Peritoneal cytokines as a predictor of colorectal anastomotic leaks on postoperative day 1: a systematic review and meta-analysis

Risk factors for anastomotic leakage and its impact on survival outcomes in radical multivisceral surgery for advanced ovarian cancer: an AGO-OVAR.OP3/LION exploratory analysis

BACKGROUND

Anastomotic leakage is a significant complication following bowel resection in cytoreductive surgery for ovarian cancer. Previous studies have highlighted the detrimental effects of anastomotic leakage on patients' postoperative course. However, there is still a lack of precise identification of the high-risk population and established strategies for preventing its occurrence.

MATERIALS AND METHODS

Patients who underwent bowel resection within the surgical phase III trial AGO-OVAR.OP3/LION investigating the impact of systematic pelvic and paraaortic lymphadenectomy in cytoreductive surgery for primary ovarian cancer were included in this analysis. All patients in the AGO-OVAR.OP3/LION trial had undergone complete cytoreduction with no macroscopic residual disease. We analyzed the occurrence of anastomotic leakage regarding surgical procedure (non-lymphadenectomy vs. lymphadenectomy and non-stoma vs. stoma) using the Fisher test. Risk factors for anastomotic leakage and its prognostic impact on survival were analyzed.

RESULTS

Overall rate of anastomotic leakage was 7.1%. Notably, the Non-lymphadenectomy subgroup had a lower anastomotic leakage rate of 3.0% compared to the lymphadenectomy subgroup (11.2%, P = 0.005). The use of protective stoma placement resulted in an anastomotic leakage rate of 5.5% regardless of lymphadenectomy compared to the Non-Stoma subgroup (7.5%, P = 0.78). Increased blood loss (odds ratio [OR] 1.04 per 100cc, 95% confidence interval [CI] 1.0001-1.09) and lymphadenectomy (OR 3.67, 95% CI 1.41-11.40) were associated with a higher risk of anastomotic leakage. Although anastomotic leakage demonstrated a numerical detrimental impact on median progression-free survival (PFS) (18 months with anastomotic leakage vs. 19 months with Non-anastomotic leakage, hazard ratio [HR] 0.86; 95% CI 0.5 to 1.4, P = 0.53) and median overall survival (OS) (31 months with anastomotic leakage vs. 58 months with Non-anastomotic leakage, HR 0.69; 95% CI 0.4 to 1.2, P = 0.17), the differences were not statistically significant.

CONCLUSION

Anastomotic leakage rates were lower in the Non-lymphadenectomy arm, the current standard of care. Blood loss and lymphadenectomy, as surrogate markers for extensive surgery, were associated with increased risk for anastomotic leakage. These findings highlight the importance of strategies to reduce surgical complexity and perioperative risk to improve clinical outcomes.

C-Reactive Protein in Peritoneal Fluid for Predicting Anastomotic Leakage After Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis

Background: Anastomotic leakage (AL) is a serious and potentially fatal complication that can occur after colorectal cancer (CRC) surgery, and it significantly affects patient recovery and increases morbidity. While serum C-reactive protein (CRP) is a recognized systemic inflammatory marker, the level of CRP in peritoneal fluid may serve as a more specific and localized biomarker for early AL detection. This meta-analysis explores the diagnostic potential of peritoneal fluid CRP, aiming to enhance postoperative care for CRC patients. Methods: A comprehensive literature search was conducted following the PRISMA guidelines. Eligible studies were included based on strict inclusion and exclusion criteria. Diagnostic accuracy was pooled using a random-effects model. The risk of bias was assessed using the QUADAS-2 tool. Results: The pooled sensitivity and specificity were 0.74 and 0.83, respectively, with an area under the curve (AUC) of 0.84, indicating good diagnostic accuracy. The overall diagnostic performance was consistent for sensitivity with no significant heterogeneity, but high heterogeneity was observed for specificity, suggesting variability between studies. Subgroup analysis revealed improved diagnostic performance between postoperative days 5-7 and higher CRP cut-off values (70-150 mg/L). The analysis confirmed the stability of the results through a sensitivity analysis and found no significant publication bias. Conclusions: Peritoneal fluid CRP is a reliable biomarker for detecting AL after CRC surgery, especially in the later postoperative period. However, heterogeneity in study methodologies and patient populations limits the generalizability of the findings. Future research should focus on standardizing protocols and exploring additional biomarkers to improve diagnostic accuracy.

