C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection

CT prognostic signs of postoperative complications in emergency surgery for acute obstructive colonic cancer

PURPOSE

To identify CT prognostic signs of poor outcomes in acute obstructive colonic cancer (AOCC).

METHODS

Demographic, clinical, laboratory, radiological and surgical data of 65 consecutive patients with AOCC who underwent emergency surgery were analyzed. CT exams were reviewed to assess diameters of cecum, ascending, transverse, descending, and sigmoid proximal to the tumor; colon segments' CD/L1-VD ratios, continence of the ileocecal valve, small bowel overdistension, presence of small bowel feces sign and cecal pneumatosis. Post Operative complications (PO), according to the Clavien-Dindo classification, were analyzed.

RESULTS

Gender, age and location of the tumor were not predictive factors of complications. Among laboratory exams, CRP was the most important predictive value of PO (OR 8.23). A cecum distension ≥ 9 cm represented the critical diameter beyond which perforation and cecal necrosis were found at surgery. Cecal pneumatosis at CT was correlated with cecal necrosis at surgery in < 50% of patients. Pre-operative transverse colon CD/L1-VD ratio ≥ 1.43 and descending colon CD/L1-VD ratio ≥ 1.31 were associated with the development of PO (grade ≥ III-V). PO (grade ≥ III-V) occurred in 18/65 patients.

CONCLUSION

Postoperative complications in emergency surgery of AOCC were not related to the age, sex and tumor's location. Preoperative PCR values (≥ 2.17) predict the development of postoperative complications. CT resulted a valid diagnostic tool to identify patients at higher risk of complications: a CD/L1-VD ratios with cut-off values of 1.43 (transverse) and 1.31 (descending) predicted major complications (grade ≥ III-V) and a cecum distension ≥ 9 cm represented the critical diameter beyond which perforation occurred in > 84% of patients.

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.

Validity of C-Reactive Protein as a Surrogate Marker for Infectious Complications After Surgery for Colorectal Cancer

Abstract Background: This study aimed to establish a threshold of C-reactive protein (CRP) level for early detection of post-operative infectious complications after surgery for colorectal cancer. Patients and Methods: In this single-center, retrospective analysis, we studied the data of 178 patients who underwent surgery for colorectal cancer between January 2018 and February 2022. Elective surgery with curative intent was performed, and serum CRP levels were measured on five consecutive days after surgery. Receiver operating characteristic curves were utilized to assess the cutoff point of the CRP level with maximum predictive value, Results: A total of 59 cases of early post-operative complications, including pneumonia, wound infection, intra-abdominal infection, and anastomotic leakage were evaluated. During the monitoring period, patients with complications had higher CRP level than those without complications. The cutoff points on the five post-operative days were estimated to be 6.50, 10.83, 11.44, 6.67, and 5.71 mg/dL, respectively, and they were correlated to the occurrence of infectious complications. Higher CRP levels were associated with greater blood loss during surgery (p = 0.003) and increased length of hospital stay (p < 0.001) than did lower CRP levels. Conclusions: C-reactive protein monitoring in the early post-operative period is a cost-effective test that can be easily performed to predict the occurrence of infectious complications. It may be helpful in improving surgical outcomes, shortening the length of hospital stay and appropriate antibiotic administration.

C-REACTIVE PROTEIN AS POSTOPERATIVE COMPLICATIONS PREDICTOR OF COLORECTAL SURGERIES

BACKGROUND

The use of inflammatory markers in order to accurate the diagnosis, decrease the reoperation rate and enable earlier interventions during the postoperative period of a colorectal surgery is increasingly necessary, with the purpose of reducing morbimortality, nosocomial infections, costs and time of a readmission.

OBJECTIVE

To analyze C-reactive protein level on the third postoperative day of an elective colorectal surgery and compare the marks between reoperated and non-reoperated patients and to establish a cutoff value to predict or avoid surgical reoperations.

METHODS

Retrospective study based on the analysis of electronic charts of over 18-year-old patients who underwent an elective colorectal surgery with primary anastomoses during the period from January 2019 to May 2021 by the proctology team of Santa Marcelina Hospital Department of General Surgery with C-reactive protein (CRP) dosage taken on the third postoperative day.

RESULTS

We assessed 128 patients with a mean age of 59.22 years old and need of reoperation of 20.3% of patients, half of these due to dehiscence of colorectal anastomosis. Comparing CRP rates on the third postoperative day between non-reoperated and reoperated patients, it was noted that in the former group the average was of 153.8±76.2 mg/dL, whereas in reoperated patients it was 198.7±77.4 mg/dL (P<0.0001) and the best CRP cutoff value to predict or investigate reoperation risk was 184.8 mg/L with an accuracy of 68% and negative predictive value of 87.6%.

CONCLUSION

CRP levels assessed on the third postoperative day of elective colorectal surgery were higher in patients who were reoperated and the cutoff value for intra-abdominal complication of 184.8mg/L presented a high negative predictive value.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

A probabilistic model for the prediction of intra-abdominal infection after colorectal surgery

AIM

Predicting intra-abdominal infections (IAI) after colorectal surgery by means of clinical signs is challenging. A naïve logistic regression modeling approach has some limitations, for which reason we study two potential alternatives: the use of Bayesian networks, and that of logistic regression model.

METHODS

Data from patients that had undergone colorectal procedures between 2010 and 2017 were used. The dataset was split into two subsets: (i) that for training the models and (ii) that for testing them. The predictive ability of the models proposed was tested (i) by comparing the ROC curves from days 1 and 3 with all the subjects in the test set and (ii) by studying the evolution of the abovementioned predictive ability from day 1 to day 5.

RESULTS

In day 3, the predictive ability of the logistic regression model achieved an AUC of 0.812, 95% CI = (0.746, 0.877), whereas that of the Bayesian network was 0.768, 95% CI = (0.695, 0.840), with a p-value for their comparison of 0.097. The ability of the Bayesian network model to predict IAI does present significant difference in predictive ability from days 3 to 5: AUC(Day 3) = 0.761, 95% CI = (0.680, 0.841) and AUC(Day 5) = 0.837, 95% CI = (0.769, 0.904), with a p-value for their comparison of 0.006.

CONCLUSIONS

Whereas at postoperative day 3, a logistic regression model with imputed data should be used to predict IAI; at day 5, when the predictive ability is almost identical, the Bayesian network model should be used.

C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann–Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann–Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study

AIM

The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery.

METHODS

We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database.

RESULTS

The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy.

CONCLUSION

On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

The role of CRP in the diagnosis of postoperative complications in rectal surgery

Postoperative complications of rectal resections classified as grade III or higher according to Clavien-Dindo system, which also include anastomotic leaks, are usually life-threatening conditions. Delayed diagnosis may account for almost 18% of deaths. Due to nonspecific clinical signs in the early postoperative period, diagnosing these complications may truly be a challenge for clinicians. Nowadays, with the implementation of the ERAS protocol (enhanced recovery after surgery) and efforts concentrated on quickly delivered treatment to patients suffering from the above-mentioned complications, an appropriate marker with high specificity is required. Postoperative levels of C-reactive protein in blood serum seem promising in this aspect. The presented study aimed to determine the cut-off level of serum C-reactive protein as a possible predictive factor for early diagnosis of serious postoperative complications associated with rectal resections. This could also lead clinicians to the diagnosis of anastomotic leak after other possible options are ruled out. This study is a retrospective observational analysis of patients who underwent open resection of rectal cancer during a one-year period. Collected data included risk factors (age, gender, BMI, bowel preparation), record of complications and C Reactive Protein (CRP) serum levels. The study included 162 patients. Uncomplicated postoperative course was observed in 58 patients (35.8%). Complications were present in 104 cases (64.2%), including surgical site infections (16.7%) and anastomotic leak (9.9%). The mortality rate was 2.5%. Serum CRP threshold predicting relevant complications reached a sensitivity of 83.3% and specificity of 82.7% on POD 4, with a 175.4 mg/L cut-off value, burdened with a 95.7% negative predictive value. Postoperative serum C-reactive protein may be used as a good predictor of infectious complications, including anastomotic leaks. Measuring CRP levels in the early postoperative period may facilitate identification oflow-risk patients ensure early and safe discharges from hospital after rectal resections.

