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Bintintan V, Fagarasan V, Schimt K, Ruzs-Fogarasi T, Fagarasan G, Cordos A, Ailioaie RC, Ilie-Ene A, Bintintan A, Mocan M, Popescu R, Negoi I, Lupan I, Dindelegan GC, Samasca G. Revisiting the value of dynamic assessment of postoperative C-reactive protein for early diagnosis of anastomotic fistulas in colorectal surgery with ileostomy. Lab Med 2025:lmae116. [PMID: 40233218 DOI: 10.1093/labmed/lmae116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2025] Open
Abstract
INTRODUCTION Anastomotic fistula is the most feared complication in colorectal surgery. It requires early diagnosis followed by urgent treatment. In this study, we analyzed the dynamics of C-reactive protein (CRP) as a marker for early detection of anastomotic fistula. METHODS A prospective study was conducted among 83 patients who underwent colorectal resection with anastomosis at the First Surgical Department, County Emergency University Clinical Hospital, Cluj Napoca, Romania. The CRP and leukocyte values were recorded at admission and on postoperative days 3, 5, 7, and 9. Total serum protein values were measured on postoperative days 3, 5, and 7, and albumin values were measured on postoperative day 3. RESULTS Only CRP values showed substantial postoperative variations. At postoperative days 3, 5, and 7, serum CRP levels in patients with anastomotic fistula were higher than those in patients without anastomotic fistula, with differences at postoperative days 5 (P <.001) and 7 (P <.001) being statistically significant. DISCUSSION A steady decrease in CRP values after postoperative day 3 is a strong sign that the development of anastomotic fistula is unlikely. An increase or a flat decrease in CRP value at postoperative days 5 and 7 with a serum value at or close to 100 mg/L suggests an increased probability for development of anastomotic fistula.
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Affiliation(s)
- Vasile Bintintan
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Vlad Fagarasan
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Katya Schimt
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Tamas Ruzs-Fogarasi
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Giorgiana Fagarasan
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Andreea Cordos
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Raluca-Cristina Ailioaie
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Alexandru Ilie-Ene
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Adriana Bintintan
- Medical Department, County Emergency Clinical Hospital, Cluj Napoca, Romania
| | - Mihaela Mocan
- Medical Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Razvan Popescu
- Department of Surgical Disciplines, "Ovidius" University of Medicine Constanta, 900470 Constanta, Romania
| | - Ionut Negoi
- Department of Surgery, Casrol Davila University of Medicine, 020021 Bucharest, Romania
| | - Iulia Lupan
- Department of Molecular Biology, Babes-Bolyai University, 400084 Cluj-Napoca, Romania
| | - George-Calin Dindelegan
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Gabriel Samasca
- Department of Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
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Smit C, Janssen-Heijnen ML, van Osch F, Rops J, Gielen AHC, van Heinsbergen M, Melenhorst J, Konsten JLM. The optimal cut-off value of postoperative day three C-reactive protein to predict for major complications in colorectal cancer patients. Langenbecks Arch Surg 2025; 410:85. [PMID: 40014145 PMCID: PMC11868158 DOI: 10.1007/s00423-025-03655-2] [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: 10/16/2024] [Accepted: 02/19/2025] [Indexed: 02/28/2025]
Abstract
PURPOSE To identify an optimal postoperative day 3 (POD3) C-reactive protein (CRP) cut-off for predicting major complications in colorectal cancer (CRC) patients. Secondary objectives included identifying patient and surgical factors associated with POD3 CRP levels and assessing the accuracy of the cut-off across subgroups. METHODS A retrospective cohort study of 1536 CRC patients who underwent an oncological resection was conducted. The predictive accuracy of POD3 CRP for major complications was tested using Receiver Operating Characteristics curves. The CRP cut-off was tested across subgroups. Multivariable logistic regression analyses was performed to evaluate the predictive value of the POD3 CRP cut-off, while also determining whether patient and surgical characteristics independently predicted major complications. RESULTS An optimal cut-off of 114 mg/L was identified, with a sensitivity of 0.80 and specificity of 0.59 and an Area Under the Curve for POD3 CRP of 0.78. Sensitivity remained consistently high across all subgroups, whereas specificity exhibited variability, with a notable decrease observed in the subgroups; aged 66-69, obese, ASA III and open surgery. After adjusting for patient and surgery characteristics, a POD3 CRP level above 114 mg/L was associated with a significant 5.29-fold increase in the odds for developing major complications. CONCLUSIONS A POD3 CRP cut-off of 114 mg/L is an effective predictor of major complications following CRC surgery, supporting safe early discharge. The cut-off remains a reliable predictor, even after adjusting for patient and surgery factors.
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Affiliation(s)
- Coco Smit
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands.
| | - Maryska L Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, 5912 BL, Venlo, The Netherlands
- Department of Epidemiology, GROW Research Institute for Oncology & Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD, Maastricht, The Netherlands
| | - Frits van Osch
- Department of Clinical Epidemiology, VieCuri Medical Centre, 5912 BL, Venlo, The Netherlands
- Department of Epidemiology, GROW Research Institute for Oncology & Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD, Maastricht, The Netherlands
| | - Jonas Rops
- Maastricht University, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | | | - Jarno Melenhorst
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
- Maastricht University, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Joop L M Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
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Agnello L, Buscemi S, Di Buono G, Vidali M, Lo Sasso B, Agrusa A, Ciaccio M. Drainage fluid LDH and neutrophil to lymphocyte ratio as biomarkers for early detecting anastomotic leakage in patients undergoing colorectal surgery. Clin Chem Lab Med 2024; 62:967-978. [PMID: 37988156 DOI: 10.1515/cclm-2023-1164] [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: 07/11/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES In this study, we investigated the role of several circulating and drainage fluid biomarkers for detecting postoperative complications (PCs) and anastomotic leakage (AL) in patients undergoing colorectal surgery. METHODS All consecutive patients undergoing colorectal surgery between June 2018 and April 2020 were prospectively considered. On postoperative days (POD) 1, 3, and 5, we measured lactate dehydrogenase (LDH) in drainage fluid, C-reactive protein (CRP) in serum and drainage fluid, and neutrophil to lymphocyte ratio (NLR). RESULTS We enrolled 187 patients. POD1 patients with AL had higher serum CRP levels, while on POD3 and on POD5 higher NLR and serum CRP. LDH and CRP in drainage fluid were also significantly higher at both time points. The area under the curves (AUCs) of serum and drainage fluid CRP were 0.752 (0.629-0.875) and 0.752 (0.565-0.939), respectively. The best cut-off for serum and drainage fluid CRP was 185.23 and 76 mg/dL, respectively. The AUC of NLR on POD3 was 0.762 (0.662-0.882) with a sensitivity and specificity of 84 and 63 %, respectively, at a cut-off of 6,6. Finally, drainage fluid LDH showed the best diagnostic performance for AL, with an AUC, sensitivity, and specificity of 0.921 (0.849-0.993), 82 %, and 90 % at a cut-off of 2,186 U/L. Trends in serum parameters between patients with or without PCs or AL were also evaluated. Interestingly, we found that NLR decreased faster in patients without PCs than in patients with PCs and patients with AL. CONCLUSIONS Drainage fluid LDH and NLR could be promising biomarkers of PCs and AL.
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Affiliation(s)
- Luisa Agnello
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine and Clinical Laboratory Medicine, University of Palermo, Palermo, Italy
| | - Salvatore Buscemi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Giuseppe Di Buono
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Matteo Vidali
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Bruna Lo Sasso
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine and Clinical Laboratory Medicine, University of Palermo, Palermo, Italy
- Department of Laboratory Medicine, AOUP "P. Giaccone", Palermo, Italy
| | - Antonino Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Marcello Ciaccio
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine and Clinical Laboratory Medicine, University of Palermo, Palermo, Italy
- Department of Laboratory Medicine, AOUP "P. Giaccone", Palermo, Italy
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Gielen AHC, Schoenmakers M, Breukink SO, Winkens B, van der Horst J, Wevers KP, Melenhorst J. The value of C-reactive protein, leucocytes and vital signs in detecting major complications after oncological colorectal surgery. Langenbecks Arch Surg 2024; 409:76. [PMID: 38409295 PMCID: PMC10896856 DOI: 10.1007/s00423-024-03266-3] [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: 09/15/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE To assess the association of postoperative C-reactive protein (CRP), leucocytes and vital signs in the first three postoperative days (PODs) with major complications after oncological colorectal resections in a tertiary referral centre for colorectal cancer in The Netherlands. METHODS A retrospective cohort study, including 594 consecutive patients who underwent an oncological colorectal resection at Maastricht University Medical Centre between January 2016 and December 2020. Descriptive analyses of patient characteristics were performed. Logistic regression models were used to assess associations of leucocytes, CRP and Modified Early Warning Score (MEWS) at PODs 1-3 with major complications. Receiver operating characteristic curve analyses were used to establish cut-off values for CRP. RESULTS A total of 364 (61.3%) patients have recovered without any postoperative complications, 134 (22.6%) patients have encountered minor complications and 96 (16.2%) developed major complications. CRP levels reached their peak on POD 2, with a mean value of 155 mg/L. This peak was significantly higher in patients with more advanced stages of disease and patients undergoing open procedures, regardless of complications. A cut-off value of 170 mg/L was established for CRP on POD 2 and 152 mg/L on POD 3. Leucocytes and MEWS also demonstrated a peak on POD 2 for patients with major complications. CONCLUSIONS Statistically significant associations were found for CRP, Δ CRP, Δ leucocytes and MEWS with major complications on POD 2. Patients with CRP levels ≥ 170 mg/L on POD 2 should be carefully evaluated, as this may indicate an increased risk of developing major complications.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
| | - Maud Schoenmakers
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Stephanie O Breukink
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jischmaël van der Horst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Kevin P Wevers
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
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Cuff SM, Reeves N, Lewis E, Jones E, Baker S, Karategos A, Morris R, Torkington J, Eberl M. Inflammatory biomarker signatures in post-surgical drain fluid may detect anastomotic leaks within 48 hours of colorectal resection. Tech Coloproctol 2023; 27:1297-1305. [PMID: 37486461 PMCID: PMC10638112 DOI: 10.1007/s10151-023-02841-y] [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: 03/22/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The optimal treatment of colorectal cancer is surgical resection and primary anastomosis. Anastomotic leak can affect up to 20% of patients and creates significant morbidity and mortality. Current diagnosis of a leak is based on clinical suspicion and subsequent radiology. Peritoneal biomarkers have shown diagnostic utility in other conditions and could be useful in providing earlier diagnosis. This pilot study was designed to assess the practical utility of peritoneal biomarkers after abdominal surgery utilising an automated immunoassay system in routine use for quantifying cytokines. METHODS Patients undergoing an anterior resection for a rectal cancer diagnosis were recruited at University Hospital of Wales, Cardiff between June 2019 and June 2021. A peritoneal drain was placed in the proximity of the anastomosis during surgery, and peritoneal fluid was collected at days 1 to 3 post-operatively, and analysed using the Siemens IMMULITE platform for interleukin (IL)-1β, IL-6, IL-10, CXCL8, tumour necrosis factor alpha (TNFα) and C-reactive protein (CRP). RESULTS A total of 42 patients were recruited (22M:20F, median age 65). Anastomotic leak was detected in four patients and a further five patients had other intra-abdominal complications. The IMMULITE platform was able to provide robust and reliable results from the analysis of the peritoneal fluid. A metric based on the combination of peritoneal IL-6 and CRP levels was able to accurately diagnose three anastomotic leaks, whilst correctly classifying all negative control patients including those with other complications. CONCLUSIONS This pilot study demonstrates that a simple immune signature in surgical drain fluid could accurately diagnose an anastomotic leak at 48 h postoperatively using instrumentation that is already widely available in hospital clinical laboratories.
