sensitivity and specificity of 0.84 and 0.74, respectively.

DISCUSSION

Our research supports the hypothesis that CRP and PCT are valuable diagnostic tools for predicting POPF, especially given the CRP levels on POD 4 and PCT levels on POD 5. Limited by the small number of the studies analyzed herein, we recommend that more randomized controlled trials be performed to verify our conclusions.

Serial estimation of serum C-reactive protein and procalcitonin for early detection of anastomotic leak after elective intestinal surgeries: a prospective cohort study

Objectives

Anastomotic leak can adversely affect the outcome of surgery especially if detected late. The present study was carried out to detect the anastomotic leak early in the postoperative period using serial estimation of procalcitonin (PCT) and C-reactive protein (CRP).

Material and Methods

A single centre prospective cohort study was done on patients undergoing elective gastrointestinal surgery with anastomosis. Serial estimation of serum procalcitonin and C reactive protein was done on the first five postoperative days. Other parameters such as hemoglobin, total protein, albumin and WBC counts were noted perioperatively. Patients were followed up to 60th postoperative day to assess for anastomotic leak, wound infection and other septic foci.

Results

Eighty-four patients were included in the study. Anastomotic leak rate was 26.19% (22/84) and 3/22 patients died in the anastomotic leak group. Wound infection rate was 23.81%. The cut off value of CRP on third postoperative day in detecting anastomotic leak was 44.322 mg/dl with sensitivity of 72.73%, specificity of 66.13% and accuracy of 59.52%. The cut off value for WBC count measured perioperatively in detecting anastomotic leak was 9470 cell/mm³ with sensitivity of 72.73%, specificity of 56.45% and accuracy of 59.74%. Serum procalcitonin, haemoglobin, total protein and albumin measured were not sensitive enough to detect the anastomotic leak early.

Conclusion

Measuring CRP on the third postoperative day can predict anastomotic leak with a cut off value of 44.32 mg/dl. Patients with raised CRP need careful evaluation to rule out anastomotic leak before deciding on early discharge.

Procalcitonin and C-Reactive Protein as an Early Predictor of Infection in Elective Gastrointestinal Cancer Surgery-a Prospective Observational Study

BACKGROUND

Postoperative infections are a common entity following elective gastrointestinal surgery among which intra-abdominal infection is notorious and life threatening. Early detection could reduce postoperative morbidity and permit safe and early discharge. This study was aimed to establish the usefulness of procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day 3 as reliable markers for early detection of intra-abdominal infection and other postoperative infections following elective gastrointestinal cancer surgery.

METHODS

A total of 125 patients following elective gastrointestinal cancer surgery were prospectively observed until discharge from January 2018 to December 2019. The incidence of intra-abdominal infections and other postoperative infections was recorded. Serum PCT and CRP were estimated on postoperative day 3 for all the patients. ROC analysis of PCT and CRP was performed to establish their predictability in detecting these infections. Risk factors for postoperative infections were also studied.

RESULTS

The incidence of intra-abdominal infection (IAI) was 24%. The difference in PCT between the infected and non-infected patients was statistically significant (p = 0.001) but not in CRP (p = 0.223). On ROC analysis of CRP and PCT in detecting IAI, the areas under the curve were 0.494 and 0.615 respectively.

CONCLUSION

Raised serum PCT values on postoperative day 3 indicate the presence of infections and should prompt the surgeon to consider other investigations to confirm the presence of IAI and other postoperative infections and plan early intervention thus expediting the postoperative recovery.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2018/12/016695.

Post-operative procalcitonin and C-reactive protein predict pancreatic fistula after laparoscopic pancreatoduodenectomy

BACKGROUND

Clinically relevant pancreatic fistula (CRPF) is a serious complication following laparoscopic pancreaticoduodenectomy (LPD). This study aimed to determine if C-reactive protein (CRP) and procalcitonin (PCT) serum levels could be used as early biomarkers to predict CRPF after LPD.

METHODS

In this retrospective study, we collected peri-operative data of patients who underwent LPD between January 2019 and November 2019. We compared serum levels of white blood cells (WBC), CRP, and PCT on post-operative days (POD) 1, 2, 3, 5, and 7 between the CRPF and non-CRPF groups and analyzed the predictive risk factors for CRPF.

