Reduction rate of C-reactive protein as an early predictor of postoperative complications and a reliable discharge indicator after gastrectomy for gastric cancer

Machine learning-based real-time prediction of duodenal stump leakage from gastrectomy in gastric cancer patients

Purpose

This study aimed to develop a machine learning (ML) model for real-time prediction of duodenal stump leakage (DSL) following gastrectomy in patients with gastric cancer (GC) using a comprehensive set of clinical variables to improve postoperative outcomes and monitoring efficiency.

Methods

A retrospective analysis was conducted on 1,107 patients with GC who underwent gastrectomy at Pusan National University Yangsan Hospital between 2019 and 2022. One hundred eighty-nine features were extracted from each patient record, including demographic data, preoperative comorbidities, and blood test outcomes from the subsequent seven postoperative days (POD). Six ML algorithms were evaluated: Logistic Regression (LR), K-nearest neighbors (KNN), Support Vector Machine (SVM), Random Forest (RF), Extreme Gradient Boosting (XGB), and Neural Network (NN). The models predicted DSL occurrence preoperatively and on POD 1, 2, 3, 5, and 7. Performance was assessed using the Area Under the Receiver Operating Characteristic Curve (AUROC) and Recall@K.

Results

Among the 1,107 patients, 29 developed DSL. XGB demonstrated the highest AUROC score (0.880), followed by RF (0.858), LR (0.823), SVM (0.819), NN (0.753), and KNN (0.726). The RF achieved the best Recall@K score of 0.643. Including additional POD features improved the predictive performance, with the AUROC value increasing to 0.879 on POD 7. The confidence scores of the model indicated that the DSL predictions became more reliable over time.

Conclusion

The study concluded that ML models, notably the XGB algorithm, can effectively predict DSL in real-time using comprehensive clinical data, enhancing the clinical decision-making process for GC patients.

C-reactive protein and digestive pathologies: A narrative review for daily clinical use

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.

Higher compliance with the enhanced recovery after surgery protocol improves postoperative recovery and 6-month mortality in upper gastrointestinal surgery

Introduction

The enhanced recovery after surgery (ERAS) protocol has been proven to accelerate recovery without increasing morbidity, but few data are available from developing countries. We aimed to demonstrate the correlation between compliance with the ERAS protocol and short-term outcomes in upper gastrointestinal (UGI) surgery.

Materials and Methods

Patients that underwent esophageal and gastric surgeries during March 2019 to June 2021 were prospectively enrolled in this nonrandomized cohort study. The ERAS protocol was applied based on patient-doctor agreement. Patients were categorized into conventional care (CC), moderate-compliance (MC), and high-compliance (HC) groups. Short-term outcomes including gastrointestinal (GI) function recovery, length of hospital stay (LOS), postoperative complications and mortality rate were compared.

Results

158 patients were enrolled: 58 in the CC, 33 in the MC, and 67 in the HC group. The HC group demonstrated reduced time to tolerate oral diet (8 vs 7 vs 3 days; p = 0.034), recovery of GI function (72 vs 96 vs 61 h; p = 0.001) and median LOS (12.5 vs 10 vs 6 days; p < 0.001). Postoperative overall (p = 0.08) and major complications (p = 0.09) were not significantly different. Non-surgical complications were lower in the HC group (31.0 % vs 54.5 % vs 25.4 %; p = 0.013). The 28-day readmission rate was not different (8.6 % vs 3.0 % vs 1.5 %; p = 0.14). The 30-day postoperative mortality was not different (0 % vs 3.1 % vs 0 %; p = 0.15), but the 6-month mortality rate was significantly lower in the HC group (13.8 % vs 15.2 % vs 0 %; p < 0.001).

Conclusion

The level of compliance with the ERAS protocol is associated with improved short-term postoperative outcome in UGI surgery. High compliance patients recovered faster, were discharged sooner, and had better 6-month survival.

