Diagnostic value of C-reactive protein to rule out infectious complications after major abdominal surgery: a systematic review and meta-analysis

Diagnostic Accuracy of C-reactive Protein, Procalcitonin, White Blood Cell Count, and Neutrophil-Lymphocyte Ratio in the Early Detection of Post-surgical Infections: A Systematic Review

Early detection of post-surgical infections is crucial for improving patient outcomes and reducing healthcare burdens. This systematic review evaluates the diagnostic accuracy of C-reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBC), and neutrophil-lymphocyte ratio (NLR) in identifying early post-surgical infections across various surgical specialties. A comprehensive search was conducted in PubMed, MEDLINE, Embase, and Cochrane Library following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, yielding eight high-quality studies, including meta-analyses, randomized controlled trials, and cohort studies. The findings indicate that CRP is the most extensively studied biomarker, with postoperative day (POD) 3-7 levels demonstrating moderate to high predictive value in abdominal, colorectal, spinal, and pancreatic surgeries. PCT was effective in guiding the management of adhesion-related small bowel obstruction, while NLR showed moderate diagnostic performance in orthopedic infections. Sensitivity and specificity varied across biomarkers and surgical types, with CRP showing the highest accuracy in spinal surgery (100% sensitivity and 96.8% specificity). Quality assessment using AMSTAR 2, ROB 2, QUADAS-2, and NOS tools revealed a moderate risk of bias in most studies due to heterogeneity in methodologies and biomarker cutoffs. The results support the integration of biomarker-based infection monitoring into perioperative protocols to optimize patient management, facilitate early discharge, and reduce unnecessary antibiotic use. Future research should focus on large-scale multicenter trials to establish standardized biomarker thresholds and explore the potential of combining multiple biomarkers with artificial intelligence-driven predictive models.

An Interior/Exterior Collaboration-Enhanced Intestinal Anastomosis (IECIA) for Multi-Tiered Leakage Complication Management

Anastomotic leakage (AL) is a pervasive and risky postoperative complication that presently features inaccessible prevention, delayed diagnosis, and intractable remediation, resulting in distressing morbidity and mortality. Herein an interior/exterior collaboration-enhanced neoteric intestinal anastomosis (IECIA) is developed, which consists of an interior hydrogel-based protective barrier adhering to mucosa, and exterior synergistic leakage-prevention safeguard sutured to serosa, for multi-tiered leakage complication management. Noticeably, the hydrogel barrier protects anastomosis stoma against injurious stimulation from digestive liquid, consequently reducing leakage risk effectively and comfortably in place of painful gastric tube insertion. The exterior safeguard encompassing fluorescein-loaded hydrogel and electrospun film functions as a secondary defense, exhibiting critical leakage-prevention capability to refrain from lethal intra-abdominal infection. Meanwhile, fluorescein is released to the enteric cavity for following detection within the excrement in case anastomotic leakage occurs, achieving presymptomatic alarming in providing valuable prompts for timely clinical intervention. Importantly, IECIA has been investigated in realistic in vivo end-to-end intestinal anastomosis scenarios as well as simulated leakage models, which present satisfactory postoperative recovery of gastrointestinal functions and systematic indexes. Moreover, the IECIA system is endowed with guaranteed biocompatibility, effective durability, comprehensibility for surgical operation, comfort, and compliance for patients, which demonstrates precious value for clinical translation.

Impact of Preoperative and Intraoperative Factors on Postoperative Outcomes in Patients with Colorectal Cancer: A 10-Year Retrospective Study

BACKGROUND AND OBJECTIVES

Colorectal cancer is a major contributor to global cancer morbidity and mortality. Surgical resection remains the cornerstone of treatment, but postoperative complications can significantly affect patient outcomes. Identifying factors that influence postoperative morbidity and mortality is crucial for optimizing patient care. This study aims to evaluate the impact of preoperative, intraoperative, and postoperative factors on surgical outcomes in patients with colorectal cancer.

METHODS

A retrospective cohort study was conducted on 688 patients who underwent colorectal cancer surgery within a 10-year period. Data collected included demographic information, comorbidities, laboratory values, surgical details, and postoperative outcomes. Statistical analyses were performed using chi-square tests for categorical variables and t-tests for continuous variables. Multivariate logistic regression was used to identify independent predictors of postoperative complications and mortality.

RESULTS

Postoperative complications occurred in 28.5% of patients, and the 30-day mortality rate was 5.2%. Preoperative factors such as elevated C-reactive protein (CRP) levels (p < 0.001), low albumin levels (p = 0.003), a high American Society of Anesthesiologists (ASA) score (p < 0.001), and presence of comorbidities like diabetes and hypertension (p = 0.005) were significantly associated with increased postoperative complications. Intraoperative factors such as blood loss greater than 500 mL (p < 0.001) and longer operative time (p = 0.021) were also significant predictors of adverse outcomes. Multivariate analysis identified elevated CRP (OR 2.1, 95% CI 1.5-2.9), low albumin (OR 1.8, 95% CI 1.3-2.5), and blood loss > 500 mL (OR 2.4, 95% CI 1.7-3.4) as independent predictors of postoperative complications.

CONCLUSIONS

Preoperative inflammatory markers, nutritional status, ASA score, comorbidities, and intraoperative factors like blood loss significantly influence postoperative outcomes in colorectal cancer surgery. Recognizing these risk factors allows for better preoperative optimization and surgical planning, potentially reducing postoperative morbidity and mortality.

Retrospective Evaluation of C-reactive Protein for Ruling Out Infection After Cesarean Section

Introduction

Infection after cesarean section is a major contributor to maternal morbidity. Measurement of C-reactive protein (CRP) is a laboratory test frequently conducted to rule out or confirm postoperative infection. The present study aimed to evaluate whether CRP is a suitable tool for ruling out infection after cesarean section and whether there are any reliable cut-off values.

Materials and Methods

2056 patients with cesarean section (CS) over a 3-year period were included in a retrospective analysis. Outcome parameters and risk factors for postoperative infection were collected. CRP values from preoperative and postoperative tests were compared. Cut-offs for ruling out infection were assessed.

Results

Among 2056 CSs, postoperative infection occurred in 78 cases (3.8%). The prevalence of infection in emergency CS was lowest, at four out of 134 (2.9%), and the highest prevalence was seen in secondary CS, at 42 of 903 (4.6%; p = 0.35). CRP values in the infection group were significantly higher (preoperative, 1.01 mg/dl vs. 0.62 mg/dl; day 1 postoperative, 7.91 mg/dl vs. 6.44 mg/dl; day 4 postoperative, 8.44 mg/dl vs. 4.09 mg/dl; p = 0.01). A suitable cut-off value for ruling out infection was not identified.

