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Gritsiuta AI, Esper CJ, Parikh K, Parupudi S, Petrov RV. Anastomotic Leak After Esophagectomy: Modern Approaches to Prevention and Diagnosis. Cureus 2025; 17:e80091. [PMID: 40196079 PMCID: PMC11973610 DOI: 10.7759/cureus.80091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2025] [Accepted: 03/04/2025] [Indexed: 04/09/2025] Open
Abstract
Anastomotic leak (AL) remains one of the most serious complications following esophagectomy, contributing to significant morbidity, prolonged hospital stays, and increased mortality. Despite advancements in surgical techniques and perioperative care, AL continues to challenge surgeons and negatively impact patient outcomes. Various factors contribute to its development, including patient-specific comorbidities, tumor characteristics, anastomotic technique, conduit perfusion, and perioperative management. Prevention strategies have evolved with the integration of intraoperative techniques such as fluorescence-guided perfusion assessment, omental reinforcement, and meticulous surgical handling of the gastric conduit. Emerging technologies, including endoluminal vacuum therapy (EVT) and multimodal perioperative protocols, have demonstrated potential in reducing leak incidence and improving management. Diagnosing AL remains complex due to its variable presentation, necessitating a combination of clinical evaluation, inflammatory markers, imaging studies, and endoscopic assessments. While routine postoperative imaging has shown limited sensitivity, on-demand CT and endoscopic evaluations play a crucial role in early detection and intervention. This review provides a comprehensive analysis of the risk factors, prevention strategies, and diagnostic modalities for AL after esophagectomy, incorporating recent advancements and emerging technologies.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Christopher J Esper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Kavita Parikh
- Department of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, USA
| | - Sreeram Parupudi
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, USA
| | - Roman V Petrov
- Department of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, USA
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Kianmanesh R, Amroun KL, Rhaiem R, Jazi AHD, Moazenzadeh H, Rached L, Zimmermann P, Durame A, Renard Y, Ravenet A, Bouche O, Deguelte S. C-reactive protein and digestive pathologies: A narrative review for daily clinical use. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2025; 30:10. [PMID: 40200962 PMCID: PMC11974606 DOI: 10.4103/jrms.jrms_537_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/02/2024] [Accepted: 01/20/2025] [Indexed: 04/10/2025]
Abstract
The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.
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Affiliation(s)
- Reza Kianmanesh
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Koceila Lamine Amroun
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
- Department of Clinical Research, Aging and Fragility Unit UR 3797, Hospital University, Reims, France
| | - Rami Rhaiem
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Amir Hossein Davarpanah Jazi
- Department of Minimally Invasive and Bariatric Surgery, Hazrate Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hashem Moazenzadeh
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Linda Rached
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Perrine Zimmermann
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Adrien Durame
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Yohann Renard
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Ambroise Ravenet
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
| | - Olivier Bouche
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of Digestive Oncology, CHU Robert Debré, Reims, France
| | - Sophie Deguelte
- Reims Medical Faculty, Champagne Ardenne University, Ardenne, France
- Department of General, Digestive and Endocrine Surgery, Christian Cabrol Hospital University, Reims, France
- Department of Clinical Research, Aging and Fragility Unit UR 3797, Hospital University, Reims, France
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Sozzi A, Aiolfi A, Bonitta G, Bona D, Bonavina L, Biondi A, Rausa E, Simić A, Skrobic O, Popa C, Schlanger D. Esophagectomy in patients with liver cirrhosis: systematic review and meta-analysis of short-term outcomes. Updates Surg 2025; 77:143-152. [PMID: 39718689 DOI: 10.1007/s13304-024-02060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Accepted: 12/13/2024] [Indexed: 12/25/2024]
Abstract
Patients with esophageal cancer and concomitant liver cirrhosis (LC) pose a surgical challenge because of the increased risk of postoperative complications and mortality. Purpose of this study was to review the existing literature and estimate perioperative short-term outcomes of esophagectomy in this patient population. Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. The search was last updated on July 30th, 2024. Primary outcomes were anastomotic leak (AL) and 90 day mortality. Ten observational studies were included for a total of 387 patients with LC. The age of the included patients ranged from 35 to 85 years, 91.2% were males. The main causes of liver cirrhosis were alcoholic (75%) and viral hepatitis (20.4%). Esophageal squamous cell carcinoma was diagnosed in 58.7% of patients. Ivor-Lewis esophagectomy with intrathoracic anastomosis was reported in 69.9% of patients, while McKeown esophagectomy with cervical anastomosis was reported in 30.1% of patients. The estimated pooled prevalence of AL and 90-day mortality were 13% (95% CI = 6-24%; I2 = 72%) and 17% (95% CI = 10-27%; I2 = 72%), respectively. The estimated pooled prevalence of postoperative pulmonary complication, sepsis, and liver failure were 52% (95% CI = 39-65%), 30% (95% CI = 14-52%), and 9% (95% CI = 4-17%), respectively. Esophagectomy can be performed in properly selected patients with LC and concomitant esophageal cancer. Foregut surgeons should be aware of the not negligible postoperative complications rates and mortality. Risk stratification and attentive perioperative care are essential to minimize serious adverse events.
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Affiliation(s)
- Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Istitituto Clinico Sant'Ambrogio, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Istitituto Clinico Sant'Ambrogio, Via C. Belgioioso, 173, 20157, Milan, Italy.
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Istitituto Clinico Sant'Ambrogio, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Istitituto Clinico Sant'Ambrogio, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Antonio Biondi
- Surgical Division, Department of General Surgery and Medical Surgical Specialties, G. Rodolico Hospital, University of Catania, 95131, Catania, Italy
| | - Emanuele Rausa
- Unit of Hereditary Digestive Tract Tumors, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Aleksandar Simić
- Department of Anaesthesiology and Intensive Care, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ognjan Skrobic
- Department of Anaesthesiology and Intensive Care, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Calin Popa
- Surgery Clinic 3, Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", "Iuliu Hațieganul" University of Medicine and Pharmacy, 400394, Cluj-Napoca-Napoca, Romania
| | - Diana Schlanger
- Surgery Clinic 3, Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", "Iuliu Hațieganul" University of Medicine and Pharmacy, 400394, Cluj-Napoca-Napoca, Romania
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Klontzas ME, Ri M, Koltsakis E, Stenqvist E, Kalarakis G, Boström E, Kechagias A, Schizas D, Rouvelas I, Tzortzakakis A. Prediction of Anastomotic Leakage in Esophageal Cancer Surgery: A Multimodal Machine Learning Model Integrating Imaging and Clinical Data. Acad Radiol 2024; 31:4878-4885. [PMID: 38955594 DOI: 10.1016/j.acra.2024.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/18/2024] [Accepted: 06/18/2024] [Indexed: 07/04/2024]
Abstract
RATIONALE AND OBJECTIVES Surgery in combination with chemo/radiotherapy is the standard treatment for locally advanced esophageal cancer. Even after the introduction of minimally invasive techniques, esophagectomy carries significant morbidity and mortality. One of the most common and feared complications of esophagectomy is anastomotic leakage (AL). Our work aimed to develop a multimodal machine-learning model combining CT-derived and clinical data for predicting AL following esophagectomy for esophageal cancer. MATERIAL AND METHODS A total of 471 patients were prospectively included (Jan 2010-Dec 2022). Preoperative computed tomography (CT) was used to evaluate celia trunk stenosis and vessel calcification. Clinical variables, including demographics, disease stage, operation details, postoperative CRP, and stage, were combined with CT data to build a model for AL prediction. Data was split into 80%:20% for training and testing, and an XGBoost model was developed with 10-fold cross-validation and early stopping. ROC curves and respective areas under the curve (AUC), sensitivity, specificity, PPV, NPV, and F1-scores were calculated. RESULTS A total of 117 patients (24.8%) exhibited post-operative AL. The XGboost model achieved an AUC of 79.2% (95%CI 69%-89.4%) with a specificity of 77.46%, a sensitivity of 65.22%, PPV of 48.39%, NPV of 87.3%, and F1-score of 56%. Shapley Additive exPlanation analysis showed the effect of individual variables on the result of the model. Decision curve analysis showed that the model was particularly beneficial for threshold probabilities between 15% and 48%. CONCLUSION A clinically relevant multimodal model can predict AL, which is especially valuable in cases with low clinical probability of AL.
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Affiliation(s)
- Michail E Klontzas
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research and Technology (FORTH), Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece
| | - Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Solna, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Emmanouil Koltsakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Stenqvist
- Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Kalarakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece; Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Boström
- Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Aristotelis Kechagias
- Department of Digestive Surgery, Kanta-Häme Central Hospital, Hämeenlinna 13530, Finland
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 115-27, Greece
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Solna, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Medical Radiation Physics and Nuclear Medicine, Section for Nuclear Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Pérez Quintero R, Bruna Esteban M, Serrano López AJ. PROFUGO study protocol: Predictive model for the early diagnosis of anastomotic leak after esophagectomy and gastrectomy. Cir Esp 2024; 102:624-629. [PMID: 39233277 DOI: 10.1016/j.cireng.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/26/2024] [Indexed: 09/06/2024]
Abstract
In esophagogastric surgery, the appearance of an anastomotic leak is the most feared complication. Early diagnosis is important for optimal management and successful resolution. For this reason, different studies have investigated the value of the use of markers to predict possible postoperative complications. Because of this, research and the creation of predictive models that identify patients at high risk of developing complications are mandatory in order to obtain an early diagnosis. The PROFUGO study (PRedictivO Model for Early Diagnosis of anastomotic LEAK after esophagectomy and gastrectomy) is proposed as a prospective and multicenter national study that aims to develop, with the help of artificial intelligence methods, a predictive model that allows for the identification of high-risk cases. of anastomotic leakage and/or major complications by analyzing different clinical and analytical variables collected during the postoperative period of patients undergoing esophagectomy or gastrectomy.
