Neutrophil to Lymphocyte Ratio and C-Reactive Protein as Two Predictive Tools of Anastomotic Leak in Colorectal Cancer Open Surgery?

Blood cell count indexes as predictors of anastomotic leakage in elective colorectal surgery: a multicenter study on 1432 patients

Article

Full-text available

May 2020
World J Surg Oncol

Background: The aim of this study was to evaluate a series of blood count inflammation indexes in predicting anastomotic leakage (AL) in elective colorectal surgery. Methods: Demographic, pathologic, and clinical data of 1432 consecutive patients submitted to colorectal surgery in eight surgical centers were retrospectively evaluated. The neutrophil to lymphocyte (NLR), derived neutrophil to lymphocyte (dNLR), lymphocyte to monocyte (LMR), and platelet to lymphocyte (PLR) ratios were calculated before surgery and on the 1st and 4th postoperative days, in patients with or without AL. Results: There were 106 patients with AL (65 males, mean age 67.4 years). The NLR, dNLR, and PLR were significantly higher in patients with AL in comparison to those without, on both the 1st and 4th postoperative days, but significance was greater on the 4th postoperative day. An NLR cutoff value of 7.1 on this day showed the best area under the curve (AUC 0.744; 95% CI 0.719-0.768) in predicting AL. Conclusions: Among the blood cell indexes of inflammation evaluated, NLR on the 4th postoperative day showed the best ability to predict AL. NLR is a low cost, easy to perform, and widely available index, which might be potentially used in clinical practice as a predictor of AL in patients undergoing elective colorectal surgery.

The value of biomarkers in early diagnosis of anastomotic leak following colorectal tumor resection: a review of the literature between 2012 and 2017

Article

Jul 2015

Predictive Values of C-Reactive Protein and Neutrophil to Lymphocyte Ratio in Detecting Anastomotic Leak in Open Colorectal Surgery

Article

Jan 2018

Prevention of Anastomotic Leak in Colorectal Surgery: Current Knowledge and Next Steps

Article

Full-text available

Feb 2024

Neutrophil-to-Lymphocyte Ratio as an Early Predictor of Symptomatic Anastomotic Leakage in Patients after Rectal Cancer Surgery: A Propensity Score-Matched Analysis

Article

Full-text available

Dec 2022

Background: This study aimed to explore the role of postoperative neutrophil-to-lymphocyte ratio in predicting symptomatic anastomotic leakage in patients who underwent laparoscopic low anterior resection for rectal cancer. Methods: In this retrospective cohort study, we analyzed data of patients who underwent laparoscopic low anterior resection from May 2009 to May 2019. A receiver operating characteristic curve analysis was performed to evaluate the cut-off values with the best predictive efficacy of a symptomatic anastomotic leakage. In addition, a propensity score-matched analysis was performed by considering all covariate variables, and 61 patients with or without symptomatic anastomotic leakage were included in the analysis. Results: The present study included 306 patients; of these, 17 (5.56%) developed symptomatic anastomotic leakage after surgery. On postoperative day 5, compared with patients without symptomatic anastomotic leakage, those with leakage had significantly higher neutrophil-to-lymphocyte levels. Notably, a neutrophil-to-lymphocyte cut-off score of 6.54 indicated the best area under the curve of 0.818 (95% confidence interval: 0.697-0.940, p < 0.001) in predicting symptomatic anastomotic leakage, with a sensitivity and specificity of 76.5% and 79.4%, respectively. Conclusions: Although evidence for the predictive role of neutrophil-to-lymphocyte ratio is accumulating, it remains inconclusive. In addition, neutrophil-to-lymphocyte levels should be considered a predictive biomarker for symptomatic anastomotic leakage; however, it can more accurately be viewed as an adjunct that helps increase the clinical suspicion of emerging symptomatic anastomotic leakage.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Article

Full-text available

May 2021

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.

A Decalogue to Avoid Routine Ileostomy in Selected Patients With Border Line Risk to Develop Anastomotic Leakage After Minimally Invasive Low-Anterior Resection: A Pilot Study

Article

Dec 2019

Purpose. Protective ileostomy (PI) during anterior resection (AR) for rectal cancer decreases the incidence of anastomotic leakage (AL) and its subsequent complications, but it may itself be the cause of morbidity. The aim is to report our protocol in the management of selected patients with borderline risk to develop AL after laparoscopic AR and ghost ileostomy (GI) creation. Methods. Patients who underwent AR were stratified based on the risk to develop AL. Steps to avoid PI were splenic flexure mobilization, reduced pelvic bleeding, to employ different stapler charge if neoadjuvant chemo-radiotherapy is performed, to perform a horizontal section of the rectum, to evaluate the anastomotic vascularization with a fluorescence angiography, to perform a side-to-end anastomosis, intraoperative methylene blue test, pelvic and transanal drainage tubes placement, and the GI creation. After surgery, inflammatory blood markers were monitored to detect potential leakages. Results. Twelve patients were included. In one case, the specimen proximal section was changed after fluorescence angiography. There were no conversions in this group of patients. One postoperative AL occurred and was treated with radiological drainage placement, not being necessary to convert the GI. PI was avoided in 100% of cases. Conclusions. Patients’ characteristics cannot be changed, but several steps were used to avoid routine PI creation. The present protocol could be a valuable option to avoid PI in selected patients. Further studies with a wider sample size, and defined criteria to stratify the patients based on the risk to develop AL, are required.

