Bradykinin Receptor B1 and C-Reactive Protein as Prognostic Factors for Pharyngocutaneous Fistula Development After Laryngectomy

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

Evaluation of the Incidence of Pharyngocutaneous Fistula after Total Laryngectomy

Introduction

Laryngeal squamous cell carcinoma is one of the most critical head and neck cancers. Total laryngectomy is one of the main options for treating laryngeal squamous cell carcinoma responsible for forming pharyngocutaneous fistula (PCF), which increases morbidity and mortality. This study aimed to determine PCF incidence and identify the factors associated with this complication.

Materials and Methods

In a retrospective cohort study, 85 patients who underwent total laryngectomy at Imam Khomeini Hospital (Tehran, Iran) from 2011 to 2019 were selected as the study population. The presence/absence of PCF, weight, anemia status (Hb <12.5 g/dl), renal dysfunction status (GFR <90 mL/min/1.73m2), malnutrition status (Albumin <3.5 g/dl), and marginal involvement status was extracted from postoperative medical records. The data were analyzed using SPSS ver. 26.0.

Results

The overall incidence of PCF was 11.8%. The mean ±SD of the duration of hospitalization in patients with PCF was 32.40 ±14.75 days, and in patients without PCF was 16.89 ±7.05 days (P = 0.009). The mean ±SD of time to develop a fistula was 7.4 ±3.74 days.

Conclusions

The statuses of anemia, malnutrition, renal dysfunction, surgical margin, history of radiotherapy, pharynx closure, gender, and age were unrelated to the incidence of PCF. Further studies with a larger sample size are recommended.

Predictive value of procalcitonin level for pharyngocutaneous fistula after laryngectomy

BACKGROUND

Pharyngocutaneous fistula (PCF) is among the most common postoperative infective complications following laryngectomy. Its diagnosis is often late and identified only after the formation of an abnormal, bacterial infection-harboring fistula track between the pharynx and the skin. This study was aimed at determining whether procalcitonin (PCT), white blood cell count (WBC), C-reactive protein (CRP), and neutrophil percentage are good predictors of PCF.

METHODS

We prospectively analysed 65 consecutive patients undergoing total laryngectomy. Clinicodemographic, surgical, and body mass index data were collected. Data on serum levels of PCT, WBC, CRP, and neutrophils were obtained before surgery and on postoperative days 2, 4, 6, 8, and 10 by immunofluorescence, immune turbidimetry, and automatic blood analyzer. The area under the receiving operating characteristic (ROC) curve was calculated for each marker.

RESULTS

There were 65 patients with a mean age of 60.34 years. The PCF occurrence rate was 18.46 % (12/65). Serum levels of PCT and CRP determined on postoperative day 2, 4, 6, 8, and 10 after surgery were higher in patients with PCF (P < 0.01). PCT level was identified as a good predictor area under the curve (AUC) > 0.800 on postoperative days 2, 4, and 6. Considering the sensitivity and specificity, the best combination was PCT on postoperative days 4, which with a cutoff level of 0.12 μg/L showed 91.67 % sensitivity and 100 % specificity.

CONCLUSIONS

Procalcitonin can predict PCF following laryngectomy. PCT > 0.12 μg/L on postoperative day 4 was a reliable predictor of PCF. This may help guide postoperative antibiotic management.

Improved Early Detection Models of Pharyngocutaneous Fistula after Total Laryngectomy

Early detection of pharyngocutaneous fistula (PCF) after total laryngectomy (TL) could prevent severe complications such as major vessel rupture. We aimed to develop prediction models for detecting PCF in the early postoperative period. We retrospectively analyzed patients (N = 263) who received TL between 2004 and 2021. We collected clinical data for fever (>38.0 °C) and blood tests (WBC, CRP, albumin, Hb, neutrophils, lymphocytes) on postoperative days (POD) 3 and 7, and fistulography on POD 7. Clinical data were compared between fistula and no fistula groups, and significant factors were selected using machine learning. Using these clinical factors, we developed improved prediction models for PCF detection. Fistula occurred in 86 (32.7%) patients. Fever was significantly (p < 0.001) more common in the fistula group, and ratios (POD 7 to 3) of WBC, CRP, neutrophils, and neutrophils-to-lymphocytes (NLR) were significantly higher (all p ≤ 0.001) in the fistula group than in the no fistula group. Leakage on fistulography was more common in the fistula group (38.2%) than in the no fistula group (3.0%). The area under curve (AUC) of fistulography alone was 0.68, but predictive models using a combination of fistulography, WBC at POD 7, and neutrophil ratio (POD 7/POD 3) showed better diagnostic performance (AUC of 0.83). Our predictive models may detect PCF early and accurately, which could reduce fatal complications following PCF.

Inflammation-Based Score (Combination of Platelet Count and Neutrophil-to-Lymphocyte Ratio) Predicts Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES/HYPOTHESIS

Postoperative complications may depend on the systemic inflammatory response. We evaluated the predictive potential of the combination of platelet count and neutrophil-to-lymphocyte ratio (COP-NLR) for the incidence of pharyngocutaneous fistula (PCF) in patients who have undergone total laryngectomy.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients who underwent total laryngectomy between 2000 and 2020 were recruited from four hospitals. The correlations between the incidence of PCF and several risk factors, including the COP-NLR, were examined. Patients with both elevated platelet count and elevated neutrophil-to-lymphocyte ratio (NLR) were categorized as COP-NLR 2, and patients with either one or no abnormal values of both parameters were assigned as COP-NLR 1 and COP-NLR 0, respectively.

RESULTS

A total of 235 patients were identified. The overall incidence of PCF was 12.3%. The cut-off value for NLR before surgery was set at 3.95 (sensitivity = 58.6%, specificity = 69.4%, area under the curve [AUC] = 0.635), and the platelet count was set at 320 × 10⁹ /L (sensitivity = 27.6%, specificity = 87.9%, AUC = 0.571). Multivariate analysis revealed that COP-NLR was an independent risk factor for PCF (COP-NLR 1 vs. COP-NLR 0: odds ratio [OR], 4.17; 95% confidence interval [CI], 1.64 to 10.59; and COP-NLR 2 vs. COP-NLR 0: OR, 5.33; 95% CI, 1.38 to 20.56).

CONCLUSIONS

COP-NLR is a novel predictive factor for the development of PCF in patients undergoing total laryngectomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.