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Affiliation(s)
- Rocío Pérez Quintero
- Unidad de Cirugía Esofagogástrica, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain.
| | - Marcos Bruna Esteban
- Unidad de Cirugía Esofagogástrica y Carcinomatosos Peritoneal, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Dell’Anna G, Fanti L, Fanizza J, Barà R, Barchi A, Fasulo E, Elmore U, Rosati R, Annese V, Laterza L, Fuccio L, Azzolini F, Danese S, Mandarino FV. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med 2024; 13:3805. [PMID: 38999371 PMCID: PMC11242239 DOI: 10.3390/jcm13133805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.
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Affiliation(s)
- Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
| | - Lorella Fanti
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Rukaia Barà
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Ugo Elmore
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy;
| | - Riccardo Rosati
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy;
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Liboria Laterza
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (L.L.); (L.F.)
| | - Lorenzo Fuccio
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (L.L.); (L.F.)
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
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Almutairi FM. Role of Biomarkers in the Diagnosis of Anastomotic Leakage After Colorectal Surgery: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e62432. [PMID: 39011204 PMCID: PMC11249052 DOI: 10.7759/cureus.62432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/11/2024] [Indexed: 07/17/2024] Open
Abstract
Due to its diverse presentation, anastomotic leakage (AL) following colorectal surgery is challenging to detect and frequently discovered when the patient becomes critically ill. When diagnosing AL in its early stages, biomarkers play a large role. This review was conducted to evaluate the diagnostic value of biomarkers in AL after colorectal surgeries. A literature search was undertaken electronically in major search engines such as Medline (PubMed), Google Scholar, ScienceDirect, EMBASE, and CENTRAL (Cochrane Library) databases. Observational studies of both retrospective and prospective nature were included. Origin Pro 2022 (Origin Labs) software was used to assess the prevalence of AL and generate the forest plot. A total of 13 articles fulfilled the eligibility criteria. A pooled prevalence of 9.19% was noted for AL in colorectal surgeries. In the present review, the observed sensitivity for C-reactive protein (CRP) was 80.5% and the specificity was 84% (postoperative day three). In contrast, these were 100% and 83.9% for procalcitonin on postoperative day five. CRP showed the highest diagnostic accuracy and excels at eliminating AL, but combining biomarkers can increase the diagnostic precision of early detection of AL.
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Affiliation(s)
- Farooq M Almutairi
- Clinical Laboratories Sciences, College of Applied Medical Sciences, University of Hafr Al-Batin, Hafr Al-Batin, SAU
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8
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Van Daele E, Vanommeslaeghe H, Peirsman L, Van Nieuwenhove Y, Ceelen W, Pattyn P. Early postoperative systemic inflammatory response as predictor of anastomotic leakage after esophagectomy: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:757-765. [PMID: 38704210 DOI: 10.1016/j.gassur.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/22/2024] [Accepted: 02/03/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Postesophagectomy anastomotic leakage occurs in up to 16% of patients and is the main cause of morbidity and mortality. The leak severity is determined by the extent of contamination and the degree of sepsis, both of which are related to the time from onset to treatment. Early prediction based on inflammatory biomarkers such as C-reactive protein (CRP) levels, white blood cell counts, albumin levels, and combined Noble-Underwood (NUn) scores can guide early management. This review aimed to determine the diagnostic accuracy of these biomarkers. METHODS This study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in the PROSPERO (International Prospective Register of Systematic Reviews) database. Two reviewers independently conducted searches across PubMed, MEDLINE, Web of Science, and Embase. Sources of bias were assessed, and a meta-analysis was performed. RESULTS Data from 5348 patients were analyzed, and 13% experienced leakage. The diagnostic accuracy of the serum biomarkers was analyzed, and pooled cutoff values were identified. CRP levels were found to have good diagnostic accuracy on days 2 to 5. The best discrimination was identified on day 2 for a cutoff value < 222 mg/L (area under the curve = 0.824, sensitivity = 81%, specificity = 88%, positive predictive value = 38.6%, and negative predictive value = 98%). A NUn score of >10 on day 4 correlated with poor diagnostic accuracy. CONCLUSION The NUn score failed to achieve adequate accuracy. CRP seems to be the only valuable biomarker and is a negative predictor of postesophagectomy leakage. Patients with a CRP concentration of <222 mg/L on day 2 are unlikely to develop a leak, and patients can safely proceed through their enhanced recovery after surgery protocol. Patients with a CRP concentration of <127 mg/L on day 5 can be safely discharged when clinically possible.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Louise Peirsman
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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9
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Bona D, Manara M, Bonitta G, Guerrazzi G, Guraj J, Lombardo F, Biondi A, Cavalli M, Bruni PG, Campanelli G, Bonavina L, Aiolfi A. Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis. Cancers (Basel) 2024; 16:1468. [PMID: 38672550 PMCID: PMC11048031 DOI: 10.3390/cancers16081468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain. AIM To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence. RESULTS Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low. CONCLUSIONS This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.
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Affiliation(s)
- Davide Bona
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Guglielmo Guerrazzi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Juxhin Guraj
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Francesca Lombardo
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, G. Rodolico Hospital, Surgical Division, University of Catania, 95131 Catania, Italy;
| | - Marta Cavalli
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Surgery, University of Insubria, 20157 Milan, Italy
| | - Piero Giovanni Bruni
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Surgery, University of Insubria, 20157 Milan, Italy
| | - Giampiero Campanelli
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Surgery, University of Insubria, 20157 Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, 20097 Milan, Italy
| | - Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
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10
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van de Beld JJ, Crull D, Mikhal J, Geerdink J, Veldhuis A, Poel M, Kouwenhoven EA. Complication Prediction after Esophagectomy with Machine Learning. Diagnostics (Basel) 2024; 14:439. [PMID: 38396478 PMCID: PMC10888312 DOI: 10.3390/diagnostics14040439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 02/25/2024] Open
Abstract
Esophageal cancer can be treated effectively with esophagectomy; however, the postoperative complication rate is high. In this paper, we study to what extent machine learning methods can predict anastomotic leakage and pneumonia up to two days in advance. We use a dataset with 417 patients who underwent esophagectomy between 2011 and 2021. The dataset contains multimodal temporal information, specifically, laboratory results, vital signs, thorax images, and preoperative patient characteristics. The best models scored mean test set AUROCs of 0.87 and 0.82 for leakage 1 and 2 days ahead, respectively. For pneumonia, this was 0.74 and 0.61 for 1 and 2 days ahead, respectively. We conclude that machine learning models can effectively predict anastomotic leakage and pneumonia after esophagectomy.
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Affiliation(s)
- Jorn-Jan van de Beld
- Faculty of EEMCS, University of Twente, 7500 AE Enschede, The Netherlands
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - David Crull
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - Julia Mikhal
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
- Faculty of BMS, University of Twente, 7500 AE Enschede, The Netherlands
| | - Jeroen Geerdink
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - Anouk Veldhuis
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - Mannes Poel
- Faculty of EEMCS, University of Twente, 7500 AE Enschede, The Netherlands
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11
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Van Daele E, Vanommeslaeghe H, Decostere F, Beckers Perletti L, Beel E, Van Nieuwenhove Y, Ceelen W, Pattyn P. Systemic Inflammatory Response and the Noble and Underwood (NUn) Score as Early Predictors of Anastomotic Leakage after Esophageal Reconstructive Surgery. J Clin Med 2024; 13:826. [PMID: 38337519 PMCID: PMC10856250 DOI: 10.3390/jcm13030826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Anastomotic leakage (AL) remains the main cause of post-esophagectomy morbidity and mortality. Early detection can avoid sepsis and reduce morbidity and mortality. This study evaluates the diagnostic accuracy of the Nun score and its components as early detectors of AL. This single-center observational cohort study included all esophagectomies from 2010 to 2020. C-reactive protein (CRP), albumin (Alb), and white cell count (WCC) were analyzed and NUn scores were calculated. The area under the curve statistic (AUC) was used to assess their predictive accuracy. A total of 74 of the 668 patients (11%) developed an AL. CRP and the NUn-score proved to be good diagnostic accuracy tests on postoperative day (POD) 2 (CRP AUC: 0.859; NUn score AUC: 0.869) and POD 4 (CRP AUC: 0.924; NUn score AUC: 0.948). A 182 mg/L CRP cut-off on POD 4 yielded a 87% sensitivity, 88% specificity, a negative predictive value (NPV) of 98%, and a positive predictive value (PPV) of 47.7%. A NUn score cut-off > 10 resulted in 92% sensitivity, 95% specificity, 99% NPV, and 68% PPV. Albumin and WCC have limited value in the detection of post-esophagectomy AL. Elevated CRP and a high NUn score on POD 4 provide high accuracy in predicting AL after esophageal cancer surgery. Their high negative predictive value allows to select patients who can safely proceed with enhanced recovery protocols.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
| | - Flo Decostere
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Louise Beckers Perletti
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Esther Beel
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
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12
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Alanazi KO, Alshammari FA, Alanazi AS, Alrashidi MO, Alrashidi AO, Aldhafeeri YA, Alanazi TH, Alkahtani AS, Alrakhimi AS, Albathali HA. Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e50370. [PMID: 38222119 PMCID: PMC10784652 DOI: 10.7759/cureus.50370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 01/16/2024] Open
Abstract
Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.