Serum Amyloid A as an Early Marker of Infectious Complications after Laparoscopic Surgery for Colorectal Cancer

Article

Full-text available

Jul 2018

Background: Our aim was to evaluate the usefulness of serum amyloid A (SAA) measurements in comparison with C-reactive protein (CRP) in the early prediction of infectious complications among patients undergoing laparoscopic surgery for colorectal cancer Methods: Consecutive patients undergoing laparoscopic resection for colorectal cancer were analyzed prospectively. All subjects had the Enhanced Recovery After Surgery protocol implemented. Blood samples were taken from all patients and SAA and CRP were measured on the day of surgery and on the three consecutive post-operative days (PODs). Patients were divided into two groups (Group 1 without complications, Group 2 with complications), and these groups were compared. Results: The study included 81 patients (61 in Group 1 and 20 in Group 2). Starting from POD2, significant differences between the groups were observed for both SAA and CRP. On POD2, the median CRP values were 116.7 mg/L and 256.9 mg/L in Groups 1 and 2, respectively (p = 0.00002). On POD3, the median SAA concentration was 445 mg/L in Group 1 and 1,412 mg/L in Group 2 (p = 0.00003). The CRP concentrations were 80.2 mg/L and 247.1 mg/L in Groups 1 and 2, respectively (p = 0.00001). A receiver operating characteristic (ROC) curve analysis showed that measurements of POD3 had the highest specificity and sensitivity with no significant differences between CRP and SAA (on POD3 for SAA sensitivity 83.3% and specificity 94%; for CRP: sensitivity 88% and specificity 86%). Conclusion: Measurements of SAA are useful in predicting infectious complications even on the early post-operative days. It has characteristics similar to CRP, and its best values are reached on POD3.

Thrombocyte decrease and hemoglobin level as simple non-inflammatory predictors of anastomotic leakage in rectal-cancer surger

Article

Full-text available

Jan 2023

Purpose: The study aimed to determine a simple diagnostic test that could predict the risk of anastomotic leakage in early postoperative period. Methods: A single-center, retrospective study was conducted. The electronic medical records of patients who underwent resection for rectal tumor between January 1, 2016, and December 31, 2021, in University Hospital Olomouc, were reviewed. The data included risk factors for leakage and laboratory parameters commonly obtained. Results: The decrease in platelets was significant as for the possibility of being a marker of anastomotic leakage; OR = 0.980 (p = 0.036). A decrease of 34 or higher predicts leakage with a sensitivity of 45 % (95 % CI: 23.1-68.5 %) and specificity of 81.1 % (95 % CI: 75.2-86.1 %). Postoperative leukocyte blood level (OR = 1.134; p = 0.019) and leukocyte level on postoperative day 1 (OR = 1.184; p = 0.023) were significant predictors for leakage. WBC values ≥ 8.8 predict leakage with a sensitivity of 70.0 % (95 % CI: 45.7-88.1 %) and specificity of 55.3 % (95 % CI: 48.4-62.0 %). Hemoglobin blood level ≤ 79.5 predicts leakage with a sensitivity of 70.0 % (95 % CI: 45.7-88.1 %) and specificity of 62.2 % (95 % CI: 55.5-68.7 %). Conclusion: Despite the fact that the specificity and sensitivity of the followed parameters are low, they could serve as markers useful for early diagnosis or suspicion for leakage (Tab. 5, Fig. 3, Ref. 14).

A novel scoring system for the early detection of anastomotic leakage: bedside leak score—a pilot study

Article

Full-text available

Jul 2023

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 183 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.

CRP in Drain Fluid as a Predictive Marker of Anastomotic Leak in Colorectal Surgery: A Systematic Review of the Literature

Article

Jun 2023

Background/aim: Anastomotic leak (AL) remains one of the most troublesome complications in general surgery. The current review aimed to assess the level of C-reactive protein (CRP) in drainage fluid after entero-enteric, colonic, or colorectal anastomosis as a predictive biomarker for AL. Materials and methods: Four medical databases (PUBMED-MEDLINE, Google Scholar, UpToDate, and Cochrane Library) were searched in January 2023 for prospective or retrospective studies on the role of acute-phase proteins in drainage fluid as a predictive biomarker of AL. Two independent researchers gathered and processed the data using MedCalc. The data were pooled and Student's t-test was used to compare the data between the AL and non-AL groups. Results: Overall, four studies were included in the current review, containing 753 patients in total, for whom various types of enteric and colonic anastomoses were constructed. Overall 79 (10.49%) of patients demonstrated AL and the mean CRP level (±standard deviation) on postoperative day 3 was 167.7±77.13 mg/l. On the contrary, the non-AL group (674/753) had a statistically significantly lower mean CRP level at 83.76±20.32 mg/l. CRP values were not related to mortality. It was not possible to propose a CRP cut-off indicating an increased risk for AL as the data were insufficient. Conclusion: The CRP level in drainage fluid might be a valuable biomarker for predicting the possibility of AL in general surgery. However, further and larger-scale studies are needed to establish a CRP cut-off value and this variable would possibly be different for patients with different pathologies.