C-reactive protein: structure, function, regulation, and role in clinical diseases

C-reactive protein (CRP) is a plasma protein that is evolutionarily conserved, found in both vertebrates and many invertebrates. It is a member of the pentraxin superfamily, characterized by its pentameric structure and calcium-dependent binding to ligands like phosphocholine (PC). In humans and various other species, the plasma concentration of this protein is markedly elevated during inflammatory conditions, establishing it as a prototypical acute phase protein that plays a role in innate immune responses. This feature can also be used clinically to evaluate the severity of inflammation in the organism. Human CRP (huCRP) can exhibit contrasting biological functions due to conformational transitions, while CRP in various species retains conserved protective functions in vivo. The focus of this review will be on the structural traits of CRP, the regulation of its expression, activate complement, and its function in related diseases in vivo.

Identifying the best candidates for reduced port gastrectomy

BACKGROUND

Previous studies have focused on the non-inferiority of RPG compared with conventional port gastrectomy (CPG); however, we assumed that some candidates might derive more significant benefit from RPG over CPG.

METHODS

We retrospectively analyzed the clinicopathological and perioperative parameters of 1442 patients with gastric cancer treated by gastrectomy between 2009 and 2022. The C-reactive protein level on postoperative day 3 (CRPD3) was used as a surrogate parameter for surgical trauma. Patients were grouped according to the extent of gastrectomy [subtotal gastrectomy (STG) or total gastrectomy (TG)] and lymph node dissection (D1+ or D2). The degree of surgical trauma, bowel recovery, and hospital stay between RPG and CPG was compared among those patient groups.

RESULTS

Of 1442 patients, 889, 354, 129, and 70 were grouped as STGD1+, STGD2, TGD1+, and TGD2, respectively. Compared with CPG, RPG significantly decreased CRPD3 only among patients in the STGD1+ group (CPG: n = 653, 84.49 mg/L, 95% CI 80.53-88.45 vs. RPG: n = 236, 70.01 mg/L, 95% CI 63.92-76.09, P < 0.001). In addition, the RPG method significantly shortens bowel recovery and hospital stay in the STGD1+ (P < 0.001 and P < 0.001), STGD2 (P < 0.001 and P < 0.001), and TGD1+ (P = 0.026 and P = 0.007), respectively. No difference was observed in the TGD2 group (P = 0.313 and P = 0.740).

CONCLUSIONS

The best candidates for RPG are patients who undergo STGD1+, followed by STGD2 and TG D1+, considering the reduction in CRPD3, bowel recovery, and hospital stay.

Role of C-Reactive Protein, White Blood Cell Counts, and Serum Glucose Levels as Early Predictors of Infectious Complications After Laparoscopic Colorectal Surgery for Colorectal Cancer

BACKGROUND

The early detection of infectious complications of colorectal surgery leads to better patient outcomes. This study aimed to assess the role of C-reactive protein (CRP), white blood cell count (WBC), and serum glucose in the early prediction of infectious complications of laparoscopic colorectal surgery.

METHODS

Patients who underwent laparoscopic colorectal surgery were included and stratified into two groups: infectious complication (IC) or no infectious complication (non-IC). Serum levels were measured on postoperative days (PODs) 2 and 4.

RESULTS

Analysis of 224 patients (IC group: 27, Non-IC group: 197) revealed higher CRP levels in IC group on POD 2 (P = .001). On POD 4, CRP levels and WBC counts were higher in IC group (P<.001, P = .011, respectively). The area under the curve (AUC) of the receiver operating characteristic (ROC) for CRP on PODs 2 and 4 were .743 and .907, respectively, and for WBC on POD 4 was .687. The cut-offs of CRP on PODs 2 and 4 were 156.2 mg/L and 91.3 mg/L, respectively; the cut-off of WBC was 7,220 cells/mm3. Sensitivity of CRP level ≥91.3 mg/L or WBC count ≥7,220 cells/mm3 was 96.3%; (cf. 88.9% for CRP alone), and specificity of CRP level ≥91.3 mg/L and WBC count ≥7,220 cells/mm3 was 93.4% (cf. 82.2% for CRP alone).

DISCUSSION

The CRP level on postoperative day (POD) 2 and the combined CRP and WBC on POD 4 were meaningful in predicting infectious complications after laparoscopic colorectal surgery. However, serum glucose levels had a low predictive value for infectious complications.

Prognostic significance of C-reactive protein in patients with cervical cancer: a meta-analysis

Background

Numerous studies have investigated the significance of pretreatment C-reactive protein (CRP) levels for determining the prognosis of cervical cancer (CC). The results of these studies, however, have been inconsistent. The present meta-analysis, therefore, focused on identifying the exact relationship of CRP levels with CC prognoses.