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Affiliation(s)
- Khalid O Alanazi
- Department of General Surgery, King Khalid General Hospital, Hafar al-Batin, SAU
| | | | | | | | - Ali Obaid Alrashidi
- Department of Family Medicine, Al-Shifa Primary Health Care Centre, Hafar al-Batin, SAU
| | - Yousif A Aldhafeeri
- Department of Internal Medicine, King Khalid General Hospital, Hafar al-Batin, SAU
| | | | | | | | - Hamdan A Albathali
- Department of Family Medicine, Al-Nozha Primary Health Care Centre, Hafar al-Batin, SAU
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13
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Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
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Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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14
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Scepanovic M, Randjelovic T, Karamarkovic A, Cuk V, Stanojevic G, Kovacevic B. C‐reactive protein as an early predictor of anastomotic dehiscence in various types of reconstruction in elective abdominal surgery. SURGICAL PRACTICE 2023; 27:205-215. [DOI: 10.1111/1744-1633.12646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/25/2023] [Indexed: 10/20/2023]
Abstract
AbstractObjectiveThe 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.MethodsThe 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.ResultsCRP 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.ConclusionsMeasurement 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.
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Affiliation(s)
- Milena Scepanovic
- University Clinical Center “Zvezdara” Clinic for Surgery Belgrade Serbia
- Proktomed Surgery Office Belgrade Serbia
| | | | | | - Vladimir Cuk
- University Clinical Center “Zvezdara” Clinic for Surgery Belgrade Serbia
| | | | - Bojan Kovacevic
- University Clinical Center “Zvezdara” Clinic for Surgery Belgrade Serbia
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15
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Lemmens J, Klarenbeek B, Verstegen M, van Workum F, Hannink G, Ubels S, Rosman C. Performance of a consensus-based algorithm for diagnosing anastomotic leak after minimally invasive esophagectomy for esophageal cancer. Dis Esophagus 2023; 36:doad016. [PMID: 36988007 PMCID: PMC10543373 DOI: 10.1093/dote/doad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/17/2023] [Indexed: 03/30/2023]
Abstract
Anastomotic leak (AL) is a common and severe complication after esophagectomy. This study aimed to assess the performance of a consensus-based algorithm for diagnosing AL after minimally invasive esophagectomy. This study used data of the ICAN trial, a multicenter randomized clinical trial comparing cervical and intrathoracic anastomosis, in which a predefined diagnostic algorithm was used to guide diagnosing AL. The algorithm identified patients suspected of AL based on clinical signs, blood C-reactive protein (cut-off value 200 mg/L), and/or drain amylase (cut-off value 200 IU/L). Suspicion of AL prompted evaluation with contrast swallow computed tomography and/or endoscopy to confirm AL. Primary outcome measure was algorithm performance in terms of sensitivity, specificity, and positive and negative predictive values (PPV, NPV), respectively. AL was defined according to the definition of the Esophagectomy Complications Consensus Group. 245 patients were included, and 125 (51%) patients were suspected of AL. The algorithm had a sensitivity of 62% (95% confidence interval [CI]: 46-75), a specificity of 97% (95% CI: 89-100), and a PPV and NPV of 94% (95% CI: 79-99) and 77% (95% CI: 66-86), respectively, on initial assessment. Repeated assessment in 19 patients with persisting suspicion of AL despite negative or inconclusive initial assessment had a sensitivity of 100% (95% CI: 77-100). The algorithm showed poor performance because the low sensitivity indicates the inability of the algorithm to confirm AL on initial assessment. Repeated assessment using the algorithm was needed to confirm remaining leaks.
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Affiliation(s)
- Jobbe Lemmens
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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16
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Menni A, Stavrou G, Tzikos G, Shrewsbury AD, Kotzampassi K. Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review. GASTROINTESTINAL DISORDERS 2023; 5:383-407. [DOI: 10.3390/gidisord5030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites.
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Affiliation(s)
- Alexandra Menni
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - George Stavrou
- Department of General Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK
| | - Georgios Tzikos
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Anne D. Shrewsbury
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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17
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Aiolfi A, Griffiths EA, Sozzi A, Manara M, Bonitta G, Bonavina L, Bona D. Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination. Ann Surg Oncol 2023; 30:5564-5572. [PMID: 37210447 DOI: 10.1245/s10434-023-13670-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a serious complication after esophagectomy. It is associated with prolonged hospital stay, increased costs, and increased risk for 90-day mortality. Controversy exists concerning the impact of AL on survival. This study was designed to investigate the effect of AL on long-term survival after esophagectomy for esophageal cancer. METHODS PubMed, MEDLINE, Scopus, and Web of Science were searched through October 30, 2022. The included studies evaluated the effect of AL on long-term survival. Primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. RESULTS Thirteen studies (7118 patients) were included. Overall, 727 (10.2%) patients experienced AL. The RMSTD analysis shows that at 12, 24, 36, 48, and 60 months, patients not experiencing AL live an average of 0.7 (95% CI 0.2-1.2; p < 0.001), 1.9 (95% CI 1.1-2.6; p < 0.001), 2.6 (95% CI 1.6-3.7; p < 0.001), 3.4 (95% CI 1.9-4.9; p < 0.001), and 4.2 (95% CI 2.1-6.4; p < 0.001) months longer compared with those with AL, respectively. The time-dependent HRs analysis for AL versus no AL shows a higher mortality hazard in patients with AL at 3 (HR 1.94, 95% CI 1.54-2.34), 6 (HR 1.56, 95% CI 1.39-1.75), 12 (HR 1.47, 95% CI 1.24-1.54), and 24 months (HR 1.19, 95% CI 1.02-1.31). CONCLUSIONS This study seems to suggest a modest clinical impact of AL on long-term OS after esophagectomy. Patients who experience AL seem to have a higher mortality hazard during the first 2 years of follow-up.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Luigi Bonavina
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
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18
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Hagens ERC, Feenstra ML, Lam WC, Eshuis WJ, Lameris W, van Berge Henegouwen MI, Gisbertz SS. C-Reactive Protein as a Negative Predictive Marker for Anastomotic Leakage After Minimally Invasive Esophageal Surgery. World J Surg 2023; 47:1995-2002. [PMID: 37103558 PMCID: PMC10310558 DOI: 10.1007/s00268-023-07013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Serum C-reactive protein (CRP) is commonly used by surgeons to raise suspicion of anastomotic leakage and other infectious complications, but most studies on optimal cut-off values are retrospective with a small sample of patients. The aim of this study was to determine the accuracy and optimal cut-off value of CRP for anastomotic leakage in patients following esophagectomy for cancer. MATERIALS AND METHODS Consecutive minimally invasive esophagectomy for esophageal cancer patients was included in this prospective study. Anastomotic leakage was confirmed if a defect or leakage of oral contrast was seen on a CT scan, by endoscopy or if saliva was draining from the neck incision. Diagnostic accuracy of CRP was assessed by receiver operator curve (ROC) analysis. Youden's index was adopted to determine the cut-off value. RESULTS A total of 200 patients were included between 2016 and 2018. Postoperative day 5 showed the highest area under the ROC (0.825) and optimal cut-off value of 120 mg/L. This resulted in a sensitivity of 75%, specificity of 82%, negative predicting value of 97%, and positive predicting value of 32%. CONCLUSIONS CRP on postoperative day 5 can be used as a negative predictor for and can be used as a marker to raise suspicion of anastomotic leakage following esophagectomy for esophageal cancer. When CRP exceeds 120 mg/L on postoperative day 5, additional investigations should be considered.
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Affiliation(s)
- Eliza R. C. Hagens
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Minke L. Feenstra
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Wing C. Lam
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - W. J. Eshuis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - W. Lameris
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mark I. van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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19
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Brown LR, Ramage MI, Dolan RD, Sayers J, Bruce N, Dick L, Sami S, McMillan DC, Laird BJA, Wigmore SJ, Skipworth RJE. The Impact of Acute Systemic Inflammation Secondary to Oesophagectomy and Anastomotic Leak on Computed Tomography Body Composition Analyses. Cancers (Basel) 2023; 15:cancers15092577. [PMID: 37174044 PMCID: PMC10177546 DOI: 10.3390/cancers15092577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
This study aimed to longitudinally assess CT body composition analyses in patients who experienced anastomotic leak post-oesophagectomy. Consecutive patients, between 1 January 2012 and 1 January 2022 were identified from a prospectively maintained database. Changes in computed tomography (CT) body composition at the third lumbar vertebral level (remote from the site of complication) were assessed across four time points where available: staging, pre-operative/post-neoadjuvant treatment, post-leak, and late follow-up. A total of 20 patients (median 65 years, 90% male) were included, with a total of 66 computed tomography (CT) scans analysed. Of these, 16 underwent neoadjuvant chemo(radio)therapy prior to oesophagectomy. Skeletal muscle index (SMI) was significantly reduced following neoadjuvant treatment (p < 0.001). Following the inflammatory response associated with surgery and anastomotic leak, a decrease in SMI (mean difference: -4.23 cm2/m2, p < 0.001) was noted. Estimates of intramuscular and subcutaneous adipose tissue quantity conversely increased (both p < 0.001). Skeletal muscle density fell (mean difference: -5.42 HU, p = 0.049) while visceral and subcutaneous fat density were higher following anastomotic leak. Thus, all tissues trended towards the radiodensity of water. Although tissue radiodensity and subcutaneous fat area normalised on late follow-up scans, skeletal muscle index remained below pre-treatment levels.