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Affiliation(s)
- S M Cuff
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - N Reeves
- University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK.
| | - E Lewis
- Technical Operations, Siemens Healthineers, Llanberis, UK
| | - E Jones
- Technical Operations, Siemens Healthineers, Llanberis, UK
| | - S Baker
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - A Karategos
- University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK
| | - R Morris
- Technical Operations, Siemens Healthineers, Llanberis, UK
| | - J Torkington
- University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK
| | - M Eberl
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Systems Immunity Research Institute, Cardiff University, Cardiff, UK
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Ozata IH, Bozkurt E, Sucu S, Karahan SN, Camci F, Cetin F, Ozoran E, Agcaoglu O, Balik E, Bugra D. A novel scoring system for the early detection of anastomotic leakage: bedside leak score-a pilot study. Front Surg 2023; 10:1204785. [PMID: 37601530 PMCID: PMC10434221 DOI: 10.3389/fsurg.2023.1204785] [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: 04/12/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background Anastomotic leakage is a major complication in colorectal surgery, resulting in significant morbidity and mortality rates. Despite substantial progress in surgical technique, anastomotic leakage rates remain stable. An early diagnosis of anastomotic leaks was proven to reduce adverse outcomes and improve survival. Objective This study aims to find a novel scoring system for detecting anastomotic leaks using inflammatory and nutritional indicators after colorectal surgery. Our purpose was to analyze the diagnostic accuracy of leak scores ( ( CRP POD 3 ) ( CRP POD 1 ) ∗ preoperative albumin level ) in predicting postoperative complications. Design The study included colorectal cancer patients who underwent curative surgery at Koc University Hospital between 2014 and 2018. Patients were categorized into two groups depending on the presence of anastomotic leaks and compared in terms of preoperative albumin levels, CRP levels in postoperative days 1 and 3, anastomotic leakage rates, length of hospital stay, and CRP quotient, which was calculated by dividing POD 3 CRP level to POD 1 CRP level. The bedside leak score is calculated by dividing the CRP quotient by the preoperative albumin level. The predictive value of bedside leak score, CRP quotient, and preoperative albumin levels in estimating anastomotic leakage was analyzed, and a cutoff value for the leak score was calculated. Results A total of 184 patients were included in the study. The leak score, CRP POD 3-1 ratio, and preoperative albumin levels were found to successfully detect anastomotic leakage. The area under the curve for the leak score was calculated as 0.78. The optimal cutoff value was found to be 50.3 for the bedside leak score, which shows 90.9% sensitivity and 59.3% specificity. Conclusion The leak score may represent a valuable diagnostic tool for detecting patients at risk for anastomotic leakage after colorectal surgery and planning a better strategy to reduce morbidity and mortality rates and associated costs. However, further multicenter studies with large cohorts are necessary to confirm these results.
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Affiliation(s)
- Ibrahim H. Ozata
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Bozkurt
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Serkan Sucu
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Salih N. Karahan
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Furkan Camci
- Koc University School of Medicine, Istanbul, Turkey
| | - Feyza Cetin
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Ozoran
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Orhan Agcaoglu
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Dursun Bugra
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
- Department of General Surgery, VKV American Hospital, Istanbul, Turkey
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Raje P, Allar BG, Arndt KR, Crowell KT, Messaris E. Early C-reactive protein after colorectal surgery is not predictive of anastomotic leak: a retrospective cohort study. Langenbecks Arch Surg 2023; 408:142. [PMID: 37036567 DOI: 10.1007/s00423-023-02884-7] [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: 11/28/2022] [Accepted: 04/04/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE Prior studies suggest postoperative C-reactive protein (CRP) trends are sensitive for predicting anastomotic leak (AL) after elective colorectal surgery. However, in the setting of enhanced recovery pathways, multi-day CRP trends may not be feasible. This study aimed to assess the realistic and clinical utility of CRP in prediction of AL. METHODS A retrospective review of patients who underwent elective colectomy or proctectomy from January 2019 to October 2020 at a single institution was performed. Comorbidities, operative characteristics, and perioperative outcomes were recorded. CRP was checked routinely on POD1 and on a clinical basis subsequently. The association between 10-point change in CRP-POD1 and AL was evaluated using multivariable logistic regression. The relationships between CRP-POD3, CRP-POD1, and AL were assessed using exploratory analyses. RESULTS Among 332 patients, 23 (6.9%) developed AL, of which 9 cases (39%) were diagnosed upon readmission. AL was not associated with mortality. Median length of stay was 3 days (IQR 2-5). Median days to AL diagnosis was 7 (IQR 4-15). Adjusting for diverting stoma, steroid use, diagnosis, and open surgery, each 10-point increase in CRP was associated with increased odds of AL (OR 1.12, 95% CI 1.03-1.21, p=0.008). CRP-POD1 had poor discriminant utility for detecting AL (AUC 0.62, 95% CI = 0.494-0.746; p=0.061). CONCLUSION CRP on POD1 is not a reliable method to predict a leak, and trending CRP may not be practical with decreasing lengths of stay in colorectal surgery.
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Affiliation(s)
- Praachi Raje
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA.
| | - Benjamin G Allar
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Kevin R Arndt
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Kristen T Crowell
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Evangelos Messaris
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
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Morar IK, Ivashchuk OI, Rohovyi YY, Bodiaka VY, Antoniv AA. Distinctive characteristics of granulation tissue in laparotomy wounds with underlying oncological processes. J Med Life 2023; 16:244-253. [PMID: 36937467 PMCID: PMC10015561 DOI: 10.25122/jml-2022-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/01/2023] [Indexed: 03/21/2023] Open
Abstract
This study aimed to investigate the effects of malignant neoplasms on the morphological characteristics of laparotomy wound granulation tissue in the muscular-aponeurotic layer. The study involved a sample of 34 deceased individuals who had undergone abdominal organ surgery. Biopsy samples were taken from the muscular-aponeurotic layer of the anterior abdominal wall and subjected to histological examination, including staining with hematoxylin and eosin and methylene blue/Chromotrope 2B using N.Z. Slinchenko's method. Descriptive methods and morphometry were used to evaluate pathomorphological changes. The results suggest that malignant neoplasms significantly impede and decelerate the maturation of laparotomy wound granulation tissue. Surgeries performed at the late stages of abdominal organ malignant neoplasms result in an uneven and slow maturation of the tissue, characterized by a higher prevalence of lymphoid cells, increased blood vessel volume, reduced optical density of stained collagen fibers, and pronounced chromotropophilia of collagen fibers. These distinct features should be considered to prevent postoperative eventration, a complication that is more likely to occur in this patient group. Clinicians should be aware of the possible consequences of malignant neoplasms on laparotomy wound granulation tissue, which may require additional measures to prevent postoperative complications in these patients.
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Affiliation(s)
- Igor Kalynovych Morar
- Department of Oncology and Radiology, Bukovinian State Medical University, Chernivtsi, Ukraine
- Corresponding Author: Igor Kalynovych Morar, Department of Oncology and Radiology, Bukovinian State Medical University, Chernivtsi, Ukraine. E-mail:
| | | | | | | | - Aliona Andriivna Antoniv
- Department of Internal Medicine, Clinical Pharmacology and Occupational Diseases, Bukovinian State Medical University, Chernivtsi, Ukraine
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Yasuda S, Hokuto D, Kamitani N, Matsuo Y, Doi S, Nakagawa K, Nishiwada S, Nagai M, Terai T, Sho M. Pre- and postoperative C-reactive protein as a risk factor of organ/space surgical site infection after hepatectomy. LANGENBECK'S ARCHIVES OF SURGERY 2023; 408:13. [PMID: 36622470 DOI: 10.1007/s00423-023-02760-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Organ/space surgical site infection (SSI) is one of the most common complications of liver resection, with significant impact on morbidity and mortality, so patients at high risk should be identified early. This study aimed to determine whether pre- and postoperative C-reactive protein (CRP) levels could predict organ/space SSIs. METHODS The hospital records of consecutive patients who underwent hepatectomy without biliary reconstruction at our institutions between 2008 and 2015 were reviewed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between patients with or without organ/space SSIs. Its risk factors were also determined. RESULTS Among 443 identified patients, 55 cases (12.5%) developed organ/space SSIs; they more frequently experienced other complications and bile leakage (47.3% vs. 16.6%, p = 0.001; 40.0% vs. 8.5%, p < 0.001, respectively). Postoperative CRP elevation from postoperative day (POD) 3 to 5 was significantly more frequent in the SSI group (21.8% vs. 4.9%, p < 0.001). Multivariate analysis identified preoperative CRP ≥ 0.2 mg/dL (odds ratio (OR), 2.01, p = 0.044], preoperative cholangitis (OR, 15.7; p = 0.020), red cell concentrate (RCC) transfusion (OR, 2.61, p = 0.018), bile leakage (OR, 9.51; p < 0.001), and CRP level elevation from POD 3 to 5 (OR, 3.81, p = 0.008) as independent risk factors for organ/space SSIs. CONCLUSIONS Preoperative CRP elevation and postoperative CRP trajectory are risk factors for organ/space SSIs after liver resection. A prolonged CRP level elevation at POD 5 indicates its occurrence. If there were no risk factors and no CRP elevation at POD 5, its presence could be excluded.
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Affiliation(s)
- Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan.
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Naoki Kamitani
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Shunsuke Doi
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Taichi Terai
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
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Zhong B, Lin ZY, Ma DD, Shang ZH, Shen YB, Zhang T, Zhang JX, Jin WD. A preoperative prediction model based on Lymphocyte-C-reactive protein ratio predicts postoperative anastomotic leakage in patients with colorectal carcinoma: a retrospective study. BMC Surg 2022; 22:283. [PMID: 35870933 PMCID: PMC9308913 DOI: 10.1186/s12893-022-01734-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background & Aims
Lymphocyte-C-reactive Protein Ratio (LCR) has been demonstrated as a promising new marker for predicting surgical and oncological outcomes in colorectal carcinoma (CRC). However, anastomotic leakage (AL) is also likely related to this inflammatory marker. Herein, we aimed to identify preoperative predictors of AL and build and develop a novel model able to identify patients at risk of developing AL.
