The role of preoperative C-reactive protein and procalcitonin as predictors of post-pancreaticoduodenectomy infective complications: A prospective observational study

Discharge C-reactive protein predicts 90-day readmission after pancreatoduodenectomy: a conditional inference tree analysis

BACKGROUND

The aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD).

METHODS

A two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission.

RESULTS

Of 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55-0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%-95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60-0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003).

CONCLUSION

CRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort.

TRIAL REGISTRATION

Our retrospective analysis did not require registration with a publicly accessible registry.

SURGICAL SITE INFECTION IN RESECTIONS OF DIGESTIVE SYSTEM TUMOURS

Postoperative infectious complications are extremely important to surgeons and the entire medical care team. Among these complications, surgical site infection (SSI) appears to be one of the earliest and most prevalent events and is considered an inherent complication of surgical procedures. In oncological patients submitted to resections of digestive system tumors, there is a confluence of several risk factors for SSI, making it necessary to establish measures to maximize the control of this condition to provide a better prognosis for these patients. Some risk factors for SSI are the manipulation of structures hosting the highest density of pathogenic microorganisms, such as the colon, the patient's performance status, the patient's nutritional status, the use of chemotherapy and/or radiotherapy, and the surgical procedure itself, which tends to last longer and be more complex than surgeries for benign conditions of the digestive system. Therefore, this review sought to provide a qualitative analysis and a summary of the literature regarding the SSI of postoperative tumor patients who underwent surgical resection and were well-structured postoperatively, to provide objective data on this problem, and alert about the well-structured needs of individualized pre-, peri-, and post-protocols to avoid the development of these events.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases

Purpose  Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases  We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion  Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.

Associations between a composite score of hemoglobin, CRP and albumin and physical performance in older patients undergoing gastrointestinal cancer surgery

BACKGROUND & AIMS

Abnormal levels of hemoglobin, C-reactive protein (CRP) and albumin are common in people with gastrointestinal cancer. The hypothesis was that this is of importance for physical performance in older persons in the perioperative context. Thus, the aim was to evaluate the association between hemoglobin, CRP and albumin and physical performance before and after abdominal cancer surgery in older patients.

METHODS

Patients ≥70 years of age scheduled for abdominal cancer surgery were invited to take part in the study. Data on levels of hemoglobin, CRP and albumin and physical performance (Six-Minute Walk Test, functional leg strength [chair-stands completed in 30 s], and maximal inspiratory muscle strength), were collected at baseline (n = 178) and physical performance was reassessed before discharge (n = 120). A composite score of 0-3 points was used, based on the presence or not of anemia, elevated CRP or hypoalbuminemia. Multivariable linear regressions were used for statistical analysis.

RESULTS

Before surgery, walking distance in patients scoring 2-3 (presence of 2 or 3 abnormal values) was shorter in comparison to patients scoring 0 (all values within normal range) in the multivariable model (-39.1 m; 95% CI -74.2, -3.9, p = 0.030). The number of chair stands performed during 30 s was lower in patients scoring 1 (-1.7; 95% CI -3.2, -0.2, p = 0.028) and 2-3 (-1.6; 95% CI -3.0, -0.1, p = 0.037) compared to patients scoring 0. No significant differences were seen between score groups and inspiratory muscle strength. After surgery, no differences were seen in walking distance or chair stands between patients with different scores.

CONCLUSIONS

Older patients with abnormal concentrations of hemoglobin, CRP and albumin before gastrointestinal cancer surgery showed impaired physical performance before surgery. Knowledge about potentially modifiable factors prior to cancer surgery increases the possibility to prepare the individual, which in turn might contribute to reduced morbidity and faster recovery after surgery.