Conclusions

Although CRP values were significantly higher in the infection group, the clinical relevance of this appears to be negligible. CRP testing does not appear to be a reliable tool for diagnosing or ruling out postoperative infection.

Early warning model to detect anastomotic leakage following colon surgery: a clinical observational study

PURPOSE

We aimed to develop a predictive tool for anastomotic leakage (AL) following colon cancer surgery by combining a clinical early warning score (EWS) with the C-reactive protein (CRP) level.

METHODS

The records of 1,855 patients who underwent colon cancer surgery at the Oxford University Hospitals NHS Foundation Trust between January 2013 and December 2018, with or without AL, were retrospectively reviewed. EWS and CRP levels were assessed daily from the first postoperative day until discharge. AL was defined as an anastomotic defect observed at reoperation, the presence of feculent fluid in a pelvic drain, or evidence of AL on computed tomography. The tool incorporated postoperative EWS and CRP levels for the accurate early detection of AL.

RESULTS

From postoperative days 3 to 7, the mean CRP level exceeded 200 mg/L in patients with AL and was under 200 mg/L in those without AL (P<0.05). From postoperative days 1 to 5, the mean EWS among patients with leakage exceeded 2, while scores were below 2 among those without leakage (P<0.05). Receiver operating characteristic curve analysis identified postoperative day 3 as the most predictive of early leakage, with cutoff values of 2.4 for EWS and 180 mg/L for CRP; this yielded an area under the curve of 0.87 (sensitivity, 90%; specificity, 70%).

CONCLUSION

We propose using an EWS of 2.4 and a CRP level of 180 mg/L on postoperative day 3 following colon surgery with anastomosis as threshold values to prompt investigation and treatment of AL.

Early Predictors of Fistula Formation Following Head and Neck Reconstruction

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Procalcitonin and C-reactive protein as early markers of anastomotic leakage in intestinal resections for advanced ovarian cancer (EDMOCS)

INTRODUCTION

Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers.

MATERIAL AND METHODS

This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity).

CONCLUSIONS

Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.

The value of C-reactive protein, leucocytes and vital signs in detecting major complications after oncological colorectal surgery

PURPOSE

To assess the association of postoperative C-reactive protein (CRP), leucocytes and vital signs in the first three postoperative days (PODs) with major complications after oncological colorectal resections in a tertiary referral centre for colorectal cancer in The Netherlands.

METHODS

A retrospective cohort study, including 594 consecutive patients who underwent an oncological colorectal resection at Maastricht University Medical Centre between January 2016 and December 2020. Descriptive analyses of patient characteristics were performed. Logistic regression models were used to assess associations of leucocytes, CRP and Modified Early Warning Score (MEWS) at PODs 1-3 with major complications. Receiver operating characteristic curve analyses were used to establish cut-off values for CRP.

RESULTS

A total of 364 (61.3%) patients have recovered without any postoperative complications, 134 (22.6%) patients have encountered minor complications and 96 (16.2%) developed major complications. CRP levels reached their peak on POD 2, with a mean value of 155 mg/L. This peak was significantly higher in patients with more advanced stages of disease and patients undergoing open procedures, regardless of complications. A cut-off value of 170 mg/L was established for CRP on POD 2 and 152 mg/L on POD 3. Leucocytes and MEWS also demonstrated a peak on POD 2 for patients with major complications.

CONCLUSIONS

Statistically significant associations were found for CRP, Δ CRP, Δ leucocytes and MEWS with major complications on POD 2. Patients with CRP levels ≥ 170 mg/L on POD 2 should be carefully evaluated, as this may indicate an increased risk of developing major complications.

Diagnostic efficacy of serum presepsin for postoperative infectious complications: a meta-analysis

Background

Postoperative infectious complications (PICs) are major concerns. Early and accurate diagnosis is critical for timely treatment and improved outcomes. Presepsin is an emerging biomarker for bacterial infections. However, its diagnostic efficacy for PICs across surgical specialties remains unclear.

Methods

In this study, a systematic search on MEDLINE, Embase, Google Scholar, and Cochrane Library was performed on September 30, 2023, to identify studies that evaluated presepsin for diagnosing PICs. PIC is defined as the development of surgical site infection or remote infection. Pooled sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) curves were calculated. The primary outcome was the assessment of the efficacy of presepsin for PIC diagnosis, and the secondary outcome was the investigation of the reliability of procalcitonin or C-reactive protein (CRP) in the diagnosis of PICs.

Results

This meta-analysis included eight studies (n = 984) and revealed that the pooled sensitivity and specificity of presepsin for PIC diagnosis were 76% (95% confidence interval [CI] 68%-82%) and 83% (95% CI 75%-89%), respectively. The HSROC curve yielded an area under the curve (AUC) of 0.77 (95% CI 0.73-0.81). Analysis of six studies on procalcitonin showed a combined sensitivity of 78% and specificity of 77%, with an AUC of 0.83 derived from the HSROC. Meanwhile, data from five studies on CRP indicated pooled sensitivity of 84% and specificity of 79%, with the HSROC curve yielding an AUC of 0.89.

Conclusion

Presepsin exhibits moderate diagnostic accuracy for PIC across surgical disciplines. Based on the HSROC-derived AUC, CRP has the highest diagnostic efficacy for PICs, followed by procalcitonin and presepsin. Nonetheless, presepsin demonstrated greater specificity than the other biomarkers. Further study is warranted to validate the utility of and optimize the cutoff values for presepsin.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023468358.

C‐reactive protein as an early predictor of anastomotic dehiscence in various types of reconstruction in elective abdominal surgery

Objective

The most important factor in abdominal surgery is the successful healing of the intestinal anastomosis performed. This study aims to evaluate the role of C‐reactive protein (CRP) in predicting anastomotic dehiscence in the first week following surgery.

Methods

The study included 100 patients surgically treated over a period of 1 year. Postoperative (p/o) values of CRP, leukocyte (white blood cells [WBCs]) and body temperature (BT) were measured in relation to the development of p/o complications.

Results

CRP p/o values were significantly higher in patients with complications and proved helpful in predicting p/o complications, while WBC and BT were not. For the development of anastomotic leakage, receiver operating characteristic curve shows the earliest diagnostic accuracy on the third p/o day with the cut‐off value of 115.1 mg/L; however, the largest area under the curve was on the fifth p/o day with a cut‐off value of 59.2 mg/L, a sensitivity of 89%, a specificity of 61%, a positive predictive value (PPV) of 21.9 and a negative predictive value (NPV) of 100.

Conclusions

Measurement of p/o CRP values may indicate problematic healing of digestive tract anastomosis before the appearance of clinical signs. High sensitivity and high NPV allow us to rule out p/o complications and anastomotic dehiscence with great certainty and safely discharge these patients from the hospital.