Methods
We collected 858 patients with CRC undergoing elective radical operation between 2007 and 2018 at a single center were retrospectively reviewed. We performed univariable and multivariable analyses and built a multivariable model that predicts AL based on preoperative factors. Propensity adjustment was used to correct the bias introduced by non-random matching of the LCR. The model's performance was evaluated by using the area under the receiver operator characteristic curves (AUROCs), decision curve analysis (DCA), Brier scores, D statistics, and R2 values.
Results
Age, nutrition risk screening 2002 (NRS2002) score, tumor location and LCR, together with hemoglobin < 90 g/l, were independent predictors of AL. The models built on these variables showed good performance (internal validation: c-statistic = 0.851 (95%CI 0.803–0.965), Brier score = 0.049; temporal validation: c-statistic = 0.777 (95%CI 0.823–0.979), Brier score = 0.096). A regression equation to predict the AL was also established by multiple linear regression analysis: [Age(≥ 60 year) × 1.281] + [NRS2002(≥ 3) × 1.341] + [Tumor location(pt.) × 1.348]-[LCR(≤ 6000) × 1.593]-[Hemoglobin(< 90 g/L) × 1.589]-6.12.
Conclusion
Preoperative LCR is an independent predictive factor for AL. A novel model combining LCR values, age, tumor location, and NRS2002 provided an excellent preoperative prediction of AL in patients with CRC. The nomogram can help clinical decision-making and support future research.
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Rama NJG, Lourenço Ó, Motta Lima PC, Guarino MPS, Parente D, Castro R, Bento A, Rocha A, Castro-Poças F, Pimentel J. Development of a warning score for early detection of colorectal anastomotic leakage: Hype or hope? World J Gastrointest Surg 2022; 14:1297-1309. [PMID: 36504511 PMCID: PMC9727571 DOI: 10.4240/wjgs.v14.i11.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/12/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL), a severe postoperative complication, is associated with high morbidity, hospital readmission, and overall healthcare costs. Early detection of CAL remains a challenge in clinical practice. However, some decision models have been developed to increase the diagnostic accuracy of this event.
AIM To develop a score based on easily accessible variables to detect CAL early.
METHODS Based on the least absolute shrinkage and selection operator method, a predictive classification system was developed [Early ColoRectAL Leakage (E-CRALL) score] from a prospective observational, single center cohort, carried out in a colorectal division from a non-academic hospital. The score performance and CAL threshold from postoperative day (POD) 3 to POD5 were estimated. Based on a precise analytical decision model, the standard clinical practice was compared with the E-CRALL adoption on POD3, POD4, or POD5. A cost-minimization analysis was conducted, on the assumption that all alternatives delivered similar health-related effects.
RESULTS In this study, 396 patients who underwent colorectal resection surgery with anastomosis, and 6.3% (n = 25) developed CAL. Most of the patients who developed CAL (n = 23; 92%) were diagnosed during the first hospital admission, with a median time of diagnosis of 9.0 ± 6.8 d. From POD3 to POD5, the area under the receiver operating characteristic curve of the E-CRALL score was 0.82, 0.84, and 0.95, respectively. On POD5, if a threshold of 8.29 was chosen, 87.4% of anastomotic failures were identified with E-CRALL adoption. Additionally, score usage could anticipate CAL diagnosis in an average of 5.2 d and 4.1 d, if used on POD3 and POD5, respectively. Regardless of score adoption, episode comprehensive costs were markedly greater (up to four times) in patients who developed CAL in comparison with patients who did not develop CAL. Nonetheless, the use of the E-CRALL warning score was associated with cost savings of €421442.20, with most (92.9%) of the savings from patients who did not develop CAL.
CONCLUSION The E-CRALL score is an accessible tool to predict CAL at an early timepoint. Additionally, E-CRALL can reduce overall healthcare costs, mainly in the reduction of hospital costs, independent of whether a patient developed CAL.
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Affiliation(s)
- Nuno J G Rama
- Division of Colorectal Surgical, Leiria Hospital Centre, Leiria 2410-021, Portugal
- Abel Salazar Biomedical Institute, University of Oporto, Oporto 4099-002, Portugal
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Óscar Lourenço
- Faculty of Economics, CeBER, University of Coimbra, Coimbra 3000-137, Portugal
| | | | - Maria Pedro S Guarino
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Diana Parente
- Division of Colorectal Surgical, Leiria Hospital Centre, Leiria 2410-021, Portugal
| | - Ricardo Castro
- Division of Clinical Pathology, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Ana Bento
- Division of Clinical Pathology, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Anabela Rocha
- Abel Salazar Biomedical Institute, University of Oporto, Oporto 4099-002, Portugal
- Division of Surgical, Oporto Hospital Centre, Oporto 4099-001, Portugal
| | - Fernando Castro-Poças
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Center, Oporto 4099-001, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of OPorto, Oporto 4099-001, Portugal
| | - João Pimentel
- Faculty of Medicine, University of Coimbra, Coimbra 3004-531, Portugal
- Division of Surgical, Montes Claros Hospital, Coimbra 3030-320, Portugal
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Garmanova TN, Agapov MA, Markaryan DR, Kakotkin VV, Kartoshkin AA, Krivonosova DA, Kazachenko EA, Gallyamov EA. THE ROLE OF INFLAMMATION MARKERS IN THE EARLY POSTOPERATIVE PERIOD FOR MANAGEMENT PATIENTS WITH COLORECTAL CANCER. SURGICAL PRACTICE 2022. [DOI: 10.38181/2223-2427-2022-3-20-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To evaluate the role of inflammatory markers in the early diagnosis of complications of colorectal cancer surgical treatment.Methods: the study was conducted in the Medical Research and Education Center of Moscow State University named after M.V. Lomonosov from 2019 to 2021. The study included all patients who underwent surgical treatment for colorectal cancer in the 1st surgical department of the Moscow Research and Educational Center, Lomonosov Moscow State University. M.V. Lomonosov. The study examined clinical and laboratory data based on case histories of patients with stage II-III colorectal cancer, who underwent elective colorectal cancer treatment with lymph node dissection with the formation of a primary anastomosis. All patients underwent routine proctography in the early postoperative period.Results: The study included 80 patients with stage I-III colorectal cancer, of which 26 had septic complications, including clinically insignificant anastomosis leakage. Statistically significant differences was found between the groups of patient with and without septic complications on the 2nd day of the postoperative day in terms of the absolute level of leukocytes (p=0.01), hemoglobin (p=0.07), total protein (p=0.02) and C-reactive protein (p=0.03).Conclusion: An increase in the level of markers of the inflammatory response, such as the number of leukocytes, the level of total protein and the level of C-reactive protein, can be observed already at a relatively early postoperative period in patients with infectious complications, including those with clinically insignificant intestinal anastomotic leaks.
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Affiliation(s)
- T. N. Garmanova
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - M. A. Agapov
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - D. R. Markaryan
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - V. V. Kakotkin
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - A. A. Kartoshkin
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - D. A. Krivonosova
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - E. A. Kazachenko
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University)
| | - E. A. Gallyamov
- Moscow State University named after M. V. Lomonosov, Faculty of Fundamental Medicine (Lomonosov Moscow State University); Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
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13
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C-reactive protein and its ratio are useful indicators to exclude anastomotic leakage requiring intervention after laparoscopic rectal surgery. Updates Surg 2022; 74:1637-1643. [DOI: 10.1007/s13304-022-01358-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/22/2022] [Indexed: 11/24/2022]
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14
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Rama NJG, Lages MCC, Guarino MPS, Lourenço Ó, Motta Lima PC, Parente D, Silva CSG, Castro R, Bento A, Rocha A, Castro-Pocas F, Pimentel J. Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage: A prospective observational study. World J Gastroenterol 2022; 28:2758-2774. [PMID: 35979163 PMCID: PMC9260864 DOI: 10.3748/wjg.v28.i24.2758] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/22/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is one of the most dreaded complications after colorectal surgery, with an incidence that can be as high as 27%. This event is associated with increased morbidity and mortality; therefore, its early diagnosis is crucial to reduce clinical consequences and costs. Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL.
AIM To assess the usefulness of plasma C-reactive protein (CRP) and calprotectin (CLP) as early predictors of CAL.
METHODS A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis, from March 2017 to August 2019. Patients were divided into three groups: G1 – no complications; G2 – complications not related to CAL; and G3 – CAL. Five biomarkers were measured and analyzed in the first 5 postoperative days (PODs), namely white blood cell (WBC) count, eosinophil cell count (ECC), CRP, CLP, and procalcitonin (PCT). Clinical criteria, such as abdominal pain and clinical condition, were also assessed. The correlation between biomarkers and CAL was evaluated. Receiver operating characteristic (ROC) curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL, and the area under the ROC curve (AUROC), specificity, sensitivity, positive predictive value, and negative predictive value (NPV) during this period were estimated.
RESULTS In total, 25 of 396 patients developed CAL (6.3%), and the mean time for this diagnosis was 9.0 ± 6.8 d. Some operative characteristics, such as surgical approach, blood loss, intraoperative complications, and duration of the procedure, were notably related to the development of CAL. The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications (median of 21 d vs 13 d and 7 d respectively; P < 0.001). For abdominal pain, the best predictive performance was on POD4 and POD5, with the largest AUROC of 0.84 on POD4. Worsening of the clinical condition was associated with the diagnosis of CAL, presenting a higher predictive effect on POD5, with an AUROC of 0.9. WBC and ECC showed better predictive effects on POD5 (AUROC = 0.62 and 0.7, respectively). Those markers also presented a high NPV (94%-98%). PCT had the best predictive effect on POD5 (AUROC = 0.61), although it presented low accuracy. However, this biomarker revealed a high NPV on POD3, POD4, and POD5 (96%, 95%, and 96%, respectively). The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications (195.5 ± 139.9 mg/L vs 59.5 ± 43.4 mg/L; P < 0.00001). On POD5, CRP had a NPV of 98%. The mean CLP value on POD3 was significantly higher in G3 compared with G1 (5.26 ± 3.58 μg/mL vs 11.52 ± 6.81 μg/mL; P < 0.00005). On POD3, the combination of CLP and CRP values showed a high diagnostic accuracy (AUROC = 0.82), providing a 5.2 d reduction in the time to CAL diagnosis.
CONCLUSION CRP and CLP are moderate predictors of CAL. However, the combination of these biomarkers presents an increased diagnostic accuracy, potentially decreasing the time to CAL diagnosis.