Effect of Preoperative Biliary Stenting on Outcomes of Pancreaticoduodenectomy

Biliary drainage before pancreaticoduodenectomy was introduced to decrease morbidity from obstructive jaundice. Recent retrospective and randomised data show that preoperative biliary drainage (PBD) increases perioperative infectious complications. Most patients presenting to our tertiary care centre have undergone drainage procedures prior to surgical consultation. We analysed the impact of PBD, specifically endoscopic stent placement, on the postoperative outcome of pancreaticoduodenectomy at our centre. A cohort of 87 patients undergoing pancreaticoduodenectomy from 2012 to 2016 was identified. Data was collected retrospectively and a comparative analysis of stented and nonstented patients was done. Comparison of the 23 stented patients was done with 23 nonstented patients after matching them for age, sex and bilirubin levels. Median total bilirubin level in stented patients was 10.2 mg/dl versus 7.7 mg/dl in nonstented patients. The infectious complication rate in the stented group was 39.1% versus 12.7% in the nonstented group (P value < 0.05). There was no difference in the anastomotic leak rate between the two groups. Time to curative surgery in the stented group was significantly more than in the nonstented group. Stented patients are at a higher risk for postoperative infectious complications. Patients with obstructive jaundice awaiting surgery should undergo selective biliary drainage after careful planning and discussion between the operating surgeon and the endoscopist.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Centralisation of Pancreatoduodenectomy in India: Where Do We Stand?

BACKGROUND

The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact.

METHOD

A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded.

RESULTS

A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively).

CONCLUSION

With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.

Predictors of early postoperative pneumonia after oncologic surgery with the patients receiving professional oral health care: A prospective, multicentre, cohort study

This study was a prospective, multicentre, cohort study on 685 patients who had undergone oncologic surgery. The patients were divided into two groups according to the presence or absence of postoperative pneumonia. The two groups were compared with respect to their background, index operation, food eaten, oral condition, contents of oral care and dental treatment, laboratory data, and bacterial flora. All postoperative pneumonias occurred in six cases within four days postoperatively. The multivariable logistic regression analysis showed that preoperative serum C-reactive protein was the strongest predictor of postoperative pneumonia. In addition, decreased postoperative Candida albicans colonies was an effective predictor of postoperative pneumonia. For patients with predictors of postoperative pneumonia, perioperative strategies for its prevention should be considered in addition to professional oral health care. This study was approved by the National Hospital Organization's Central Ethics Review Board and was also approved by the directors of the participating institutions.

Risk Factors for Duodenal Stump Leakage after Laparoscopic Gastrectomy for Gastric Cancer

Purpose

Duodenal stump leakage (DSL) is a potentially fatal complication that can occur after gastrectomy, but its underlying risk factors are unclear. This study aimed to investigate the risk factors and management of DSL after laparoscopic radical gastrectomy for gastric cancer (GC).

Materials and Methods

Relevant data were collected from several prospective databases to retrospectively analyze the data of GC patients who underwent Billroth II (B-II) or Roux-en-Y (R-Y) reconstruction after laparoscopic gastrectomy from 2 institutions (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, and HwaMei Hospital, University of Chinese Academy of Sciences). The DSL risk factors were analyzed using univariate and multivariate analysis regression.

Results

A total of 810 patients were eligible for our analysis (426 with R-Y, 384 with B-II with Braun). Eleven patients had DSL (1.36%). Body mass index (BMI), elevated preoperative C-reactive protein (CRP) level, and unreinforced duodenal stump were the independent risk factors for DSL. DSL was diagnosed in 2–12 days, with a median of 8 days. Seven patients received conservative treatment, 3 patients received puncture treatment, and only 1 patient required reoperation. All patients recovered successfully after treatment.

Conclusions

The risk factors of DSL were BMI ≥24 kg/m², elevated preoperative CRP level, and unreinforced duodenal stump. Nonsurgical treatments for DSL are preferred.

Prediction of early C-reactive protein levels after non-cardiac surgery under general anesthesia

Background

Early detection of postoperative increase in C-reactive protein (CRP) correlates with postoperative complications. The present study examined the association between preoperative / intraoperative factors and postoperative CRP levels, with development and validation of a prediction model of early postoperative CRP level, for prophylactic management of postoperative complications in patients undergoing surgery under general anesthesia.

Material and methods

Multivariate regression analysis was retrospectively performed to determine the independent factor of CRP levels on postoperative day (POD) 1 and to develop a prediction model. Validation of the prediction model was prospectively performed. Data from 316 adult patients on perioperative variables were retrospectively obtained in a training cohort in patients undergoing elective non-cardiac surgery. In a validation cohort, 88 patients undergoing mastectomy and 68 patients undergoing laparoscopic colon surgery were prospectively utilized to evaluate the value of the prediction model. Major complications after surgery were defined as the Clavien-Dindo grade IIIa or greater.

