Serum amylase and C-reactive protein in risk stratification of pancreas-specific complications after pancreaticoduodenectomy

Background

Pancreas-specific complications (PSCs), comprising postoperative pancreatic fistula, haemorrhage and intra-abdominal collections, are drivers of morbidity and mortality after pancreaticoduodenectomy (PD). A serum amylase concentration of 130 units/l or more on postoperative day (POD) 0 has been shown to be an objective surrogate of pancreatic texture, a determinant of PSCs. This study evaluated serial measurements of C-reactive protein (CRP) to refine PSC risk stratification.

Methods

Consecutive patients undergoing PD between 2008 and 2014, with vascular resection if required and without preoperative chemoradiotherapy, had serum investigations from the day before operation until discharge. Receiver operating characteristic (ROC) curve analysis was used to identify a threshold value of serum CRP with clinically relevant PSCs for up to 30 days after discharge as outcome measure.

Results

Of 230 patients, 95 (41·3 per cent) experienced a clinically relevant PSC. A serum CRP level of 180 mg/l or higher on POD 2 was associated with PSCs, prolonged critical care stay and relaparotomy (all P < 0·050). Patients with a serum amylase concentration of 130 units/l or more on POD 0 who developed a serum CRP level of at least 180 mg/l on POD 2 had a higher incidence of morbidity. Patients were stratified into high-, intermediate- and low-risk groups using these markers. The low-risk category was associated with a negative predictive value of 86·5 per cent for development of clinically relevant PSCs. There were no deaths among 52 patients in the low-risk group, but seven deaths among 79 (9 per cent) in the high-risk group.

Conclusion

A serum amylase level below 130 units/l on POD 0 combined with a serum CRP level under 180 mg/l on POD 2 constitutes a low-risk profile following PD, and may help identify patients suitable for early discharge.

Sacral osteomyelitis following restorative rectal cancer resection: a delayed presentation of dormant pelvic sepsis

Sacral osteomyelitis is a rare but potentially fatal complication of pelvic surgery. It is often diagnosed late due to the presence of vague, non-specific symptoms and a low index of suspicion. Previous literature has been limited to a number of case series of patients who have undergone ileoanal pouch formation following proctocolectomy and patients who have undergone pelvic floor reconstruction with mesh sacral colpopexy. Here, we present a patient presenting with sacral osteomyelitis 12 years following anterior resection for colorectal malignancy. We then review the previous literature and discuss the salient management points that may assist in the diagnosis and management of this uncommon complication.