Early prediction of anastomotic leakage after laparoscopic rectal surgery using creactive protein

At present, anterior resection of the rectum or transabdominal rectal resection is the most common surgical technique for rectal cancer. Laparoscopic techniques are popular, and the efficacy and safety of laparoscopic rectal surgery have been confirmed. However, postoperative anastomotic leakage is a common, severe complication that leads to high mortality. Thus, early diagnosis of anastomotic leakage is important for reducing clinical consequences.The aim of this study was to determine whether C-reactive protein (CRP) is a good predictor of anastomotic leakage in laparoscopic transabdominal rectal resection.Our retrospective study involved a series of 196 rectal cancer patients who underwent laparoscopic transabdominal rectal resection without ileostomy between May 2013 and April 2015 at the Sir Run Run Shaw Hospital, Zhejiang University College of Medicine. The following patient data were collected: demographic data, manifestations of the complication, CRP levels and neutrophil percentage during the first 7 postoperative days.Anastomotic leakage was detected in 11 patients (5.6%). Each group showed significant differences (P < .05) in CRP levels on postoperative days 3 to 7; compared with other groups, the anastomotic leakage group showed significant differences in CRP levels (P < .05) on postoperative day 6. When patients were divided into groups with or without anastomotic leakage, CRP was a reliable predictor on postoperative days 4 to 7 (P < .05, area under the curve > 0.800). The best combination was CRP on postoperative day 6 (area under the curve = 0.932) with a cut-off of 76.6 mg/L, resulting in a sensitivity of 83.3%, a specificity of 94.6% and a negative predictive value of 99%.CRP is a reliable predictor of anastomotic leakage after laparoscopic transabdominal rectal resection surgery. High CRP levels on postoperative days 4 to 7 indicate the need for a more careful patient evaluation.

Infected versus sterile abdominal fluid collections in postoperative CT: a scoring system based on clinical and imaging findings

PURPOSE

Characterization of intraabdominal fluid collections as postoperative complication is a challenging task. The aim was to develop and validate a new score to differentiate infected from sterile postoperative abdominal fluid collections and to compare it with a published score.

MATERIALS AND METHODS

From May to November 2015, all patients with postoperative CT and C-reactive protein (CRP) 24 hours before CT-guided drainage were retrospectively included (Group A). HU, gas entrapment and wall enhancement of fluid collections were evaluated in the CT. All parameters were correlated with microbiology. To validate the score and to compare it with a published score, a second patient cohort was retrospectively recruited (Group B; January 2013-April 2015; December 2015-September 2016).

RESULTS

In Group A (50 patients), univariate analysis confirmed that the four parameters were significantly associated with infected fluid collections. Based on binary logistic regression analysis, a score from 0 to 11 was developed (CRP </≥ 150 mg/l: 0/4 points; HU </≥ 20: 0/2 points; wall enhancement no/yes: 0/2 points; gas entrapment no/yes: 0/3 points). The best cutoff to diagnose infected fluid collections was ≥ 5 points (sensitivity 85%, specificity 79%, PPV 82%, NPV 79%). In Group B (425 patients), this score yielded sensitivity, specificity, PPV and NPV of 93%, 80%, 90% and 86%, respectively. For the published score, values were in the same range (93%, 44%, 77%, 77%).

CONCLUSION

The score provides good discrimination between infected and sterile postoperative abdominal fluid collections. It yields comparable accuracy as the published score.

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.

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.

Use of ulinastatin was associated with reduced mortality in critically ill patients with sepsis

Background

Ulinastatin has anti-inflammatory properties and could potentially benefit critically ill septic patients. Nevertheless, clinical studies have yielded conflicting results. The present study examined the efficacy of ulinastatin in intensive care unit (ICU) patients with sepsis and/or septic shock.

Methods

All septic patients admitted to the ICU of Wuhu No. 2 People's Hospital between 2014 and 2017 were screened for potential eligibility for this retrospective study. The primary outcome was 28-day mortality, and its correlation with ulinastatin was assessed using multiple logistic regression models.

Results

The study included 263 patients, with an overall 28-day mortality of 38%. Patients receiving ulinastatin showed significantly lower mortality than the control patients (31% vs. 55%; P<0.001). Ulinastatin use was associated with significantly reduced risk of death (OR: 0.317, 95% CI: 0.158-0.621; P=0.001) after adjustment for age, Sequential Organ Failure Assessment score, vasopressor use, and patient type as determined with a multivariable regression model.

Conclusions

Treatment with ulinastatin was associated with a decrease in 28-day mortality in critically ill septic patients.

Should They Stay or Should They Go? The Utility of C-Reactive Protein in Predicting Readmission and Anastomotic Leak After Colorectal Resection

BACKGROUND

Hospital readmission and anastomotic leak following colorectal resection have a negative impact on patients, surgeons, and the health care system. Novel markers of patients unlikely to experience these complications are of value in avoiding readmission.

OBJECTIVE

This study aimed to determine the predictive value of C-reactive protein for readmission and anastomotic leak within 30 days following colorectal resection.

DESIGN

This is a retrospective review of a prospectively compiled single-institution database.

PATIENTS

From January 1, 2013, to July 20, 2017, consecutive patients undergoing elective colorectal resection with anastomosis without the presence of proximal intestinal stoma, who had C-reactive protein measured on postoperative day 3, were included.

MAIN OUTCOME MEASURES

The primary outcome measured was the predictive value of C-reactive protein measured on postoperative day 3 for readmission or anastomotic leak within 30 days after colorectal resection.

RESULTS

Of the 752 patients examined, 73 (10%) were readmitted within 30 days of surgery and 17 (2%) had an anastomotic leak. Mean C-reactive protein in patients who neither had an anastomotic leak nor were readmitted (127 ± 77 mg/L) was lower than for patients who were readmitted (157 ± 96 mg/L, p = 0.002) and lower than for patients who had an anastomotic leak (228 ± 123 mg/L, p = 0.0000002). The area under the receiver operating characteristic curve for the diagnostic accuracy of C-reactive protein for readmission was 0.59, with a cutoff value of 145 mg/L, generating a 93% negative predictive value. The area under the curve for the diagnostic accuracy of C-reactive protein for anastomotic leak was 0.76, with a cutoff value of 147 mg/L generating a 99% negative predictive value.

LIMITATIONS

This study was limited by its retrospective design and because all patients were treated at a single center.

CONCLUSIONS

Patients with a C-reactive protein below 145 mg/L on postoperative day 3 after colorectal resection have a low likelihood of readmission within 30 days, and a very low likelihood of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A761.

Use of inflammatory markers in the early detection of infectious complications after laparoscopic colorectal cancer surgery with the ERAS protocol

Introduction

Thanks to laparoscopy and enhanced recovery protocols (ERAS) it is possible to shorten hospitalization. Therefore, it seems reasonable to search for new early markers of infectious complications in order to select patients who are prone to development of complications.

Aim

To assess the usefulness of serum levels of C-reactive protein, interleukin-6 and procalcitonin as early indicators of infectious complications in patients after laparoscopic colorectal surgery with ERAS.