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Affiliation(s)
- Leo R Brown
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Michael I Ramage
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Ross D Dolan
- Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
| | - Judith Sayers
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
- St Columba's Hospice, Edinburgh EH5 3RW, UK
| | - Nikki Bruce
- Department of General Surgery, Borders General Hospital, Melrose TD6 9BS, UK
| | - Lachlan Dick
- Department of General Surgery, Victoria Hospital, Kirkcaldy KY2 5AH, UK
| | - Sharukh Sami
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Dumfries DG2 8RX, UK
| | - Donald C McMillan
- Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
| | - Barry J A Laird
- St Columba's Hospice, Edinburgh EH5 3RW, UK
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh EH4 2XR, UK
| | - Stephen J Wigmore
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Richard J E Skipworth
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
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20
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Harada K, Matsumoto C, Toihata T, Kosumi K, Iwatsuki M, Baba Y, Ohuchi M, Eto K, Ogawa K, Sawayama H, Iwagami S, Miyamoto Y, Yoshida N, Baba H. C-Reactive Protein Levels After Esophagectomy are Associated with Increased Surgical Complications and Poor Prognosis in Esophageal Squamous Cell Carcinoma Patients. Ann Surg Oncol 2023; 30:1554-1563. [PMID: 36581721 DOI: 10.1245/s10434-022-12831-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/29/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND C-reactive protein (CRP) levels are reported to predict complications and survival after surgery in various cancers. However, the relationship between postoperative CRP levels and short- and long-term outcomes of esophageal squamous cell carcinoma (ESCC) patients after esophagectomy is unclear. METHOD We reviewed the records of 543 ESCC patients who underwent subtotal esophagectomy with gastric conduit reconstruction at Kumamoto University Hospital between August 2010 and July 2021. Blood tests for CRP were done on postoperative days (PODs) 1, 3, 5 or 6, and 7 or 8. RESULTS The mean CRP levels on day 1, day 3, day 5/6, and day 7/8 were 6.68 ± 0.13 mg/dL, 11.49 ± 0.27 mg/dL, 7.48 ± 0.26 mg/dL, and 5.38 ± 0.22 mg/dL, respectively. Mean CRP levels were highest on day 3, and CRP levels after day 3 correlated with grade >2 complications based on the Clavien-Dindo classification. Receiver operating characteristic curve analysis established the optimal cut-off value for CRP day 3 levels to be 12.19 mg/dL. Multivariate logistic regression analyses found that high CRP day 3 levels significantly correlated with grade >2 complications (odds ratio [OR] 3.77, 95% confidence interval [CI] 2.56-5.35; p < 0.001). Moreover, high day 7/8 CRP levels (>3.52) correlated with postoperative survival, and based on multivariate logistic regression analyses, were significantly associated with poor prognosis (hazard ratio 1.67, 95% CI 1.14-2.43; p = 0.008). CONCLUSION Our findings suggest CRP day 3 levels as a potential biomarker for predicting postoperative complications and that CRP day 7/8 levels have potential prognostic value for ESCC patients after esophagectomy.
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Affiliation(s)
- Kazuto Harada
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Chihiro Matsumoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Keisuke Kosumi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Mayuko Ohuchi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Katsuhiro Ogawa
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Sawayama
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.
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21
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Binda C, Jung CFM, Fabbri S, Giuffrida P, Sbrancia M, Coluccio C, Gibiino G, Fabbri C. Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:136. [PMID: 36676760 PMCID: PMC9864982 DOI: 10.3390/medicina59010136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Paolo Giuffrida
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
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22
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Bona D, Danelli P, Sozzi A, Sanzi M, Cayre L, Lombardo F, Bonitta G, Cavalli M, Campanelli G, Aiolfi A. C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:166-179. [PMID: 36175720 DOI: 10.1007/s11605-022-05473-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/16/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Piergiorgio Danelli
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Via Luigi Giuseppe Faravelli, n.16, 20149, Milan, Italy
| | - Andrea Sozzi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Marcello Sanzi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Luigi Cayre
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Francesca Lombardo
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Marta Cavalli
- Department of Surgery, University of Insubria, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Giampiero Campanelli
- Department of Surgery, University of Insubria, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy.
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23
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Stuart SK, Kuypers TJL, Martijnse IS, Heisterkamp J, Matthijsen RA. C-reactive protein and drain amylase: their utility in ruling out anastomotic leakage after minimally invasive Ivor-Lewis esophagectomy. Scand J Gastroenterol 2022; 58:448-452. [PMID: 36346047 DOI: 10.1080/00365521.2022.2141076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) is one of the most feared complications after esophagectomy for esophageal cancer. We investigated the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL. METHODS This is a retrospective study of 193 patients who underwent a minimally invasive Ivor-Lewis procedure between January 2017 and October 2021. Mean CRP and median drain amylase levels between patients with and without AL were compared during the first five postoperative days (POD). ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP. RESULTS In 30 of the 193 patients (16%), AL was diagnosed with a median time to diagnosis of 9 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 59, 110 and 106 mg/L had a high sensitivity of 93%, 90% and 90% on POD 3, 4 and 5. No difference in median drain amylase levels was observed. CONCLUSIONS CRP levels with a cut-off point of 110 mg/L on POD 4 do not improve earlier detection of AL, but have a high sensitivity for excluding AL. The value of drain amylase in the first 5 days after surgery is limited.
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Affiliation(s)
- Sanne K Stuart
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Toon J L Kuypers
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ingrid S Martijnse
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Robert A Matthijsen
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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24
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Aiolfi A, Sozzi A, Bonitta G, Lombardo F, Cavalli M, Cirri S, Campanelli G, Danelli P, Bona D. Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:3297-3309. [PMID: 36242619 DOI: 10.1007/s00423-022-02706-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy. METHODS PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42). CONCLUSIONS LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy. .,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy. .,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy.
| | - Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Francesca Lombardo
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Marta Cavalli
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Silvia Cirri
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Giampiero Campanelli
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Piergiorgio Danelli
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
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25
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Rat P, Piessen G, Vanderbeken M, Chebaro A, Facy O, Rat P, Boisson C, Ortega-Deballon P. C-reactive protein identifies patients at low risk of anastomotic leak after esophagectomy. Langenbecks Arch Surg 2022; 407:3377-3386. [PMID: 36207546 DOI: 10.1007/s00423-022-02703-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/04/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE Fast-track protocols are increasingly used after digestive surgery. After esophagectomy, the gravity and the fear of anastomotic leak may be an obstacle to generalization of such protocols. C-reactive protein (CRP) might be a reliable tool to identify patients at low risk of anastomotic leak after esophagectomy, so that they can be safely included in a fast-track program. The aim of our retrospective bicentric study is to evaluate the interest of C-reactive protein measurement for the early diagnosis of anastomotic leak after esophagectomy. METHODS Patients having undergone Ivor-Lewis procedure between January 2009 and September 2017 were included in this bicentric retrospective study. CRP values were recorded between postoperative day 3 (POD 3) and postoperative day 5 (POD 5). All postoperative complications were recorded, and the primary endpoint was anastomotic leak. RESULTS We included 585 patients. Among them, 241 (41.2%) developed infectious complications and 69 patients (11.8%) developed anastomotic leak. CRP had the best predictive value on POD 5 (AUC = 0.74; 95% CI: 0.67-0.81). On POD 5, a cut-off value of 130 mg/L yielded a sensitivity of 87%, a specificity of 51%, and a negative predictive value of 96% for the detection of anastomotic leak. CONCLUSIONS CRP may help in identifying patients at very low risk of anastomotic leak after esophagectomy. Patients with CRP values < 130 mg/L on POD 5 can safely undertake an enhanced recovery protocol.
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Affiliation(s)
- Paul Rat
- Department of Digestive and Oncological Surgery, Dijon-Bourgogne University Hospital, Univ. Bourgogne-Franche-Comté, 14 rue Paul Gaffarel, F-21000, Dijon, France.
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Univ. Lille, F-59000, Lille, France
| | - Marguerite Vanderbeken
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Univ. Lille, F-59000, Lille, France
| | - Alexandre Chebaro
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Univ. Lille, F-59000, Lille, France
| | - Olivier Facy
- Department of Digestive and Oncological Surgery, Dijon-Bourgogne University Hospital, Univ. Bourgogne-Franche-Comté, 14 rue Paul Gaffarel, F-21000, Dijon, France.,Univ. Bourgogne-Franche-Comté, UMR LNC, Dijon, France.,Inserm, U1231, Équipe CADIR, Dijon, France
| | - Patrick Rat
- Department of Digestive and Oncological Surgery, Dijon-Bourgogne University Hospital, Univ. Bourgogne-Franche-Comté, 14 rue Paul Gaffarel, F-21000, Dijon, France.,Univ. Bourgogne-Franche-Comté, UMR LNC, Dijon, France.,Inserm, U1231, Équipe CADIR, Dijon, France
| | - Cyril Boisson
- LabEx LipSTIC, Dijon-Bourgogne, University Hospital, Univ. Bourgogne-Franche-Comté, Dijon, France.,Dijon-Bourgogne University Hospital, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive and Oncological Surgery, Dijon-Bourgogne University Hospital, Univ. Bourgogne-Franche-Comté, 14 rue Paul Gaffarel, F-21000, Dijon, France.,Univ. Bourgogne-Franche-Comté, UMR LNC, Dijon, France.,Inserm, U1231, Équipe CADIR, Dijon, France
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26
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Schena CA, de’Angelis GL, Carra MC, Bianchi G, de’Angelis N. Antimicrobial Challenge in Acute Care Surgery. Antibiotics (Basel) 2022; 11:1315. [PMID: 36289973 PMCID: PMC9598495 DOI: 10.3390/antibiotics11101315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/07/2022] Open
Abstract
The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.