Preoperative Cancer Inflammation Prognostic Index as a Superior Predictor of Short- and Long-Term Outcomes in Patients with Stage I–III Colorectal Cancer after Curative Surgery

Article

Full-text available

Dec 2022

Inflammatory reactions play a crucial role in cancer progression and may contribute to systemic inflammation. In routine clinical practice, some inflammatory biomarkers can be utilized as valuable predictors for colorectal cancer (CRC). This study aims to determine the usefulness of a novel cancer-inflammation prognostic index (CIPI) marker derived from calculating carcinoembryonic antigen (CEA) multiplied by the neutrophil-to-lymphocyte ratio (NLR) values established for non-metastatic CRCs. Between January 1995 and December 2018, 12,092 patients were diagnosed with stage I to III primary CRC and had radical resection—they were all included in this study for further investigation. There were 5996 (49.6%) patients in the low-CIPI group and 6096 (50.4%) patients in the high-CIPI group according to the cutoff value of 8. For long-term outcomes, the high-CIPI group had a significantly higher incidence of recurrence (30.6% vs. 16.0%, p < 0.001) and worse relapse-free survival (RFS) and overall survival (OS) rates (p < 0.001). High CIPI was an independent prognostic factor for RFS and OS in univariate and multivariate analyses. This research is the first to document the independent significance of CIPI as a prognostic factor for CRC. To ensure that it works, this CIPI needs to be tested on more CRC prediction models.

Anastomotic Rings and Inflammation Values as Biomarkers for Leakage of Stapled Circular Colorectal Anastomoses

Article

Full-text available

Nov 2022

Reliable markers to predict or diagnose anastomotic leakage (AL) of stapled circular anastomoses following colorectal resections are an important clinical need. Here, we aim to quantitatively investigate the morphology of anastomotic rings as an early available prognostic marker for AL and compare them to established inflammatory markers. We perform a prospective single-center cohort study, including patients undergoing stapled circular anastomosis between August 2020 and August 2021. The predictive value of the anastomotic ring configuration and the neutrophil-to-lymphocyte ratio (NLR) regarding anastomotic leakage is examined by ROC analyses and compared to the C-reactive protein (CRP) as an established marker. We included 204 patients, of which 19 suffered from anastomotic leakage (LEAK group), while in 185 patients the anastomoses healed well (HEAL group). The minimal height of the anastomotic rings as a binary classifier had a good ROC-AUC of 0.81 but was inferior to the NLR at postoperative day (POD) 5, with an excellent ROC-AUC of 0.93. Still, it was superior to the NLR at POD 3 (0.74) and the CRP at POD 3 (ROC-AUC 0.54) and 5 (ROC-AUC 0.70). The minimal height of the anastomotic rings as indicator for technically insufficient anastomoses is a good predictor of AL, while postoperatively the NLR was superior to the CRP in prediction of AL.

Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage: A prospective observational study

Article

Full-text available

Jun 2022
WORLD J GASTROENTERO

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.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Article

Full-text available

Dec 2021

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Sixty-Day Mortality of Patients With Metastatic Colorectal Cancer Randomized to Systemic Treatment vs Primary Tumor Resection Followed by Systemic Treatment: The CAIRO4 Phase 3 Randomized Clinical Trial

