Early diagnosis of anastomotic leakage in colorectal surgery: prospective observational study of the utility of inflammatory markers and determination of pathological levels

Simultaneous incisional hernia repair and colorectal surgery: one or two-step procedure?

PURPOSE

Patients requiring colorectal surgery in the context of an incisional hernia are common, but it is not clear whether the repair should be performed as a single or two-step surgery. Our aim was to evaluate complications after concomitant abdominal wall repair and colorectal surgery compared to those after incisional hernia repair alone.

METHODS

Adult patients who underwent elective incisional hernia surgery from 2012-2022 from the EVEREG registry were included. Patients who underwent midline incisional hernia repair as a single procedure and patients who underwent midline incisional hernia repair concomitant with colorectal surgery were included. The primary outcome was surgical site infection (SSI). The secondary outcomes were the Clavien-Dindo classification grade, in-hospital mortality and recurrence.

RESULTS

A total of 7783 patients were included: 256(3.3%) who underwent concomitant surgery and 7527(96.7%) who underwent only midline incisional hernia repair. The first group included more comorbid patients and complex hernias. SSI was found in 55.4% of patients who underwent simultaneous surgery compared to 30.7% of patients who underwent hernia repair alone (P = 0.000). Multivariate analysis revealed that the risk factors for SSI were BMI (OR = 1.07, 95% CI 1.02-1.11; P = 0.004), smoking (OR = 1.89, 95% CI 1.12-3.19; P = 0.017), transverse diameter (OR = 1.06, 95% CI 1.01-1.11; P = 0.017), component separation (OR = 1.996, 95% CI 1.25-3.08; P = 0.037) and clean-contaminated and contaminated surgeries(OR = 3.86, 95% CI 1.36-10.66; P = 0.009). Higher grades of Clavien-Dindo (P = 0.001) and mortality rates (P < 0.001) were found in the colorectal surgery group, although specific risk factors were detected. No differences were observed in terms of recurrence (P = 0.104).

CONCLUSIONS

Concomitant surgery is related to greater risk of complications, especially in patients with comorbidities and complex hernias. In properly selected cases, simultaneous procedures can yield satisfactory results.

Procalcitonin as an Early Marker of Colorectal Anastomotic Leakage in Postoperative Colorectal Cancer Patients: A Systematic Review and Meta-Analysis

Background The timely identification of colorectal anastomotic leakage (CAL) is still a significant challenge, and identifying reliable markers is essential to minimize patient morbidity and mortality. While procalcitonin (PCT) has shown promise as a biomarker for CAL, its effectiveness must be specifically evaluated in colorectal cancer patients. This systematic review and meta-analysis sought to assess the mean differences in PCT levels between individuals with and without CAL who underwent colorectal surgery for colorectal cancer. Methodology A comprehensive search of the "PubMed," "Scopus," and "Web of Science" databases was carried out, covering studies published through April 2024. The objective was to identify studies examining PCT levels in colorectal cancer patients who underwent colorectal surgery, with a particular focus on the occurrence of CAL. Data on the mean of PCT levels in CAL and non-CAL patients were extracted from the selected studies. The mean differences in PCT levels were subsequently analyzed for each postoperative day (POD). Results Seventeen articles were selected for inclusion in this systematic review. The statistical analysis included five eligible articles that assessed PCT levels in groups exclusively involving patients with colorectal cancer. The findings showed no significant increase in PCT levels in CAL patients compared to non-CAL patients on any POD when a leave-one-out sensitivity analysis was performed to validate the results. Conclusions To date, PCT levels should not be regarded as early indicators of CAL after colorectal surgery in patients with colorectal cancer. Additional research is necessary to evaluate if PCT could be a dependable marker for CAL in this particular setting.

TAilored SToma policY after TME for rectal cancer: The TASTY approach

AIM

Diverting stomas are routinely used in restorative surgery following total mesorectal exicision (TME) for rectal cancer to mitigate the clinical risks of anastomotic leakage (AL). However, routine diverting stomas are associated with their own complication profile and may not be required in all patients. A tailored approach based on personalized risk of AL and selective use of diverting stoma may be more appropriate. The aim of the TAilored SToma policY (TASTY) project was to design and pilot a standardized, tailored approach to diverting stoma in low rectal cancer.