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Affiliation(s)
- Carlo Alberto Schena
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Maria Clotilde Carra
- Rothschild Hospital, AP-HP, Université Paris Cité, U.F.R. of Odontology, 75006 Paris, France
| | - Giorgio Bianchi
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Nicola de’Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
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27
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Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022; 109:864-871. [PMID: 35759409 PMCID: PMC10364775 DOI: 10.1093/bjs/znac226] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/02/2022] [Accepted: 05/31/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score. METHODS This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally. RESULTS Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification. CONCLUSION The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group, Almelo, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust, Newcastle upon Tyne, UK
- Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
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Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C, Matthée E, Slootmans CAM, Ultee G, Schouten J, Gisbertz SS, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, van Etten B, Poelmann F, Vuurberg N, van den Berg JW, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TCM, van Esser S, Dekker JWT, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JWA, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CMS, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RPR, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJE, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, et alUbels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C, Matthée E, Slootmans CAM, Ultee G, Schouten J, Gisbertz SS, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, van Etten B, Poelmann F, Vuurberg N, van den Berg JW, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TCM, van Esser S, Dekker JWT, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JWA, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CMS, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RPR, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJE, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MAH, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Silviu C, Rodica B, Florin A, Cristian Gelu R, Petre H, Guevara Castro R, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Abdelkarem Ahmed H, Elhadi A, Elnagar FA, Msherghi AAA, Wills V, Campbell C, Perez Cerdeira M, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Adelino Barbosa J, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZL, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler MI, Schofield WA, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Leturio Fernández S, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Abdullah Ben Taher F, Ekheel M, Msherghi AAA. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022. [DOI: https://doi.org/10.1093/bjs/znac226] [Show More Authors] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.
Methods
This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.
Results
Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.
Conclusion
The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+ , Maastricht , the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group , Almelo , the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham , Birmingham , UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen , Groningen , the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital , Tilburg , the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust , Newcastle upon Tyne , UK
- Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust , Coventry , UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust , Nottingham , UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital , Guildford , UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre , Rotterdam , the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
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Comparison of pleural drain amylase and serum C-reactive protein for early detection of intrathoracic esophago-gastric anastomotic leaks. Langenbecks Arch Surg 2022; 407:2715-2724. [PMID: 35581392 DOI: 10.1007/s00423-022-02550-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Early detection of anastomotic leaks following esophagectomy has the potential to reduce hospital length of stay and mortality. The aim of this study was to compare the predictive value of pleural drain amylase and serum C-reactive protein for the early diagnosis of leak. METHODS A retrospective observational cohort study was conducted on 121 patients who underwent Ivor Lewis esophagectomy and intrathoracic gastric conduit reconstruction. Pleural drain amylase levels were measured daily until postoperative day (POD) 5 and compared with CRP values measured on POD 3, 5, and 7. Specificity and sensitivity for both tests, and the respective ROC curves, were calculated. RESULTS Anastomotic leak occurred in 12 patients. There was a significant statistical association between pleural drain amylase and serum CRP levels and the presence of anastomotic leakage. Pleural drain amylase cutoff of 209 IU/L on POD 2 yielded a sensitivity of 75% and a specificity of 94% (AUC = 0.813), whereas CRP cutoff value of 22.5 mg/dL on POD 3 yielded a sensitivity of 56% and a specificity of 92% (AUC = 0.772). The negative likelihood ratio of pleural drain amylase was 0.27 and 0.12 on POD 2 and 5, respectively. There was no statistically significant difference between ROC curves of amylase and CRP on POD 3 and 5 (p = 0.79 and p = 0.14, respectively). CONCLUSIONS Pleural drain amylase seems more efficient than serum CRP for early detection of esophago-gastric anastomotic leak. The practice of monitoring drain amylase and CRP may allow safer implementation of enhanced postoperative recovery pathway.
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Kuru O, Cakır I, Akgor U, Sen S, Gorgulu G, Ozdemir HE, Basok BI, Akpınar G, Gokcu M. Serum markers for the early diagnosis of intestinal anastomotic leak after gyne-oncological operations. Int J Clin Pract 2021; 75:e14609. [PMID: 34231277 DOI: 10.1111/ijcp.14609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/02/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To analyse the serum markers for the early diagnosis of intestinal anastomotic leak (AL) after the gyne-oncological operations. METHODS Between September 2017 and March 2021, patients with an intestinal anastomosis performed during the gyne-oncological surgeries were identified from a tertiary centre in Turkey. As the local guideline of the clinic, all these patients were followed by measuring serum samples including procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day (POD) 1 through the day of discharge or the day of re-operation for AL. RESULTS 12.5% (5/40) of the patients suffered an AL and 4 of them were re-operated. The mean albumin values on POD 3-4 and the mean platelet values on POD 1 were lower in the AL group (P < .05). Although it was not statistically significant (P > .05), median PCT values (ng/mL) on POD 8-10 were higher in the AL group compared with no leak group. The best cut-off point for PCT on POD 9 was determined to be 0.11 ng/mL (AUC: 0.917, Sensitivity = 100.0%, specificity = 66.7%, positive predictive value = 66.7%, negative predictive value = 100.0%). CONCLUSION Serum PCT and CRP concentrations were not found to be helpful for the early diagnosis of AL in patients operated for gyne-oncological malignancies. Low levels of albumin and platelets in the first days after the operation may be clue for a possible AL.
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Affiliation(s)
- Oguzhan Kuru
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Ilker Cakır
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Utku Akgor
- Department of Gynecologic Oncology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Serhat Sen
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Izmir Katip Celebi University, Izmir, Turkey
| | - Goksen Gorgulu
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Hasan Emre Ozdemir
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Banu Isbilen Basok
- Department of Clinical Biochemistry, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Goksever Akpınar
- Department of General Surgery, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Mehmet Gokcu
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Izmir, Turkey
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Aaron DJ, Anandhi A, Sreenath GS, Sureshkumar S, Shaikh OH, Balasubramaniyan V, Kate V. Serial estimation of serum C-reactive protein and procalcitonin for early detection of anastomotic leak after elective intestinal surgeries: a prospective cohort study. Turk J Surg 2021; 37:22-27. [PMID: 34585090 DOI: 10.47717/turkjsurg.2021.5102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/05/2021] [Indexed: 02/08/2023]
Abstract
Objectives Anastomotic leak can adversely affect the outcome of surgery especially if detected late. The present study was carried out to detect the anastomotic leak early in the postoperative period using serial estimation of procalcitonin (PCT) and C-reactive protein (CRP). Material and Methods A single centre prospective cohort study was done on patients undergoing elective gastrointestinal surgery with anastomosis. Serial estimation of serum procalcitonin and C reactive protein was done on the first five postoperative days. Other parameters such as hemoglobin, total protein, albumin and WBC counts were noted perioperatively. Patients were followed up to 60th postoperative day to assess for anastomotic leak, wound infection and other septic foci. Results Eighty-four patients were included in the study. Anastomotic leak rate was 26.19% (22/84) and 3/22 patients died in the anastomotic leak group. Wound infection rate was 23.81%. The cut off value of CRP on third postoperative day in detecting anastomotic leak was 44.322 mg/dl with sensitivity of 72.73%, specificity of 66.13% and accuracy of 59.52%. The cut off value for WBC count measured perioperatively in detecting anastomotic leak was 9470 cell/mm3 with sensitivity of 72.73%, specificity of 56.45% and accuracy of 59.74%. Serum procalcitonin, haemoglobin, total protein and albumin measured were not sensitive enough to detect the anastomotic leak early. Conclusion Measuring CRP on the third postoperative day can predict anastomotic leak with a cut off value of 44.32 mg/dl. Patients with raised CRP need careful evaluation to rule out anastomotic leak before deciding on early discharge.
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Affiliation(s)
- Devarajan Jebin Aaron
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Amaranathan Anandhi
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Gubbi Shamanaa Sreenath
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sathasivam Sureshkumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Oseen Hajilal Shaikh
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vairrappan Balasubramaniyan
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Jiang Y, Xu D, Song H, Qiu B, Tian D, Li Z, Ji Y, Wang J. Inflammation and nutrition-based biomarkers in the prognosis of oesophageal cancer: a systematic review and meta-analysis. BMJ Open 2021; 11:e048324. [PMID: 34593492 PMCID: PMC8487212 DOI: 10.1136/bmjopen-2020-048324] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Accumulating literature has shown the predictive values of inflammation and nutrition-based biomarkers in the prognosis of oesophageal cancer but with inconsistent findings. METHOD We performed a meta-analysis to systematically evaluate the predictive value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), C reactive protein-to-albumin ratio (CAR), systemic inflammation index (SII), prognostic nutritional index (PNI), Glasgow Prognostic Score (GPS) and modified Glasgow Prognostic Score (mGPS) in oesophageal cancer. The outcome indicators include the overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS). We applied pooled HR, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio and area under the curve together with 95% CI to estimate the predictive accuracy. RESULTS A total of 72 studies, including 22 260 patients, were included in the meta-analysis. Elevated NLR, PLR CAR, SII, GPS, mGPS and decreased LMR and PNI were associated with poor OS of oesophageal cancer. A high level of NLR, PLR and GPS was related to poor DFS. A high level of NLR and GPS was related to poor CSS. The summarised AUC of CAR (0.72, 95% CI: 0.68 to 0.75) and mGPS (0.75, 95% CI: 0.71 to 0.78) surpassed any other indicators. CONCLUSIONS Clinical indicators such as NLR, PLR, LMR, PNI, SII, CAR, GPS and mGPS have the moderate predictive ability in OS, DFS and CSS of oesophageal cancer. The pretreatment level of CAR and mGPS showed an outstanding prediction value in 5-year OS for oesophageal cancer.