RESULTS

Among the 186 patients included in this study, 18 patients (9.7%) developed CRPF, including 15 and 3 patients with grade B and C fistulas, respectively. The mean WBC, CRP, and PCT levels were higher on most PODs in the CRPF group compared to the non-CRPF group. Receiver operating characteristic (ROC) analysis indicated that CRP levels on POD 2, 5, and 7 can predict CRPF development after LPD, with the area under the curve (AUC) value reaching the highest level on POD 2 (AUC 0.794). PCT levels on POD 2, 3, 5, and 7 were highly predictive of CRPF after LPD. The highest AUC value was achieved on POD 3 [PCT > 2.10 ng/ml (AUC 0.951; sensitivity 88.2%, specificity 92.9%, P < 0.001)].

CONCLUSIONS

Both CRP and PCT levels can be used to predict CRPF development after LPD, with PCT having a higher predictive value.

The diagnostic value of C-reactive protein for predicting pancreatic fistula following pancreatoduodenectomy

INTRODUCTION

Pancreaticoduodenectomy is the preferred treatment of neoplasms in the pancreas and duodenum. Postoperative pancreatic fistula is a critical complication. A potential predictive marker is C-reactive protein. This retrospective study examined the predictive value of C-reactive protein as a marker for development of postoperative pancreatic fistulas.

METHODS

All patients who had a pancreaticoduodenectomy from 1 January 2015 to 31 December 2019, were included. Levels of the biomarker and linear trajectory were determined for postoperative days one to four. Univariate analysis was used to identify predictive variables for a postoperative pancreatic fistula. Receiver operating characteristics curves, specificity, and sensitivity were calculated.

RESULTS

Five hundred and fifty-two patients underwent pancreaticoduodenectomy. C-reactive protein level greater than 121.5mg/L on the third postoperative day and an increase in C-reactive protein level between the first and fourth postoperative days, greater than 21.7mg/L, seemed to be reliable predictors. For Grade C postoperative pancreatic fistulas, increases in C-reactive protein, greater than 40.6ml/L the first four postoperative days, had a sensitivity of 100%. White blood cell count did not have similar reliability in predicting postoperative pancreatic fistulas.

CONCLUSION

Our findings indicate that small rises in C-reactive protein during the first postoperative days after pancreaticoduodenectomy are associated with an increased risk of developing postoperative pancreatic fistula.

Postoperative serum procalcitonin versus C-reactive protein as a marker of postoperative infectious complications in pancreatic surgery: a meta-analysis

BACKGROUND

Aim of this meta-analysis was to compare diagnostic accuracy C-reactive protein and procalcitonin between postoperative days 3 and 5 to predict infectious complications post pancreatic surgery.

METHODS

A systemic literature search was performed using MEDLINE, EMBASE and SCOPUS to identify studies evaluating the diagnostic accuracy of procalcitonin and C-reactive protein to predict infectious complications between postoperative days 3 and 5 following pancreatic surgery. A meta-analysis was performed using random-effect model and pooled predictive parameters.

RESULTS

Fifteen studies consisting of 2212 patients were included in the final meta-analysis. Pooled sensitivity, specificity, area under curve and diagnostic odds ratio (DOR) for day 3 C-reactive protein were 62%, 67%, 0.772 and 6.54, respectively. Pooled sensitivity, specificity, area under curve and DOR for day 3 procalcitonin were 74%, 79%, 0.8453 and 11.03, respectively. Sensitivity, specificity, area under the curve and DOR for day 4 C-reactive protein were 60%, 68%, 0.8022 and 11.90, respectively. Sensitivity, specificity and DOR of postoperative day 5 procalcitonin level for predicting infectious complications were 83%, 70% and 12.9, respectively. Pooled sensitivity, specificity, Area Under Receiver Operating Curve and DOR were 50%, 70%, 0.777 and 10.19, respectively.

CONCLUSION

Postoperative procalcitonin is a better marker to predict postoperative infectious complications after pancreatic surgeries.

Predictive factors of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy

Background

Clinically relevant postoperative pancreatic fistula (CR-POPF) continues to be a major contributor to morbidity after pancreaticoduodenectomy (PD), but it remains unclear what risk factors can precisely predict the development of CR-POPF after laparoscopic pancreatoduodenectomy (LPD). We thus aimed to identify the risk factors for predicting CR-POPF after LPD.

Methods

A total of 388 consecutive patients who underwent LPD at our institution between July 2014 and December 2018 were identified. All data, including pre-, intra-, and postoperative risk factors associated with CR-POPF defined by the International Study Group of Pancreatic Fistula, were collected retrospectively. To evaluate the predictive performance of the risk factor models, areas under the receiver operating characteristic curve (ROC) were determined.