Material and methods

The prospective analysis included consecutive patients who underwent laparoscopic colorectal cancer resection. The following parameters were included in the analysis: C-reactive protein (CRP), interleukin 6 (IL-6) and procalcitonin measured on postoperative days (PODs) 1, 2, 3. Patients were divided into two groups: uncomplicated (group 1) and complicated (group 2). The difference in levels of the markers and the dynamics of changes observed in both groups were analyzed.

Results

Group 1 comprised 34 patients, and group 2 consisted of 17 patients. A significant increase of both absolute values and delta increments on all postoperative days was noted. ROC curve analysis showed that the best cut-off values indicating an infectious process were: CRP 129 mg/l on POD3 (92% sensitivity/80% specificity), IL-6 of 78 pg/ml on POD2 (91% sensitivity/97% specificity) and PCT 0.24 ng/ml on POD3 (93% sensitivity/68% specificity).

Conclusions

Our study showed that regular measurement of all analyzed markers in the early postoperative days may be beneficial in the detection of postoperative infectious complications. Further studies are needed to fully assess the role of routine biochemical measurements in the postoperative period after laparoscopic surgery with the ERAS protocol.

A new dimensional-reducing variable obtained from original inflammatory scores is highly associated to morbidity after curative surgery for colorectal cancer

PURPOSE

Several scores have been developed to define the inflammatory status of oncological patients. We suspect they share iterative information. Our hypothesis is that we may summarise their information into one or two new variables which will be independent. This will help us to predict, more accurately, which patients are at an increased risk of suffering postoperative complications after curative surgery for CRC.

METHODS

Observational prospective study with those patients undergoing curative surgery for CRC between September 2015 and February 2017. We analysed the influence of inflammatory scores (PNI, GPS, NLR, PLR) on postoperative morbidity (overall and severe complications, anastomotic leakage and reoperation).

RESULTS

Finally, 168 patients were analysed. We checked these four original scores are interrelated among them. Using a complex and innovative statistical method, we created two new independent variables (resultant A and resultant B) which resume the information coming from them. One of these two new variables (resultant A) was statistically associated to overall complications (OR, 2.239; 95% CI, 1.541-3.253; p = 0.0001), severe complications (OR, 1.773; 95% CI, 1.129-2.785; p = 0.013), anastomotic leakage (OR, 3.208; 95% CI, 1.416-7.268; p = 0.005) and reoperation (OR, 2.349; 95% CI, 1.281-4.305; p = 0.006).

CONCLUSIONS

We evinced the four original scores we used share redundant information. We created two new independent new variables which resume their information. In our sample of patients, one of these variables turned out to be a great predictive factor for the four complications we analysed.

Early Inflammatory Biomarkers as Predictive Factors for Freedom from Infection after Colorectal Cancer Surgery: A Prospective Cohort Study

PURPOSE

Different biomarkers are useful in diagnosing infections. The aim of this work was to clarify the relation between different inflammatory biomarkers (white blood cell [WBC] count, C-reactive protein [CRP], procalcitonin [PCT], and C-reactive protein-to-albumin ratio [CAR]) and early infectious complications after colorectal surgery.

METHODS

This prospective single-center cohort study included 130 patients undergoing elective colorectal surgery. The WBC count, CRP, and PCT were measured at post-operative day one (POD1) and POD3 and albumin on POD3.

RESULTS

Patients with surgical site infections (SSI) exhibited significantly higher CRP concentrations on POD1 and CRP and CAR on POD3 than did patients without SSI. According to receiver operating characteristic analysis, the CRP concentration on POD1 and the CRP and CAR on POD3 showed the highest area under the curve (AUC) for predicting SSI (AUC 0.639, 0.736, and 0.729, respectively). Multivariable logistic regression analysis showed that CRP on POD1 and CRP and CAR on POD3 were independent predictors of SSI (odds ratio 7.355, 7.605, and 8.337, respectively).

CONCLUSIONS

The CRP concentration on PO1 and CRP and CAR on POD3 can positively identify patients at low risk of SSI. They can be used as a prognostic tool to predict an uneventful post-operative period and therefore have been incorporate into our discharge criteria after elective colorectal resection, improving clinical decision-making.

Procalcitonin and C-reactive protein as early markers of anastomotic leak after laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) program

BACKGROUND

C-reactive protein (CRP) and procalcitonin (PCT) have been described as good predictors of anastomotic leak after colorectal surgery, obtaining the highest diagnostic accuracy on the 5th postoperative day. However, if an enhanced recovery after surgery (ERAS) program is performed, early predictors are needed in order to ensure a safe and early discharge. The aim of this study was to investigate the efficacy of CRP, PCT, and white blood cell (WBC) count determined on first postoperative days, in predicting septic complications, especially anastomotic leak, after laparoscopic colorectal surgery performed within an ERAS program.

METHODS

We conducted a prospective study including 134 patients who underwent laparoscopic colorectal surgery within an ERAS program between 2015 and 2017. The primary endpoint investigated was anastomotic leak. CRP, PCT, and WBC count were determined in the blood sample extracted on postoperative day 1 (POD 1), POD 2 and POD 3.

RESULTS

Anastomotic leak (AL) was detected in 6 patients (4.5%). Serum levels of CRP and PCT, but not WBC, determined on POD 1, POD 2, and POD 3 were significantly higher in patients who had AL in the postoperative course. Using ROC analysis, the best AUC of the CRP and PCT levels was on POD 3 (0.837 and 0.947, respectively). A CRP cutoff level at 163 mg/l yielded 85% sensitivity, 80% specificity, and 99% negative predictive value (NPV). A PCT cutoff level at 2.5 ng/ml achieved 85% sensitivity, 95% specificity, 44% positive predictive value, and 99% NPV.

CONCLUSIONS

CRP and PCT are relevant markers for detecting postoperative AL after laparoscopic colorectal surgery. Furthermore, they can ensure an early discharge with a low probability of AL when an ERAS program is performed.

Neopterin, kynurenine and tryptophan as new biomarkers for early detection of rectal anastomotic leakage

Introduction

At present, there are no strong predictors, nor a useful scoring system, that clearly identifies patients at risk for anastomotic leakage.

Aim

This study aimed to investigate a new method that assesses this risk by monitoring levels of neopterin, tryptophan, and kynurenine, in bodily fluids.

Material and methods

This prospective study included patients who underwent elective rectal resection for carcinoma. The basic condition for inclusion was rectal anastomosis using the double-stapling technique. Preoperative levels of neopterin, tryptophan, kynurenine, and their ratios, were assessed with blood and urine samples. These levels were then monitored for 6 postoperative days in venous blood, urine, and abdominal drainage fluid.

Results

A total of 42 patients were enrolled in the study. Thirty-six patients underwent a laparoscopic resection and 6 patients had an open procedure. No differences were found among neopterin, tryptophan, and kynurenine serum levels. However, the groups were observed to have significant differences in the urinary neopterin/creatinine ratio: the preoperative neopterin/creatinine ratio was 139.5 μmol/mol in the group with leakage, vs 114.8 μmol/mol in the group without complications, p = 0.037. The same results were observed during the postoperative period, p = 0.012. Additionally, the group with complications had a higher mean value of neopterin in drainage fluid, p = 0.048.

Conclusions

Our study demonstrated that high preoperative levels of urinary neopterin could be interpreted as a risk for anastomotic leakage. Moreover, pathological levels of neopterin in urine and abdominal drainage fluid could be useful for early identification of anastomotic leakage during the postoperative period prior to its clinical development.