Article

Oct 2021

Importance: The role of primary tumor resection (PTR) in synchronous patients with metastatic colorectal cancer (mCRC) who had unresectable metastases and few or absent symptoms of their primary tumor is unclear. Studying subgroups with low postoperative mortality may identify patients who potentially benefit from PTR. Objective: To determine the difference in 60-day mortality between patients randomized to systemic treatment only vs PTR followed by systemic treatment, and to explore risk factors associated with 60-day mortality. Design, setting, and participants: CAIRO4 is a randomized phase 3 trial initiated in 2012 in which patients with mCRC were randomized to systemic treatment only or PTR followed by systemic treatment with palliative intent. This multicenter study was conducted by the Danish and Dutch Colorectal Cancer Group in general and academic hospitals in Denmark and the Netherlands. Patients included between August 2012 and December 2019 with histologically proven colorectal cancer, unresectable metastases, and a primary tumor with few or absent symptoms were eligible. Interventions: Systemic treatment, consisting of fluoropyrimidine-based chemotherapy with bevacizumab vs PTR followed by fluoropyrimidine-based chemotherapy with bevacizumab. Main outcomes and measures: The aim of the current analysis was to compare 60-day mortality rates in both treatment arms. A secondary aim was the identification of risk factors for 60-day mortality in the treatment arms. These aims were not predefined in the study protocol. Results: A total of 196 patients were included in the intention-to-treat analysis (112 [57%] men; median [IQR] age, 65 [59-70] years). Sixty-day mortality was 3% (95% CI, 1%-9%) in the systemic treatment arm and 11% (95% CI, 6%-19%) in the PTR arm (P = .03). In a per-protocol analysis, 60-day mortality was 2% (95% CI, 1%-7%) vs 10% (95% CI, 5%-18%; P = .048). Patients with elevated serum levels of lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and/or neutrophils who were randomized to PTR had a significantly higher 60-day mortality than patients without these characteristics. Conclusions and relevance: Patients with mCRC who were randomized to PTR followed by systemic treatment had a higher 60-day mortality than patients randomized to systemic treatment. Especially patients randomized to the PTR arm with elevated serum levels of lactate dehydrogenase, neutrophils, aspartate aminotransferase, and/or alanine aminotransferase were at high risk of postoperative mortality. Final study results on overall survival have to be awaited. Trial registration: ClinicalTrials.gov Identifier: NCT01606098.

Bacteriological Concentration of Peritoneal Drainage Fluid Could Make an Early Diagnosis of Anastomotic Leakage Following Rectal Resection

Preprint

Full-text available

Mar 2021

Purpose: To investigate that the bacteriological concentration and pH value in peritoneal drainage fluid might serve as indicators of early diagnosis of anastomotic leakage following rectal resection. Methods: We prospectively analyzed consecutive patients who were treated for rectal diseases with anastomotic stoma at the department of general surgery, the affiliated hospital of Nanjing University Medical School between August 2018 and December 2020. The bacteriological concentration and the pH levels in peritoneal drainage fluid were tested on the first, fourth, seventh days postoperatively. Results: A total of 300 consecutive patients underwent rectal resection were tested. 21 patients present with AL and the overall AL rate was 7%. The bacteriological concentration in peritoneal drainage fluid of AL group was significantly higher than that in non-AL group. The AUC value was 0.98 according to the ROC curve. The best cut-off value was 1143/uL and the sensitivity and specificity were 100% and 93.19% respectively. There was no difference of pH value between the AL and non-AL groups. Conclusion: According the results of present study, a high bacteriological concentration in peritoneal drainage fluid is a good marker for predicting and diagnosing AL following rectal resection. The best cut-off value is1143/uL and the sensitivity and specificity are 100% and 93.19% respectively.

C-reactive protein can predict anastomotic leak in colorectal surgery: a systematic review and meta-analysis

Article

Full-text available

Jun 2021
INT J COLORECTAL DIS

Background Anastomotic leakage (AL) is one of the most significant complications after colorectal surgery, affecting length of stay, patient morbidity, mortality, and long-term oncological outcome. Serum C-reactive protein (CRP) level rises in infective and inflammatory states. Elevated CRP has been shown to be associated with anastomotic leak.Objective Perform a meta-analysis of current CRP data in AL after colorectal surgery.Data sourcesMEDLINE, EMBASE, CINAHL, CENTRAL databasesStudy selectionComparative studies studying serum CRP levels in adult patients with and without AL after colorectal surgery.Intervention(s)Elective and emergency open, laparoscopic or robotic colorectal excisions for cancer and benign pathology.Main outcome measuresMean serum CRP measurements between post-operative days (POD) 1 through 7 in patients with and without AL. Perform ROC analysis to determine cut-off CRP values to indicate AL.ResultsTwenty-three studies with 6647 patients (482 AL). Pooled mean time to diagnosis of AL was 7.70 days. AL associated with higher CRP on POD1 (mean difference (MD) 15.19, 95% CI 5.88–24.50, p = 0.001), POD2 (MD 51.98, 05% CI 37.36–66.60, p < 0.00001), POD3 (MD 96.92, 95% CI 67.96–125.89, p < 0.00001), POD4 (MD 93.15, 95% CI 69.47–116.84, p < 0.00001), POD5 (MD 112.10, 95% CI 89.74–134.45, p < 0.00001), POD6 (MD 98.38, 95% CI 80.29–116.46, p < 0.00001), and POD7 (MD 106.41, 95% CI 75.48–137.35, p < 0.00001) compared with no AL. ROC analysis identified a cut-off CRP of 148 mg/l on POD3 with sensitivity and specificity of 95%. On POD4 through POD7, cut-off levels were 123 mg/l, 115 mg/l, 105 mg/l, and 96 mg/l, respectively, with sensitivity and specificity of 100%.LimitationsStudy heterogeneity, some characteristics unreported, no RCTConclusionsAL is associated with higher CRP levels on each post-operative day compared to no AL after colorectal surgery. The cut-off CRP values can be used to predict AL to expedite investigation and treatment.