METHOD

A mixed-methods approach was employed. Phase I externally validated the anastomotic failure observed risk score (AFORS). We compared the observed rate of AL in our cohort to the theoretical, predicted risk of the AFORS score. To identify the subset of patients who would benefit from early closure of the diverting stoma using C-reactive protein (CRP) we calculated the Youden index. Phase II designed the TASTY approach based on the results of Phase I. This was evaluated within a second prospective cohort study in patients undergoing TME for rectal cancer between April 2018 and April 2020.

RESULTS

A total of 80 patients undergoing TME surgery for rectal cancer between 2016 and 2018 participated in the external validation of the AFORS score. The overall observed AL rate in this cohort of patients was 17.5% (n = 14). There was a positive correlation between the predicted and observed rates of AL using the AFORS score. Using ROC curves, we calculated a CRP cutoff value of 115 mg/L on postoperative day 2 for AL with a sensitivity of 86% and a negative predictive value of 96%. The TASTY approach was designed to allocate patients with a low risk AFORS score to primary anastomosis with no diverting stoma and high risk AFORS score patients to a diverting stoma, with early closure at 8-14 days, if CRP values and postoperative CT were satisfactory. The TASTY approach was piloted in 122 patients, 48 (39%) were identified as low risk (AFORS score 0-1) and 74 (61%) were considered as high risk (AFORS score 2-6). The AL rate was 10% in the low-risk cohort of patient compared to 23% in the high-risk cohort of patients, p = 0.078 The grade of Clavien-Dindo morbidity was equivalent. The incidence of major LARS was lowest in the no stoma cohort at 3 months (p = 0.014).

CONCLUSION

This study demonstrates the feasibility and safety of employing a selective approach to diverting stoma in patients with a low anastomosis following TME surgery for rectal cancer.

Diagnostic Modalities for Early Detection of Anastomotic Leak After Colorectal Surgery

INTRODUCTION

Anastomotic leak (AL) remains a severe complication following colorectal surgery, leading to increased morbidity and mortality, particularly in cases of delayed diagnosis. Existing diagnostic methods, including computed tomography (CT) scans, contrast enemas, endoscopic examinations, and reoperations can confirm AL but lack strong predictive value. Early detection is crucial for improving patient outcomes, yet a definitive and reliable predictive test, or "gold standard," is still lacking.

METHODS

A comprehensive PubMed review was focused on CT imaging, serum levels of C-reactive protein (CRP), and procalcitonin (PCT) to assess their predictive utility in detecting AL after colorectal resection. Three independent reviewers evaluated eligibility, extracted data, and assessed the methodological quality of the studies.

RESULTS

Summarized in detailed tables, our analysis revealed the effectiveness of both CRP and PCT in the early detection of AL during the postoperative period. CT imaging, capable of identifying fluid collection, pneumoperitoneum, extraluminal contrast extravasation, abscess formation, and other early signs of leak, also proved valuable.

CONCLUSIONS

Considering the variability in findings and statistics across these modalities, our study suggests a personalized, multimodal approach to predicting AL. Integrating CRP and PCT assessments with the diagnostic capabilities of CT imaging provides a nuanced, patient-specific strategy that significantly enhances early detection and management. By tailoring interventions based on individual clinical characteristics, surgeons can optimize patient outcomes, reduce morbidity, and mitigate the consequences associated with AL after colorectal surgery. This approach emphasizes the importance of personalized medicine in surgical care, paving the way for improved patient health outcomes.

Procalcitonin and C-reactive protein as early predictors in patients at high risk of colorectal anastomotic leakage

OBJECTIVE

To assess the diagnostic value of C-reactive protein (CRP) and procalcitonin (PCT) for anastomotic leakage (AL) following colorectal surgery.