Systematic review and meta-analysis of the use of serum procalcitonin levels to predict intra-abdominal infections after colorectal surgery

PURPOSE

There has been much recent interest in the use of procalcitonin (PCT) as a marker of intra-abdominal infection (IAI) following colorectal surgery. However, the literature remains divided on the value of PCT in this setting. This meta-analysis aims to evaluate the value of PCT in predicting IAI after colorectal surgery.

METHODS

Systemic literature search was performed using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews to identify studies evaluating the diagnostic accuracy of PCT as a predictor for detecting IAI on postoperative days (POD) 3 to 5 following colorectal surgery. A meta-analysis was performed using random effect model and pooled predictive parameters as well as cut-off values for POD 3 to 5 were derived.

RESULTS

Eight studies consisting 1629 patients were included. The pooled prevalence of IAI was 5.7% on POD 3, 9.7% on POD 4, and 6.3% on POD 5. The pooled AUC for POD 3 to 5 were 0.83 (95% CI 0.78-0.88), 0.79 (95% CI 0.64-0.93), and 0.94 (95% CI 0.91-0.97), respectively. The derived PCT cut-off values were 1.45 ng/ml on POD 3, 1.28 ng/ml on POD 4, and 1.26 ng/ml on POD 5. PCT had the highest diagnostic capability on POD 5 with diagnostic odds ratio of 32.9 (95% CI 15.01-69.88), sensitivity of 0.78 (95% CI 0.65-0.89), and specificity of 0.88 (95% CI 0.85-0.90).

CONCLUSIONS

PCT is a useful diagnostic predictor of IAI after colorectal surgery. It has the greatest diagnostic accuracy on POD 5 and can help guide safe discharge of patients after colorectal surgery.

[Postoperative C-reactive protein is a reliable marker to detect complications after radical cystectomy]

PURPOSE

Postoperative serum C-reactive protein (CRP) can be measured after major abdominal surgery to predict of complications at postoperative day (POD) 4. However, in urology, no studies have been conduced to analyze the role of CRP after radical cystectomy. The present study aims to analyze the relationship between a high postoperative level of CRP and the presence of complications after radical cystectomy for cancer.

MATERIALS AND METHODS

This multicenter retrospective study included 313 patients treated with radical cystectomy for cancer between January 2013 and July 2016. Among the patients, 57.5% of patients received urinary diversion using a Bricker ileal conduit, 30.5% an orthotropic ileal neobladder, and 11.5% had an ureterocutaneostomy.

RESULTS

Three hundred and thirteen patients were included (mean age 68.1±9.2 years). Among the patients, 26.5% had grade≥2 complications, according to the Clavien-Dindo classification. In multivariate analysis, only CRP level at POD 4 predicted the risk of a complication (P<0.001). CRP>150mg/L at POD 4 was strongly associated with a risk of a postoperative complication after a cystectomy (OR=81.42, 95% CI [25.6-258.3], P<0.001). CRP assessed on POD4 was reliable at ruling out the existence of an infectious complications with a negative predictive value of 0.94. The main limitation of our study was it observational design.

CONCLUSIONS

CRP at POD4 with a threshold of 150mg/L would reliably predict the risk of postoperative complications after cystectomy. Monitoring postoperative CRP could help adapt rehabilitation protocols after radical cystectomy and also the early management of complications.

C-reactive protein as a marker of the surgical stress reduction within an ERAS protocol (Enhanced Recovery After Surgery) in colorectal surgery: A prospective cohort study

BACKGROUND

The aim of this study is to evaluate the effectiveness of an Enhanced Recovery After Surgery Protocol (ERAS) in relation to reduce the Systemic Inflammatory Response (SIR) to surgery using C-reactive protein (CRP) in the first (POD1), second (POD2) and third (POD3) postoperative day.

METHODS

We enrolled 121 patients (ERAS group) that underwent elective colorectal surgery with ERAS, and compared them with 135 patients (preERAS group) that had undergone surgery prior to the implementation. We made a univariate analysis to compare the CRP values in POD1, POD2, and POD3 between preERAS/ERAS group, laparoscopic/open surgery and the presence or not of Clavien Dindo complications. Multivariable lineal regression was used to assess if the ERAS had a decreasing effect on the CRP in POD1, POD2, and POD3, and was adjusted by age, male sex, use of laparoscopy, and complications.

RESULTS

The presence of complications was independently associated with an increase in CRP values ​​in POD1, POD2, and POD3. Laparoscopy in POD1 and POD2, and ERAS in POD2 was independently associated with a decrease in CRP values.

CONCLUSION

The analysis shows an increase in SIR measured as a CRP value in those patients that had complications. The SIR decreased with laparoscopy in POD1 and POD2 and with ERAS in POD2.

Impact of angiotensin-converting enzyme 2 levels on postoperative pneumonia after esophagectomy

BACKGROUND

Pulmonary complications after esophagectomy are often fatal. The prediction of postoperative pulmonary complications remains a challenge. Accumulating evidence demonstrates a physiological and pathological role for angiotensin-converting enzyme 2 (ACE2) in the respiratory system. The purpose of this study was to evaluate the predictive value of ACE2 levels for the development of postoperative pneumonia.

METHODS

To evaluate the association between serum ACE2 levels and pneumonia after esophagectomy, we retrospectively reviewed the medical records of 80 patients who underwent thoracoscopic esophagectomy for esophageal cancer from 2009 to 2014.

RESULTS

Nineteen patients (23.8%) developed pneumonia after esophagectomy. Patients with pneumonia had significantly higher levels of ACE2 from the preoperative day to postoperative day (POD) 3, white blood cell count (POD7), and C-reactive protein (POD3, POD5, and POD7) than patients without pneumonia. Patients with postoperative pneumonia had higher serum ACE2 levels on POD3 than patients without pneumonia.

CONCLUSIONS

The elevation of ACE2 levels on POD3 may predict the incidence of pneumonia.

C-reactive protein in predicting major postoperative complications are there differences in open and minimally invasive colorectal surgery? Substudy from a randomized clinical trial

BACKGROUND

In search of improvement of patient assessment in the postoperative phase, C-reactive protein (CRP) is increasingly being studied as an early marker for postoperative complications following major abdominal surgery. Several studies reported an attenuated immune response in minimally invasive surgery, which might affect interpretation of postoperative CRP levels. The aim of the present study was to compare the value of CRP as a predictor for major postoperative complications in patients undergoing open versus laparoscopic colorectal surgery.

METHODS

A subgroup analysis from a randomized clinical trial (LAFA-trial) was performed, including all patients with non-metastasized colorectal cancer. In the LAFA trial, patients were randomized to open or laparoscopic segmental colectomy. In a subgroup of 79 patients of the LAFA trial, postoperative assessment of CRP levels was conducted routinely preoperatively and 1, 2, 24 and 72 h after surgery.

RESULTS

Thirty-seven patients were randomized to the open group and 42 patients to the laparoscopic group. Major complications occurred in 19% of laparoscopic procedures and 13.5% of open procedures (p = 0.776). CRP levels rise following surgical procedures. In uncomplicated cases, the rise in CRP levels was significantly lower at 24 and 72 h following laparoscopic resection in comparison to open resection. No differences in CRP levels were observed when comparing open and laparoscopic resection in patients with major complications.

CONCLUSION

In patients with an uncomplicated postoperative course, CRP levels were lower following minimally invasive resection, possibly due to decreased operative trauma. No differences in CRP were observed stratified for surgical technique in patients with major complications. These results suggest that CRP may be applied as a marker for major postoperative complications in both open and minimally invasive colorectal surgery. Future research should aim to assess the role of standardized postoperative CRP measurements.