Methods

We searched the following databases from their inception until April 18, 2023: PubMed; Web of Science; Embase; and Cochrane Library. From the search results, we estimated the significance of CRP levels in determining the prognosis of CC, based on combined hazard ratios (HRs) and relevant 95% confidence intervals (CIs).

Results

The present meta-analysis included 12 studies, encompassing 2,204 patients. Based on combined data, an increased CRP level was significantly related to an unfavorable overall survival (OS) of patients with CC (HR = 1.63; 95% CI = 1.36-1.95; P < 0.001). Moreover, an increased CRP level was significantly associated with shortened progression-free survival (PFS) in patients with CC (HR = 1.68; 95% CI = 1.39-2.03; P < 0.001). According to the subgroup and sensitivity analyses, CRP level was a reliable factor in determining CC prognoses.

Conclusion

Based on the results of our present analyses, increased CRP levels were significant predictors of poor OS and PFS in patients with CC. CRP level, therefore, could be an independent and inexpensive factor for determining the prognosis of patients with CC in clinical settings.

Systematic review registration

INPLASY, identifier INPLASY202360074.

Proteína C reactiva y su progresión en el tiempo para la detección de las fugas anastomóticas

Introducción. Las fugas anastomóticas son una complicación común y crítica en cirugía gastrointestinal, por lo que su identificación y tratamiento temprano son necesarios para evitar resultados adversos. El uso convencional con un valor límite de la proteína C reactiva ha demostrado una utilidad limitada. El objetivo de este estudio fue determinar la utilidad de la medición seriada de la proteína C reactiva en la detección de fugas anastomóticas. Métodos. Revisión prospectiva de base de datos retrospectiva de pacientes sometidos a cirugía abdominal mayor con al menos una anastomosis intestinal. Se midió la proteína C reactiva al tercer y quinto día posoperatorio. Las complicaciones se categorizaron según la clasificación de Clavien-Dindo. La precisión diagnóstica fue evaluada por el área bajo la curva. Resultados. Se incluyeron 157 pacientes, el 52 % mujeres. La edad promedio fue de 63,7 años. El mayor número de cirugías correspondió a gastrectomía (36,3 %), resección anterior de recto (15,3 %) y hemicolectomía derecha (13,4 %). El 25,5 % tuvieron alguna complicación postoperatoria y el 32,5 % (n=13) presentaron fuga en la anastomosis. El aumento de la proteína C reactiva tuvo un área bajo la curva de 0,918 con un punto de corte de aumento en 1,3 mg/L, sensibilidad de 92,3 % (IC95% 78 – 100) y una especificidad de 92,4 % (IC95% 88 – 96). Conclusiones. El aumento de 1,3 mg/L en la proteína C reactiva entre el día de la cirugía y el quinto día fue un predictor preciso de fugas anastomóticas en pacientes con cirugía abdominal mayor.

C-Reactive Protein as a Prognostic Biomarker for Gynecologic Cancers: A Meta-Analysis

Background

The prognostic role of CRP (C-reactive protein) in gynecological tumors has been previously reported in individual studies, but whether CRP can be used as a separate potential prognostic factor has not been systematically reviewed. The purpose of this research is to determine if there is a link between CRP levels and the prognosis of gynecological cancer patients.

Methods

A systematic search was carried out to find the literature evaluating the predictive role of CRP in the prognosis of gynecological cancer patients. For the purpose of determining the relationship between CRP and clinicopathological characteristics, the pooled odds ratio (OR) was calculated. A hazard ratio (HR) with a 95% confidence interval (CI) was used to determine differences in overall survival (OS), disease-free survival (DFS), or progression-free survival (PFS) between patients with low and high CRP levels.