METHODS

We retrospectively analyzed data for patients who underwent colorectal surgery at our hospital between November 2019 and December 2023. CRP and PCT were measured postoperatively to compare patients with/without AL, and changes were compared between low- and high-risk groups. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic accuracy of CRP and PCT to identify AL in high-risk patients.

RESULTS

Mean CRP was 142.53 mg/L and 189.57 mg/L in the low- and high-risk groups, respectively, on postoperative day (POD)3. On POD2, mean PCT was 2.75 ng/mL and 8.16 ng/mL in low- and high-risk patients, respectively; values on POD3 were 3.53 ng/mL and 14.86 ng/mL, respectively. The areas under the curve (AUC) for CRP and PCT on POD3 were 0.71 and 0.78, respectively (CRP cut-off: 235.64 mg/L; sensitivity: 96%; specificity: 89.42% vs PCT cut-off: 3.94 ng/mL; sensitivity: 86%; specificity: 93.56%; AUC: 0.78). The AUC, sensitivity, and specificity for the combined diagnostic ability of CRP and PCT on POD3 were 0.92, 90%, and 100%, respectively (cut-off: 0.44).

CONCLUSIONS

Combining PCT and CRP on POD3 enhances the diagnostic accuracy for AL.

A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy

BACKGROUND

The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy.

METHODS

In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance.

RESULTS

Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model.

CONCLUSIONS

This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.

Development and Validation of a Novel Nomogram Model for Early Diagnosis of Anastomotic Leakage After Laparoscopic Colorectal Cancer Surgery

Background: This study aimed to investigate the clinical value of inflammatory factors for predicting anastomotic leakage (AL) after laparoscopic colorectal cancer surgery and establish a nomogram model to assess the probability of its occurrence. Patients and Methods: Data of 637 patients who underwent laparoscopic colorectal cancer surgery between June 2019 and June 2022 were collected. Differences in procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) levels before surgery and on postoperative day (POD) 3 and 5 were compared between patients with and without AL (AL and non-AL groups, respectively). The diagnostic accuracy was determined using the area under the receiver operating characteristic curve (AUC), and a nomogram model was developed. Results: Post-operative AL occurred in 46 (7.2%) patients. Procalcitonin, CRP, and WBC levels on POD 3 and 5 were higher in the AL group than in the non-AL group. The AUCs of PCT, CRP, and WBC levels for predicting AL on POD 3 were 0.833, 0.757, and 0.756, respectively, which were better than those on POD 5 (AUC = 0.669, 0.581, and 0.588, respectively). The nomogram model for AL was developed based on five variables (PCT, CRP, WBC, American Society of Anesthesiologists [ASA] grade and comorbidities), and it had an AUC of 0.922. Calibration curves demonstrated that the nomogram had good fit. The Delong test showed that the AUC of the nomogram for predicting the probability of AL was higher than that of PCT alone (z = 2.311, p = 0.02). Conclusions: Procalcitonin measured on POD 3 seems to be a promising negative predictor of AL after laparoscopic colorectal cancer surgery. Furthermore, the nomogram model developed in our study, which utilizes a series of predictors that can be easily accessed, has demonstrated potential to further improve the prediction accuracy.

Systematic review of the significance of neutrophil to lymphocyte ratio in anastomotic leak after gastrointestinal surgeries

INTRODUCTION

The inflammatory response is thought to be a critical initiator of epigenetic alterations. The neutrophil to lymphocyte ratio (NLR), a biomarker of inflammation, is computed by dividing the number of neutrophils by the number of lymphocytes. The primary goal of this systematic review and meta-analysis was to evaluate the pre-operative NLR of gastrointestinal surgery patients who had an anastomotic leak (AL) in comparison to those who did not AL.

METHODS

We performed a comprehensive search for relevant papers published before May 4, 2022, using PubMed, Scopus, and Web of Science. Standardized mean difference (SMD) with a 95% confidence interval (CI) was pooled in meta-analysis to yield a summary estimate. We utilized the random-effects model to create pooled effects since we discovered a substantial heterogeneity level. For evaluating quality, the Newcastle-Ottawa scale (NOS) was implemented.