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Affiliation(s)
- Nuno J G Rama
- Colorectal Surgical Division, Leiria Hospital Centre, Leiria 2410-021, Portugal
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Marlene C C Lages
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Maria Pedro S Guarino
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Óscar Lourenço
- Faculty of Economics, CeBER, University of Coimbra, Coimbra 3000-137, Portugal
| | | | - Diana Parente
- Colorectal Surgical Division, Leiria Hospital Centre, Leiria 2410-021, Portugal
| | - Cândida S G Silva
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Ricardo Castro
- Clinical Pathology Division, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Ana Bento
- Clinical Pathology Division, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Anabela Rocha
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Surgical Division, Oporto Hospital Centre, Oporto 4099-001, Portugal
| | - Fernando Castro-Pocas
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Center, Porto 4099-001, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto 4099-001, Portugal
| | - João Pimentel
- Faculty of Medicine, University of Coimbra, Coimbra 3004-531, Portugal
- Surgical Division, Montes Claros Hospital, Coimbra 3030-320, Portugal
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15
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Casas SGDL, Spagnolo E, Saverio SD, Álvarez-Gallego M, Carrasco AL, López MC, Cobos ST, Campo CF, Gutiérrez AH, Miguelañez IP. Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases. Ann Coloproctol 2022:ac.2021.00829.0118. [PMID: 35255203 DOI: 10.3393/ac.2021.00829.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/06/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI). Methods A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections. Results The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy. Conclusion In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.
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Affiliation(s)
| | - Emanuela Spagnolo
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
| | - Salomone Di Saverio
- Department of General Surgery, Hospital of San Benedetto del Tronto (AP), San Benedetto, Italy
| | | | - Ana López Carrasco
- Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
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Yao L, Zaghiyan K. When you think something is wrong – something IS wrong: timely diagnosis of anastomotic leak. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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El Zaher HA, Ghareeb WM, Fouad AM, Madbouly K, Fathy H, Vedin T, Edelhamre M, Emile SH, Faisal M. Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections. World J Surg Oncol 2022; 20:33. [PMID: 35151339 PMCID: PMC8840033 DOI: 10.1186/s12957-022-02506-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/05/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery. Method Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation. Results This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively). Conclusion The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.
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18
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Hoek VT, Sparreboom CL, Wolthuis AM, Menon AG, Kleinrensink G, D'Hoore A, Komen N, Lange JF. C-reactive protein (CRP) trajectory as a predictor of anastomotic leakage after rectal cancer resection: A multicentre cohort study. Colorectal Dis 2022; 24:220-227. [PMID: 34706131 PMCID: PMC9298339 DOI: 10.1111/codi.15963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/01/2021] [Accepted: 10/22/2021] [Indexed: 12/08/2022]
Abstract
AIM This study aimed to identify whether CRP-trajectory measurement, including increase in CRP-level of 50 mg/l per day, is an accurate predictor of anastomotic leakage (AL) in patients undergoing resection for rectal cancer. METHODS A prospective multicentre database was used. CRP was recorded on the first three postoperative days. Sensitivity, specificity, positive and negative predictive values, and area under the receiver operator characteristic (ROC) curve were used to analyse performances of CRP-trajectory measurements between postoperative day (POD) 1-2, 2-3, 1-3 and between any two days. RESULTS A total of 271 patients were included in the study. AL was observed in 12.5% (34/271). Increase in CRP-level of 50 mg/l between POD 1-2 had a negative predictive value of 0.92, specificity of 0.71 and sensitivity of 0.57. Changes in CRP-levels between POD 2-3 were associated with a negative predictive value, specificity and sensitivity of 0.89, 0.93 and 0.26, respectively. Changes in CRP-levels between POD 1-3 showed a negative predictive value of 0.94, specificity of 0.76 and sensitivity of 0.65. In addition, 50 mg/l changes between any two days showed a negative predictive value of 0.92, specificity of 0.66 and sensitivity of 0.62. The area under the ROC curve for all CRP-trajectory measurements ranged from 0.593-0.700. CONCLUSION The present study showed that CRP-trajectory between postoperative days lacks predictive value to singularly rule out AL. Early and safe discharge in patients undergoing rectal surgery for adenocarcinoma cannot be guaranteed based on this parameter. High negative predictive values are mainly caused by the relatively low prevalence of AL.
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Affiliation(s)
- Vincent T. Hoek
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - Cloë L. Sparreboom
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | | | - Anand G. Menon
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands,Department of SurgeryIJsselland HospitalCapelle aan den IJsselThe Netherlands
| | - Gert‐Jan Kleinrensink
- Department of Neuroscience‐AnatomyErasmus University Medical CentreRotterdamThe Netherlands
| | - André D'Hoore
- Department of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
| | - Niels Komen
- Department of SurgeryAntwerp University HospitalAntwerpBelgium,Antwerp Surgical Training, Anatomy and Research Centre (ASTARC)Faculty of Medicine and Health SciencesUniversity of AntwerpWilrijkBelgium
| | - Johan F. Lange
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
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19
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Detection of Anastomotic Leakage Following Elective Colonic Surgery: Results of the Prospective Biomarkers and Anastomotic Leakage (BALL) Study. J Surg Res 2022; 273:85-92. [PMID: 35033821 DOI: 10.1016/j.jss.2021.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 10/28/2021] [Accepted: 12/15/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is an infrequent but life-threatening surgical complication following colorectal surgery. Early diagnosis remains clinically difficult but is a necessity to reduce associated morbidity and mortality. Clinical review and radiological modalities for the diagnosis of leakage remain non-specific and often only detect AL once it is well developed. Inflammatory biomarkers however have shown promise in early pre-clinical detection of leakage following colorectal surgery. METHODS A multi-center, prospective observational study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were initially recruited over a 3-y period. Perioperative blood samples were collected to measure interleukin (IL)-6, IL-1β, tumor necrosis factor α, IL-10, C-reactive protein (CRP), leukocyte and neutrophil counts. Statistical analysis was performed to compare patients with an uncomplicated recovery with patients with AL. RESULTS Sixteen patients developed AL (5.7%), diagnosed at a median post-operative (POD) day 7. CRP and IL-6 were consistently elevated in the early post-operative period in patients with AL, and had the best diagnostic accuracy on POD 3 (area under the curve 0.70; P = 0.02) and POD 1 (area under the curve 0.69; P = 0.02), respectively. IL-10, once adjusted for body mass index and surgical approach, was the sole biomarker significantly elevated in patients with AL on POD 4. CONCLUSIONS Early post-operative elevations of CRP and IL-6 provide utility for early detection of AL after elective colectomy. Application of these inflammatory biomarkers and their combinations in daily practice warrants further investigation.
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Pecorelli N, Guarneri G, Palucci M, Gozzini L, Vallorani A, Crippa S, Partelli S, Falconi M. Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein. Surg Endosc 2022; 36:5431-5441. [PMID: 34988737 DOI: 10.1007/s00464-021-08883-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/16/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP. METHODS Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed. RESULTS At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001). CONCLUSIONS Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy. .,Vita-Salute San Raffaele University, Milan, Italy.
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21
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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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22
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Cagigas Fernández C, Palazuelos C, Cristobal Poch L, Gomez Ruiz M. A probabilistic model for the prediction of intra-abdominal infection after colorectal surgery. Int J Colorectal Dis 2021; 36:2481-2488. [PMID: 34081170 DOI: 10.1007/s00384-021-03955-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 02/04/2023]
Abstract
AIM Predicting intra-abdominal infections (IAI) after colorectal surgery by means of clinical signs is challenging. A naïve logistic regression modeling approach has some limitations, for which reason we study two potential alternatives: the use of Bayesian networks, and that of logistic regression model. METHODS Data from patients that had undergone colorectal procedures between 2010 and 2017 were used. The dataset was split into two subsets: (i) that for training the models and (ii) that for testing them. The predictive ability of the models proposed was tested (i) by comparing the ROC curves from days 1 and 3 with all the subjects in the test set and (ii) by studying the evolution of the abovementioned predictive ability from day 1 to day 5. RESULTS In day 3, the predictive ability of the logistic regression model achieved an AUC of 0.812, 95% CI = (0.746, 0.877), whereas that of the Bayesian network was 0.768, 95% CI = (0.695, 0.840), with a p-value for their comparison of 0.097. The ability of the Bayesian network model to predict IAI does present significant difference in predictive ability from days 3 to 5: AUC(Day 3) = 0.761, 95% CI = (0.680, 0.841) and AUC(Day 5) = 0.837, 95% CI = (0.769, 0.904), with a p-value for their comparison of 0.006. CONCLUSIONS Whereas at postoperative day 3, a logistic regression model with imputed data should be used to predict IAI; at day 5, when the predictive ability is almost identical, the Bayesian network model should be used.
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Affiliation(s)
- Carmen Cagigas Fernández
- General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain.,Valdecilla Biomedical Research Institute (IDIVAL), 39011, Santander, Spain
| | - Camilo Palazuelos
- Valdecilla Biomedical Research Institute (IDIVAL), 39011, Santander, Spain.,Department of Mathematics, Statistics, and Computing, University of Cantabria, 39011, Santander, Spain
| | - Lidia Cristobal Poch
- General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain.,Valdecilla Biomedical Research Institute (IDIVAL), 39011, Santander, Spain
| | - Marcos Gomez Ruiz
- General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain. .,Valdecilla Biomedical Research Institute (IDIVAL), 39011, Santander, Spain.
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23
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Morimoto M, Taniguchi K, Yamamoto O, Naka T, Sugitani A, Fujiwara Y. Preoperative white blood cell count predicts anastomotic leakage in patients with left-sided colorectal cancer. PLoS One 2021; 16:e0258713. [PMID: 34669737 PMCID: PMC8528338 DOI: 10.1371/journal.pone.0258713] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/04/2021] [Indexed: 01/09/2023] Open
Abstract
To determine whether preoperative white blood cell (WBC) counts reflect risk of anastomotic leak (AL) for patients with colorectal cancer (CRC), we retrospectively examined data from records of 208 consecutive patients who had undergone resections for left-sided CRC, including their clinicopathological parameters and preoperative laboratory data. The diagnostic value of WBC count for AL was evaluated and compared with those of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio and platelet count × C-reactive protein level multiplier (P-CRP) value; optimal cut-off values were derived from receiver operating characteristic curves. AL was observed in 11 of the 208 patients (5.3%). Compared with the no-AL group, the AL group had a significantly higher mean WBC count and smoking rate. In multivariate analysis, WBC count and smoking were independent risk factors for AL. Compared with the other tested inflammatory indicators, the cut-off value for WBC (6,200/μL) had the highest sensitivity (81.8%) and negative predictive value (98.4%), as well as the lowest likelihood ratio (0.289). Preoperative WBC count could therefore be a convenient predictor of AL in patients with left-sided CRC.
