C-reactive protein elevation ratio as an early predictor of postoperative severe complications after laparoscopic gastrectomy for gastric cancer: a retrospective study

Predictive Postoperative Inflammatory Response Indicators of Infectious Complications Following Gastrectomy for Gastric Cancer

BACKGROUND

Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy.

METHODS

We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification).

RESULTS

Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×102/μL, and 37.4°C, respectively.

CONCLUSIONS

Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×102/μL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

Can prospective monitoring improve complication rates after gastrectomy? Experience of Billroth I reconstruction at a high-volume tertiary center

INTRODUCTION

Prospective database is imperative in surgical outcome monitoring and has shown success in providing a comprehensive complication index to monitor surgical quality. This study aims to review whether prospective monitoring has an effect on postoperative complication rates, especially leakage after Billroth I (BI) anastomosis and to identify risk factors of anastomosis leakage after BI anastomosis.

MATERIALS AND METHODS

Patients who underwent distal gastrectomy with BI reconstruction at Seoul National University Hospital between January 2018 and April 2021 were enrolled. Clinicopathological characteristics and perioperative variables were retrieved. The risk factor that was statistically significant in univariate analysis was further analyzed by binomial logistic regression analysis.

RESULTS

BI leakage rate in three years has declined by half on a yearly basis from 5.7% to 1.8%. The leakage group patients were predominantly male (100%) when compared to the non-leakage group (67.6%) (p = 0.04). The BMI (25.00 ± 1.42 vs. 24.16 ± 3.15, p = 0.048) and CRP measured on POD#2 (16.47 ± 5.64 vs. 9.99 ± 5.42, p < 0.001) showed significant differences between the two groups. POD#2 CRP greater than 12.7 mg/dL was able to predict risk of anastomosis leak with sensitivity 73.3% and specificity 73.1%.

CONCLUSION

Understanding variations in outcomes is important for improvements in surgical care, and through prospective monitoring and intra-departmental feedback, it is possible to reduce complication rates after gastrectomy. This study shows that age, gender and BMI are risk factors to BI leakage and POD#2 CRP greater than 12.7 mg/dL can be used to suspect leakage after BI anastomosis.

Impact of anastomotic leakage on survival after surgery for gastric carcinoma: A PRISMA systematic review and meta-analysis

BACKGROUND

The long-term survival of postoperative anastomotic leakage (AL) following gastric cancer (GC) surgery is still debating. Our aim was to investigate the association between AL and survival of the patients following GC.

METHODS

We searched articles in databases from inception to July 2023 to retrieve literature related to postoperative AL and survival of GC patients. We evaluated the association of postoperative AL and survival of GC patients using the software STAT10.0.

RESULTS

Seven articles with 6209 GC patients were included. Our results showed that the postoperative AL were associated with pooled 1-year patient overall survival (OS) result in an odds ratio (OR) of 0.504 (95% confidence interval (CI): 0.372-0.682; I2 = 84.1%; P = .000), pooled 3-year patient OS (OR = 0.467, 95% CI: 0.356-0.614; I2 = 85.3%; P = .000) and pooled 5-year patient OS (OR = 0.370, 95% CI: 0.171-0.805; I2 = 82.5%; P = .012). The P value of Egger test were 0.759, 0.187, 0.175. The postoperative AL were associated with pooled 1-year patient disease-free survival (DFS) result in an OR of 0.538 (95% CI: 0.171-1.691; I2 = 89.0%; P = .289), the pooled 3-year patient DFS (OR = 0.143, 95% CI: 0.119-1.431; I2 = 91.7%; P = .163), and the pooled 5-year patient DFS (OR = 0.344, 95% CI: 0.088-1.338; I2 = 91.0%; P = .124), and the P value of Egger test of pooled 1-, 3-, and 5-year DFS were 0.759, 0.247, 0.07.

CONCLUSION

Postoperative AL was correlated with a worse OS in GC patients, but not correlated with DFS in GC patients, but more studies are required to confirm this conclusion.

Comparison of perioperative outcomes between bipolar sealing, ultrasonic shears and a hybrid device during laparoscopic gastrectomy for early gastric cancer: a prospective, multicenter, randomized study

BACKGROUND

Although EBDs are essential for minimally invasive surgery, well-established prospective randomized studies comparing EBDs are scarce. This study aimed to compare the intraoperative inflammatory response and short-term surgical outcomes among different energy-based devices (EBDs) in laparoscopic distal gastrectomy (LDG).