Post-interventional infectious complications in percutaneous transabdominal lymphatic interventions: an observational study

The purpose of this retrospective study was to evaluate the occurrence of infectious complications and inflammatory reactions after transabdominal lymphatic-interventions. 63 lymphatic-interventions were performed in 60 patients (male/female: 35/25; mean age 56 [9-85] years) [chylothorax n = 48, chylous ascites n = 7, combined chylothorax/chylous ascites n = 5]. Post-interventional clinical course and laboratory findings were analyzed in the whole cohort as well as subgroups without (group A; n = 35) and with peri-interventional antibiotics (group B; n = 25) (pneumonia n = 16, drainage-catheter inflammation n = 5, colitis n = 1, cystitis n = 1, transcolonic-access n = 2). No septic complications associated with the intervention occurred. Leucocytes increased significantly, peaking on post-interventional day-1 (8.6 ± 3.9 × 106 cells/mL vs. 9.8 ± 4.7 × 106 cells/mL; p = 0.009) and decreased thereafter (day-10: 7.3 ± 2.7 × 106 cells/mL, p = 0.005). CRP-values were pathological in 89.5% of patients already at baseline (40.1 ± 63.9 mg/L) and increased significant on day-3 (77.0 ± 78.8 mg/L, p < 0.001). Values decreased thereafter (day-15: 25.3 ± 34.4 mg/L, p = 0.04). In subgroup B, 13/25 patients had febrile episodes post-interventionally (pneumonia n = 11, cystitis n = 1, drainage-catheter inflammation n = 1). One patient developed biliary peritonitis despite continued antibiotics and underwent cholecystectomy. Baseline leucocytes and CRP-levels were higher in group B than A, but with comparable post-interventional profiles. Clinically relevant infectious complications associated with transabdominal lymphatic-interventions are rare irrespective of peri-interventional antibiotic use. Post-interventional elevation of leucocytes and CRP are observed with normalization over 10-15 days.

Early postoperative CRP predicts major complications following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

OBJECTIVES

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is associated with significant postoperative complications. Early detection of at-risk patients may lead to improved outcomes. The role of C-reactive protein (CRP) in predicting postoperative complications has only been recently investigated.

METHODS

Postoperative complications were categorized according to Clavien-Dindo classification and further divided into minor (Grade <3) and major complications (Grade ≥3A). Absolute CRP counts (mg/L) on postoperative days (POD) 1-7, and proportional change in CRP was compared and the area under (AUC) receiver operating characteristics (ROC) curve was calculated. Univariate and multivariate analysis was performed. Significant findings were externally validated.

RESULTS

Twenty-five percent of patients experienced one or more major complications. A CRP level of ≥106 mg/L on POD 2 and 65.5 mg/L on POD 4 were significantly associated with an increased risk of major complications with an AUC of 0.658 and 0.672, respectively. The proportional increase in CRP between POD 1 and 4 (ΔCRP POD 1/4) at a cut-off of 30 % had the best AUC of 0.744 and was the only independent risk factor for major complications (p<0.0001) on multivariate analysis. ∆CRP had an AUC of 0.716 (p=0.002) when validated in an independent database.

CONCLUSIONS

CRP can be used in a variety of ways to predict major complications after CRS and HIPEC. However, the ∆CRP POD 1/4>30 % is the best indicator of major complications. Serial CRP measurements in the early postoperative period may lead to early detection of patients at risk of major complications allowing for alternative management strategies to improve outcomes.

Impact of Perioperatively Administered Amino Acids, Lidocaine, and Magnesium on Inflammatory Response and Pain Associated with Abdominal Surgery: A Prospective Clinical Study

BACKGROUND Abdominal surgery is associated with a systemic inflammatory response which facilitates postoperative complications through immune imbalance and hypercatabolism. The aim of the study was to evaluate the effect of the combined perioperative lidocaine, magnesium, and amino acids on postoperative inflammation and pain. MATERIAL AND METHODS This prospective, randomized, double-blind study included 2 groups of patients undergoing abdominal surgery: Group 1 - receiving the aforementioned substances; and Group 2 - control (undergoing conventional general anesthesia). The following parameters were evaluated intraoperatively: arterial blood pressure, end-tidal CO₂ level, urine output, bispectral index, base excess, oxygen saturation, operating room temperature and body temperature (BT), opioid use, and surgery duration; and postoperatively: total leukocyte (WBC), neutrophil, lymphocyte and platelet count; fibrinogen, C-reactive protein (CRP), procalcitonin (PCT) and interleukin (IL)-6 levels; numeric rating scale (NRS) pain level, first flatus and bowel movement, and postoperative complications. The postoperative parameters were evaluated 2 h and 6 h postoperatively, as well as on postoperative days (POD) 1, 2, 3, and 5. RESULTS Group 1 showed lower counts of WBC, neutrophils, and lymphocytes and lower fibrinogen, CRP, PCT, IL-6, and BT in the first 5 POD, as well as NRS scores and time to first flatus/bowel movement. The groups did not differ significantly regarding postoperative complications. CONCLUSIONS The isolated effects of lidocaine, magnesium, and amino acids in surgery have been described previously. To the best of our knowledge, this is the first study to show the anti-inflammatory and analgesic effects of simultaneous use of these substances in abdominal surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of antibiotic prophylaxis and conditioning modalities in per-oral endoscopic myotomy for esophageal motor disorders

BACKGROUND AND AIMS

No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety.

PATIENTS AND METHODS

This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered.

RESULTS

A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (n = 135, 60.3%). Antibiotic prophylaxis was administered to 170 patients (75.2%) during 3.93 ± 3.46 days [1-21]. The overall adverse events rate was 9.3% (n = 21). Antibiotic prophylaxis was associated with the occurrence of adverse events (p = .003), but had no impact on their severity (p = .238). Antibiotic prophylaxis didn't influence the effectiveness of POEM (1 [0-4] vs 1 [0-9], p = .231). The use of a liquid diet in the 48 h prior to the procedure was significantly associated with a lower adverse events rate (3.1% vs 6.19%, p = .0002).

CONCLUSION

The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.

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

Background

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

Materials and Methods

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

Results

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

Conclusion

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

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

Soluble Urokinase Receptor Levels Are Not Affected by the Systemic Inflammatory Response to Anesthesia and Operative Trauma

INTRODUCTION

Soluble urokinase plasminogen activator receptor (suPAR) is an emerging biomarker of the level of chronic systemic inflammation and the general condition of the patient. We aimed to investigate the impact of general anesthesia and major surgery on perioperative suPAR and C-reactive protein (CRP) levels.

METHODS

This study included patients undergoing elective major noncardiac surgery with an expected duration of ≥2 h under general anesthesia. Inclusion criteria were age ≥18 years and American Society of Anesthesiologists' physical status I-IV. Blood was drawn 30 min prior to induction of anesthesia (preoperatively), as well as 30 min after emergence from anesthesia (postoperatively). Plasma suPAR levels were determined using the suPARnostic® Quick Triage lateral flow assay. CRP measurements were performed by particle-enhanced immunoturbidimetric assay.