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Affiliation(s)
- Masaki Morimoto
- National Hospital Organization, Yonago Medical Center, Yonago, Japan
- Faculty of Medicine, Division of Gastrointestinal Surgery, Department of Surgery, Tottori University, Yonago, Japan
| | - Kenjiro Taniguchi
- National Hospital Organization, Yonago Medical Center, Yonago, Japan
| | - Osamu Yamamoto
- National Hospital Organization, Yonago Medical Center, Yonago, Japan
| | - Takuji Naka
- National Hospital Organization, Yonago Medical Center, Yonago, Japan
| | - Atsushi Sugitani
- National Hospital Organization, Yonago Medical Center, Yonago, Japan
| | - Yoshiyuki Fujiwara
- Faculty of Medicine, Division of Gastrointestinal Surgery, Department of Surgery, Tottori University, Yonago, Japan
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24
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Sala Hernandez A, Frasson M, García-Granero A, Hervás Marín D, Laiz Marro B, Alonso Pardo R, Aldrey Cao I, Alvarez Perez JA, Roque Castellano C, García González JM, Tabet Almeida J, García-Granero E. Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study. Colorectal Dis 2021; 23:2723-2730. [PMID: 34314565 DOI: 10.1111/codi.15845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/30/2021] [Accepted: 07/20/2021] [Indexed: 12/08/2022]
Abstract
AIM The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery. METHODS We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database. RESULTS The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy. CONCLUSION On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.
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Affiliation(s)
- Angela Sala Hernandez
- Colorectal Surgery Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - Matteo Frasson
- Colorectal Surgery Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - Alvaro García-Granero
- Colorectal Surgery Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - David Hervás Marín
- Biostatistical Unit, Hospital Universitario y Politecnico la Fe, Valencia, Spain
| | - Begoña Laiz Marro
- Clinical Laboratory, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Ricardo Alonso Pardo
- Clinical Laboratory, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inés Aldrey Cao
- Colorectal Surgery Unit, Complexo Hospitalario Universitario de Ourense, Galicia, Spain
| | | | - Cristina Roque Castellano
- Colorectal Surgery Unit, Islas Canarias, Hospital Universitario de Gran Canaria Doctor Negrín, Spain
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25
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Paliogiannis P, Deidda S, Maslyankov S, Paycheva T, Farag A, Mashhour A, Misiakos E, Papakonstantinou D, Mik M, Losinska J, Scognamillo F, Sanna F, Feo CF, Porcu A, Xidas A, Zinellu A, Restivo A, Zorcolo L. C reactive protein to albumin ratio (CAR) as predictor of anastomotic leakage in colorectal surgery. Surg Oncol 2021; 38:101621. [PMID: 34126521 DOI: 10.1016/j.suronc.2021.101621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/25/2021] [Accepted: 06/06/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most severe complications in colorectal surgery. Currently, no predictive biomarkers of AL are available. The aim of this study was to investigate the role of C reactive protein (CRP) to albumin ratio (CAR) as a predictor of AL in patients undergoing elective surgery for colorectal cancer. MATERIALS AND METHODS Data on 1183 consecutive patients surgically treated for histologically proven colorectal cancer in the surgical units involved in the study were collected. Data included sex, age, BMI, ASA score, Charlson comorbidity index, localization, histology and stage of the disease, as well as blood tests including albumin and CRP at the 4th postoperative day. Differences in CAR between patients who developed AL and those who did not were analyzed, and the ability of CAR to predict AL was investigated with ROC analysis. RESULTS CAR was significantly higher in patients with AL in comparison to those without, at the 4th postoperative day. In ROC analysis CAR showed a good ability in detecting AL (AUC 0.825, 95%CI: 0,786-0,859), greater than those of CRP and albumin alone. CAR also showed a high ability in detecting postoperative deaths (AUC 0.750, 95% CI 0,956-0,987). These findings were confirmed in multivariate analysis including the most relevant risk factors for AL. CONCLUSION Our study evidenced that CAR, an inexpensive and widely available laboratory biomarker, adequately predicts AL and death in patients who underwent elective surgery for colorectal cancer.
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Affiliation(s)
- Panagiotis Paliogiannis
- University of Sassari, Department of Biomedical Sciences, Laboratory Quality Controll Unit, AOU Sassari, 07100, Sassari, Italy.
| | - Simona Deidda
- Colorectal Surgery Unit, Department of Surgical Sciences, University of Cagliari, Monserrato, 09042, Cagliari, Italy
| | - Svilen Maslyankov
- Second Surgery Clinic, Department of Surgery, Medical University of Sofia, G.Sofijski Str. 1, 1404, Sofia, Bulgaria
| | - Tsvetelina Paycheva
- Second Surgery Clinic, Department of Surgery, Medical University of Sofia, G.Sofijski Str. 1, 1404, Sofia, Bulgaria
| | - Ahmed Farag
- Colorectal Surgery Unit, General Surgery Department, Faculty of Medicine, Cairo University, Kaser Alainy Hospital, 89 Almanial, Cairo, Egypt
| | - Abdrabou Mashhour
- Colorectal Surgery Unit, General Surgery Department, Faculty of Medicine, Cairo University, Kaser Alainy Hospital, 89 Almanial, Cairo, Egypt
| | - Evangelos Misiakos
- Third Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Dimitrios Papakonstantinou
- Third Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Michal Mik
- Department of General and Colorectal Surgery, Medical University in Lodz, Plac Hallera 1, 90-647, Lodz, Poland
| | - Joanna Losinska
- Department of General and Colorectal Surgery, Medical University in Lodz, Plac Hallera 1, 90-647, Lodz, Poland
| | - Fabrizio Scognamillo
- First Surgery Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Fabio Sanna
- First Surgery Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Claudio Francesco Feo
- Second Surgery Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Alberto Porcu
- Second Surgery Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Andreas Xidas
- First Surgery Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Angelo Zinellu
- Clinical Biochemistry and Clinical Molecular Biology, Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Angelo Restivo
- Colorectal Surgery Unit, Department of Surgical Sciences, University of Cagliari, Monserrato, 09042, Cagliari, Italy
| | - Luigi Zorcolo
- Colorectal Surgery Unit, Department of Surgical Sciences, University of Cagliari, Monserrato, 09042, Cagliari, Italy
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26
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Oxidative Stress Level as a Predictor of Anastomotic Leakage after Rectal Surgery. Mediators Inflamm 2021; 2021:9968642. [PMID: 34257521 PMCID: PMC8261183 DOI: 10.1155/2021/9968642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background Early diagnosis of anastomotic leakage (AL) after rectal surgery can reduce the adverse effects of AL, thereby reducing morbidity and mortality. Currently, there are no accepted indicators or effective scoring systems that can clearly identify patients at risk of anastomotic leakage. Methods A prospective study with assessment of the diagnostic accuracy of oxidative stress level (CAT, SOD, MDA) in serum and drain fluid compared to white blood cell count (WBC), C-reactive protein (CRP), and neutrophil percentage (NEUT) in prediction of AL in patients undergoing elective rectal surgery with anastomosis. Results Most of the oxidative stress indicators we detected are of considerable significance in the diagnosis of anastomotic leakage. The level of MDA on postoperative day (POD)3 (areas under the curve (AUC): 0.831) and POD5 (AUC: 0.837) in the serum and on POD3 (AUC: 0.845) in the drain fluid showed the same excellent diagnostic accuracy as the level of CRP on the POD3 (AUC: 0.847) and POD5 (AUC: 0.896). Conclusions The overall level of oxidative stress in serum and drain fluid is a reliable indicator for the early diagnosis of anastomotic leakage after rectal surgery. More specifically, among the redox indicators analyzed, MDA has almost the same predictive value as CRP, which provides another useful biomarker for the early diagnosis of anastomotic leakage.
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27
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Gray M, Marland JRK, Murray AF, Argyle DJ, Potter MA. Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients. J Pers Med 2021; 11:471. [PMID: 34070593 PMCID: PMC8229046 DOI: 10.3390/jpm11060471] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.
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Affiliation(s)
- Mark Gray
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Jamie R. K. Marland
- School of Engineering, Institute for Integrated Micro and Nano Systems, University of Edinburgh, Scottish Microelectronics Centre, King’s Buildings, Edinburgh EH9 3FF, UK;
| | - Alan F. Murray
- School of Engineering, Institute for Bioengineering, University of Edinburgh, Faraday Building, The King’s Buildings, Edinburgh EH9 3DW, UK;
| | - David J. Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Mark A. Potter
- Department of Surgery, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;
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28
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Early diagnosis of anastomotic leakage in colorectal surgery: prospective observational study of the utility of inflammatory markers and determination of pathological levels. Updates Surg 2021; 73:2103-2111. [PMID: 34018141 DOI: 10.1007/s13304-021-01082-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Procalcitonin (PCT) and C-Reactive Protein (CRP) are acute-phase reactants that indicate the presence and severity of an infection. The aim of this study was to verify the utility of CRP and PCT as tools for early diagnosis of anastomotic leakage (AL) in patients undergoing elective colorectal surgery. A prospective observational study including 95 patients undergoing elective colorectal surgery with anastomosis, where patients were divided into two groups according to whether or not AL happened. Different variables were compared using a uni- and multivariate analyses to identify the risk factors for AL. Receiver Operating Characteristic (ROC) curves were added to establish a cut-off point for CRP and PCT. The inflammatory marker levels were analysed in other complications different from AL. AL was detected in 11 patients (14%), 7 required an emergency reoperation. The overall morbidity rate was 42.1% and the mortality was 3.2%. In the univariate study, increased CRP on days 3 and 5, male sex and intraoperative complications were significantly associated with AL. In the multivariate study, CRP on day 5 was the only factor related to AL. AUC at ROC curves showed that CRP results ≥ 15.3 mg/dL on day 3 and 9.1 mg/dL on day 5 were predictors of AL. Normal CRP and PCT values had a high negative predictive value. CRP on postoperative day 5 is a reliable marker for early detection of anastomotic leakage in colorectal surgery. Both CRP and PCT on days 3 and 5 have a high negative predictive value.Trial registration: The study has been registered at ClinicalTrials.gov. Code: NCT04632446.
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29
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Ye H, Huang S, Yu J, Zhou Q, Xi C, Cao L, Wang P, Shen J, Gong Z. Comparison of the clinical outcomes of skin bridge loop ileostomy and traditional loop ileostomy in patients with low rectal cancer. Sci Rep 2021; 11:9101. [PMID: 33907300 PMCID: PMC8079674 DOI: 10.1038/s41598-021-88674-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 04/14/2021] [Indexed: 01/18/2023] Open
Abstract
To compare the clinical results of patients with low rectal cancer who underwent skin bridge loop ileostomy and traditional loop ileostomy, and provide clinical evidence for choosing a better ostomy method. We retrospectively collected data of 118 patients with rectal cancer who underwent low anterior resection and loop ileostomy. To investigate the patients characteristics, postoperative stoma-related complications and the frequency of exchanged ostomy bags. The differences of these indicators between the two groups of patients who underwent skin bridge loop ileostomy and traditional loop ileostomy were compared. The Visual Analog Scale (VAS) score of the skin bridge loop ileostomy group was lower than that of the traditional ileostomy loop group (P < 0.05). The skin bridge group had a lower Discoloration, Erosion, Tissue overgrowth (DET) score and incidence of mucocutaneous separation than the traditional group at the 1st and 2nd weeks after operation (P < 0.05). The average number of weekly exchanged ostomy bags was significantly less in the skin bridge group than in the traditional group within 4 weeks after surgery (P < 0.05). Our experience demonstrates that the skin bridge loop ileostomy may significantly reduce early postoperative stoma-related complications, the frequency of exchanged ostomy bags and patients' medical costs after discharge.