METHODS

Patients with clinical stage I gastric cancer scheduled for LDG at two different medical centers were prospectively randomized into three groups: ultrasonic shears (US), advanced bipolar (BP) and ultrasonic-bipolar hybrid (HB). The C-reactive protein (CRP) level, operation time, intraoperative blood loss (IBL), laboratory tests, cytokines (interleukin (IL)-6 and IL-10), hospital stay, and complication rate were analyzed. A novel semiquantitative measurement method using indocyanine green (ICG) and a near-infrared camera measured the amount of lymphatic leakage.

RESULTS

The primary endpoint, the CRP level, was significantly lower in the BP (n = 60) group than in the US (n = 57) or HB (n = 57) group [9.03 ± 5.55 vs. 11.12 ± 5.02 vs. 12.67 ± 6.14, p = 0.001, on postoperative day (POD) 2 and 7.48 vs. 9.62 vs. 9.48, p = 0.026, on POD 4]. IBL was significantly lower in BP than in US or HB (26.3 ± 25.3 vs. 43.7 ± 42.0 vs. 34.9 ± 37.0, p = 0.032). Jackson-Pratt drainage triglycerides were significantly lower in BP than in US (53.6 ± 33.7 vs. 84.2 ± 59.0, p = 0.11; HB: 71.3 ± 51.4). ICG fluorescence intensity, operation time, laboratory results, cytokines, hospital stay, and complication rate were not significantly different among the 3 groups.

CONCLUSION

BP showed a lower postoperative CRP level and less IBL than US and HB, suggesting less collateral thermal damage and better sealing function. Surgeons may consider this when selecting EBDs for laparoscopic surgery.

C-Reactive Protein/Albumin Ratio on the First Day after Surgery Predicts Short-Term Complications of Gastrectomy for Gastric Cancer

Postoperative complications of gastrectomy for gastric cancer affect the efficacy of surgery. It is of clinical significance to identify high-risk patients with postoperative complications as early as possible. A total of 206 patients who underwent gastrectomy were enrolled in this study. Univariate and multivariate analyses were used to determine the risk factors for postoperative complications. The cutoff value and diagnostic accuracy of the C-reactive protein/albumin ratio were calculated by receiver operating characteristic curves. A total of 64 (31.1%) patients developed postoperative complications. Multivariate analysis confirmed that the C-reactive protein/albumin ratio on the first day after operation was an independent risk factor for postoperative complications (OR = 2.538, 95%CI: 1.346-4.785, P = 0.004). The cutoff value of the C-reactive protein/albumin ratio on the first day after operation was 2.105 calculated by receiver operating characteristic curves. Patients with a C-reactive protein/albumin ratio greater than 2.105 had a higher incidence of postoperative complications (43.2% vs 22.0%, P = 0.001) and longer postoperative hospital stay (15.3 ± 1.2 vs 13.0 ± 0.5, P = 0.042) than patients with less than 2.105. Patients with C-reactive protein/albumin ratio greater than 2.105 on the first day after operation are more likely to have postoperative complications.

The ratio of serum C-reactive protein level on postoperative day 3 to day 2 is a good marker to predict postoperative complications after laparoscopic radical gastrectomy for gastric cancer

PURPOSE

Study reported that C-reactive protein (CRP) would peak at 48 h after the initiation of an acute inflammatory response. We proposed that the ratio of CRP level on postoperative day 3 to day 2 (POD3/2 CRP) can be used to early predict major postoperative complications (PCs) for patients who underwent laparoscopic radical gastrectomy.

METHODS

Patients were randomized into training cohort and validation cohort at a ratio of 7:3. PCs greater than grade II or more, according to Clavien-Dindo classification, were defined as major PCs. Three predictive models for major PCs based on CRP level were constructed, including POD3/2 CRP, the CRP level on POD3 (POD3 CRP), and the ratio of CRP level on POD3 to POD1 (POD3/1 CRP). The performances of three prediction models were assessed by AUC. Univariate and multivariate logistic regression analyses were performed to identify risk factors of major PCs.

RESULTS

344 patients were included. Major PCs were observed in 57 patients (16.6%). In the training cohort, POD3/2 CRP provided the best diagnostic accuracy with an AUC of 0.929 at an optimal cut-off value of 1.08, and the sensitivity and specificity were 0.902 and 0.880, respectively. In the validation cohort, the corresponding AUC was 0.917. BMI ≥ 25 kg/m² and POD3/2 CRP > 1 were identified as risk factors for major PCs.

CONCLUSION

POD3/2 CRP is a reliable marker to predict major PCs after laparoscopic radical gastrectomy. If CRP is higher on POD3 than on POD2, major PCs are highly likely.

C-reactive protein (CRP) trajectory as a predictor of anastomotic leakage after rectal cancer resection: A multicentre cohort study

AIM

This study aimed to identify whether CRP-trajectory measurement, including increase in CRP-level of 50 mg/l per day, is an accurate predictor of anastomotic leakage (AL) in patients undergoing resection for rectal cancer.