C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer

AIM

Anastomotic leak (AL) after anterior resection results in increased morbidity, mortality and local recurrence. The aim of this study was to assess the ability of C-reactive protein (CRP) to predict AL in the first week after anterior resection for rectal cancer.

METHOD

A retrospective review of a prospectively maintained database that included all patients undergoing anterior resection between January 2008 and December 2013 was performed. The ability of CRP to predict AL was assessed using area under the receiver-operating characteristics (AUC) curves. The severity of AL was defined using the International Study Group of Rectal Cancer (ISREC) grading system.

RESULTS

Two-hundred and eleven patients were included in the study. Statistically significant differences in mean CRP values were found between those with and without an AL on postoperative days 5, 6 and 7. A CRP value of 132 mg/l on postoperative day 5 had an AUC of 0.75, corresponding to a sensitivity of 70%, a specificity of 76.6%, a positive predictive value of 16.3% and a negative predictive value of 97.5%. Multivariable analysis found that a CRP of > 132 mg/l on postoperative day 5 was the only statistically significant patient factor that was linked to an increased risk of AL (HR = 8.023, 95% CI: 1.936-33.238, P = 0.004).

CONCLUSION

Early detection of AL may minimize postoperative complications. CRP is a useful negative predictive test for the development of AL following anterior resection.

A review of recent advances in data analytics for post-operative patient deterioration detection

Most deaths occurring due to a surgical intervention happen postoperatively rather than during surgery. The current standard of care in many hospitals cannot fully cope with detecting and addressing post-surgical deterioration in time. For millions of patients, this deterioration is left unnoticed, leading to increased mortality and morbidity. Postoperative deterioration detection currently relies on general scores that are not fully able to cater for the complex post-operative physiology of surgical patients. In the last decade however, advanced risk and warning scoring techniques have started to show encouraging results in terms of using the large amount of data available peri-operatively to improve postoperative deterioration detection. Relevant literature has been carefully surveyed to provide a summary of the most promising approaches as well as how they have been deployed in the perioperative domain. This work also aims to highlight the opportunities that lie in personalizing the models developed for patient deterioration for these particular post-surgical patients and make the output more actionable. The integration of pre- and intra-operative data, e.g. comorbidities, vitals, lab data, and information about the procedure performed, in post-operative early warning algorithms would lead to more contextualized, personalized, and adaptive patient modelling. This, combined with careful integration in the clinical workflow, would result in improved clinical decision support and better post-surgical care outcomes.

Inflammatory markers as early predictors of infection after colorectal surgery: the same cut-off values in laparoscopy and laparotomy?

PURPOSE

C-reactive protein and procalcitonin are reliable early predictors of infection after colorectal surgery. However, the inflammatory response is lower after laparoscopy as compared to open surgery. This study analyzed whether a different cutoff value of inflammatory markers should be chosen according to the surgical approach.

METHODS

A prospective, observational study included consecutive patients undergoing elective colorectal surgery in three academic centers. All infections until postoperative day (POD) 30 were recorded. The inflammatory markers were analyzed daily until POD 4. Areas under the ROC curve and diagnostic values were calculated in order to assess their accuracy as a predictor of intra-abdominal infection.

RESULTS

Five-hundred-one patients were included. The incidence of intra-abdominal infection was 11.8%. The median levels of C-reactive protein (CRP) and procalcitonin (PCT) were lower in the laparoscopy group at each postoperative day (p < 0.0001). In patients without intra-abdominal infection, they were also lower in the laparoscopy group (p = 0.0036) but were not different in patients presenting with intra-abdominal infections (p = 0.3243). In the laparoscopy group, CRP at POD 4 was the most accurate predictor of overall and intra-abdominal infection (AUC = 0.775). With a cutoff of 100 mg/L, it yielded 95.7% negative predictive value, 75% sensitivity, and 70.3% specificity for the detection of intra-abdominal infection.

CONCLUSION

The impact of infection on inflammatory markers is more important than that of the surgical approach. Defining a specific cutoff value for early discharge according to the surgical approach is not justified. A patient with CRP values lower than 100 mg/L on POD 4 can be safely discharged.

Clinical evaluation of C-reactive protein and procalcitonin for the early detection of postoperative complications after laparoscopic sleeve gastrectomy

INTRODUCTION

Among the most common early complications after bariatric surgery are anastomosis leak and bleeding. In order to react quickly and perform accurate treatment before the clinical signs appear, early predictors should be found. In the study C-reactive protein (CRP) and procalcitonin (PCT) levels were investigated. Characterized by a relatively short half-life, they can predict surgical complications.

AIM

To develop and implement certain standards for early detection of complications.

MATERIAL AND METHODS

The study involved 319 adults who underwent laparoscopic sleeve gastrectomy (LSG) as a surgical intervention for morbid obesity at the Department of General Surgery of Ceynowa Hospital in Wejherowo. Every patient had CRP and PCT levels measured before the surgery and on the 1^st and 2^nd postoperative day (POD).

RESULTS

Early postoperative complications occurred in 19 (5.96%) patients. Septic and non-septic complications occurred in 3 and 16 patients respectively. Among the patients with septic postoperative complications CRP level increased significantly on the 2^nd POD compared to the remainder (p = 0.0221). Among the patients with non-septic postoperative complications CRP level increased significantly on the 1^st and 2^nd POD compared to the remainder. Among the patients with septic and non-septic postoperative complications PCT level increased significantly on the 2^nd POD compared to the remainder.

CONCLUSIONS

The CRP and PCT level are supposed to be relevant diagnostic markers to predict non-septic and septic complications after LSG.

C-Reactive Protein Was an Early Predictor of Postoperative Infectious Complications After Pancreaticoduodenectomy for Pancreatic Cancer

Objective

The study objective was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications (PICs) after pancreaticoduodenectomy.

Summary of Background Data

The incidence of PICs after pancreaticoduodenectomy still remains high and a clinically relevant problem, despite improvements in the surgical procedure.

Methods

We examined 110 consecutive patients who underwent pancreaticoduodenectomy for primary pancreatic cancer between 2006 and 2014. The predictive value was assessed by estimating the area under the receiver operating characteristic curve (AUC). Clinical and laboratory data, including CRP, were analyzed with univariate and multivariate logistic regression analyses to identify predictors of PICs of grade III or higher according to the Clavien-Dindo classification.

Results

PICs of grade III or higher occurred in 13 patients [11.8%; 95% confidence interval (CI), 6.45%–19.36%]. CRP level on postoperative day 3 (POD 3) was a good predictor of PICs (AUC, 0.815; 95% CI, 0.651–0.980), showing the highest accuracy among clinical and laboratory data. A cutoff value of 13.2 mg/dL yielded a sensitivity of 0.846 and a specificity of 0.794. On multivariate analysis, a POD 3 CRP level of 13.2 mg/dL or higher (odds ratio, 20.0; 95% CI, 4.07–97.9; P = 0.002) was a significant predictor of PICs after pancreaticoduodenectomy.

Conclusions

CRP elevation above 13.2 mg/dL on POD 3 is a significant predictive factor for PICs and should prompt an intense clinical search and therapeutic approach for PICs.

Value of procalcitonin as a biomarker for postoperative hospital-acquired pneumonia after abdominal surgery

Background

Hospital-acquired pneumonia (HAP) is a common complication after abdominal surgery. The aim of this study was to evaluate the role of procalcitonin (PCT) and C-reactive protein (CRP) as early biomarkers for the diagnosis of postoperative HAP after abdominal surgery.