Results

Duration of surgery, mean nociceptive response (NR) during surgery as intraoperative nociception level, and preoperative CRP level were selected to set up the prediction model of CRP level on POD1 (P < 0.0001). In the validation cohort, the predicted CRP levels on POD1 significantly correlated with the measured CRP after mastectomy (P < 0.0001) and laparoscopic colon surgery (P = 0.0001). Receiver-operating characteristic curve analysis showed that the predicted CRP levels on POD1 was significantly associated with major complications after mastectomy (P = 0.0259) and laparoscopic colon surgery (P = 0.0049). The measured and predicted CRP levels significantly increased in the order of severity of postoperative complications (P < 0.01).

Conclusion

Increases in duration of surgery, intraoperative nociceptive level and preoperative CRP level were selected to predict early increases in CRP level after non-cardiac surgery under general anesthesia. Predicted CRP levels on POD1 were likely associated with severity of postoperative complications.

Serum procalcitonin as a predictor of infectious complications after pancreaticoduodenectomy: review of the literature and our experience

Procalcitonin (PCT) is an early predictor of bacterial infection. We reviewed the literature and analyzed data on our own patients to assess the value of PCT as a predictor of infectious complications after pancreaticoduodenectomy (PD). The relevant literature published up until November 30, 2018, was reviewed, with no publication date restrictions. Letters to the editor and studies lacking necessary data were excluded. We also reviewed, retrospectively, the medical records of 77 patients who underwent PD between January, 2011 and April, 2016 at our hospital, to evaluate infectious complications and laboratory results on postoperative days (PODs) 1 and 3. Six studies were screened, and four cohort studies on patients undergoing PD were analyzed. One report examined preoperative PCT and C-reactive protein (CRP) levels, whereas the others examined only postoperative PCT and/or CRP levels. All reports demonstrated the usefulness of PCT as a predictor of postoperative infectious complications; however, no report concluded that PCT was a better predictor than CRP, except for the one report that examined preoperative PCT levels. Conversely, our experience demonstrated that the most significant factor predicting infectious complications was PCT on POD 3 (sensitivity, 0.87; specificity, 0.88). Thus, serum PCT could be a predictor of all complications, including infectious complications, after PD, but no advantage over CRP was identified.

A single preoperative blood test predicts postoperative sepsis and pneumonia after coronary bypass or open aneurysm surgery

BACKGROUND

Major surgery comes with a high risk for postoperative inflammatory complications. Preoperative risk scores predict mortality risk but fail to identify patients at risk for complications following cardiovascular surgery. We therefore assessed the value of preoperative red cell distribution width (RDW) as a predictor for pneumonia and sepsis after cardiovascular surgery and studied the relation of RDW with hematopoietic tissue activity.

METHODS

RDW is an easily accessible, yet seldomly used parameter from routine haematology measurements. RDW was extracted from the Utrecht Patient Orientated Database (UPOD) for preoperative measurements in patients undergoing open abdominal aortic anuerysm repair (AAA)(N = 136) or coronary artery bypass grafting (CABG)(N = 2193). The cohorts were stratified in tertiles to assess effects over the different groups. Generalized Linear Models were used to determine associations between RDW and postoperative inflammatory complications. Hematopoietic tissue activity was scored using fluor-18-(18F)-deoxyglucose positron emission tomography and associated with RDW using linear regression models.

RESULTS

In total, 43(31.6%) and 73 patients (3.3%) suffered from inflammatory complications after AAA-repair or CABG, respectively; the majority being pneumonia in both cohorts. Postoperative inflammatory outcome incidence increased from 19.6% in the lowest to 48.9% in the highest RDW tertile with a corresponding risk ratio (RR) of 2.35 ([95%CI:1.08-5.14] P = 0.032) in AAA patients. In the CABG cohort, the incidence of postoperative inflammatory outcomes increased from 1.8% to 5.3% with an adjusted RR of 1.95 ([95%CI:1.02-3.75] P = 0.044) for the highest RDW tertile compared with the lowest RDW tertile. FDG-PET scans showed associations of RDW with tissue activity in the spleen (B = 0.517 [P = 0.001]) and the lumbar bone marrow (B = 0.480 [P = 0.004]).

CONCLUSION

Elevated RDW associates with increased risk for postoperative inflammatory complications and hematopoietic tissue activity. RDW likely reflects chronic low-grade inflammation and should be considered to identify patients at risk for postoperative inflammatory complications following cardiovascular surgery.