Valor del Ratio Neutrófilo-Linfocito, Ratio Plaqueta-Linfocito y Proteína C Reactiva del primer día como predictores de complicaciones postoperatorias tras cirugía oncológica gástrica

Article

Full-text available

Jan 2021

Resumen Introducción La Relación Neutrófilo-Linfocito (NLR, por sus siglas en inglés «Neutrophil-to-Lymphocyte Ratio»), la Relación Plaqueta-Linfocito (PLR, por sus siglas en inglés «Platelet-to-Lymphocyte Ratio») y la Proteína C Reactiva (PCR) son parámetros analíticos sencillos que pueden informarnos sobre el estado inflamatorio del organismo. La PCR ha mostrado ser predictor de complicaciones postoperatorias, mientras la NLR y la PLR han mostrado mayor utilidad en el pronóstico de patologías oncológicas. Objetivo Evaluar la asociación de NLR y PLR con las complicaciones postoperatorias tras cirugía oncológica gástrica y compararlo con la PCR. Material y métodos Se realizó un estudio prospectivo sobre 66 pacientes sometidos a cirugía gástrica oncológica entre enero de 2014 y marzo de 2019. Se tomaron variables sociodemográficas, técnica quirúrgica, extensión tumoral, NLR, PLR y PCR del primer día postcirugía y complicaciones postoperatorias. Resultados 17 pacientes (25.8%) presentaron complicaciones grado III-V de la Clasificación de Clavien-Dindo. El valor NLR medio fue 11.30 y se asoció de forma estadísticamente significativa con la aparición de complicaciones mayores (p = 0.009). El PLR medio fue 266.05 y no se asoció de forma significativa con las complicaciones (p = 0.149). La PCR media de 54 pacientes fue 143.24 y no se relacionó con la aparición de complicaciones mayores (p = 0.164). Conclusión El NLR es un parámetro sencillo y barato, y en nuestra muestra, predice la aparición de complicaciones mayores postoperatorias desde el primer día. En comparación con la PCR precoz, parece ser un mejor parámetro predictor de las mismas. Se deben realizar estudios más amplios para confirmar esta tendencia.

Preoperative Neutrophil and Lymphocyte Ratio as a Predictor of Mortality and Morbidity After Cardiac Surgery

Article

Jul 2020

Background Inflammatory markers, such as neutrophils and lymphocytes, for risk stratification of postoperative morbidity and mortality in patients with cardiovascular disease may provide benefit for patient selection for cardiac surgery. This study aimed to investigate the association between preoperative neutrophil to leucocyte ratio (NLR) after cardiac surgery. Methods A retrospective study from September 2014 to November 2017 undergoing cardiac surgery at Waikato Hospital was conducted. Preoperative haematological profiles, patient factors and primary end secondary endpoints were obtained. The primary endpoint was 30-day new postoperative atrial fibrillation requiring treatment, new neurological insult, readmission within 30 days and 30-day mortality. The secondary endpoint was long-term all cause mortality. Results Of the 1,694 patients included in the study, 21% (356/1,694) incidents of new atrial fibrillation (AF), 3.0% (51/1,694) strokes, 10.6% (180/1,694) readmissions and 2.8% (47/1,694) deaths within 30 days were observed. Receiver operator curve (ROC) returned a cut-off value of NLR equal to or greater than 3.23 (high NLR) to be associated with greatest mortality. Subsequently, a high NLR was compared to the endpoints. High NLR was associated with higher postoperative (p<0.001) and discharge creatinine, longer ICU stay (p=0.012), prolonged intubation and ventilation (p<0.001), new neurological status (p=0.002) and increased risk of returning to theatre (p=0.009). After logistic regression, high NLR was associated with increased mortality (OR 3.36, p=0.001). Conclusions The interpretation and utilisation of readily available haematological markers can provide further risk stratification data to the surgeon when considering the postoperative cardiac surgery risks.

Consensus on the definition of colorectal anastomotic leakage: A modified Delphi study

Article

Full-text available

Jun 2020
WORLD J GASTROENTERO

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.

Utilización del índice neutrófilo linfocito para detección temprana de fuga de anastomosis. Estudio piloto.