Inflammatory biomarker signatures in post-surgical drain fluid may detect anastomotic leaks within 48 hours of colorectal resection

BACKGROUND

The optimal treatment of colorectal cancer is surgical resection and primary anastomosis. Anastomotic leak can affect up to 20% of patients and creates significant morbidity and mortality. Current diagnosis of a leak is based on clinical suspicion and subsequent radiology. Peritoneal biomarkers have shown diagnostic utility in other conditions and could be useful in providing earlier diagnosis. This pilot study was designed to assess the practical utility of peritoneal biomarkers after abdominal surgery utilising an automated immunoassay system in routine use for quantifying cytokines.

METHODS

Patients undergoing an anterior resection for a rectal cancer diagnosis were recruited at University Hospital of Wales, Cardiff between June 2019 and June 2021. A peritoneal drain was placed in the proximity of the anastomosis during surgery, and peritoneal fluid was collected at days 1 to 3 post-operatively, and analysed using the Siemens IMMULITE platform for interleukin (IL)-1β, IL-6, IL-10, CXCL8, tumour necrosis factor alpha (TNFα) and C-reactive protein (CRP).

RESULTS

A total of 42 patients were recruited (22M:20F, median age 65). Anastomotic leak was detected in four patients and a further five patients had other intra-abdominal complications. The IMMULITE platform was able to provide robust and reliable results from the analysis of the peritoneal fluid. A metric based on the combination of peritoneal IL-6 and CRP levels was able to accurately diagnose three anastomotic leaks, whilst correctly classifying all negative control patients including those with other complications.

CONCLUSIONS

This pilot study demonstrates that a simple immune signature in surgical drain fluid could accurately diagnose an anastomotic leak at 48 h postoperatively using instrumentation that is already widely available in hospital clinical laboratories.

Peritoneal and Systemic Interleukin-10 as Early Biomarkers for Colorectal Anastomotic Leakage Following Surgery in Colorectal Cancer Patients: A Systematic Review and Meta-Analysis

<b><br>Introduction:</b> Despite advancements in diagnostic methods, the early detection of colorectal anastomotic leakage (CAL) continues to pose challenges. The identification of reliable markers is crucial to reduce patient morbidity and mortality. Cytokines present in drain fluid and systemic cytokine levels have shown promise as predictive markers for CAL; however, additional high-quality evidence is warranted to enhance the reliability and validity of the findings in this field.</br> <b><br>Aim:</b> This systematic review and meta-analysis aimed to assess the significance of peritoneal and serum/plasma interleukin-10 (IL-10) levels in the early detection of CAL in patients undergoing colorectal surgery for colorectal cancer.</br> <b><br>Methods:</b> A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science databases, covering studies published until July 2023. The search aimed to identify relevant studies investigating the levels of plasma/serum and peritoneal IL-10 (or both) in colorectal cancer patients undergoing colorectal surgery, specifically focusing on the presence of CAL. Data on the mean and standard deviation of IL-10 levels in both CAL and non-CAL patients were extracted from the selected studies. Mean differences in IL-10 levels were analyzed for each postoperative day (POD) using the OpenMeta [analyst] software.</br> <b><br>Results:</b> 11 articles were selected for inclusion in this systematic review. Among them, nine articles reported data on peritoneal IL-10 levels, while four articles focused on circulating IL-10 levels. The statistical analysis included four eligible articles that assessed peritoneal IL-10 levels, and the results indicated no significant increase in CAL patients compared to non-CAL patients on any postoperative day (POD). Meta-analysis for circulating IL-10 levels was not feasible.</br> <b><br>Conclusions:</b> Up to now, peritoneal and systemic IL-10 levels cannot be considered as early markers for CAL after colorectal surgery in colorectal cancer patients. More high-quality studies are needed to establish the potential of IL-10 as a reliable marker for detecting anastomotic leakage after colorectal surgery.</br>.