RESULTS

The difference in preoperative and postoperative suPAR levels was not statistically significant (7.7 [5.28-10.4] ng/mL vs. 7.15 [5.68-9.8] ng/mL, p = 0.462). CRP levels increased significantly during surgery (0.81 [0.24-2.1] mg/dL vs. 5.76 [2.2-8.75] mg/dL, p < 0.001). No correlation was observed between CRP and suPAR levels, both preoperatively (rho = 0.127; p = 0.208) and postoperatively (rho = 0.017; p = 0.87). A statistically significant increase was also observed in postoperative white blood cell count (7.576 vs. 10.711, p < 0.001).

CONCLUSION

General anesthesia and operative trauma did not affect perioperative suPAR levels despite the activation of systemic inflammatory response.

C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage

Background

Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C.

Methods

Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C.

Results

High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started.

Discussion

High postoperative CRP levels are related to an increased risk of PPH C.

Impact of Dental Referral Prior to Elective Surgery on Postoperative Outcomes

OBJECTIVES

Oral bacteria may contribute to postoperative infectious complications including postoperative pneumonia or surgical site infection. The aim of this study was to investigate the impact of preoperative dental care on postoperative outcomes among surgical patients under general anesthesia.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We analyzed clinical records of major surgical patients at a university hospital between 2016 and 2018. Subjects were categorized into either the preoperative dental care group, those being referred to dentists by their surgeons based on an individual surgeon's judgment for dental care before surgery, or the control group.

METHODS

The primary outcome was postoperative infectious complications. Secondary outcomes were postoperative inflammation markers (C-reactive protein and fever), and economic outcomes (postoperative length of hospital stay and medical expenses). As the main analysis, the average treatment effects of the preoperative dental care were obtained from the augmented inverse-probability weighting (AIPW) method with consideration of demographics and perioperative risk factors to estimate causal effect of the intervention from the observational data. Then, stratified analyses by age and surgical sites were conducted with the inverse-probability weighting and linear regression methods, respectively.

RESULTS

In the AIPW estimation, compared with the control group, the care group saw a significantly lower rate of postoperative infection (average treatment effect -3.02) and shorter fever duration (-2.79 days). The stratified analysis by age revealed significant positive impact of dental care in all age groups, including the highest treatment effects observed among patients younger than 60. Also, treatment effect was observed in wider surgical sites than previously known.

CONCLUSION/IMPLICATIONS

This study indicates a significant impact of preoperative dental care on preventing postoperative infection and inflammation. Along with old age or certain types of surgeries in which advantages of dental referral have been already known, preoperative dental referral could be beneficial for broader types of patients.

J.van GrevensteinW.M.U.KarstenT.M.. 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.

Clinically relevant features for predicting the severity of surgical site infections

Surgical site infections are hospital-acquired infections resulting in severe risk for patients and significantly increased costs for healthcare providers. In this work, we show how to leverage irregularly sampled preoperative blood tests to predict, on the day of surgery, a future surgical site infection and its severity. Our dataset is extracted from the electronic health records of patients who underwent gastrointestinal surgery and developed either deep, shallow or no infection. We represent the patients using the concentrations of fourteen common blood components collected over the four weeks preceding the surgery partitioned into six time windows. A gradient boosting based classifier trained on our new set of features reports, respectively, an AUROC of 0:991 and 0:937 at predicting a postoperative infection and the severity thereof. Further analyses support the clinical relevance of our approach as the most important features describe the nutritional status and the liver function over the two weeks prior to surgery.

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.

Longitudinal Changes in CT Body Composition in Patients Undergoing Surgery for Colorectal Cancer and Associations With Peri-Operative Clinicopathological Characteristics

There is evidence for the direct association between body composition, the magnitude of the systemic inflammatory response, and outcomes in patients with colorectal cancer. Patients with a primary operable disease with and without follow-up CT scans were examined in this study. CT scans were used to define the presence and changes in subcutaneous fat, visceral fat, skeletal muscle mass, and skeletal muscle density (SMD). In total, 804 patients had follow-up scans and 83 patients did not. Furthermore, 783 (97%) patients with follow-up scans and 60 (72%) patients without follow-up scans were alive at 1 year. Patients with follow-up scans were younger (p < 0.001), had a lower American Society of Anaesthesiology Grade (p < 0.01), underwent a laparoscopic surgery (p < 0.05), had a higher BMI (p < 0.05), a higher skeletal muscle index (SMI) (p < 0.01), a higher SMD (p < 0.01), and a better 1-year survival (p < 0.001). Overall only 20% of the patients showed changes in their SMI (n = 161) and an even lower percentage of patients showed relative changes of 10% (n = 82) or more. In conclusion, over the period of ~12 months, a low–skeletal muscle mass was associated with a systemic inflammatory response and was largely maintained following surgical resection.

C-reactive protein can predict anastomotic leak in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

Anastomotic leakage (AL) is one of the most significant complications after colorectal surgery, affecting length of stay, patient morbidity, mortality, and long-term oncological outcome. Serum C-reactive protein (CRP) level rises in infective and inflammatory states. Elevated CRP has been shown to be associated with anastomotic leak.

OBJECTIVE

Perform a meta-analysis of current CRP data in AL after colorectal surgery.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, CENTRAL databases STUDY SELECTION: Comparative studies studying serum CRP levels in adult patients with and without AL after colorectal surgery.

INTERVENTION(S)

Elective and emergency open, laparoscopic or robotic colorectal excisions for cancer and benign pathology.

MAIN OUTCOME MEASURES

Mean serum CRP measurements between post-operative days (POD) 1 through 7 in patients with and without AL. Perform ROC analysis to determine cut-off CRP values to indicate AL.

RESULTS

Twenty-three studies with 6647 patients (482 AL). Pooled mean time to diagnosis of AL was 7.70 days. AL associated with higher CRP on POD1 (mean difference (MD) 15.19, 95% CI 5.88-24.50, p = 0.001), POD2 (MD 51.98, 05% CI 37.36-66.60, p < 0.00001), POD3 (MD 96.92, 95% CI 67.96-125.89, p < 0.00001), POD4 (MD 93.15, 95% CI 69.47-116.84, p < 0.00001), POD5 (MD 112.10, 95% CI 89.74-134.45, p < 0.00001), POD6 (MD 98.38, 95% CI 80.29-116.46, p < 0.00001), and POD7 (MD 106.41, 95% CI 75.48-137.35, p < 0.00001) compared with no AL. ROC analysis identified a cut-off CRP of 148 mg/l on POD3 with sensitivity and specificity of 95%. On POD4 through POD7, cut-off levels were 123 mg/l, 115 mg/l, 105 mg/l, and 96 mg/l, respectively, with sensitivity and specificity of 100%.