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Affiliation(s)
- Yan Jiang
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Dian Xu
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
- Department of Epidemiology, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, China
| | - Huan Song
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Beibei Qiu
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Dan Tian
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Zhongqi Li
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Ye Ji
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Jianming Wang
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
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Procalcitonin and C-Reactive Protein as an Early Predictor of Infection in Elective Gastrointestinal Cancer Surgery-a Prospective Observational Study. J Gastrointest Cancer 2021; 53:605-613. [PMID: 34328613 DOI: 10.1007/s12029-021-00661-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postoperative infections are a common entity following elective gastrointestinal surgery among which intra-abdominal infection is notorious and life threatening. Early detection could reduce postoperative morbidity and permit safe and early discharge. This study was aimed to establish the usefulness of procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day 3 as reliable markers for early detection of intra-abdominal infection and other postoperative infections following elective gastrointestinal cancer surgery. METHODS A total of 125 patients following elective gastrointestinal cancer surgery were prospectively observed until discharge from January 2018 to December 2019. The incidence of intra-abdominal infections and other postoperative infections was recorded. Serum PCT and CRP were estimated on postoperative day 3 for all the patients. ROC analysis of PCT and CRP was performed to establish their predictability in detecting these infections. Risk factors for postoperative infections were also studied. RESULTS The incidence of intra-abdominal infection (IAI) was 24%. The difference in PCT between the infected and non-infected patients was statistically significant (p = 0.001) but not in CRP (p = 0.223). On ROC analysis of CRP and PCT in detecting IAI, the areas under the curve were 0.494 and 0.615 respectively. CONCLUSION Raised serum PCT values on postoperative day 3 indicate the presence of infections and should prompt the surgeon to consider other investigations to confirm the presence of IAI and other postoperative infections and plan early intervention thus expediting the postoperative recovery. CLINICAL TRIAL REGISTRATION NUMBER CTRI/2018/12/016695.
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Giulini L, Nasser CA, Tank J, Papp M, Stein HJ, Dubecz A. Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis. Eur J Cardiothorac Surg 2021; 59:1279-1285. [PMID: 33448299 DOI: 10.1093/ejcts/ezaa473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/15/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Robotic-assisted oesophagectomy for cancer has been increasingly employed worldwide; however, the benefits of this technique compared to conventional minimally invasive oesophagectomy are unclear. Since 2016, hybrid robotic minimally invasive oesophagectomy (R-HMIE) has increasingly replaced hybrid laparoscopic minimally invasive oesophagectomy (HMIE) as the standard of care in our institution. The aim of this study was to compare these procedures. METHODS Over a 10-year period, 686 patients underwent oesophagectomy at our institution. Out of these patients, 128 patients with cancer were treated with a hybrid minimally invasive technique. Each patient who underwent R-HMIE was matched according to gender, age, comorbidity, American Society of Anesthesiologists classification, Union International Contre le Cancer stage, localization, histology and neoadjuvant treatment with a patient who underwent HMIE. Perioperative parameters were extracted from our database and compared between the 2 groups. RESULTS After the matching procedure, 88 patients were included in the study. Between HMIE and R-HMIE, no significant differences (P > 0.05) were found in operating time (median 281 vs 300 min), R0 resection rate (n = 42 vs 42), harvested lymph nodes (median 28 vs 24), hospital stay (median 19 vs 17 days) and intensive care unit stay (median 7 vs 6.5 days). Regarding surgical complications, no difference could be observed either (n = 42 vs 44). CONCLUSIONS Minimally invasive oesophagectomy remains a challenging operation with high morbidity even in a high-volume institution. According to our intra- and short-term results, we have found no difference between R-HMIE and HMIE.
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Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Corinna A Nasser
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Julian Tank
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marton Papp
- Centre for Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Hubert J Stein
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Plat VD, Voeten DM, Daams F, van der Peet DL, Straatman J. C-reactive protein after major abdominal surgery in daily practice. Surgery 2021; 170:1131-1139. [PMID: 34024474 DOI: 10.1016/j.surg.2021.04.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/24/2021] [Accepted: 04/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Infectious complications are frequently encountered after abdominal surgery. Early recognition, diagnosis, and subsequent timely treatment is the single most important denominator of postoperative outcome. This study prospectively addressed the predictive value of routine assessment of C-reactive protein levels as an early marker for infectious complications after major abdominal surgery. METHODS Consecutive patients undergoing major abdominal surgery between November 2015 and November 2019 were prospectively enrolled. Routine C-reactive protein measurements were implemented on postoperative days 3, 4, and 5, and additional computed tomography examinations were performed on demand. The primary endpoint was the occurrence of Clavien-Dindo grade III or higher infectious complications. RESULTS Of 350 patients, 71 (20.3%) experienced a major infectious complication, and median time to diagnosis was 7 days. C-reactive protein levels were significantly higher in patients with major infectious complications compared to minor or no infectious complications. The optimal cut-off was calculated for each postoperative day, being 175 mg/L on day 3, 130 mg/L on day 4, and 144 mg/L on day 5, and corresponding sensitivities, specificities, and positive and negative predictive values were over 80%, 65%, 40%, and 92% respectively. Alternative safe discharge cut-offs were calculated at 105 mg/L, 71 mg/L and 63 mg/L on days 3, 4, and 5, respectively, each having a negative predictive value of over 97%. CONCLUSION The C-reactive protein cut-offs provided in this study can be used as a discharge criterion or to select patients that might require an invasive intervention due to infectious complications. These diagnostic criteria can easily be implemented in daily surgical practice.
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Affiliation(s)
- Victor D Plat
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands.
| | - Daan M Voeten
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
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Zhang C, Li XK, Hu LW, Zheng C, Cong ZZ, Xu Y, Luo J, Wang GM, Gu WF, Xie K, Luo C, Shen Y. Predictive value of postoperative C-reactive protein-to-albumin ratio in anastomotic leakage after esophagectomy. J Cardiothorac Surg 2021; 16:133. [PMID: 34001160 PMCID: PMC8130324 DOI: 10.1186/s13019-021-01515-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Among the many possible postoperative complications, anastomotic leakage (AL) is the most common and serious. Therefore, the purpose of this study was to explore the ability of various inflammatory and nutritional markers to predict postoperative AL in patients after esophagectomy. Methods A total of 273 patients were retrospectively evaluated and enrolled into this study. Perioperative, surgery-related, tumor-related and laboratory tests data were extracted and analyzed. The discriminatory ability and optimal cut-off value was evaluated according to the receiver operating characteristic (ROC) curve analysis. Univariate and multivariate analyses were performed to access the potential risk factors for AL. Results The overall incidence of AL was 12.5% (34/273). C-reactive protein-to-albumin ratio (CRP/ALB ratio) [AUC 0.943 (95% confidence interval (CI) = 0.911–0.976, p < 0.001)] and operation time [AUC 0.747 (95% CI = 0.679–0.815, p < 0.001)] had the greatest discrimination on AL prediction. Multivariate analysis demonstrated that CRP/ALB ratio and operation time were two independent risk factors for AL, and CRP/ALB ratio (OR = 102.909, p < 0.001) had an advantage over operation time (OR = 9.363, p = 0.020; Table 3). Conclusion Operation time and postoperative CRP/ALB ratio were two independent predictive indexes for AL. Postoperative CRP/ALB ratio greater than 3.00 indicated a high risk of AL. For patients with abnormal postoperative CRP/ALB ratio, early non-operative treatment or surgical intervention are needed to reduce the serious sequelae of AL.
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Affiliation(s)
- Chi Zhang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiao Kun Li
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.
| | - Li Wen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhuang Zhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gao Ming Wang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou School of Clinical Medicine of Nanjing Medical University, Nanjing, China
| | - Wen Feng Gu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Kai Xie
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China. .,Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China. .,Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China. .,Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou School of Clinical Medicine of Nanjing Medical University, Nanjing, China. .,Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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Bonavina L. Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:907. [PMID: 34164541 PMCID: PMC8184442 DOI: 10.21037/atm.2020.03.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The esophagogastric anastomosis is most commonly performed to restore digestive tract continuity after esophagectomy for cancer. Despite a long history of clinical research and development of high-tech staplers, this procedure is still feared by most surgeons and associated with a 10% leakage rate. Among specific factors that may contribute to failure of the esophageal anastomosis are the absence of serosa layer, longitudinal orientation of muscle fibers, and ischemia of the gastric conduit. It has recently been suggested that the gut microbiome may influence the healing process of the anastomosis through the presence of collagenolytic bacterial strains, indicating that suture breakdown is not only a matter of collagen biosynthesis. The esophagogastric anastomosis can be performed either in the chest or neck, and can be completely hand-sewn, completely stapled (circular or linear stapler), or semi-mechanical (linear stapler posterior wall and hand-sewn anterior wall). Because of the lack of randomized clinical trials, no conclusive evidence is available, and the debate between the hand-sewn and the stapling technique is still ongoing even in the present era of robotic surgery. Centralization of care has improved the overall postoperative outcomes of esophagectomy, but the esophagogastric anastomosis remains the Achille’s heel of the procedure. More research and network collaboration of experts is needed to improve safety and clinical outcomes.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
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Barbaro A, Eldredge TA, Shenfine J. Diagnosing anastomotic leak post-esophagectomy: a systematic review. Dis Esophagus 2021; 34:5889927. [PMID: 33565590 DOI: 10.1093/dote/doaa076] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/13/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
Esophagectomy is the gold-standard treatment for esophageal cancer; however, postoperative anastomotic leakage remains the primary concern for surgeons. No consensus exists on the optimal investigations to predict an anastomotic leak. This systematic review aims to identify a single test or combination of tests with acceptable sensitivity and specificity to identify anastomotic leak after esophagectomy and to formulate a diagnostic algorithm to facilitate surgical decision-making. A systematic review of PubMed and EMBASE databases was undertaken to evaluate diagnostic investigations for anastomotic leak post-esophagectomy. Each study was reviewed and where possible, the sensitivity, specificity, positive predictive value, and negative predictive value were extracted. The review identified 3,204 articles, of which 49 met the inclusion criteria. Investigations most commonly used for diagnosis of anastomotic leak were: C-reactive protein (CRP), oral contrast imaging, computed tomography (CT), pleural drain amylase concentration, and the 'NUn score'. The sensitivity of CRP for detecting anastomotic leak varied from 69.2% to 100%. Oral contrast studies sensitivities varied between 16% and 87.5% and specificity varied from 20% to 100%. Pleural drain amylase sensitivities ranged between 75% and 100% and specificity ranged from 52% to 95.5%. The NUn score sensitivities ranged from 0% to 95% and specificity from 49% to 94.4%. No single investigation was identified to rule out anastomotic leak in asymptomatic patients. However, the authors propose a diagnostic algorithm incorporating CRP, pleural drain amylase concentration, and CT with oral contrast to aid clinicians in predicting anastomotic leak to facilitate safe, timely discharge post-esophagectomy.