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Affiliation(s)
- Hui Ye
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Shujuan Huang
- Department of Respiratory and Critical Care Medicine, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, 434020, Hubei Province, China
| | - Jie Yu
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Qichang Zhou
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Changlei Xi
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Longlei Cao
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Peiyun Wang
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Jie Shen
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Zhilin Gong
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China.
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Farooqui W, Riemenschneider KA, Penninga L, Vyrdal CD, Hansen CP, Storkholm JH. The diagnostic value of C-reactive protein for predicting pancreatic fistula following pancreatoduodenectomy. Scand J Gastroenterol 2021; 56:329-335. [PMID: 33427522 DOI: 10.1080/00365521.2020.1867895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Pancreaticoduodenectomy is the preferred treatment of neoplasms in the pancreas and duodenum. Postoperative pancreatic fistula is a critical complication. A potential predictive marker is C-reactive protein. This retrospective study examined the predictive value of C-reactive protein as a marker for development of postoperative pancreatic fistulas. METHODS All patients who had a pancreaticoduodenectomy from 1 January 2015 to 31 December 2019, were included. Levels of the biomarker and linear trajectory were determined for postoperative days one to four. Univariate analysis was used to identify predictive variables for a postoperative pancreatic fistula. Receiver operating characteristics curves, specificity, and sensitivity were calculated. RESULTS Five hundred and fifty-two patients underwent pancreaticoduodenectomy. C-reactive protein level greater than 121.5mg/L on the third postoperative day and an increase in C-reactive protein level between the first and fourth postoperative days, greater than 21.7mg/L, seemed to be reliable predictors. For Grade C postoperative pancreatic fistulas, increases in C-reactive protein, greater than 40.6ml/L the first four postoperative days, had a sensitivity of 100%. White blood cell count did not have similar reliability in predicting postoperative pancreatic fistulas. CONCLUSION Our findings indicate that small rises in C-reactive protein during the first postoperative days after pancreaticoduodenectomy are associated with an increased risk of developing postoperative pancreatic fistula.
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Affiliation(s)
- Waqas Farooqui
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Luit Penninga
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Carsten Palnaes Hansen
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jan Henrik Storkholm
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Fang AH, Chao W, Ecker M. Review of Colonic Anastomotic Leakage and Prevention Methods. J Clin Med 2020; 9:E4061. [PMID: 33339209 PMCID: PMC7765607 DOI: 10.3390/jcm9124061] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022] Open
Abstract
Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.
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Affiliation(s)
- Alex H. Fang
- Texas Academy of Mathematics and Science, University of North Texas, Denton, TX 76203, USA; (A.H.F.); (W.C.)
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
| | - Wilson Chao
- Texas Academy of Mathematics and Science, University of North Texas, Denton, TX 76203, USA; (A.H.F.); (W.C.)
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
| | - Melanie Ecker
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
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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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Yang W, Chen X, Zhang P, Li C, Liu W, Wang Z, Yin Y, Tao K. Procalcitonin as an Early Predictor of Intra-abdominal Infections Following Gastric Cancer Resection. J Surg Res 2020; 258:352-361. [PMID: 33109404 DOI: 10.1016/j.jss.2020.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/19/2020] [Accepted: 08/02/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the prognostic value of postoperative procalcitonin (PCT) and C-reactive protein (CRP) for their ability to detect Intra-abdominal infections (IAIs) in patients after GC surgery. METHODS Patients who underwent elective gastrectomy for primary GC were retrospectively enrolled between October 2018 and October 2019. The PCT and CRP levels and white blood cell (WBC) count were measured before surgery and on postoperative days (POD) 1, 3, 5, and 7. The differences in serum PCT, CRP, and WBC levels between IAIs and non-IAIs groups were compared. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve. Univariate and multivariate logistic regression analyses identified independent clinical factors that predicted postoperative IAIs. RESULTS A total of 155 patients who underwent GC surgery were enrolled. IAIs were observed in 12 patients (7.74%). The postoperative CRP and PCT values in the IAI group were higher than those in the non-IAI group. PCT had superior diagnostic accuracy on POD 3 (area under the curve 0.769) with an optimal cutoff value of 2.03 ng/mL, yielding 75% sensitivity, 87.4% specificity, and 97.6% negative predictive value. Multivariate analysis identified a PCT level of 2.03 mg/mL or greater on POD 3 as a significant predictive factor for IAIs after gastrectomy (odds ratio: 21.447, 95% confidence interval: 5.081-91.672). CONCLUSIONS PCT values less than 2.03 ng/mL on POD 3 is an excellent negative predictor of IAIs, which may ensure a safe early discharge after gastric cancer surgery.
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Affiliation(s)
- Wenchang Yang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Chen
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chengguo Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weizhen Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zheng Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuping Yin
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Chuan L, Linfeng G, Hongchang L, Xiaosong W, Huaxing L, Chao Z, Yu P, Bo T. Short-term outcomes of pelvic floor peritoneum closure in endoscopic low anterior resection of rectal cancer: A propensity score matching analysis. J Surg Oncol 2020; 123:271-277. [PMID: 33047338 DOI: 10.1002/jso.26238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/23/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The efficacy of pelvic floor peritoneum closure (PC) during endoscopic low anterior resection (E-LAR) of rectal cancer remains unclear. This study aimed to clarify whether pelvic floor PC affected short-term outcomes. METHODS The study group comprised patients with the pathologically confirmed diagnosis of rectal cancer who underwent E-LAR with pelvic floor PC or with no PC (NPC) between January 2013 and December 2018 in Southwest Hospital. After propensity score matching (PSM), 584 patients (292 who underwent PC and 292 who underwent NPC) were evaluated. Postoperative indicators, including the rates of complications, anastomotic leakage (AL), reoperation, and inflammation, were observed in the two groups. RESULTS No significant difference was observed in the rates of postoperative complications between the PC and NPC groups. The rates of AL were similar (11.3% vs. 9.2%, p = .414). However, the reoperation rate of patients in the PC group was significantly lower than that of patients in the NPC group after AL (36.4% vs. 11.1%, p = .025). The hospital costs were higher in the NPC leakage subgroup (p = .001). Additionally, the serum C-reactive protein levels were lower in the PC group on postoperative days (PODs) 1, 3, and 5, whereas procalcitonin levels on POD 1 and 3 were lower in the PC group but did not differ significantly on POD 5. CONCLUSION Pelvic peritonization did not affect the rate of complications, especially AL; however, it effectively reduced the reoperation and inflammation rates and reduced hospitalization costs. Other short-term outcomes were similar, which warrant the increased use of pelvic peritonization in endoscopic surgery.
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Affiliation(s)
- Li Chuan
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Gao Linfeng
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Liu Hongchang
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Wang Xiaosong
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Luo Huaxing
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhang Chao
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Peiwu Yu
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Tang Bo
- Department of General Surgery & Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
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Stephensen BD, Reid F, Shaikh S, Carroll R, Smith SR, Pockney P. C-reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study. Br J Surg 2020; 107:1832-1837. [PMID: 32671825 DOI: 10.1002/bjs.11812] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/17/2020] [Accepted: 05/25/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anastomotic leak is a common complication after colorectal surgery, associated with increased morbidity and mortality, and poorer long-term survival after oncological resections. Early diagnosis improves short-term outcomes, and may translate into reduced cancer recurrence. Multiple studies have attempted to identify biomarkers to enable earlier diagnosis of anastomotic leak. One study demonstrated that the trajectory of C-reactive protein (CRP) levels was highly predictive of anastomotic leak requiring intervention, with an area under the curve of 0·961. The aim of the present study was to validate this finding externally. METHODS This was a prospective international multicentre observational study of adults undergoing elective colorectal resection with an anastomosis. CRP levels were measured before operation and for 5 days afterwards, or until day of discharge if earlier than this. The primary outcome was anastomotic leak requiring operative or radiological intervention. RESULTS Between March 2017 and July 2018, 933 patients were recruited from 20 hospitals across Australia, New Zealand, England and Scotland. Some 833 patients had complete CRP data and were included in the primary analysis, of whom 41 (4·9 per cent) developed an anastomotic leak. A change in CRP level exceeding 50 mg/l between any two postoperative days had a sensitivity of 0·85 for detecting a leak, and a high negative predictive value of 0·99 for ruling it out. A change in CRP concentration of more than 50 mg/l between either days 3 and 4 or days 4 and 5 after surgery had a high specificity of 0·96-0·97, with positive likelihood ratios of 4·99-6·44 for a leak requiring intervention. CONCLUSION This study confirmed the value of CRP trajectory in accurately ruling out an anastomotic leak after colorectal resection.
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Affiliation(s)
- B D Stephensen
- Department of Colorectal Surgery, Newcastle, New South Wales, Australia
| | - F Reid
- Department of Colorectal Surgery, Newcastle, New South Wales, Australia
| | - S Shaikh
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.,Department of Surgery, University of Aberdeen, Aberdeen, UK
| | - R Carroll
- Department of Colorectal Surgery, Newcastle, New South Wales, Australia.,Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - S R Smith
- Department of Colorectal Surgery, Newcastle, New South Wales, Australia.,Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - P Pockney
- Department of Colorectal Surgery, Newcastle, New South Wales, Australia.,Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Pak H, Maghsoudi LH, Soltanian A, Gholami F. Surgical complications in colorectal cancer patients. Ann Med Surg (Lond) 2020; 55:13-18. [PMID: 32435475 PMCID: PMC7229272 DOI: 10.1016/j.amsu.2020.04.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/01/2020] [Accepted: 04/18/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Advancements in diagnostic and therapeutic sciences have allowed early diagnosis and treatment of cancer. Colorectal cancer is one of the most commonly reported cancers, particularly in elderly patients. METHODS Open and laparoscopic surgeries are used for the removal of the tumor, along with chemotherapy, depending on the stage of cancer. However, colorectal cancer surgery is associated with a great number of complications, that affect the efficacy of the surgery and overall health and survival of the patient. RESULTS Prevalence of these complications have shown discrepancies depending on the condition of the patient and disease and surgical skills of the surgeon. Preoperative evaluation, intraoperative care and postoperative measures can reduce the incidence of these complications. CONCLUSION This review highlights some frequently reported complications associated with colorectal cancer surgery, their risk factors and subsequent therapeutic measures to treat them.