Thesis

Jul 2017

Julian Zilli

Evaluar si existe relación entre los valores del índice neutrófilo linfocito > de 5 puntos en el tercer día posoperatorio con la presencia de fuga de anastomosis corroborada por tomografía y/o laparotomía en pacientes operados de resección intestinal y anastomosis en el servicio de Coloproctología del Hospital General de México. Se trata de un estudio observacional, retrospectivo, descriptivo y transversal, en pacientes con anastomosis intestinal operados en el servicio de Coloproctología del Hospital General de México “Dr. Eduardo Liceaga” entre el 1 de enero de 2016 y el 30 de junio de 2017. Con el objeto de detectar alguna asociación entre INL-5 a los tres días y fuga se obtuvo su respectiva tabla de contingencia, el estadístico de prueba fue la prueba exacta de Fisher. (Van Belle et al, 2004). Para evaluar la capacidad diagnóstica de INL-5 con fuga se obtuvo la curva ORC y el criterio de efectividad como variable diagnóstica de fuga se midió con el área bajo la curva (ABC). Un total de 112 pacientes (13.3%) del total de la muestra cumplieron con los criterios de inclusión; 51.4% fueron hombres y 48.6% mujeres 48.6% [Fig. 1]. El motivo de anastomosis más frecuente fue el cierre de estomas en el 39% de los casos, cáncer en el 35%, enfermedad diverticular en el 16%, y otros diagnósticos en el 10%. El tipo de anastomosis más frecuente fue la anastomosis colorrectal en 53%, la ileo-colonica en 37%, y la ileo-recto anastomosis en 10% [Fig. 3]. El índice de fuga de anastomosis fue de 15.3%, y la mortalidad en el 2.7% [Fig. 4]. En la poblacion se tuvo una media de edad de 52 años, con una desviación típica de +/- 15.4 El promedio de edad fue de 52 años con una desviación típica de 15.4 [Fig. 6]. Durante el análisis se decidió exlcuir a los pacientes oncológicos ya que se presentaron múltiples outliers por INL muy fuera de rango tras lo cual quedaron 72 pacientes. Tras el análisis, persistieron outliers por INL fuera de rango . Las pruebas de T de Student, Wilcoxon, Levene arrojaron resultados no significativos. Se analizaron los puntos de corte de INL con cifras de 5, 9 y 16 puntos para identificar capacidad diagnóstica de dichos puntos de corte; el INL de 5 puntos presentó un área bajo la curva de .0587, y los puntos de corte de 9 y 16 puntos mostraron un ABC < de 0.5 [Fig. 6]. La media de INL en el día posoperatorio 3 fue de 8.8 puntos, con una desviación típica de +/- 6.4 De acuerdo a los datos arrojados por este estudio, el INL mayor de 5 puntos no es útil para la detección temprana de una fuga de anastomosis. Consideramos que por la heterogeneidad de la muestra no se logró identificar un punto de corte adecuado para sospechar fuga de anastomosis. Las carácterísticas demográficas de los pacientes que presentaron fuga de anastomosis son similares a lo referido por otros autores.

Systematic use of the serum C‐reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks

Article

Full-text available

Nov 2019
ANZ J SURG

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.

Early Active Drainage by Fine Tube Bundles Improves the Clinical Outcome of Anastomotic Leak after Abdominal Surgery: A Pilot Randomized, Controlled Trial in Two Tertiary Hospitals in China

Article

Jan 2019

Background: Post-operative anastomotic leak (PAL) is the most feared complication after abdominal surgery. Timely drainage of enteric effluent is beneficial in the healing of PAL. Methods: We introduced a new and feasible approach for early active drainage of PAL using fine tube bundles (FTBs). The therapeutic effects of FTBs were observed prospectively and compared with the traditional drainage tube without FTBs in a non-blinded randomized controlled trial. Results: Sixty patients with PAL in two tertiary hospitals in China from 2010 to 2016 were included in this study. Of these patients, 30 received FTBs and 30 were treated with a traditional drainage tube. The implantation failure rate was zero in the FTB group. No statistical difference was observed between the two groups in terms of demographic data. After these interventions, patients in the FTB group showed a faster decline in infection-related indictors, a higher ratio of spontaneous PAL closure, and shorter treatment duration of antibacterial agents compared with those in the traditional drainage tube group. Fatal complications and financial cost were also reduced in the FTB group. Conclusion: Fine tube bundles may contribute to the healing of PAL through active drainage. This method should be validated by further clinical trials for wider use.

The impact of sarcopenia and myosteatosis on postoperative outcomes in patients with inflammatory bowel disease

Article

Full-text available

Dec 2018

Background Inflammatory bowel disease (IBD) is a relatively common disorder with significant associated morbidity. Sarcopenia and myosteatosis are associated with adverse postoperative outcomes. This study investigated outcomes in IBD patients undergoing surgical resection relative to the presence of sarcopenia and myosteatosis. Methods A retrospective analysis of a prospectively maintained surgical database was conducted. All patients undergoing elective or emergency resection for IBD between 2011 and 2016, with a contemporaneous perioperative computed tomography (CT) scan, were included. Patient demographics, clinical and biochemical measurements were collected. Skeletal muscle index and attenuation were measured on perioperative CT scans using Osirix version 5.6.1. Univariate and multivariate regression analysis was used to identify risk factors for adverse postoperative outcomes. Results Seventy-seven patients (46 male, 31 female; mean age 42 years, range 20–80 years) were included. Thirty patients (30%) had sarcopenia and 26 (34%) had myosteatosis. Myosteatosis was significantly associated with increased hospital stay postoperatively (9 versus 13 days). Sarcopenia and myosteatosis were associated with hospital readmission within 30 days on univariate analysis. Multivariate regression analysis demonstrated an independent association between myosteatosis and hospital readmission. Sixteen patients (21%) had a clinically relevant postoperative complication, but an association with sarcopenia and myosteatosis was not observed. A neutrophil-lymphocyte ratio greater than 5 was predictive of clinically relevant postoperative complications on multivariate regression analysis. Conclusions Myosteatosis was associated with increased hospital stay and increased 30-day hospital readmission rates on multivariate regression analysis. Sarcopenia and myosteatosis in IBD were not associated with clinically relevant postoperative complications.