Methods

This study was conducted on 100 patients undergoing abdominal surgery. White blood cell counts, highest body temperature, and serum levels of CRP and PCT were recorded preoperatively and daily postoperatively until postoperative day (POD) 5. Chest radiography was performed preoperatively and daily postoperatively until POD 5.

Results

HAP was diagnosed in 14% of patients. Regarding the biomarkers studied after POD 1, CRP and PCT were significantly higher in patients with HAP than in those without HAP (P < 0.05). On POD 2, PCT had higher sensitivity and specificity (84% and 72%, respectively) than those for CPR (70% and 60%, respectively). The cut-off value of PCT on POD 2 was 1.4 ng/ml. On POD 3, 4, and 5, the sensitivity and specificity of PCT and CRP were not significantly different.

Conclusions

PCT and CRP are accurate biomarkers for early prediction of postoperative HAP after abdominal surgery. The diagnostic ability of PCT was significantly better than that of CRP on POD 2. After POD 2, the diagnostic ability was not significantly different between the biomarkers.

Biomarkers and anastomotic leakage in colorectal surgery: C-reactive protein trajectory is the gold standard

BACKGROUND

Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak.

METHODS

C-reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma-glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post-operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers.

RESULTS

A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma-glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961.

CONCLUSION

This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study.

Predicting Value of Serum Procalcitonin, C-Reactive Protein, Drain Fluid Culture, Drain Fluid Interleukin-6, and Tumor Necrosis Factor-α Levels in Anastomotic Leakage after Rectal Resection

BACKGROUND

Anastomotic leak is the most dreaded septic complication of colorectal surgical procedures. Death is proportional to the time between occurrence and diagnosis of the leakage. Biomarkers, which may help to predict anastomotic leakage before appearance of its clinical features, may be beneficial in preventing adverse outcomes. This study investigates a biomarker that might be useful to predict rectal anastomotic leakage before its clinical presentation.

PATIENTS AND METHODS

Serum procalcitonin and C-reactive protein (CRP) levels, bacterial proliferation, interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels of drain fluid were evaluated in 50 consecutive patients who underwent low anterior resection without diverting ostomy for rectal carcinoma.

RESULTS

Anastomotic leakage occurred in seven of 50 (14%) patients. Serum CRP and procalcitonin levels at post-operative day three were higher in patients with anastomotic leakage (p = 0.01, p = 0.02 respectively). Drain TNF-α values were increased 63.2% on post-operative day five when compared with post-operative day three in patients with anastomotic leakage, but were decreased in patients without leakage. There was no statistical difference for drain IL-6 levels between groups. The bacterial proliferation rate of drain fluid culture in the leakage group was 42.9% at post-operative day three and 85.7% at post-operative day five (p = 0.29 and p = 0.0001, respectively).

CONCLUSIONS

High serum CRP and procalcitonin values on post-operative day three are alarming, and assessment of anastomotic leakage by abdominal imaging with rectal contrast is suggested. In addition, increasing levels of TNF-α and bacterial proliferation in drain fluid are predictive, whereas IL-6 is not.

Procalcitonin Reveals Early Dehiscence in Colorectal Surgery: The PREDICS Study

OBJECTIVES

We designed a multicentric, observational study to test if Procalcitonin (PCT) might be an early and reliable marker of anastomotic leak (AL) after colorectal surgery (ClinicalTrials.govIdentifier:NCT01817647).

BACKGROUND

Procalcitonin is a biomarker used to monitor bacterial infections and guide antibiotic therapy. Anastomotic leak after colorectal surgery is a severe complication associated with relevant short and long-term sequelae.

METHODS

Between January 2013 and September 2014, 504 patients underwent colorectal surgery, for malignant colorectal diseases, in elective setting. White blood count (WBC), C-reactive protein (CRP) and PCT levels were measured in 3rd and 5th postoperative day (POD). AL and all postoperative complications were recorded.

RESULTS

We registered 28 (5.6%) anastomotic leaks. Specificity and negative predictive value for AL with PCT less than 2.7 and 2.3 ng/mL were, respectively, 91.7% and 96.9% in 3rd POD and 93% and 98.3% in 5th POD. Receiver operating characteristic curve for biomarkers shows that in 3rd POD, PCT and CRP have similar area under the curve (AUC) (0.775 vs 0.772), both better than WBC (0.601); in 5th POD, PCT has a better AUC than CRP and WBC (0.862 vs 0.806 vs 0.611). Measuring together PCT and CRP significantly improves AL diagnosis in 5th POD (AUC: 0.901).

CONCLUSIONS

PCT and CRP demonstrated to have a good negative predictive value for AL, both in 3rd and in 5th POD. Low levels of PCT, together with low CRP values, seem to be early and reliable markers of AL after colorectal surgery. These biomarkers might be safely added as additional criteria of discharge protocols after colorectal surgery.

Diagnostic Accuracy of Inflammatory Markers As Early Predictors of Infection After Elective Colorectal Surgery: Results From the IMACORS Study

BACKGROUND

Intra-abdominal infections are frequent and life-threatening complications after colorectal surgery. An early detection could diminish their clinical impact and permit safe early discharge.

OBJECTIVE

This study aimed to find the most accurate marker for the detection of postoperative intra-abdominal infection and the appropriate moment to measure it.

METHODS

A prospective, observational study was conducted in 3 centers. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. C-reactive protein and procalcitonin were measured daily until the fourth postoperative day. Postoperative infections were recorded according to the definitions of the Centres for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the diagnostic accuracy of each marker.

RESULTS

Five-hundred and one patients were analyzed. The incidence of intra-abdominal infection was 11.8%, with 24.6% of patients presenting at least one infectious complication. Overall mortality was 1.2%. At the fourth postoperative day, C-reactive protein was more discriminating than procalcitonin for the detection of intra-abdominal infection (areas under the ROC curve: 0.775 vs 0.689, respectively, P = 0.03). Procalcitonin levels showed wide dispersion. For the detection of all infectious complications, C-reactive protein was also significantly more accurate than procalcitonin on the fourth postoperative day (areas under the ROC curve: 0.783 vs 0.671, P = 0.0002).

CONCLUSIONS

C-reactive protein is more accurate than procalcitonin for the detection of infectious complications and should be systematically measured at the fourth postoperative day. It is a useful tool to ensure a safe early discharge after elective colorectal surgery.

Post-Operative Infection Is an Independent Risk Factor for Worse Long-Term Survival after Colorectal Cancer Surgery

BACKGROUND

Colorectal cancer surgery is associated with a high incidence of post-operative infections, the outcome of which may be improved if diagnosed and treated early enough. We compared white blood cell (WBC) count, C-reactive protein (CRP), and procalcitonin (PCT) as predictors of post-operative infections and analyzed their impact on long-term survival.

METHODS

This retrospective study included 186 patients undergoing colorectal surgery. Post-operative values of WBC, CRP, and PCT were analyzed by the receiver operating characteristic (ROC) analysis. We followed infections 30 d after the surgery. A five-year survival was analyzed by Kaplan-Meier method and prognostic factors by Cox regression model.

RESULTS

Fifty-five patients (29.5%) developed post-operative infection, the most frequent of which was surgical site infection (SSI). C-reactive protein on post-operative day three and PCT on post-operative day two demonstrated the highest diagnostic accuracy for infection (area under the curve [AUC] 0.739 and 0.735). C-reactive protein on post-operative day three was an independent predictor of infection. Five-year survival was higher in the non-infected group (70.8%), compared with the infected group (52.1%). The worst survival (40.9%) was identified in patients with organ/space SSI. Post-operative infection and tumor stage III-IV were independent predictors of a worse five-year survival.