Results

A total of 19 studies, including 4062 patients, were analyzed retrospectively. The FIGO stage was related to the CRP level (OR = 0.43, 95% CI: 0.19-1.00). Age, lymph node metastasis, and histological grade were not associated with CRP level (OR = 0.93, 95% CI: 0.69-1.25; OR = 0.91, 95% CI: 0.65-1.28; OR = 0.74, 95% CI: 0.52-1.05). Worse OS (HR = 1.40, 95% CI: 1.23-1.57), DFS (HR = 1.20, 95% CI: 1.12-1.28), and PFS (HR = 1.57, 95%CI: 1.23-1.91) were associated with elevated CRP levels, as shown by the pooled results. Subgroup analysis was performed according to cancer type (endometrial cancer: HR = 1.15, 95% CI: 1.02-1.28; ovarian cancer: HR = 1.67, 95% CI: 1.03-2.31; cervical cancer: HR = 1.42, 95% CI: 1.19-1.64), multivariate value (HR = 1.22, 95% CI: 1.10-1.33), and age (HR = 1.50, 95% CI: 1.28-1.72). Significant correlations were observed between CRP and OS.

Conclusions

CRP may be utilized as a prognostic indicator for a variety of gynecologic malignancies, including cervical cancer, ovarian cancer, endometrial cancer, and vulvar cancer.

C-Reactive Protein as a Marker of Postoperative Complication of Emergency Colorectal Surgery

Introduction The literature converges regarding the use of C-reactive protein (CRP) tests between postoperative days (PODs) 3 and 5 of elective procedures. In this period, they have great sensitivity and negative predictive value (NPV) for severe and anastomotic complications about two days before the first clinical sign. The few studies on colorectal urgency suggest that, despite the different initial values according to the surgical indication, following POD 3, the level of CRP is similar to that of elective procedures. However, given the heterogeneity of the studies, there is no consensus on the cutoff values for this use.

Objective To validate the use and propose a PO CRP cut-off value in urgent colorectal procedures as an exclusion criterion for complications of anastomosis or the abdominal cavity.

Method Retrospective analysis of the medical records of 308 patients who underwent urgent colorectal surgical procedures between January 2017 and December 2019. The following data were considered: age, gender, surgical indication, type of procedure performed, complications, CRP levels preoperatively and from POD 1 to 4, and the severity of the complications. We compared the CRP levels and the percentage variations between the preoperative period and PODs 1 to 4 as markers of severe complications using the receiver operating characteristic (ROC) curve.

Results The levels of CRP on POD4, and their percentage drops between PODs 2 to 4 and PODs 3 to 4, were better to predict severe complications. A cutoff of 7.45 mg/dL on POD 4 had 91.7% of sensitivity and NPV. A 50% drop between PODs 3 and 4 had 100% of sensitivity and NPV.

Conclusion Determining the level of CRP is useful to exclude severe complications, and it could be a criterion for hospital discharge in POD 4 of emergency colorectal surgery.

Clinical significance and prognostic value of C-reactive protein/albumin ratio in gastric cancer

Purpose

This study was aimed to evaluate the clinical significance and prognostic value of CRP/albumin ratio (CAR) in patients with gastric cancer.

Methods

The data of 205 gastric cancer patients who underwent surgery was analyzed retrospectively. The association of CAR with the clinical features and prognostic value in gastric cancer was analyzed. The data of this study was combined with previous studies to further determine the prognostic value of CAR in patients with gastric cancer using a meta-analysis method.

Results

Cox analysis revealed that preoperative CAR was an independent prognosis indicator in patients with gastric cancer. High expression of CAR indicated a shorter survival time than in those with lower expression. CAR has a higher prognostic value in the 1-, 3-, and 5-year overall survival in patients with gastric cancer. CAR showed significant difference regarding the gastric cancer patients' age, M stage, and clinical stage. The discriminate value of CAR in M stage of gastric cancer was high (area under the curve, 0.809). A meta-analysis combining previous data and our data showed that preoperative CAR demonstrated a significant association with the overall survival of patients with gastric cancer.

Conclusion

This study demonstrated that preoperative CAR could serve as an important prognostic indicator in patients with gastric cancer.

Clinical impact of creatine phosphokinase and c-reactive protein as predictors of postgastrectomy complications in patients with gastric cancer

BACKGROUND

Postoperative complications have been linked to the morbidity and mortality of several cancers. However, predicting whether complications will occur in the early period after surgery or not is challenging. Hence, this study aimed to examine the diagnostic accuracy of serum creatine phosphokinase (CPK) and c-reactive protein (CRP) in predicting the development of postgastrectomy complications.