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Affiliation(s)
- Antonio Barbaro
- Department of Surgery, The Royal Adelaide Hospital, Adelaide, Australia
| | - Thomas A Eldredge
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Department of Surgery, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jonathan Shenfine
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Division of Surgery, Flinders Medical Centre, Bedford Park, Australia
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Al Lawati Y, Alkaaki A, Luis Ramírez García Luna J, Skothos E, Mueller C, Spicer J, Mulder D, Ferri L, Cools-Lartigue J. The Predictive Value of Inflammatory Biomarkers in Esophageal Anastomotic Leaks. Ann Thorac Surg 2021; 112:1790-1796. [PMID: 33440175 DOI: 10.1016/j.athoracsur.2020.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 11/14/2020] [Accepted: 12/01/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study investigated the role of the neutrophil-to-lymphocyte ratio (NLR) in predicting anastomotic leak (AL) after esophagectomy for esophageal adenocarcinoma. METHODS This is a retrospective analysis of a prospectively collected database from the McGill University Health Center. Included were all patients with esophageal adenocarcinoma who underwent esophagectomy between 2005 and 2016. Patients with chronic infections, concurrent active malignancies, and autoimmune conditions were excluded. NLR values were obtained on postoperative days (POD) 0, 1, 2, and 3. Receiver operating characteristic curve study and multivariable logistic analysis were conducted to evaluate the diagnostic value of NLR. RESULTS The study included 330 patients, and AL developed in 16%. Mean NLR values on POD1, 2, and 3 were higher in patients with leaks (20 vs 14 on POD1, P < .001; 20 vs 12 on POD2, P < .001; and 19 vs 10 on POD3, P < .001). The NLR value on POD3 was associated with an area under the curve of 70% and a negative predictive value of 92.4%. Multivariable analyses identified higher American Society of Anesthesiologists Physical Status Classification, increasing NLR trend (between POD1 and POD3), POD1 NLR, POD2 NLR, and POD3 NLR as independent factors associated with AL. CONCLUSIONS Patients who developed AL demonstrate higher mean NLR values in the early postoperative period with rising trends. Conversely a low NLR is associated with a high negative predictive value for AL. This simple metric allows risk stratification that may guide treatment decisions in esophagectomy patients.
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Affiliation(s)
- Yaseen Al Lawati
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Aroub Alkaaki
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Elena Skothos
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Carmen Mueller
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - David Mulder
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada.
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Deana C, Vetrugno L, Stefani F, Basso A, Matellon C, Barbariol F, Vecchiato M, Ziccarelli A, Valent F, Bove T, Bassi F, Petri R, De Monte A. Postoperative complications after minimally invasive esophagectomy in the prone position: any anesthesia-related factor? TUMORI JOURNAL 2020; 107:525-535. [PMID: 33323061 DOI: 10.1177/0300891620979358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the incidence of postoperative complications arising within 30 days of minimally invasive esophagectomy in the prone position with total lung ventilation and their relationship with 30-day and 1-year mortality. Secondary outcomes included possible anesthesia-related factors linked to the development of complications. METHODS The study is a retrospective single-center observational study at the Anesthesia and Surgical Department of a tertiary care center in the northeast of Italy. Patients underwent cancer resection through esophagectomy in the prone position without one-lung ventilation. RESULTS We included 110 patients from January 2010 to December 2017. A total of 54% of patients developed postoperative complications that increased mortality risk at 1 year of follow-up. Complications postponed first oral intake and delayed patient discharge to home. Positive intraoperative fluid balance was related to increased mortality and the risk to develop postoperative complications. C-reactive protein at third postoperative day may help detect complication onset. CONCLUSIONS Complication onset has a great impact on mortality after esophagectomy. Some anesthesia-related factors, mainly fluid balance, may be associated with postoperative mortality and morbidity. These factors should be carefully taken into account to obtain better outcomes after esophagectomy in the prone position without one-lung ventilation.
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Affiliation(s)
- Cristian Deana
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Luigi Vetrugno
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Francesca Stefani
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Andrea Basso
- Department of Medicine, University of Udine, Udine, Italy
| | - Carola Matellon
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Federico Barbariol
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Massimo Vecchiato
- General Surgery, Department of Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Antonio Ziccarelli
- General Surgery, Department of Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Francesca Valent
- Institute of Epidemiology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Tiziana Bove
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Flavio Bassi
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Roberto Petri
- General Surgery, Department of Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Amato De Monte
- Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
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Plat VD, Bootsma BT, Straatman J, van den Bergh J, van Waesberghe JHTM, Luttikhold J, Luyer MDP, van der Peet DL, Daams F. The clinical suspicion of a leaking intrathoracic esophagogastric anastomosis: the role of CT imaging. J Thorac Dis 2020; 12:7182-7192. [PMID: 33447407 PMCID: PMC7797855 DOI: 10.21037/jtd-20-954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND CT imaging is the primary diagnostic approach to assess the integrity of the intrathoracic anastomosis following Ivor Lewis esophagectomy. In the postoperative setting interpretation of CT findings, such as air and fluid collections, may be challenging. Establishment of a scoring system that incorporates CT findings to diagnose anastomotic leakage could assist radiologists and surgeons in the postoperative phase. METHODS Consecutive patients who underwent a CT scan for a clinical suspicion of postoperative anastomotic leakage following Ivor Lewis esophagectomy between 2010 and 2016 in two medical centers were retrospectively included. Scans were excluded when oral contrast was not (correctly) administered. Acquired images were randomized and independently assessed by two experienced gastrointestinal radiologists, blinded for clinical information. For this study anastomotic leakage was defined as a visible defect during endoscopy or thoracotomy. RESULTS A total of 80 patients had 101 CT scans, resulting in 32 scans with a confirmed anastomotic leak (25 patients). After multivariable backward stepwise logistic regression, a practical 5-point scoring system was developed, which included the following CT findings: presence of extraluminal oral contrast, air collection at the anastomotic site, fluid collection at the anastomotic site, pneumothorax and loculated pleural effusion. Patients with a score of ≥3 were considered at high risk for anastomotic leakage (positive predictive value: 83.3%), patients with scores <3 were considered at low risk for anastomotic leakage (negative predictive value: 84.4%). The scoring system showed a superior diagnostic performance compared to the original CT report and blinded interpretation of two radiologists. CONCLUSIONS Our CT-based practical scoring system enables a standardized approach in CT assessment and could facilitate early recognition of anastomotic leakage in patients after Ivor Lewis esophagectomy.
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Affiliation(s)
- Victor D Plat
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Boukje T Bootsma
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Janneke van den Bergh
- Department of Radiology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Joanna Luttikhold
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Micha D P Luyer
- Department of Gastrointestinal Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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42
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Yu Y, Wu Z, Shen Z, Cao Y. Preoperative C-reactive protein-to-albumin ratio predicts anastomotic leak in elderly patients after curative colorectal surgery. Cancer Biomark 2020; 27:295-302. [PMID: 31658046 DOI: 10.3233/cbm-190470] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Anastomotic leak (AL), as one of the most devastating complications, is the leading cause of mortality in colorectal cancer (CRC) patients after resection. This study was aimed to investigate potential risk factors for AL in elderly surgical CRC patients. METHODS A total of 1068 elderly subjects who underwent elective curative colorectal surgery from 2012 to 2018 were retrospectively evaluated and enrolled into this study population. The predictive value of C-reactive protein-to-albumin ratio (CAR) for AL in surgical CRC patients was evaluated by receiver operating characteristic (ROC) curve analysis. Potential risk factors for AL were assessed by the univariate and multivariate logistic regression analyses. RESULTS Of all the 1068 enrolled patients, 81 patients have developed AL with an incidence of 7.6% (81/1068). Preoperative CAR was an effective predictor for AL with an area under the curve (AUC) of 0.758, 95% CI of 0.700-0.817, a cut-off value of 2.44, a sensitivity of 61.09% and a specificity of 80.25%, respectively (P< 0.001). Duration of operation (OR: 2.05, 95% CI: 1.21-3.44, P= 0.013) and preoperative CAR (OR: 1.94, 95% CI: 1.21-3.11, P= 0.007) were two independent risk factors for AL by the multivariate logistic regression analysis. CONCLUSIONS Our study indicate that preoperative CAR level and duration of operation were two independent predictors for AL among elderly surgical CRC patients.