CONCLUSIONS

C-reactive protein on post-operative day three and PCT on post-operative day two may be early predictors of infection after colorectal cancer surgery. Post-operative infections in particular organ/space SSI have a negative impact on long-term survival.

Does C-reactive protein monitoring after colorectal resection with anastomosis give any practical benefit for patients with intra-abdominal septic complications?

AIM

This study aimed to assess the influence of the C-reactive protein (CRP) level on the early outcome after elective colorectal resection.

METHOD

Patients with colorectal cancer operated on between 2006 and 2013 were identified retrospectively. They were divided into a study group operated on between 2010 and 2013 when CRP was measured routinely on the fourth postoperative day and a control group operated on between 2006 and 2009 when the CRP level was not measured routinely. Mortality, intra-abdominal septic complications (IASC), abscesses and anastomotic leakage (AL), the need for reoperation, the interval from index surgery to relaparotomy, length of hospital stay and imaging studies were compared by multivariate analysis.

RESULTS

A total of 1189 patients were assessed, including 598 (50.3%) in the study group (mean age 61.3 ± 13 years; 282 female) and 591 (49.7%) in the control group (mean age 61.8 ± 11 years; 267 female). There were seven (1.2%) postoperative deaths in the study group and nine (1.5%) in the control group (P = 0.598). Abdominal ultrasound (US) was performed more often in the study group [97 (16.2%) vs 71 (12.0%); P = 0.037]. In the study group the interval to diagnosis of IASC was shorter than in the control group (5.7 ± 1.5 days vs 7.3 ± 1.3 days; P = 0.029). The decision to reoperate was also made earlier in the study group (6.2 ± 1.7 days vs 7.4 ± 2.8 days; P = 0.043).

CONCLUSION

Routine measurement of CRP can help to make an earlier diagnosis of IASC and earlier decision for relaparotomy, without any influence on mortality or length of hospital stay.

Cholangitis in the postoperative course after biliodigestive anastomosis

BACKGROUND

Hepatobiliary surgery with biliodigestive anastomosis (BDA) results in a loss of the sphincter of Oddi with consecutive ascension of bacteria into the bile system which may cause cholangitis in the postoperative course.

METHODS

Patients who received reconstruction with a BDA after hepatobiliary surgery were analyzed retrospectively for their postoperative course of disease depending on intraoperatively obtained bile cultures and antibiotic prophylaxis.

RESULTS

Two hundred forty-three patients were included in the analysis, 49.4 % of whom had received endoscopic stenting before the operation. Stenting was significantly associated with the presence of drug-resistant bacteria in the intraoperatively obtained bile sample (p < 0.001, OR = 4.09). Of all patients, 14.4 % developed postoperative cholangitis. This was significantly associated with the postoperative length of stay in the intensive care unit (p = 0.002, OR = 1.035). The highest incidence of postoperative cholangitis was found in patients with cholangiocellular carcinoma (n = 12, p = 0.046, OR = 2.178). Patients were more likely to harbor strains with resistance against the antibiotic that was given intraoperatively.

CONCLUSION

The risk for the presence of drug-resistant bacteria is increased by preoperative stenting of the common bile duct. Bile culture by intraoperative swabs can be altered by the perioperative antibiotic prophylaxis as it induces microbiological selection in the common bile duct.

Blood tests: One too many? Evaluating blood requesting guidance developed for acute patients admitted to trauma and orthopaedic units

In a recently published report from the Academy of Medical Royal Colleges, around 20% of clinical practice which encompasses blood science investigations is considered wasteful. Blood tests including liver function tests (LFTs), C-reactive protein (CRP), coagulation screens, and international normalising ratios (INR) are frequently requested for patients who undergo emergency hospital admission. The paucity of guidance available for blood requesting in acute trauma and orthopaedic admissions can lead to inappropriate requesting practices and over investigation. Acute admissions over a period of one month were audited retrospectively for the frequency and clinical indications of requests for LFTs, coagulation screens/INR, and CRP. The total number of blood tests requested for the duration of the patient's admission was recorded. Initial auditing of 216 admissions in January 2014 demonstrated a striking amount of over-investigation. Clinical guidelines were developed with multidisciplinary expert input and implemented within the department. Re-audit of 233 admissions was carried out in September 2014. Total no. of LFTs requested: January 895, September 336 (-62.5%); coagulation screens/INR requested: January 307, September 210 (-31.6%); CRPs requested: January 894, September 317 (-64.5%). No. of blood requests per patient: January (M=4.81, SD 4.75), September (M=3.60, SD=4.70). Approximate combined total cost of LFT, coagulation/INR, CRP in January £2674.14 and September £1236.19 (-£1437.95, -53.77%). A large decrease was observed in admission requesting and subsequent monitoring (p<0.01) following the implementation. This both significantly reduced cost and venepuncture rates.

Validation in colorectal procedures of a useful novel approach for the use of C-reactive protein in postoperative infectious complications

AIM

Our aim was to validate a novel use of C-reactive protein (CRP) measurement to identify postoperative infectious complications in patients undergoing colorectal surgery, and to compare the predictive value in this setting against white blood cell (WBC) count and neutrophil-to-lymphocyte ratio (NLR).

METHOD

This was a retrospective study of CRP, NLR and WBC measurements in patients undergoing colorectal surgery. CRP, NLR and WBC were recorded on the second postoperative day and on the day of infectious complication (patients who developed infectious complications) or within 3 days prior to discharge (subjects with no complications). The test for detecting infectious complications consisted of comparing the value of the inflammatory marker on the day on which a complication was suspected against the value recorded on the second postoperative day. The test was considered positive if a given value was higher than the registered peak at postoperative day 2. Factors influencing the postoperative peak CRP were also studied.

RESULTS

A total of 254 patients were retrospectively studied. Patients whose CRP value was higher than on the second postoperative day had a diagnostic accuracy for infectious complications of up to 94.4% and sensitivity, specificity, positive predictive value and negative predictive value of up to 97.4%, 93.4%, 85.7% and 99.1%, respectively. Poorer results were observed when WBC count and NLR were used rather than CRP measurement. Multiple linear regression analysis showed that surgical procedure and approach, as well as additional resections, were independent factors for 48 h peak CRP.

CONCLUSION

C-reactive protein is a better parameter than WBC count and NLR for detecting infectious complications. Our proposed methodology presents good diagnostic accuracy and performance and could potentially be used for any surgical procedure.

C-reactive protein and procalcitonin predict anastomotic leaks following colorectal cancer resections - a prospective study

INTRODUCTION

Early safe discharge is paramount for the success of ERAS following colorectal cancer resections. Anastomotic leakage (AL) has high morbidity, particularly if the patient has been discharged to the community.

AIM

To evaluate whether C-reactive protein (CRP) and procalcitonin (PCT) can predict AL before early discharge.

MATERIAL AND METHODS

Fifty-five consecutive patients undergoing open and robotic colorectal cancer resections were included. C-reactive protein and PCT were measured pre-operatively, 8 h after incision, and on the first and third postoperative day. Thirty-day readmissions, re-operations and mortality were recorded.

RESULTS

Twenty-nine patients underwent robotic and the remainder open (n = 26) resections. Five patients had AL. The mean CRP and PCT increased on postoperative day 1 (POD 1) and POD 3 in all patients. On POD 3, mean CRP was 114 mg/l in non-AL patients and 321 mg/l in AL patients (p = 0.0001). Mean PCT on POD 3 was 0.56 ng/ml in the non-AL group and 10.4 ng/ml in AL patients (p = 0.017). On analysis of ROC and AUC curves, the cut-off for CRP on POD 3 was 245.64 mg/l, with 100% sensitivity and 98% specificity for AL. The cut-off for PCT on POD 3 was 3.83 ng/ml, with 75% sensitivity and 100% specificity for AL.