METHODS

A prospective multicentre database was used. CRP was recorded on the first three postoperative days. Sensitivity, specificity, positive and negative predictive values, and area under the receiver operator characteristic (ROC) curve were used to analyse performances of CRP-trajectory measurements between postoperative day (POD) 1-2, 2-3, 1-3 and between any two days.

RESULTS

A total of 271 patients were included in the study. AL was observed in 12.5% (34/271). Increase in CRP-level of 50 mg/l between POD 1-2 had a negative predictive value of 0.92, specificity of 0.71 and sensitivity of 0.57. Changes in CRP-levels between POD 2-3 were associated with a negative predictive value, specificity and sensitivity of 0.89, 0.93 and 0.26, respectively. Changes in CRP-levels between POD 1-3 showed a negative predictive value of 0.94, specificity of 0.76 and sensitivity of 0.65. In addition, 50 mg/l changes between any two days showed a negative predictive value of 0.92, specificity of 0.66 and sensitivity of 0.62. The area under the ROC curve for all CRP-trajectory measurements ranged from 0.593-0.700.

CONCLUSION

The present study showed that CRP-trajectory between postoperative days lacks predictive value to singularly rule out AL. Early and safe discharge in patients undergoing rectal surgery for adenocarcinoma cannot be guaranteed based on this parameter. High negative predictive values are mainly caused by the relatively low prevalence of AL.

Inflammatory biomarkers to predict postoperative infectious complications after cytoreductive surgery and HIPEC for peritoneal carcinomatosis

BACKGROUND

Early detection of postoperative infectious complications (IC) is crucial after Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). The aim of this study was to evaluate the predictive role of early postoperative inflammatory biomarkers level for the detection of postoperative IC.

METHODS

a retrospective study was performed including 199 patients treated with complete CRS/HIPEC for PC from various primary origins from September 2012 to January 2021. Patients were monitored by a routine measurement of inflammatory biomarkers (CRP, leukocytes, neutrophils, lymphocytes, neutrophile-to-lymphocyte ratio and platelets-to-lymphocyte ratio). Inflammatory biomarkers were compared between patients with vs without IC.

RESULTS

IC occurred for 68 patients (34.2%). CRP values were significantly higher in patients with IC on POD 3, 5 and 7 (CRP = 166 mg/L [128-244], 155 mg/L [102-222] and 207 mg/L [135-259], respectively). The CRP on POD7, with a cut-off value of 100 mg/L, was an excellent predictor of postoperative IC (AUC = 90.1%). The CRP on POD 5, with a cut-off value of 90 mg/L, was a good predictor of postoperative IC (AUC = 83.2%). NLR values were significantly higher in patients with IC on POD 3, 5 and 7. NLR on POD 5 and 7 higher than 9.7 and 6.3, respectively, were fair predictors (AUC = 70.8 and 79.6, respectively).

CONCLUSION

CRP levels between POD3 and 7 are the best predictors of postoperative IC after CRS/HIPEC. The presence of postoperative IC should be suspected in patients with CRP higher than 140 mg/L, 90 mg/L or 100 mg/L on PODs 3, 5 or 7.

Can intraoperative endoscopy prevent esophagojejunal anastomotic leakage after total gastrectomy?

BACKGROUND

Esophagojejunostomy (EJ) is frequently performed after total gastrectomy for proximal gastric tumors. Despite evolving surgical techniques and improving perioperative care, the EJ leak is one of the most severe life-threatening complications. This study investigated the preventability of postoperative anastomotic complications by performing intraoperative endoscopy.

METHODS

We included 86 patients who underwent total gastrectomy and Roux-en-Y esophagojejunostomy anastomosis in the study. Patients were divided into two groups and analyzed retrospectively. Group 1 consisted of 43 patients who did not undergo intraoperative endoscopy between 2017 and 2019, and Group 2 included 43 patients who underwent intraoperative endoscopy between 2019 and 2020.

RESULTS

Esophagojejunostomy anastomotic leak (EAL) was observed in 2.3 % of patients in Group 1 but not in Group 2. Anastomosis-related abnormal findings (anastomotic defect, bleeding, air leak, mucosal separation) were recorded in seven patients of Group 2 during endoscopy. When such findings were observed, additional full-thickness sutures were placed on the anastomosis line and strengthened. Complication related to anastomosis was not observed in the postoperative period in Group 2.

DISCUSSION

After a total gastrectomy, the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage. Most of these complications are induced by technical errors not noticed during surgery. The crucial advantage of performing intraoperative endoscopy is the technically detailed evaluation of anastomosis.