METHODS

We retrospectively analyzed 188 patients with gastric cancer (GC) who underwent gastrectomy. The diagnostic accuracy of serum CPK and CRP was investigated using the areas under the curves (AUC). The CPK ratio was defined as the CPK on postoperative day (POD) 1 to the CPK on a preoperative day.

RESULTS

Out of 188 patients, 48 (25.5%) developed postoperative complications. The complications group had a greater operative time (p = 0.037), higher CPK ratio on POD1 (p < 0.0001), and a higher serum CRP level on POD3 (p = 0.001). The AUC for the CPK ratio was 0.772, with an optimal cutoff value of 7.05, whereas that for CRP was 0.659, with an optimal cutoff value of 11.4 mg/L. The CPK ratio on POD1 (p < 0.0001) and the CRP on POD3 (p = 0.007) were independent factors for predicting the development of postgastrectomy complications. The CPK ratio on POD1 and the CRP on POD3 predicted postgastrectomy complications in 41 patients (85.4%). According to combined value of both CPK ratio and CRP level, the positive predictive value and the negative predictive value was 0.70 and 0.829. And sensitivity and specificity were 0.438 and 0.936.

CONCLUSION

The CPK ratio on POD1 and the CRP on POD3 after gastrectomy for GC were predictive factors for complication development and may be employed to prevent the development of such complications and improve the prognosis of patients with GC.

Reduced fasting time in patients who underwent totally laparoscopic distal gastrectomy

Purpose

The aim of this study was to analyze the effects of reduced fasting time on postoperative recovery in patients who underwent totally laparoscopic distal gastrectomy (TLDG).

Methods

This retrospective study included 347 patients who underwent TLDG. Patients were divided into 2 groups: reduced fasting time group (n = 139) and conventional feeding group (n = 208). We compared the total hospital cost and recovery parameters, such as postoperative complications, mean hospital stay, day of first flatus, initiation of soft diet, and serum CRP levels, between the 2 groups.

Results

The reduced fasting time group had a lower total hospital cost (P < 0.001) than the conventional feeding group. Regarding postoperative complications, there was no significant difference between the 2 groups (P = 0.085). Patients in the reduced fasting time group had a significantly shorter duration of mean hospital stay (P < 0.001), an earlier first flatus (P = 0.002), an earlier initiation of soft diet (P < 0.001), and lower level of serum CRP concentration (day of surgery, P = 0.036; postoperative days 2, 5, and 7, P = 0.01, 0.009, and 0.012, respectively) than patients in the conventional feeding group.

Conclusion

Reduced fasting time can enhance postoperative recovery in patients who undergo TLDG and may reduce medical costs.

Cytokines in abdominal exudate and serum predict small bowel obstruction following appendectomy

BACKGROUND

This study aimed to investigate the value of inflammatory markers for the prediction of small bowel obstruction (SBO) following appendectomy.

METHODS

We included cases of acute appendicitis that underwent laparoscopic appendectomy (LA) in the Qingdao Municipal Hospital between January 2017 and January 2019. The cases were divided into an SBO group and a non-SBO group depending on whether patients had or did not have SBO, and patients were followed up for at least 1 year. The levels of interleukin (IL)-1β, IL-6 and tumour necrosis factor-alpha (TNF-α) in abdominal exudate and venous blood were examined using enzyme-linked immunosorbent assay.

RESULTS

After 1 year of follow-up, there were 985 cases in the non-SBO group and 16 cases in the SBO group. The levels of IL-1β, IL-6 and TNF-α in abdominal exudate on post-operative day 1 in the SBO group were 172.5 ± 14.7, 2167.3 ± 372.1 and 253.9 ± 12.9 pg/mL, respectively, which were significantly higher than that in the non-SBO group. The serum levels of IL-1β, IL-6, TNF-α and C-reactive protein (CRP) in the SBO group were significantly higher than that in the non-SBO group before surgery. Post-operatively, the inflammatory markers above decreased significantly and became similar with time in both groups. The logistic regression showed that the levels of peritoneal IL-6, preoperative serum CRP and perforated appendicitis were significant risk factors of SBO. The specificity and sensitivity of peritoneal IL-6 were 0.81 and 0.921, respectively.

CONCLUSION

The IL-1β, IL-6, TNF-α and CRP in serum and abdominal exudate played an important role in SBO after LA. The peritoneal IL-6 was the most reliable prediction marker for SBO.