Red cell distribution width and mean platelet volume as predictors of anastomotic dehiscence in colorectal surgery A pilot multicenter case-match study

Article

Sep 2018
ANN ITAL CHIR

Aim: One of the most serious complications in modern colorectal surgery is the occurrence of an anastomotic dehiscence. The aim of this study was to evaluate the role of preoperative red cell distribution width (RDW) and mean platelet volume (MPV) as predictors of anastomotic dehiscence in elective surgery for colorectal cancer. Materials and methods: Forty-two patients with a clinically manifested anastomotic dehiscence after oncological colorectal surgery, and 42 controls matched for age, sex, pathological stage and tumor localization were enrolled. Correlations between the preoperative RDW and MPV values and anastomotic dehiscence were investigated. Results: Both the median RDW value (14.4 % vs 13.1%; p=0.007) and the median MPV value (8.0 fL vs 7.5 fL; p=0.037) were significantly higher in patients with anastomotic dehiscence than in those without. In multiple regression analysis only the RDW remained significantly associated with anastomotic dehiscence. Conclusions: The preoperative values of RDW may be useful in predicting anastomotic damage in elective oncological surgery. Key words: Anastomotic Dehiscence, MPV, RDW.

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

Article

Full-text available

Sep 2018
WIDEOCHIRURGIA TEC M

Introduction Thanks to laparoscopy and enhanced recovery protocols (ERAS) it is possible to shorten hospitalization. Therefore, it seems reasonable to search for new early markers of infectious complications in order to select patients who are prone to development of complications. Aim To assess the usefulness of serum levels of C-reactive protein, interleukin-6 and procalcitonin as early indicators of infectious complications in patients after laparoscopic colorectal surgery with ERAS. Material and methods The prospective analysis included consecutive patients who underwent laparoscopic colorectal cancer resection. The following parameters were included in the analysis: C-reactive protein (CRP), interleukin 6 (IL-6) and procalcitonin measured on postoperative days (PODs) 1, 2, 3. Patients were divided into two groups: uncomplicated (group 1) and complicated (group 2). The difference in levels of the markers and the dynamics of changes observed in both groups were analyzed. Results Group 1 comprised 34 patients, and group 2 consisted of 17 patients. A significant increase of both absolute values and delta increments on all postoperative days was noted. ROC curve analysis showed that the best cut-off values indicating an infectious process were: CRP 129 mg/l on POD3 (92% sensitivity/80% specificity), IL-6 of 78 pg/ml on POD2 (91% sensitivity/97% specificity) and PCT 0.24 ng/ml on POD3 (93% sensitivity/68% specificity). Conclusions Our study showed that regular measurement of all analyzed markers in the early postoperative days may be beneficial in the detection of postoperative infectious complications. Further studies are needed to fully assess the role of routine biochemical measurements in the postoperative period after laparoscopic surgery with the ERAS protocol.

Inflammatory Markers and MicroRNAs: The Backstage Actors Influencing Prognosis in Colorectal Cancer Patients

Article

Full-text available

Jun 2018
INT J MOL SCI

Background: Colorectal cancer (CRC) remains a deadly disease, afflicting the lives of millions worldwide. The prognosis of CRC patients is best predicted by surgical resection and pathological analysis of specimens. Emerging evidence has attributed a significant role to inflammatory markers and microRNAs (miRNAs) in the prognosis and survival of CRC patients. Aim: Here, we review the literature on inflammatory markers and miRNAs with an established role on survival rates, response to systemic chemotherapy, and other clinic-pathological parameters in CRC patients. Results: Our literature review revealed a critical role of inflammatory markers—specifically, the acute-phase proteins, inflammatory cytokines, and blood cell ratios—on prognostic outcomes in CRC patients. MiRNAs, on the other hand, were useful in predicting prognosis and clinical response and accordingly stratifying CRC patients for optimal drug selection. Conclusion: These biomarkers are easily measured in routine blood exams and can be used in adjunct to the tumor-node-metastasis (TNM) staging system to identify high-risk patients and those who are more likely to benefit from chemotherapy and other targeted therapies. However, more prospective studies are needed for the validation of these discussed prognostic and predictive biomarkers.