RESULTS

The research comprised 12 studies with a total of 2940 individuals who had GI operations, 353 of whom went on to develop AL. We discovered that patients who had GI surgeries and acquired AL had significantly higher NLR levels than those who did not (random-effects model: SMD = 0.75, 95% CI = 0.11-1.38, p = 0.02). Patients with AL showed significantly higher NLR levels than control group in retrospective studies (SMD = 0.93, 95% CI = 0.20-1.66, p=0.01) but not in prospective studies (SMD = - 0.11, 95% CI = - 0.65-0.43, p = 0.69), according to the subgroup analysis based on research design. Subgroup analysis based on ethnicity yielded that white patients with AL exhibited significantly higher NLR values than the control group (SMD = 1.35, 95% CI = 0.01-2.68, p = 0.04) but this result was not applied to East Asian patients (SMD = 0.14, 95% CI = -0.13-0.41, p = 0.29).

CONCLUSION

Our research suggests a potential association between preoperative NLR and postoperative AL. However, it is essential to acknowledge the variability in the findings, with significantly higher NLR levels observed in retrospective studies and among white patients, but not consistently replicated in prospective studies and among East Asian patients. Further investigations with larger and more diverse cohorts are warranted to validate these findings and explore potential factors contributing to the observed discrepancies.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.

Role of Damage-Associated Molecular Patterns (DAMPS) in the Postoperative Period after Colorectal Surgery

Anastomotic leakage (AL) is a defect of the intestinal wall at the anastomotic site and is one of the most severe complications in colorectal surgery. Previous studies have shown that the immune system response plays a significant role in the development of AL. In recent years, DAMPs (damage-associated molecular patterns) have been identified as cellular compounds with the ability to activate the immune system. The NLRP3 inflammasome plays an important role in the inflammatory responses which are mediated by DAMPs such as ATP, HSP proteins or uric acid crystals, when found in extracellular environments. Recent publications suggest that systemic concentration of DAMPs in patients with colorectal surgery may determine the inflammatory process and have a role in the occurrence of AL and other post-surgery complications. This review provides valuable knowledge about the current evidence supporting this hypothesis and highlights the possible role of these compounds in postoperative processes, which could open a new path to explore new strategies to prevent possible post-surgical complications.

Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study

Background

anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle.

Methods

Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle.

Results

The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05).

Conclusions

The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions.

Register study

The study has been registered at clinicaltrials.gov Code: nct04632446.

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.

An umbrella review of meta-analyses on diagnostic accuracy of C-reactive protein

BACKGROUND

Multiple studies and meta-analyses have reported the diagnostic value of C-reactive protein (CRP) in several diseases. However, the precision, and influence of potential bias regarding the diagnostic values of existing evidence may have implications for clinical practice.

METHODS

We performed an umbrella review of diagnostic test accuracy studies of CRP for diseases by searching PubMed, Embase, China National Knowledge Infrastructure, and WanFang databases up to March 7, 2021. Five independent reviewers evaluated eligibility, extracted data, and assessed methodological quality. We descriptively analyzed the diagnostic accuracy of CRP for multiple diseases, heterogeneity between studies, and publication bias.

RESULTS

Seventy-four meta-analyses were included, with 13 diseases classified according to the International Classification of Diseases-11 (ICD-11). The methodological quality of the included meta-analyses was mostly low, with only 16 meta-analyses rated as moderate or high, including seven diseases classified by ICD-11. CRP had a relatively greater diagnostic accuracy for two of these diseases. For postoperative infectious complications after bariatric surgery, sensitivity and specificity were 0.81 (0.34-1) and 0.91 (0.73-1), respectively. For anastomotic leakage after colorectal surgery, sensitivity and specificity were 0.95 (0.75-0.99) and 0.95 (0.75-0.99), respectively.

CONCLUSIONS

The diagnostic accuracy of CRP for multiple diseases has been extensively studied; however, most studies have low methodological quality. Evidence indicates that CRP has a relatively greater diagnostic accuracy for inflammation and infection diseases, especially for postoperative infectious complications after bariatric surgery and anastomotic leakage after colorectal surgery.