CONCLUSION

Intraoperative endoscopy is a safe method to evaluate the strength of anastomosis. This procedure provides detailed information regarding anastomotic integrity. HIPPOKRATIA 2021, 25 (3):108-112.

Clinical significance and prognostic value of C-reactive protein/albumin ratio in gastric cancer

Purpose

This study was aimed to evaluate the clinical significance and prognostic value of CRP/albumin ratio (CAR) in patients with gastric cancer.

Methods

The data of 205 gastric cancer patients who underwent surgery was analyzed retrospectively. The association of CAR with the clinical features and prognostic value in gastric cancer was analyzed. The data of this study was combined with previous studies to further determine the prognostic value of CAR in patients with gastric cancer using a meta-analysis method.

Results

Cox analysis revealed that preoperative CAR was an independent prognosis indicator in patients with gastric cancer. High expression of CAR indicated a shorter survival time than in those with lower expression. CAR has a higher prognostic value in the 1-, 3-, and 5-year overall survival in patients with gastric cancer. CAR showed significant difference regarding the gastric cancer patients' age, M stage, and clinical stage. The discriminate value of CAR in M stage of gastric cancer was high (area under the curve, 0.809). A meta-analysis combining previous data and our data showed that preoperative CAR demonstrated a significant association with the overall survival of patients with gastric cancer.

Conclusion

This study demonstrated that preoperative CAR could serve as an important prognostic indicator in patients with gastric cancer.

C-reactive protein adjusted for body mass index as a predictor of postoperative complications following laparoscopic gastrectomy for gastric cancer

PURPOSE

This study aimed to clarify the relationship between obesity and postoperative C-reactive protein (CRP) and assess the usefulness of obesity status-adjusted CRP levels for predicting early complications following laparoscopic gastrectomy for gastric cancer.

METHODS

This study retrospectively analyzed 527 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2013 and March 2019. Patients were classified into three groups according to body mass index (BMI): BMI < 20; BMI ≥ 20 to < 25; and BMI ≥ 25. The correlation between BMI and perioperative CRP was investigated in 447 patients, excluding 80 with postoperative complications. The optimal CRP cutoff value of Clavien-Dindo (CD) grade ≥ 3 for predicting severe complications for each group was determined.

RESULTS

BMI was significantly correlated with CRP on postoperative day (POD) 3 (p < 0.001) in 447 patients without complications. According to the receiver operating characteristic curve analysis, CRP cutoff values on POD 3 for predicting severe complications were 92.4, 111.1, and 171.9 in the BMI < 20, BMI ≥ 20 to < 25, and BMI ≥ 25 groups, respectively. In multivariate analysis for CD grade ≥ 3 complications, cardiac history and POD 3 CRP levels higher than the adjusted cutoff were identified as independent factors significantly associated with severe complications (p = 0.021 and 0.015, respectively).

CONCLUSION

CRP cutoff values on POD 3 adjusted for BMI were useful for predicting severe complications in gastrectomy for gastric cancer.

Is laparoscopic approach still a risk factor for postappendectomy intra-abdominal abscess?

BACKGROUND

The impact of laparoscopic appendectomy (LA) on the incidence of intra-abdominal abscess (IAA) remains controversial. We aimed to identify risk factors for postappendectomy IAA and assess the impact of appendectomy approach in postoperative morbidity.

METHODS

A retrospective single-center study including consecutive patients who underwent appendectomy for acute appendicitis between 2015 and 2018 was performed. Demographic, clinical, intraoperative, and perioperative variables were collected. Univariate and multivariate analyses was performed to detect independent risk factors for IAA. Comparison of LA and open appendectomy was conducted, and propensity score model (PSM) was used to overcome differences between groups. Independent risk factors for IAA were identified by univariate and multivariate analyses in the PSM cohort.

RESULTS

A total of 532 appendectomies were included. The median age was 35 years. Three hundred two patients (56.7%) underwent LA. The most frequent operative finding was American Association for the Surgery of Trauma (AAST) grade 1 appendicitis in 303 patients (57%). Peritonitis was found in 109 patients (20.5%). Postoperative morbidity and mortality were 14.4% and 0%, respectively. Intra-abdominal abscess rate was 6.2%. An AAST grade of ≥2, a preoperative C-reactive protein level of >100 mg/dL, and diabetes mellitus were identified as independent risk factors for IAA in the multivariate analysis. Comparing LA and open appendectomy, there were no differences in IAA rates. After PSM, LA showed lower morbidity and shorter hospital stay.

CONCLUSIONS

Laparoscopic appendectomy is a safe approach and not related to a higher risk of IAA. Patients with an AAST grade of ≥2, a preoperative C-reactive protein level of >100, and diabetes mellitus have higher risk for postappendectomy IAA.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.