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43
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Halliday E, George A. Using post-operative trend in C-reactive protein to predict fistula in neopharyngeal repairs following laryngectomy and pharyngectomy surgery in fifty-five patients. Clin Otolaryngol 2020; 46:119-122. [PMID: 32881308 DOI: 10.1111/coa.13645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 07/20/2020] [Accepted: 08/23/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Edwin Halliday
- University Hospitals of North Midlands NHS Trust, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Ajith George
- University Hospitals of North Midlands NHS Trust, Royal Stoke University Hospital, Stoke-on-Trent, UK.,Keele University School of Medicine, Hospital Campus, Stoke-on-Trent, UK
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Barrie J, Cockbain A, Tsachiridi M, Surendrakumar V, Maxwell M, Tamhankar AP. Predicting Delayed Complications After Esophagectomy in the Current Era of Early Discharge and Enhanced Recovery. Am Surg 2020; 86:615-620. [PMID: 32683954 DOI: 10.1177/0003134820923314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Enhanced recovery protocols after esophagectomy aim to discharge patients by day 7. A small risk of delayed complications exists. We aimed to assess whether C-reactive protein (CRP) levels on day 7 could help predict delayed complications and assist safe discharge. METHODS All consecutive esophagectomies over 3 years were retrospectively reviewed. Patients were categorized on day 7 into (1) those clinically unsafe for discharge; (2) those clinically safe for discharge; and (3) those considered safe for discharge but develop a delayed complication. CRP level on day 7 and the trend in CRP levels between days 3 and 7 were compared. RESULTS A total of 140 patients underwent esophagectomy, of which 64 patients (46%) had at least one complication. On day 7, 62 (44%) patients were considered clinically unsafe for discharge; 74 (53%) were considered safe for discharge; and 4 (3%) were safe but developed a delayed complication. No patient with delayed complication had a day 7 CRP level < 84 mg/L. CRP trend did not help predict delayed complications. CONCLUSIONS The actual CRP level on day 7 after esophagectomy, rather than the trend, can predict delayed complications. Early discharge after esophagectomy should be desisted if the clinical picture is better than the actual blood results.
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Affiliation(s)
- J Barrie
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - A Cockbain
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - M Tsachiridi
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - V Surendrakumar
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - M Maxwell
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
| | - A P Tamhankar
- 105628 Department of Upper Gastro-Intestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, South Yorkshire, UK
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Bona D, Micheletto G, Bonitta G, Panizzo V, Cavalli M, Rausa E, Cirri S, Aiolfi A. Does C-reactive Protein Have a Predictive Role in the Early Diagnosis of Postoperative Complications After Bariatric Surgery? Systematic Review and Bayesian Meta-analysis. Obes Surg 2020; 29:3448-3456. [PMID: 31240535 DOI: 10.1007/s11695-019-04013-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative leak and intra-abdominal infections are common after bariatric surgery with a significant impact on perioperative outcomes, hospital length of stay, and readmission rates. In the era of enhanced recovery programs, with patients being discharged from the hospital 24-36 h after surgery and potentially before developing any complications, an early indicator of postoperative complications may be decisive. The aim of this study was to evaluate the predictive role of the C-reactive protein (CRP) in the early diagnosis of complications in patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS PubMed, Embase, and Web of Science databases were consulted. A systematic review and a fully Bayesian meta-analysis were conducted. RESULTS Seven studies met the inclusion criteria for a total of 1401 patients. Overall, 57.7% underwent LSG while 42.3% underwent LRYGB. The pooled prevalence of postoperative complications was 9.8% (95% CI = 5-16%). The estimated pooled CRP cut-off value on postoperative day 1 (POD1) was 6.1 mg/dl with a significant diagnostic accuracy and a pooled area under the curve of 0.92 (95% credible interval (CrI) 0.73-0.98). The positive and negative likelihood ratios were 13.6 (95% CrI 8.40-15.9) and 0.16 (95% CrI 0.04-0.31), respectively. CONCLUSION A CRP value lower than the derived cut-off of 6.1 mg/dl on POD1, combined with reassuring clinical signs, could be useful to rule out early postoperative leak and complications after LSG and LRYGB. In the context of enhanced recovery after surgery protocols, the integration of a CRP-based diagnostic algorithm as an additional complementary instrument may be valuable to reduce cost and improve outcomes and patient care.
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Affiliation(s)
- Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy.
| | - Giancarlo Micheletto
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Valerio Panizzo
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Marta Cavalli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Emanuele Rausa
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Silvia Cirri
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
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46
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Huang C, Yao H, Huang Q, Lu H, Xu M, Wu J. A novel nomogram to predict the risk of anastomotic leakage in patients after oesophagectomy. BMC Surg 2020; 20:64. [PMID: 32252738 PMCID: PMC7137293 DOI: 10.1186/s12893-020-00726-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 03/25/2020] [Indexed: 01/25/2023] Open
Abstract
Background Anastomotic leakage is a dangerous postoperative complication of oesophageal surgery. The present study aimed to develop a simple and practical scoring system to predict the risk of anastomotic leakage after oesophageal resection. Methods A consecutive series of 330 patients who underwent oesophageal cancer surgery from January 2016 to January 2018 at the Shanghai Chest Hospital were included to develop a prediction model. Anastomotic leakage was evaluated using oesophagography, computed tomography, or flexible endoscopy. Least absolute shrinkage and selection operator regression based on a generalized linear model was used to select variables for the anastomotic leakage risk model while avoiding overfitting. Multivariable logistic regression analysis was applied to build forest plots and a prediction model. The concordance index or the area under the curve was used to judge the discrimination, and calibration plots verified the consistency. Internal validation of the model was conducted, and the clinical usefulness and threshold screening of the model were evaluated by decision curve analysis. Results The factors included in the predictive nomogram included Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia. The model displayed a discrimination performance with a concordance index of 0.690 (95% confidence interval: 0.620–0.760) and good calibration. A concordance index value of 0.664 was maintained during the internal validation. The calibration curve showed good agreement between the actual observations and the predicted results. Conclusion The present prediction model, which requires only seven variables and includes Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia, may be useful for predicting anastomotic leakage in patients after oesophagectomy.
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Affiliation(s)
- Chengya Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Haixia Yao
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Qi Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Huijie Lu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Meiying Xu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Jingxiang Wu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China.
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47
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Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5709700. [PMID: 31957798 DOI: 10.1093/dote/doz089] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/07/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, UK
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thahesh Tharmaraja
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yashvi Bharwada
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Department of Academic Surgery and College of Medical and Dental Sciences, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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48
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The emerging predictive role of C-reactive protein after ventral hernia repair with mesh. Hernia 2020; 24:1415. [PMID: 32140966 DOI: 10.1007/s10029-020-02160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
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49
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Babic B, Tagkalos E, Gockel I, Corvinus F, Hadzijusufovic E, Hoppe-Lotichius M, Lang H, van der Sluis PC, Grimminger PP. C-reactive Protein Levels After Esophagectomy Are Associated With Increased Surgical Trauma and Complications. Ann Thorac Surg 2020; 109:1574-1583. [PMID: 31987821 DOI: 10.1016/j.athoracsur.2019.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 11/10/2019] [Accepted: 12/04/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND With the introduction of minimally invasive esophagectomy, postoperative complications rates have decreased. Daily laboratory tests are used to screen patients for postoperative complications. The course of inflammatory indicators after esophagectomy after different surgical approaches has not been described yet. The aim of the study was to describe the postoperative C-reactive protein (CRP) and leukocyte levels after different surgical approaches for esophagectomy and relate it to postoperative complications. METHODS Between 2010 and 2018, 217 consecutive patients underwent thoracoabdominal esophagectomy with gastric conduit reconstruction. Blood tests to assess CRP and leukocytes were performed daily in all patients. Differences between treatment groups were analyzed with a linear mixed model. All postoperative complications were recorded in a prospective database. Prognostic factors were analyzed using multivariate logistic regression modeling. RESULTS The study evaluated 4 different esophagectomy techniques: open (n = 57), hybrid (n = 53), totally minimally invasive (n = 52), and robot-assisted minimally invasive (n = 55). The increase of inflammatory indicators was significantly higher after open esophagectomy on the first 2 postoperative days compared with the 3 minimally invasive procedures (P < .001). Postoperative CRP values exceeding 200 mg/L on the second postoperative day and open esophagectomy were independently associated with postoperative complications. CONCLUSIONS Open esophagectomy results in significantly higher CRP and leukocyte values compared with hybrid, minimally invasive, and robot-assisted minimally invasive esophagectomy. Open esophagectomy and a CRP increase on the second postoperative day above 200 mg/L are independent positive predictors for postoperative complications in multivariate analysis.
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Affiliation(s)
- Benjamin Babic
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Evangelos Tagkalos
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ines Gockel
- Department of Visceral-, Transplant-, Thoracic-, and Vascular-Surgery and Department of Operative Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Florian Corvinus
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Pieter Christiaan van der Sluis
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Peter Philipp Grimminger
- Department of General-, Visceral- and Transplant-Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
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50
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Bona D, Micheletto G, Bonitta G, Aiolfi A. Does C-Reactive Protein Day 1 Post-Surgery Have a Predictive Role for Postoperative Complications: Reply. Obes Surg 2020; 30:1580-1581. [PMID: 31907827 DOI: 10.1007/s11695-019-04381-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Faravelli n. 16, Milan, Italy
| | - Giancarlo Micheletto
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Faravelli n. 16, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Faravelli n. 16, Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Faravelli n. 16, Milan, Italy.
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