CONCLUSIONS

C-reactive protein and PCT measurement on POD 3 following colorectal cancer resection can positively identify patients at low risk of anastomotic leakage.

C-reactive protein on postoperative day 3 as a predictor of infectious complications following gastric cancer resection

BACKGROUND

Postoperative infectious complications (PICs) after gastric cancer resection remain a clinically relevant problem. Early detection of PICs, before critical illness develops, may be of considerable clinical benefit. The aims of this study were to investigate the predictive factors for PICs and to define the clinical parameters for detecting them early in patients with gastric cancer resection.

METHODS

Clinical data for 417 consecutive patients undergoing elective gastrectomy for primary gastric cancer between 2009 and 2012 were retrospectively analyzed. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Univariate and multivariate logistic regression analyses identified clinical factors predicting PICs of grade III or more according to the Clavien-Dindo classification.

RESULTS

Forty-four patients developed PICs of grade ≥ III [10.6%, 95% confidence interval (CI) 7.6-13.5%]. As a systemic inflammatory marker, C-reactive protein (CRP) on postoperative day (POD) 3 had superior diagnostic accuracy for PICs (AUC 0.802, 95% CI 0.735-0.870) with a calculated cutoff value of 17.7 mg/dl, yielding a sensitivity of 0.66 (95% CI 0.524-0.774) and a specificity of 0.84 (95% CI 0.821-0.850). Multivariate analysis identified CRP on POD 3 of 17.7 mg/dl or greater [odds ratio (OR) 8.094, 95% CI 3.568-19.342) as well as clinical stage ≥ II (OR 4.445, 95% CI 1.478-15.881) and operation time ≥ 250 min (OR 3.638, 95% CI 1.449-10.137) as significant predictive factors for PICs after gastrectomy.

CONCLUSIONS

Elevated CRP levels on POD 3 will help physicians predict the postoperative course and facilitate decision-making regarding prompt, comprehensive clinical searches and therapeutic approaches for PICs.

C-Reactive Protein as a Marker for Postoperative Complications. Are There Differences in Emergency and Elective Colorectal Surgery?

BACKGROUND

C-reactive protein levels are frequently raised in patients with major complications following elective colorectal surgery and used as a predictor for complications. The significance of raised C-reactive protein levels to predict outcome in emergency colorectal surgery is unclear, because preoperative C-reactive protein levels are often raised.

OBJECTIVE

The aim of this study was to determine whether serum C-reactive protein is an adequate predictive marker for major postoperative complications after colorectal surgery in an acute setting.

DESIGN

This is an observational cohort study of all patients undergoing colorectal surgery.

PATIENTS

Consecutive patients undergoing colorectal surgery with reconstruction via anastomosis and/or stoma from January 2009 to March 2014 were included.

SETTING

This study was conducted at VU University Medical Center, Amsterdam.

MAIN OUTCOME MEASURES

Postoperative C-reactive protein levels, operative details, and postoperative complications were recorded to determine the differences in C-reactive protein as a marker for complications in emergency and elective colorectal surgery.

RESULTS

A total of 724 patients underwent colorectal resection, 559 elective cases and 165 emergency cases. A major complication was observed in 176 of 724 patients (24.3%). Major complications were observed more often in patients who underwent emergency surgery, 37% versus 20.9% after elective resections. C-reactive protein levels were significantly higher preoperatively in patients operated on in an acute care setting and on the first two postoperative days; from the third postoperative day, no statistically significant differences were found in C-reactive protein levels.

LIMITATIONS

This study was limited by its observational nature.

CONCLUSIONS

Although acute colorectal surgery is associated with higher C-reactive protein levels in the first 2 postoperative days, this study shows that postoperative C-reactive protein levels may be used as a predictor for complications in both acute and elective surgery from the third postoperative day onward. It is hypothesized that the stimulus for C-reactive protein production is removed during surgery, and, with a short-half-life of 19 hours, C-reactive protein levels drop to similar levels as seen in patients undergoing elective surgery.

C-reactive protein is a predictor of complications after elective laparoscopic colorectal surgery: five-year experience

Introduction

With the development and improvement of laparoscopic surgery, procedures have become common. However, post-operative complications occur when patients are released from hospital. These complications increase patients’ morbidity and mortality. They also lead to re-hospitalization, an extended recovery period, and an increase in the cost of treatment.

Aim

To evaluate and determine the prognostic properties of C-reactive protein in the early diagnosis of postoperative complications after a laparoscopic colon resection.

Material and methods

The prospective study included patients who underwent laparoscopic colorectal surgery in 2010–2014. The patients were divided into two groups – uncomplicated ones and those with complications. C-reactive protein concentrations in their blood serum were measured on the 2^nd, 4^th and 6^th day after surgery. Logistic regression analysis was used to evaluate the relation between C-reactive protein values measured on the 2^nd, 4^th and 6^th postoperative day and related complications. Receiver operating characteristic curves were used to determine the sensitivity and specificity of each C-reactive protein value measured on the 2^nd, 4^th and 6^th postoperative day.

Results

One hundred and six patients were included in the trial; 14 of them had complications. On the second day, a C-reactive protein cut-off value of 88.6 mmol/l provided the highest sensitivity and specificity for predicting evolving complications, being 71.4% and 84.8% respectively (p = 0.003). The significant predictive cut-off value decreases and becomes more sensitive and specific each post-operative day.

Conclusions

It is possible to detect developing post-operative complications early on by monitoring C-reactive protein concentration levels in the blood serum on the 2^nd, 4^th, and 6^th post-operative days.

Factors affecting serum albumin in the perioperative period of colorectal surgery: a retrospective study

Background

Albumin is considered a negative acute-phase protein because its concentration decreases during injury and sepsis. Hypoalbuminemia is a risk factor for mortality, postoperative complications, and prolonged hospital stay. The magnitude of the systemic inflammatory response during the perioperative period, as indicated by the acute-phase proteins—C-reactive protein (CRP) in particular—, may help identify the risk of postoperative infectious complication. The correlation between serum albumin and CRP with gastrointestinal cancer has been reported. However, it is unclear whether antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period in colorectal surgery. The primary endpoint of this study was to reveal that antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period of colorectal surgery.

Methods

Thirty-seven patients who underwent elective open colorectal surgery were included in this study. Correlations between preoperative CRP and serum albumin on postoperative day (POD) 3, between preoperative CRP and serum albumin on POD 7 and between CRP on POD 3 and serum albumin on POD 7 were examined. Relationships between preoperative CRP and hypoalbuminemia on POD 3, between preoperative CRP and hypoalbuminemia on POD 7 and between CRP on POD 3 and hypoalbuminemia on POD 7 were examined by receiver operating characteristic analysis.

Results

Three-quarters of patients were older than 65 years of age. Significant correlations were observed between preoperative CRP and serum albumin on POD 3 (p = 0.023), between preoperative CRP and serum albumin on POD 7 (p = 0.023) and between CRP on POD 3 and serum albumin on POD 7 (p < 0.001). The area under the receiver operating characteristic curve of CRP on POD 3 to development of hypoalbuminemia on POD 7 was 0.833 (95 % CI 0.679–0.987) with an optimal threshold of 12.43 mg/dL, sensitivity 75 % and specificity 80 %.

Conclusions

The present study revealed that antecedent CRP was associated with future serum albumin. Additionally, CRP on POD 3 could be useful in predicting the development of hypoalbuminemia on POD 7. This result suggests that CRP on POD 3 may be a valuable indicator for early nutritional intervention.