Results

CR-POPF was observed in 31 patients (8.0%) with significant association observed with body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), intra-abdominal fat thickness, main pancreatic duct width, soft pancreatic texture, operative time, underlying pathology, and albumin (Alb) on postoperative days (POD) 1­–3. Multivariate analyses revealed that VFA >82 cm² [odds ratio (OR) =11.088; P=0.029], main pancreatic duct width <3 mm (OR =7.701; P=0.001), soft pancreatic texture (OR =12.543; P=0.022), and operative time >320 min (OR =6.061; P<0.001) were independent risk factors for CR-POPF after LPD. Areas under the ROC curve (AUC) analysis revealed the pancreatic texture was the strongest single predictor (AUC =0.854) of CR-POPF, and pancreatic texture + pancreatic duct width was the best two-predictor model (AUC =0.904). Meanwhile, our findings indicated an association between the TFA >221 cm² (OR =8.637; P=0.001) and VFA >82 cm² (OR =7.009; P<0.001) with soft pancreatic texture.

Conclusions

Soft pancreatic texture, VFA >82 cm², main pancreatic duct width <3 mm, and operative time >320 min were independent predictive risk factors of CR-POPF for LPD.

Impaired immune reaction and increased lactate and C-reactive protein for early prediction of severe morbidity and pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Prediction of complications after pancreatoduodenectomy (PD) remains of interest. Blood parameters and biomarkers during first and second postoperative days (POD1, POD2) may be early indicators of complications.

METHODS

This case-control study included 50 patients. Baseline, POD1 and POD2 values of leukocytes, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein (CRP), procalcitonin and arterial lactate were compared between individuals presenting Clavien ≥ III morbidity, pancreatic fistula (PF) or clinically relevant PF (CRPF) and those without these morbidities. Common variables reaching significance were further analyzed in order to calculate a predictive score.

RESULTS

Severe morbidity, PF and CRPF rates were 28.0%, 26.0% and 14.0%, respectively. Patients with severe morbidity had lower leukocytes on POD2 (P = 0.04). Patients with PF presented higher CRP on POD2 (P = 0.001), higher lactate on POD1 (P = 0.007) and POD2 (P = 0.008), and lower lymphocytes on POD1 (P = 0.007) and POD2 (P = 0.008). Patients with CRPF had lower leukocytes and neutrophils on POD1 (P = 0.048, P = 0.038), lower lymphocytes on POD1 (P = 0.001) and POD2 (P = 0.003), and higher CRP on POD2 (P = 0.001). Baseline parameters and procalcitonin obtained no statistical associations. Score was defined according to lymphocytes on POD1 < 650/µL and CRP on POD2 ≥ 250 mg/L allocating patients in 3 risk categories. PF and CRPF rates were statistically higher as risk category increased (P<0.001). Receiver operating characteristic curves and Hosmer-Lemeshow tests showed a good accuracy.

CONCLUSIONS

Impaired immunological reaction during early postoperative period (lower leukocytes and, particularly, lymphocytes) in response to surgical aggression would favor complications after PD. Likewise, acidosis (higher arterial lactate) could behave as risk factor of PF. An elevated CRP on POD2 is also an early biomarker of PF. Our novel score based on postoperative lymphocyte count and CRP seems reliable for early prediction of PF.

Early recognition of clinically relevant postoperative pancreatic fistula: a systematic review

BACKGROUND

Early recognition of postoperative pancreatic fistula might decrease the risk of subsequent life threatening complications. The aim of this review was to systematically evaluate the accuracy of postoperative clinical, biochemical and radiologic variables for early recognition of clinically relevant postoperative pancreatic fistula.

METHODS

A systematic literature search was performed up to August 2018. Clinical studies reporting on the association between postoperative variables and clinically relevant postoperative pancreatic fistula were included. Variables were stratified: early prediction (postoperative day 1-2) versus early diagnosis (day 3) and had to be reported in 2 cohorts.

RESULTS

Overall, 37 included studies reported on 17 different diagnostic variables after 8701 pancreatic resections. Clinically relevant postoperative pancreatic fistula occurred in 1532/8701 patients (18%). Early prediction variables included elevated serum and drain amylase (day 1). Identified variables for early diagnosis were: non-serous drain efflux (day 3); positive drain culture (day 3); elevated temperature (any day); elevated C-Reactive Protein (CRP; day 4); elevated white blood cell count (day 4) and peripancreatic collections on computed tomography (CT; day 5-10).

CONCLUSION

This review provides a comprehensive overview of postoperative variables associated with clinically relevant pancreatic fistula. Incorporation of variables in future algorithms could potentially mitigate the clinical impact of postoperative pancreatic fistula.