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Affiliation(s)
- Haleh Pak
- Department of Surgery, School of Medicine, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Leila Haji Maghsoudi
- Department of Anesthesiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Ali Soltanian
- Department of Surgery, School of Medicine, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Farshid Gholami
- Department of Surgery, School of Medicine, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
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van Helsdingen CPM, Jongen ACHM, de Jonge WJ, Bouvy ND, Derikx JPM. Consensus on the definition of colorectal anastomotic leakage: A modified Delphi study. World J Gastroenterol 2020; 26:3293-3303. [PMID: 32684743 PMCID: PMC7336323 DOI: 10.3748/wjg.v26.i23.3293] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/14/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite the emerging knowledge about colorectal anastomotic leakage (CAL) through the increasing number of clinical and experimental studies, there is no generally accepted definition of CAL. Because of the wide variety of definitions used in literature, comparison of study outcomes and quality of care is complicated.
AIM To reach consensus on the definition of CAL using a modified Delphi method.
METHODS The RAND/UCLA appropriateness method was used. The expert panel consisted of international colorectal surgeons and researchers who had published three or more articles about CAL. The consensus process consisted of two online distributed questionnaires and a third round with a recommendation. In the questionnaires participants were asked to rate the appropriateness of statements using a 1-9 Likert scale. Consensus was defined as a panel median between 1-3 or 7-9 without disagreement. In the final round a recommendation was formed regarding the definition of CAL and the expert panel was asked if they agreed or disagreed.
RESULTS Twenty-three authors participated in the first round and twenty-one finished the second round. After two rounds consensus was reached on 37 items (80%) in nine different categories. The International Study Group of Rectal Cancer definition is the most frequently advised general definition by our panel. Consensus was reached regarding the clinical symptoms of CAL, which serum markers contributes to the suspicion of CAL, which radiological and perioperative findings should be considered as CAL, which grading system is appropriate and if there should be a range of postoperative days in the definition. Eventually, 19 experts completed all three rounds of which 16 (84%) agreed with our final recommendations for the definition of CAL.
CONCLUSION A consensus-based recommendation for the definition of CAL was formed using our modified Delphi method that can be widely incorporated in the field.
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Affiliation(s)
- Claire PM van Helsdingen
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam 1105 AZ, Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 BK, Netherlands
| | - Audrey CHM Jongen
- Department of Surgery, Maastricht University Medical Center, Maastricht 6202 AZ, Netherlands
| | - Wouter J de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 BK, Netherlands
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn 53127, Germany
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht 6202 AZ, Netherlands
| | - Joep PM Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam 1105 AZ, Netherlands
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Bednarz-Misa I, Fleszar MG, Zawadzki M, Kapturkiewicz B, Kubiak A, Neubauer K, Witkiewicz W, Krzystek-Korpacka M. L-Arginine/NO Pathway Metabolites in Colorectal Cancer: Relevance as Disease Biomarkers and Predictors of Adverse Clinical Outcomes Following Surgery. J Clin Med 2020; 9:jcm9061782. [PMID: 32521714 PMCID: PMC7355854 DOI: 10.3390/jcm9061782] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 12/24/2022] Open
Abstract
The L-Arginine/NO pathway is involved in carcinogenesis and immunity. Its diagnostic and prognostic value in colorectal cancer (CRC) was determined using tandem mass spectrometry in 199 individuals (137 with CRC) and, during a three-day follow up, in 60 patients undergoing colorectal surgery. Citrulline was decreased and asymmetric (ADMA) and symmetric (SDMA) dimethylarginines and dimethylamine (DMA) were increased in CRC. The DMA increase corresponded with CRC advancement while arginine, ADMA, and SDMA levels were higher in left-sided cancers. Arginine, citrulline, ADMA, and DMA dropped and SDMA increased post incision. Females experienced a more substantial drop in arginine. The arginine and ADMA dynamics depended on blood loss. The initial SDMA increase was higher in patients requiring transfusions. Postoperative dynamics in arginine and dimethylarginines differed in robot-assisted and open surgery. Concomitant SDMA, citrulline, and DMA quantification displayed a 92% accuracy in detecting CRC. Monitoring changes in arginine, ADMA, and SDMA in the early postoperative period predicted postoperative ileus with 84% and surgical site infections with 90% accuracy. Changes in ADMA predicted operative morbidity with 90% and anastomotic leakage with 77% accuracy. If positively validated, L-arginine/NO pathway metabolites may facilitate CRC screening and surveillance, support differential diagnosis, and assist in clinical decision-making regarding patients recovering from colorectal surgery.
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Affiliation(s)
- Iwona Bednarz-Misa
- Department of Medical Biochemistry, Wroclaw Medical University, 50-368 Wrocław, Poland
| | - Mariusz G Fleszar
- Department of Medical Biochemistry, Wroclaw Medical University, 50-368 Wrocław, Poland
| | - Marek Zawadzki
- Department of Oncological Surgery, Regional Specialist Hospital, 51-124 Wrocław, Poland
- Department of Physiotherapy, Wroclaw Medical University, 51-618 Wrocław, Poland
| | - Bartosz Kapturkiewicz
- First Department of Oncological Surgery of Lower Silesian Oncology Center, 53-413 Wrocław, Poland
| | - Agnieszka Kubiak
- Department of Medical Biochemistry, Wroclaw Medical University, 50-368 Wrocław, Poland
| | - Katarzyna Neubauer
- Department of Gastroenterology and Hepatology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Wojciech Witkiewicz
- Department of Oncological Surgery, Regional Specialist Hospital, 51-124 Wrocław, Poland
- Research and Development Centre at Regional Specialist Hospital, 51-124 Wrocław, Poland
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Carvello M, Di Candido F, Greco M, Foppa C, Maroli A, Fiorino G, Cecconi M, Danese S, Spinelli A. The trend of C-Reactive protein allows a safe early discharge after surgery for Crohn's disease. Updates Surg 2020; 72:985-989. [PMID: 32406043 DOI: 10.1007/s13304-020-00789-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/02/2020] [Indexed: 02/06/2023]
Abstract
Postoperative C-reactive protein (CRP) level allows to rule out infectious complications ensuring safe hospital discharge in colorectal cancer surgery. Since its clinical significance in Crohn's disease (CD) has not been studied yet, we investigated whether CRP can guide decision-making on hospital discharge in this population. Only consecutive CD patients undergoing resections with primary anastomosis and without covering stoma (2013-2017) were analysed. Pre- and post-operative CRP values, measured daily until discharge, were correlated with postoperative complications including anastomotic leakage (AL), infectious and non-infectious complications. The diagnostic accuracy of CRP in predicting AL was evaluated according to the area under the curve (AUC), using the receiver-operating characteristic (ROC) methodology. Two-hundred and fifty-one consecutive patients undergoing elective surgery for CD were selected. AL was diagnosed in 10 patients (4%). High CRP level was associated with AL on postoperative day (POD) 3-5 (p = 0.002, AUC 0.825) with a positive predictive value of 60%. CRP linear difference of 140 between POD 1 and 3 (AUC 0.800) maximizes sensitivity and specificity with a NPV of 98.6%. CRP trend, measured with the linear difference between POD 1 and 3, is able to rule out anastomotic complications with a high NPV and may allow a safe early hospital discharge after surgery for CD.
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Affiliation(s)
- Michele Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Massimiliano Greco
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Caterina Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Gionata Fiorino
- Department of Gastroenterology, IBD Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milano), Italy
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milano), Italy
| | - Silvio Danese
- Department of Gastroenterology, IBD Center, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milano), Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milano), Italy.
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Man W, Lin H, Liu Z, Jin L, Wang J, Zhang J, Bai Z, Yao H, Zhang Z, Deng W. Usefulness of Inflammation-Based Prognostic Scores for Predicting the Risk of Complications After Radical Resection of Colorectal Carcinoma. Cancer Manag Res 2020; 12:1029-1038. [PMID: 32104084 PMCID: PMC7023871 DOI: 10.2147/cmar.s234448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/22/2020] [Indexed: 12/23/2022] Open
Abstract
Purpose We aimed to investigate the value of inflammation-based prognostic scores for predicting early complications after radical surgery for colorectal carcinoma. Methods We retrospectively analyzed data of 154 patients who underwent elective resection of colorectal carcinoma between January 2017 and December 2018 at Beijing Friendship Hospital. Univariate, multivariate, and receiver operating characteristic curve analyses were conducted. As inflammation indices, we evaluated the preoperative modified Glasgow Prognostic Score (GPS), as well as the C-reactive protein/albumin ratio (CAR), postoperative GPS, and C-reactive protein levels on postoperative day 3 (POD3). Results Within 30 days postoperatively, complications occurred in 80 patients (51.9%). And high levels of preoperative mGPS (P=0.002), preoperative CAR (P=0.019), POD3 CAR (P<0.001) and POD3 poGPS (P<0.001) can significantly affect postoperative complications after surgery for colorectal cancer, with CRP on POD3 (odds ratio, 1.015; 95% confidence interval, 1.006–1.024; P=0.001) as independent risk factors. Among all inflammation-based indicators, POD3 CAR had the highest area under the curve (0.711) and positive predictive value (83.2%). Higher CAR (≥2.6) on POD3 was associated with a higher rate of complications (92.9% vs 36.6%, P<0.001), especially of infectious nature (54.8% vs 16.1%, P<0.001). Conclusion CAR≥2.6 on POD3 reflects sustained systemic inflammation and represents a useful predictor of complications after surgery for colorectal carcinoma, facilitating early detection, timely intervention, and enhanced recovery.
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Affiliation(s)
- Wenhao Man
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Huajun Lin
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Zhao Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Lei Jin
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Jin Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Jun Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Zhigang Bai
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Hongwei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
| | - Wei Deng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing 100050, People's Republic of China
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41
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Messias BA, Botelho RV, Saad SS, Mocchetti ER, Turke KC, Waisberg J. Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery. Sci Rep 2020; 10:1687. [PMID: 32015374 PMCID: PMC6997159 DOI: 10.1038/s41598-020-58780-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 01/21/2020] [Indexed: 01/16/2023] Open
Abstract
Anastomotic leakage is a complication of colorectal surgery. C-reactive protein (CRP) is an acute-phase marker that can indicate surgical complications. We determined whether serum CRP levels in patients who had undergone colorectal surgery can be used to exclude the presence of anastomotic leakage and allow safe early discharge. We included 90 patients who underwent colorectal surgery with primary anastomosis. Serum CRP levels were measured retrospectively on postoperative days (PODs) 1 - 7. Patients with anastomotic leakage (n = 11) were compared to those without leakage (n = 79). We statistically analysed data and plotted receiver operating characteristic curves. The incidence of anastomotic leakage was 12.2%. Diagnoses were made on PODs 3 - 24. The overall mortality rate was 3.3% (18.2% in the leakage group, 1.3% in the non-leakage group; P < 0.045). CRP levels were most accurate on POD 4, with a cutoff level of 180 mg/L, showing an area under the curve of 0.821 and a negative predictive value of 97.2%. Lower CRP levels after POD 2 and levels <180 mg/L on POD 4 may indicate the absence of anastomotic leakage and may allow safe discharge of patients who had undergone colorectal surgery with primary anastomosis.