LIMITATIONS

Study heterogeneity, some characteristics unreported, no RCT CONCLUSIONS: AL is associated with higher CRP levels on each post-operative day compared to no AL after colorectal surgery. The cut-off CRP values can be used to predict AL to expedite investigation and treatment.

Use of a standardized discharge checklist with daily post-operative C-reactive protein monitoring does not impact readmission rates after colon and rectal surgery

PURPOSE

Elevated CRP has been associated with infectious complications after colorectal surgery but has not been evaluated in a prospective fashion as part of a discharge checklist. The objective of this study was to evaluate the effectiveness of a multi-component "discharge criteria checklist" that included daily use of CRP in decreasing hospital readmission rates after colorectal surgery.

METHODS

This is a prospective before and after study design that included consecutive patients undergoing major colorectal operations at a single university-affiliated community hospital over a 2-year period. The primary outcome was inpatient or emergency department readmission after 30 days. Selected pre- and peri-operative factors associated with readmissions were then examined in a multivariate analysis model.

RESULTS

The study included a total of 1546 patients. Surgical indications were inflammatory bowel disease (15%), colorectal cancer (24%), and benign disease (60%); 9.5% were emergencies. The readmission rates for each group were similar, 17.3% and 17.0%, for the control and discharge checklist groups, respectively (p=0.88). On multivariate analysis of the discharge checklist group dataset, only age, sex, surgical acuity and operating time were statistically significant risk factors. The difference of median CRP values on the day of discharge of those readmitted compared to those not readmitted (35 vs 32 mg/L) was not statistically significant (p=0.28).

CONCLUSIONS

The institution of a "discharge checklist" did not impact post-operative hospital readmissions. Not only were readmissions unchanged by the use of a CRP threshold at discharge, but CRP levels at the time of discharge were not associated with readmissions.

C-reactive protein after major abdominal surgery in daily practice

BACKGROUND

Infectious complications are frequently encountered after abdominal surgery. Early recognition, diagnosis, and subsequent timely treatment is the single most important denominator of postoperative outcome. This study prospectively addressed the predictive value of routine assessment of C-reactive protein levels as an early marker for infectious complications after major abdominal surgery.

METHODS

Consecutive patients undergoing major abdominal surgery between November 2015 and November 2019 were prospectively enrolled. Routine C-reactive protein measurements were implemented on postoperative days 3, 4, and 5, and additional computed tomography examinations were performed on demand. The primary endpoint was the occurrence of Clavien-Dindo grade III or higher infectious complications.

RESULTS

Of 350 patients, 71 (20.3%) experienced a major infectious complication, and median time to diagnosis was 7 days. C-reactive protein levels were significantly higher in patients with major infectious complications compared to minor or no infectious complications. The optimal cut-off was calculated for each postoperative day, being 175 mg/L on day 3, 130 mg/L on day 4, and 144 mg/L on day 5, and corresponding sensitivities, specificities, and positive and negative predictive values were over 80%, 65%, 40%, and 92% respectively. Alternative safe discharge cut-offs were calculated at 105 mg/L, 71 mg/L and 63 mg/L on days 3, 4, and 5, respectively, each having a negative predictive value of over 97%.

CONCLUSION

The C-reactive protein cut-offs provided in this study can be used as a discharge criterion or to select patients that might require an invasive intervention due to infectious complications. These diagnostic criteria can easily be implemented in daily surgical practice.

Hypoalbuminemia as Surrogate and Culprit of Infections

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

THE ROLE OF MARKERS OF SYSTEMIC INFLAMMATORY RESPONSE IN THE POSTOPERATIVE PERIOD. REVIEW

Despite all the achievements of modern surgery, the number of postoperative infectious complications in the world remains high. Their occurrence leads to a longer period of patients’ hospitalization, requires the use of additional medical and diagnostic measures, which ultimately leads to higher treatment costs and significant financial losses in the health care system. Therefore, it is important to identify postoperative complications at an early stage, even before the development of pronounced clinical symptoms, and to predict their possible development in a certain category of patients. For these purposes, scientists try to use various laboratory markers. In this paper, we analyzed both well-known indicators of the inflammatory response, such as: C-reactive protein, albumin, their ratio, procalcitonin and interleukin-6, and relatively new parameters that research teams are trying to apply for these purposes: neutrophil granularity intensity and neutrophil reactivity intensity, pancreatic stone protein and pancreatitis-associated protein. We tried to collect the most complete information available at the moment, evaluate the opinions of researchers, identify contradictions in their works and try to explain their cause. As a result, it turned out that even the markers of inflammation known for many years are not absolutely specific for postoperative infectious complications. We concluded that most of the laboratory parameters described in this article can be used to some extent in the early diagnosis of postoperative infectious complications, but if we want to obtain more complete information in this area of knowledge, it is necessary to conduct new largescale studies.

Role of serum C-reactive protein and interleukin-6 as a predictor of intra-abdominal and surgical site infections after elective abdominal surgery

Introduction:

Infections after surgeries considerably increase patients' hospital stay, thereby prolonging patients' early return to productive life. At the same time, the cost of hospitalization also increases. Therefore, if objective tests can predict infections before it actually happens, then more preventive measures in the form of upgrading antibiotics can be taken which might prevent patients from developing serious infections and thereby reduce morbidity and mortality of surgery.

Material and Methods:

It was a prospective cross sectional study to assess the efficacy of acute phase reactants C-reactive protein (CRP) and interleukin 6 (IL 6) in predicting infections in patients undergoing routine general surgical operations. A total of 74 patients were included in the study. Laparoscopic surgical procedures were not included in the study to maintain uniformity in the procedures. Data so collected were analyzed by using SPSS version 22.

Results:

A total of 27 patients developed wound infections postoperatively. The mean rise in the levels of CRP and IL 6 was higher in those patients who developed postoperative wound infections. The positive predictive value and negative predictive value was found to be better with IL 6 than with CRP.

Conclusion:

It may be concluded that a serial estimation of CRP and IL 6 postoperatively can predict infections and may be utilized routinely in general surgical practice.

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak

Setting:

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives:

This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients and Methods:

This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results:

GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions:

Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Prognostic value of inflammatory markers for detecting anastomotic leakage after esophageal resection

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).

Perioperative nutrition: Recommendations from the ESPEN expert group

BACKGROUND & AIMS

Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

METHODS

This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

RESULTS

Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

CONCLUSIONS

Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

C-reactive protein is superior to white blood cell count for early detection of complications after pancreatoduodenectomy: a retrospective multicenter cohort study

BACKGROUND

Early detection of major complications after pancreatoduodenectomy could improve patient management and decrease the "failure-to-rescue" rate. In this retrospective cohort study, we aimed to compare the value of C-reactive protein (CRP) and white blood cell count (WBC) in the early detection of complications after pancreatoduodenectomy.

METHODS

We assessed pancreatoduodenectomies between January 2012 and December 2017. Major complications were defined as grade III or higher according to the Clavien-Dindo classification. Postoperative pancreatic fistula (POPF) was a secondary endpoint. ROC-curve and logistic regression analysis were performed for CRP and WBC. Results were validated in an external cohort.

RESULTS

In the development cohort (n = 285), 103 (36.1%) patients experienced a major complication. CRP was superior to WBC in detecting major complications on postoperative day (POD) 3 (AUC:0.74 vs. 0.54, P < 0.001) and POD 5 (AUC:0.77 vs. 0.68, P = 0.031), however not on POD 7 (AUC:0.77 vs. 0.76, P = 0.773). These results were confirmed in multivariable analysis and in the validation cohort (n = 202). CRP was also superior to WBC in detecting POPF on POD 3 (AUC: 0.78 vs. 0.54, P < 0.001) and POD 5 (AUC: 0.83 vs. 0.71, P < 0.001).

CONCLUSION

CRP appears to be superior to WBC in the early detection of major complications and POPF after pancreatoduodenectomy.

The effect of the visceral fat area on the predictive accuracy of C-reactive protein for infectious complications after laparoscopy-assisted gastrectomy

AIM

To investigate the influence of visceral fat area on postoperative C-reactive protein levels and whether it affects its ability to diagnose infectious complications after laparoscopy-assisted gastrectomy.

METHODS

A total of 435 consecutive patients who underwent laparoscopy-assisted resection for gastric cancer from 2008 to 2017 were reviewed and divided into four groups according to visceral fat area quartiles. We evaluated the relationship between C-reactive protein and visceral fat area and whether visceral fat area affects the sensitivity and specificity of C-reactive protein in diagnosing postoperative infectious complications.

RESULTS

Postoperative C-reactive protein levels increased with increasing visceral fat areas at every postoperative assessment. Multiple linear regression revealed that levels on postoperative day 3 significantly positively correlated with visceral fat area. Postoperative day 3 levels also showed moderate accuracy for diagnosing infectious complications (area under the curve, 0.78; sensitivity, 0.86; specificity, 0.65), with an optimal cut-off of 11.8 mg/dL. The sensitivity for predicting infectious complications was low in the 1st visceral fat area quartile group but high in the 2nd, 3rd, and 4th groups (0.43 vs 1.0 vs 1.0 vs 0.94, respectively). By contrast, the specificity was high in the 1st and 2nd group but low in the 3rd and 4th (0.84 vs 0.70 vs 0.54 vs 0.48, respectively).

CONCLUSION

Visceral fat area positively correlated with postoperative C-reactive protein levels and this affected its accuracy in diagnosing infectious complications. A uniform C-reactive protein cut-off may not provide accurate predictions in patients with more extreme visceral fat areas.

Predictive Ability of C-Reactive Protein in Detecting Short-Term Complications After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Retrospective Cross-Sectional Study

Background

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for peritoneal carcinomatosis.

Objective

The aim of this study was to determine the predictive value of postoperative inflammatory biomarkers in assessing complications after CRS and HIPEC.

Methods

A prospective database of 181 patients, who underwent CRS-HIPEC between March 2014 through April 2018 in the Erasmus MC, was retrospectively analyzed. Postoperative complications were defined according to the serious adverse event (SAE) grading system. Levels of C-reactive protein (CRP) and white blood cell (WBC) count were compared between patients with SAE grade < 3 and SAE grade ≥ 3. The area under the receiver operating characteristic curve (AUC) was calculated for CRP and WBC against SAE ≥ 3 and various intra-abdominal complications.

Results

SAE ≥ 3 postoperative complications occurred in 50 patients. From the second until the fifth postoperative day (POD), CRP levels were significantly higher (p = 0.023, p < 0.001, p = 0.002, and p = 0.002, respectively) in these patients. CRP concentrations above 166 mg/L on POD3 (AUC 0.75) and 116 mg/L on POD4 (AUC 0.70) were associated with the highest risk of an SAE ≥ 3. Postoperative WBC levels were not significantly different between patients with SAE < 3 and SAE ≥ 3 complications.

Conclusion

Data from our hospital suggest that CRP levels that continue to rise after POD2 or that are ≥ 166 mg/L at POD3 or ≥ 116 mg/L at POD4, indicate a considerable risk for developing high-grade SAEs. The cut-off values we found can potentially be used as a threshold for additional diagnostic interventions, after they have been validated in external data.

Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery

INTRODUCTION

C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery.

METHODS

A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy.

RESULTS

A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5.

CONCLUSIONS

The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.

The trend of C-Reactive protein allows a safe early discharge after surgery for Crohn's disease

Postoperative C-reactive protein (CRP) level allows to rule out infectious complications ensuring safe hospital discharge in colorectal cancer surgery. Since its clinical significance in Crohn's disease (CD) has not been studied yet, we investigated whether CRP can guide decision-making on hospital discharge in this population. Only consecutive CD patients undergoing resections with primary anastomosis and without covering stoma (2013-2017) were analysed. Pre- and post-operative CRP values, measured daily until discharge, were correlated with postoperative complications including anastomotic leakage (AL), infectious and non-infectious complications. The diagnostic accuracy of CRP in predicting AL was evaluated according to the area under the curve (AUC), using the receiver-operating characteristic (ROC) methodology. Two-hundred and fifty-one consecutive patients undergoing elective surgery for CD were selected. AL was diagnosed in 10 patients (4%). High CRP level was associated with AL on postoperative day (POD) 3-5 (p = 0.002, AUC 0.825) with a positive predictive value of 60%. CRP linear difference of 140 between POD 1 and 3 (AUC 0.800) maximizes sensitivity and specificity with a NPV of 98.6%. CRP trend, measured with the linear difference between POD 1 and 3, is able to rule out anastomotic complications with a high NPV and may allow a safe early hospital discharge after surgery for CD.

C-reactive protein and drain amylase accurately predict clinically relevant pancreatic fistula after partial pancreaticoduodenectomy

BACKROUND

C-reactive protein (CRP) and procalcitonin (PCT) have shown to be reliable predictors of inflammatory complications and anastomotic leak after colorectal surgery. Their predictive value after partial pancreaticoduodenectomy (PD) remains unclear.

MATERIALS AND METHODS

All consecutive pancreaticoduodenectomies (2009-2018) at our hospital were included. Drain amylase was evaluated on postoperative day (POD) 1, serum CRP and PCT were evaluated on POD 1-3. Receiver-operating characteristics curves were performed and significant cut-off values were tested using logistic regression.