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Affiliation(s)
- Bruno A Messias
- Department of Surgery, General Hospital of Carapicuiba, Carapicuiba, SP, Brazil.
| | - Ricardo V Botelho
- Department of Surgery, State Public Servant Hospital (IAMSPE), São Paulo, SP, Brazil
| | - Sarhan S Saad
- Department of Surgery, Paulista Medical School, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Erica R Mocchetti
- Department of Surgery, General Hospital of Carapicuiba, Carapicuiba, SP, Brazil
| | - Karine C Turke
- Department of Surgery, State Public Servant Hospital (IAMSPE), São Paulo, SP, Brazil.,Department of Surgery, ABC Medical School, Santo André, SP, Brazil
| | - Jaques Waisberg
- Department of Surgery, State Public Servant Hospital (IAMSPE), São Paulo, SP, Brazil.,Department of Surgery, ABC Medical School, Santo André, SP, Brazil
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Bundred J, Hollis AC, Hodson J, Hallissey MT, Whiting JL, Griffiths EA. Validation of the NUn score as a predictor of anastomotic leak and major complications after Esophagectomy. Dis Esophagus 2020; 33:5487967. [PMID: 31076741 DOI: 10.1093/dote/doz041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/27/2019] [Indexed: 12/11/2022]
Abstract
Predicting major anastomotic leak (AL) and major complications (Clavien-Dindo 3-5) following esophagectomy improves postoperative management of patients. The role of the NUn score in their prediction is controversial. This study aims to evaluate the predictive ability of this simple score. Data were retrospectively collected for consecutive esophagectomies over a 10-year period, and NUn scores were retrospectively calculated for each patient from informatics data. A standardized definition of major AL was used, excluding minor asymptomatic, radiologically detected leaks. The predictive accuracy of the NUn score and its constituent parts, for major AL and major complications, was assessed using area under receiver operating characteristics curves (AUROCs). Of 382 patients, 48 (13%) developed major AL and 123 (32%) developed major complications. The NUn score calculated on postoperative day 4 was significantly predictive of both outcomes, with AUROCs of 0.77 and 0.71, respectively (both P < 0.001). A NUn score cut-off of 10 had a negative predictive value of 95% for major AL. The NUn score was predictive of major complications on multivariable analysis. The NUn score was found to be a significant predictor of major AL, suggesting that this is a useful early warning score for major AL. The score may also be useful in identifying patients that are the most likely to benefit from enhanced recovery protocols.
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Affiliation(s)
- James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alexander C Hollis
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Mike T Hallissey
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John L Whiting
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, 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
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43
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Ho YM, Laycock J, Kirubakaran A, Hussain L, Clark J. Systematic use of the serum C-reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks. ANZ J Surg 2019; 90:109-112. [PMID: 31770827 DOI: 10.1111/ans.15568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/18/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to characterize the time-dependent relationship between serum C-reactive protein (CRP) and anastomotic integrity in the early post-operative period and to develop a systematic use of CRP and computed tomography. METHODS Patients aged 18 years or over who had the formation of a left-sided colonic or a colorectal anastomosis, in Royal Sussex County Hospital, were included. The post-operative day (POD) CRP cut-off values were calculated according to receiver operating characteristic analysis to evaluate the sensitivities and specificities of the proposed cut-off parameters. RESULTS A total of 125 left-sided colonic and colorectal anastomoses were recruited and analysed. When comparing to POD1 CRP cut-off, the calculated CRP ratio cut-off values of all the rest of PODs (2-5) were highly significant in the laparoscopic group and the overall group (P < 0.001). This statistically significant ratio was also demonstrated in the open group at POD2 (P < 0.0001). CONCLUSION CRP and CRP ratios cut-off values were sensitive to detect an anastomotic leak in the early post-operative period. The cut-off values could facilitate the development of systematic use of CRP and computed tomography.
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Affiliation(s)
- Yiu Ming Ho
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Juliet Laycock
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Arangan Kirubakaran
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Labib Hussain
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jeremy Clark
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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44
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Su'a B, Tutone S, MacFater W, Barazanchi A, Xia W, Zeng I, Hill AG. Diagnostic accuracy of procalcitonin for the early diagnosis of anastomotic leakage after colorectal surgery: a meta‐analysis. ANZ J Surg 2019; 90:675-680. [DOI: 10.1111/ans.15291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/06/2019] [Accepted: 04/11/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Bruce Su'a
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Senitila Tutone
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Wiremu MacFater
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Ahmed Barazanchi
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Weisi Xia
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Irene Zeng
- Department of SurgeryThe University of Auckland Auckland New Zealand
| | - Andrew G. Hill
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
- Department of General SurgeryMiddlemore Hospital, Counties‐Manukau District Health Board Auckland New Zealand
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Shao CY, Liu KC, Li CL, Cong ZZ, Hu LW, Luo J, Diao YF, Xu Y, Ji SG, Qiang Y, Shen Y. C-reactive protein to albumin ratio is a key indicator in a predictive model for anastomosis leakage after esophagectomy: Application of classification and regression tree analysis. Thorac Cancer 2019; 10:728-737. [PMID: 30734487 PMCID: PMC6449232 DOI: 10.1111/1759-7714.12990] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/06/2019] [Accepted: 01/06/2019] [Indexed: 12/14/2022] Open
Abstract
Background Anastomotic leakage (AL), a serious complication after esophagectomy, might impair patient quality of life, prolong hospital stay, and even lead to surgery‐related death. The aim of this study was to show a novel decision model based on classification and regression tree (CART) analysis for the prediction of postoperative AL among patients who have undergone esophagectomy. Methods A total of 450 patients (training set: 356; test set: 94) with perioperative information were included. A decision tree model was established to identify the predictors of AL in the training set, which was validated in the test set. A receiver operating characteristic curve was also created to illustrate the diagnostic ability of the decision model. Results A total of 12.2% (55/450) of the 450 patients suffered AL, which was diagnosed at median postoperative day 7 (range: 6–16). The decision tree model, containing surgical duration, postoperative lymphocyte count, and postoperative C‐reactive protein to albumin ratio, was established by CART analysis. Among the three variables, the postoperative C‐reactive protein to albumin ratio was identified as the most important indicator in the CART model with normalized importance of 100%. According to the results validated in the test set, the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of the prediction model were 80%, 98.8%, 88.9%, 97.6%, and 96.8%, respectively. Moreover, the area under the receiver operating characteristic curve was 0.95. Conclusion The decision model based on CART analysis presented good performance for predicting AL, and might allow the early identification of patients at high risk.
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Affiliation(s)
- Chen-Ye Shao
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Kai-Chao Liu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chu-Ling Li
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Li-Wen Hu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yi-Fei Diao
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Sai-Guang Ji
- Department of Cardiothoracic Surgery, Jingling Hospital, Bengbu Medical College, Anhui, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
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van den Bos J, Jongen ACHM, Melenhorst J, Breukink SO, Lenaerts K, Schols RM, Bouvy ND, Stassen LPS. Near-infrared fluorescence image-guidance in anastomotic colorectal cancer surgery and its relation to serum markers of anastomotic leakage: a clinical pilot study. Surg Endosc 2019; 33:3766-3774. [PMID: 30710314 PMCID: PMC6795629 DOI: 10.1007/s00464-019-06673-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/17/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) might help reduce anastomotic leakage (AL) after colorectal surgery. This pilot study aims to analyze whether a relation exists between measured fluorescence intensity (FI) and postoperative inflammatory markers of AL, C-reactive protein (CRP), Intestinal fatty-acid binding protein (I-FABP), and calprotectin, to AL, in order to evaluate the potential of FI to objectively predict AL. METHODS Patients scheduled for anastomotic colorectal cancer surgery were eligible for inclusion in this prospective pilot study. During surgery, at three time points (after bowel devascularization; before actual transection; after completion of anastomosis) a bolus of 0.2 mg/kg ICG was administered intravenously for assessment of bowel perfusion. FI was scored in scale from 1 to 5 based on the operating surgeon's judgment (1 = no fluorescence visible, 5 = maximum fluorescent signal). The complete surgical procedure was digitally recorded. These recordings were used to measure FI postoperatively using OsiriX imaging software. Serum CRP, I-FABP, and calprotectin values were determined before surgery and on day 1, 3, and 5 postoperative; furthermore, the occurrence of AL was recorded. RESULTS Thirty patients (n = 19 males; mean age 67 years; mean BMI 27.2) undergoing either laparoscopic or robotic anastomotic colorectal surgery were included. Indication for surgery was rectal-(n = 10), rectosigmoid-(n = 2), sigmoid-(n = 10), or more proximal colon carcinomas (n = 8). Five patients (16.7%) developed AL (n = 2 (6.6%) grade C according to the definition of the International Study group of Rectal Cancer). In patients with AL, the maximum fluorescence score was given less often (P = 0.02) and a lower FI compared to background FI was measured at 1st assessment (P = 0.039). However, no relation between FI and postoperative inflammatory parameters could be found. CONCLUSION Both subjective and measured FI seem to be related to AL. In this study, no relation between FI and inflammatory serum markers could yet be found.
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Affiliation(s)
- Jacqueline van den Bos
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands. .,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Audrey C H M Jongen
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Stéphanie O Breukink
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Kaatje Lenaerts
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
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March B, Leigh L, Brussius-Coelho M, Holmes M, Pockney P, Gani J. Can CRP velocity in right iliac fossa pain identify patients for intervention? A prospective observational cohort study. Surgeon 2018; 17:284-290. [PMID: 30309747 DOI: 10.1016/j.surge.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/11/2018] [Accepted: 08/25/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. METHODS A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. RESULTS 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5-6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5-8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81-0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63-315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. CONCLUSIONS CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.
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Affiliation(s)
- Brayden March
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | | | - Merran Holmes
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Peter Pockney
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Jon Gani
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia.
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Reynolds IS, Deasy J, Burke JP, McNamara DA. Response to: shift in paradigm of clinical management of anastomotic leak. Colorectal Dis 2017; 19:943-944. [PMID: 28746794 DOI: 10.1111/codi.13825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 02/08/2023]
Affiliation(s)
- I S Reynolds
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Republic of Ireland
| | - J Deasy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Republic of Ireland
| | - J P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Republic of Ireland
| | - D A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Republic of Ireland
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