RESULTS

Among 188 patients who underwent partial PD, clinically relevant pancreatic fistulas (POPF) occurred in 30 (16%) patients, including 20 (10.6%) with Grade B and 10 (5.3%) patients with Grade C. Postoperative complications (Clavien-Dindo ≥ III) were reported in 46 (24.5%) patients, including Grade IIIa in 16 (8.5%), IIIb in 18 (9.6%), IVa in 3 (1.6%), IVb in 2 (1.1%) and V in 7 (3.7%) patients. Drain amylase on POD 1 showed the largest area under the curve (0.872, p < 0.001), followed by CRP (0.803, p < 0.001) and PCT on POD 3 (0.651, p < 0.011). Drain amylase on POD 1 > 303 U/l (OR 0.045, 95% CI 0.010-0.195, p < 0.001), CRP > 203 mg/l (OR 0.098, 95% CI 0.041-0.235, p < 0.001) and PCT > 0.85 μg/l (OR 0.393, 95%CI 0.178-0.869, p = 0.02) were significant predictors of relevant POPF in the univariate analysis. CRP > 203 mg/l (OR 0.098, 95% CI 0.024-0.403, p = 0.001) and drain amylase > 303 U/l (OR 0.064, 95% CI 0.007-0.554, p = 0.01) remained independent predictors in the multivariable analysis. The combination of drain amylase on POD 1 and CRP on POD 3 had a sensitivity and specificity of 87.4% and 90.9% to predict relevant POPF.

CONCLUSION

Drain amylase on POD 1 and CRP on POD 3 can accurately predict clinically relevant POPF after partial pancreaticoduodenectomy. The accuracy of PCT on POD 3 is limited.

A pilot study of a novel molecular host response assay to diagnose infection in patients after high-risk gastro-intestinal surgery

PURPOSE

SeptiCyte LAB measures the expression of four host-response RNAs in peripheral blood to distinguish sepsis from sterile inflammation. This study evaluates whether sequential monitoring of this assay has diagnostic utility in patients after esophageal surgery.

MATERIALS AND METHODS

Patients who developed a complication within 30 days following esophageal surgery and a random sample of 100 patients having an uncomplicated course. SeptiCyte LAB scores (ranging 0-10 reflecting increasing likelihood of infection) were compared to post-hoc physician adjudication of infection likelihood.

RESULTS

Among 370 esophagectomy patients, 120 (32%) subjects developed a complication requiring ICU (re)admission, 63 (53%) of whom could be analyzed. Immediate postoperative SeptiCyte LAB scores were highly variable, yet similar for patients having a complicated and uncomplicated postoperative course (median score of 2.4 (IQR 1.6-3.3) versus 2.2 (IQR 1.3-3), respectively). In a direct comparison of patients developing a confirmed infectious (n = 34) and non-infectious complication (n = 12), addition of SeptiCyte LAB to CRP improved diagnostic discrimination of infectious complications (AUC 0.88 (95%CI 0.77-0.99)) compared to CRP alone (AUC 0.76 (95%CI 0.61-0.91); p = .04).

CONCLUSIONS

Sequential measurement of SeptiCyte LAB may have diagnostic value in the monitoring of surgical patients at high risk of postoperative infection, but its clinical performance in this setting needs to be validated.

The use of APACHE II, SOFA, SAPS 3, C-reactive protein/albumin ratio, and lactate to predict mortality of surgical critically ill patients: A retrospective cohort study

Several prognostic indices have been employed to predict the outcome of surgical critically ill patients. Among them, acute physiology and chronic health evaluation (APACHE) II, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS 3) are widely used. It seems that biological markers such as C-reactive protein (CRP), albumin, and blood lactate levels correlate with the degree of inflammation during the immediate postoperative phase and could be used as independent predictors. The objective of this study is to compare the different predictive values of prognostic indices and biological markers in the outcome of 847 surgical patients admitted to the intensive care unit (ICU) in the postoperative phase.The patients were divided into survivors (n = 765, 57.4% males, age 61, interquartile range 51-71) and nonsurvivors (n = 82, 57.3% males, age 70, interquartile range 58-79). APACHE II, APACHE II death probability (DP), SOFA, SAPS 3, SAPS 3 DP, CRP, albumin, and lactate were recorded on ICU admission (first 24 hours). The area under the ROC curve (AUROC) and 95% confidence interval (95% CI) were used to measure the index accuracy to predict mortality.The AUROC and 95% CI for APACHE II, APACHE II DP, SOFA, SAPS 3, SAPS 3 DP, CRP/albumin ratio, CRP, albumin, and lactate were 0.850 (0.824-0.873), 0.855 (0.829-0.878), 0.791 (0.762-0.818), 0.840 (0.813-0.864), 0.840 (0.813-0.864), 0.731 (0.700-0.761), 0.708 (0.676-0.739), 0.697 (0.665-0.728), and 0.601 (0.567-0.634), respectively. The ICU and overall in-hospital mortality were 6.6 and 9.7%, respectively. The APACHE II, APACHE II DP, SAPS 3, SAPS 3 DP, and SOFA scores showed a better performance than CRP/albumin ratio, CRP, albumin, or lactate to predict in-hospital mortality of surgical critically ill patients.Even though all indices were able to discriminate septic from nonseptic patients, only APACHE II, APACHE II DP, SOFA and to a lesser extent SAPS 3, SAPS 3 DP, and blood lactate levels could predict in the first 24-hour ICU admission surgical patients who have survived sepsis.

Maximizing Interpretability and Cost-Effectiveness of Surgical Site Infection (SSI) Predictive Models Using Feature-Specific Regularized Logistic Regression on Preoperative Temporal Data

This study describes a novel approach to solve the surgical site infection (SSI) classification problem. Feature engineering has traditionally been one of the most important steps in solving complex classification problems, especially in cases with temporal data. The described novel approach is based on abstraction of temporal data recorded in three temporal windows. Maximum likelihood L1-norm (lasso) regularization was used in penalized logistic regression to predict the onset of surgical site infection occurrence based on available patient blood testing results up to the day of surgery. Prior knowledge of predictors (blood tests) was integrated in the modelling by introduction of penalty factors depending on blood test prices and an early stopping parameter limiting the maximum number of selected features used in predictive modelling. Finally, solutions resulting in higher interpretability and cost-effectiveness were demonstrated. Using repeated holdout cross-validation, the baseline C-reactive protein (CRP) classifier achieved a mean AUC of 0.801, whereas our best full lasso model achieved a mean AUC of 0.956. Best model testing results were achieved for full lasso model with maximum number of features limited at 20 features with an AUC of 0.967. Presented models showed the potential to not only support domain experts in their decision making but could also prove invaluable for improvement in prediction of SSI occurrence, which may even help setting new guidelines in the field of preoperative SSI prevention and surveillance.

Amniotic fluid C-reactive protein as a predictor of infection in caesarean section: a feasibility study

This study evaluated the feasibility of maternal C-reactive protein (CRP) in amniotic fluid (AF) as a predictor of post-partum infection in women who undergo emergency or elective caesarean section (CS). AF bacterial culture and levels of hs-CRP in maternal serum and AF were evaluated in Day 0 and three days thereafter (Day 3) in 79 women undergoing CS. Univariate analyses assessed the clinical and demographic characteristics, whereas the ROC curves assessed the feasibility of hs-CRP as marker of inflammation in women who undergo CS. There was no difference in AF, Day 0, and Day 3 serum hs-CRP levels between women with sterile compared to those with bacterial growth in AF. Among women with positive AF cultures, AF and Day 0 serum hs-CRP levels were higher in women who underwent emergency compared to those who had elective CS (p = 0.04, and p = 0.02 respectively). hs-CRP in Day 0 and Day 3 serum but not in AF has a fair predictor value of infection in emergency CS only (AUC 0.767; 95% CI 0.606-0.928, and AUC 0.791; 95% CI 0.645-0.036, respectively). We conclude that AF hs-CRP is not feasible in assessing the risk of post-cesarean inflammation or infection.

Procalcitonin and C-reactive protein as early markers of postoperative intra-abdominal infection in patients operated on colorectal cancer

PURPOSE

The aim of this study was to evaluate the accuracy of serum procalcitonin (PCT) and C-reactive protein (CRP) for early diagnosis of postoperative intra-abdominal infections (PIAI) after elective surgery for colorectal cancer.

METHODS

Prospective observational study including patients operated on for colorectal cancer between January and December of 2015 was performed. Serum PCT and CRP levels were measured before surgery and daily until postoperative day 3.

RESULTS

One hundred twenty patients were included. Seven patients (5.8%) had PIAI. PCT levels were significantly higher in patients with PIAI on postoperative days 1 and 3, whereas CRP levels only were significantly more elevated on postoperative day 3. The ratio between CRP levels on postoperative day 3 and CRP levels on postoperative days 2 (CRP D3/CRP D2) and 1 (CRP D3/CRP D1) was significantly higher in patients with PIAI. PCT on postoperative day 3, for a cutoff of 0.45 ng/mL, had the best sensitivity (100%) with a specificity of 73.8%. The ratio CRP D3/CRP D1 yielded the higher specificity and positive predictive value (90.9 and 27.3%, respectively, for a cutoff of 1.8). The higher negative predictive value was obtained for PCT on postoperative days 1 and 3 (100%, with cutoff of 0.76 and 0.45 ng/mL, respectively) and for CRP on postoperative day 3 (100% with cutoff of 10 mg/dL).

CONCLUSION

PCT and CRP serum levels are associated with the appearance of PIAI after colorectal cancer surgery, although the positive predictive values were low for both PCT and CRP. However, the negative predictive values were high.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic Accuracy of Procalcitonin and C-reactive Protein for the Early Diagnosis of Intra-abdominal Infection After Elective Colorectal Surgery: A Meta-analysis

OBJECTIVE

Intra-abdominal infections (IAIs) after elective colorectal surgery impact significantly the short- and long-term outcomes. In the era of fast-track surgery, they often come to light after discharge from hospital. Early diagnosis is therefore essential. C-reactive protein levels have proved to be accurate in this setting. Procalcitonin has been evaluated in several studies with conflicting results. This meta-analysis aimed to compare the predictive abilities of C-reactive protein and procalcitonin in the occurrence of IAIs after elective colorectal surgery.

METHODS

This meta-analysis included studies analyzing C-reactive protein and/or procalcitonin levels at postoperative days 2, 3, 4, and/or 5 as markers of intra-abdominal infection after elective colorectal surgery. Methodological quality was assessed by the QUADAS2 tool. The area under the curve summary receiver-operating characteristic was calculated for each day and each biomarker, using a random-effects model in cases of heterogeneity.

RESULTS

The meta-analysis included 11 studies (2692 patients). An IAI occurred in 8.9% of the patients. On postoperative day 3, area under the curve was 0.80 (95% CI, 0.76-0.85) for C-reactive protein and 0.78 (95% CI, 0.68-0.87) for procalcitonin. On postoperative day 5, their predictive accuracies were 0.87 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.82-0.98), respectively. The accuracy of C-reactive protein and procalcitonin did not differ at any postoperative day.

CONCLUSIONS

Levels of inflammatory markers under the cutoff value between postoperative days 3 and 5 ensure safe early discharge after elective colorectal surgery. Procalcitonin seems not to have added value as compared to C-reactive protein in this setting.

Basal insulin therapy is associated with beneficial effects on postoperative infective complications, independently from circulating glucose levels in patients admitted for cardiac surgery

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The effect of insulin per se on infective complications during cardiac surgery was evaluated.

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Eight hundred twelve patients were included.

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Insulin therapy decreased infections independently from glycemic levels.

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Basal + premeal insulin therapy is well tolerated without severe hypoglycemia cases.

Background

Although hyperglycemia is a strong predictor of postoperative infective complications (PIC), little is known about the effect of basal insulin therapy (BIT) per se on PIC.

Aim

To evaluate if there is an association between BIT, independent of glucose levels, and a possible improvement of PIC during the perioperative cardiosurgery period (PCP).

Methods

In 812 patients admitted for cardiac intervention and treated with a continuous intravenous insulin infusion (CIII) for hyperglycemic levels (>130 mg/dl), a retrospective analysis was performed during the PCP (January 2009–December 2011). Upon transfer to the cardiac surgery division, if fasting glucose was ≥130 mg/dl, a basal + premeal insulin therapy was initiated (121 patients, group 1); for <130 mg/dl, a premeal insulin alone was initiated (691 patients, group 2).

Findings

Compared with group 2, group 1 showed reductions in PIC (2.48% vs 7.96%, p < 0.049; odds ratio: 0.294; 95% CI: 0.110–0.780), C-Reactive Protein (p < 0.05) and white blood cell (p < 0.05) levels despite glucose levels and CIII that were higher during the first two days after surgery (179.8 ± 25.3 vs 169.5 ± 10.6 mg/dl, p < 0.01; 0.046 ± 0.008 vs 0.037 ± 0.015 U/kg/h, p < 0.05, respectively). Normal glucose levels were achieved in both groups from day 3 before the discharge. The mean length of hospital duration was 18% lower in group 1 than in group 2 (7.21 ± 05.08 vs 8.76 ± 9.08 days, p < 0.007), providing a significant impact on public health costs.

Conclusions

Basal + preprandial insulin therapy was associated with a lower frequency of PIC than preprandial insulin therapy alone, suggesting a beneficial effect of basal insulin therapy on post-surgery outcome.