Inflammatory cell indexes as preoperative predictors of hospital stay in open elective thoracic surgery

Article

Apr 2018

Background Shorter and safer hospital stay (HS) is a desired outcome for patients undergoing thoracic surgery. The aim of the present study was to evaluate the predictive capacity of a series of pre‐defined inflammatory cell indexes based on preoperative complete blood counts, towards length of HS in open elective thoracic surgery. Methods We retrospectively studied 157 consecutive patients undergoing open elective thoracic surgery. Preoperative neutrophil to lymphocyte, platelet to lymphocyte and lymphocyte to monocyte ratios were calculated, and the red cell distribution width and mean platelet volume were registered. In addition, the systemic inflammation response index (SIRI) and a further derivative index, the aggregate inflammation systemic index (AISI) were calculated. Results Statistically significant and positive correlations were observed between HS and SIRI, and between HS and AISI. In multiple logistic regression analysis, after dividing the patients in groups with normal and prolonged HS and adjusting for several confounders, only AISI was independently associated with HS. Conclusions Our results suggest that simple, inexpensive and widely available inflammatory cell indexes like SIRI and, particularly AISI, can be useful for the early identification of patients at risk of prolonged HS in open elective thoracic surgery.

Preoperative Full Blood Count Markers as a Predictor of Mortality and Morbidity Risk After Cardiac Surgery

Article

Full-text available

Nov 2018

The association of the neutrophil-to-lymphocyte ratio and postoperative complications in colorectal cancer surgery: a scoping review

Preprint

Full-text available

Apr 2024

BACKGROUND: Surgical resection of tumors is usually performed in patients with colorectal carcinoma regardless of the disease's stage. Nonetheless, prior to surgical operations different postoperative complications may occur. The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker related to complications following surgical operations. Hence, the present review study was undertaken to assess the association of the NLR and postoperative complications in resections of colorectal tumors. METHODS: Major electronic databases were searched to find all available existing literature. Data was extracted and processed from the eligible studies and presented in the present review. RESULTS: Overall, a total of 32 observational and case-control studies consisting of 9095 colorectal cancer patients were included in the review. In 27/32 of the studies a statistically significant positive association was found between the NLR and post-operative complications. Preoperative NLR was assessed in 25/32 of the studies and postoperative NLR was assessed in 8/32 of the studies including studies in which NLR was assessed in both moments. CONCLUSIONS: The preoperative and postoperative values of the NLR can predict the risk of developing postsurgical complications. However, it is important to conduct further prospective cohort studies to verify the results and deepen knowledge in this area.

Drainage fluid LDH and neutrophil to lymphocyte ratio as biomarkers for early detecting anastomotic leakage in patients undergoing colorectal surgery

Article

Nov 2023

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. ClinicalTrial identifier NCT04846283 Unique protocol ID ANASTOMOTICLEAKAGE 01_2021 https://clinicaltrials.gov/show/NCT04846283

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

Article

Oct 2022
AM SURGEON

Background The early detection of infectious complications of colorectal surgery leads to better patient outcomes. This study aimed to assess the role of C-reactive protein (CRP), white blood cell count (WBC), and serum glucose in the early prediction of infectious complications of laparoscopic colorectal surgery. Methods Patients who underwent laparoscopic colorectal surgery were included and stratified into two groups: infectious complication (IC) or no infectious complication (non-IC). Serum levels were measured on postoperative days (PODs) 2 and 4. Results Analysis of 224 patients (IC group: 27, Non-IC group: 197) revealed higher CRP levels in IC group on POD 2 ( P = .001). On POD 4, CRP levels and WBC counts were higher in IC group ( P<.001, P = .011, respectively). The area under the curve (AUC) of the receiver operating characteristic (ROC) for CRP on PODs 2 and 4 were .743 and .907, respectively, and for WBC on POD 4 was .687. The cut-offs of CRP on PODs 2 and 4 were 156.2 mg/L and 91.3 mg/L, respectively; the cut-off of WBC was 7,220 cells/mm ³ . Sensitivity of CRP level ≥91.3 mg/L or WBC count ≥7,220 cells/mm ³ was 96.3%; (cf. 88.9% for CRP alone), and specificity of CRP level ≥91.3 mg/L and WBC count ≥7,220 cells/mm ³ was 93.4% (cf. 82.2% for CRP alone). Discussion The CRP level on postoperative day (POD) 2 and the combined CRP and WBC on POD 4 were meaningful in predicting infectious complications after laparoscopic colorectal surgery. However, serum glucose levels had a low predictive value for infectious complications.

C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis

Article

Sep 2022

Background Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery.Methods Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD).ResultsTwenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7–9%), and the median time to diagnosis was 6.9 days (range 3–10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23–0.85), 0.84 (95% CIs 0.18–0.86) and 0.84 (95% CIs 0.18–0.89) respectively. Negative likelihood ratios (LR−) showed moderate evidence to rule out AL on POD 3 (LR− 0.29), POD4 (LR− 0.24) and POD5 (LR− 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (−0.18) showed moderate evidence to rule out AL.Conclusions In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development.

Bacteriological concentration of peritoneal drainage fluid could make an early diagnosis of anastomotic leakage following rectal resection

Article

Full-text available

Nov 2021

To investigate that the bacteriological concentration and pH value in peritoneal drainage fluid might serve as indicators of early diagnosis of anastomotic leakage following rectal resection. We prospectively analyzed consecutive patients who were treated for rectal diseases with anastomosis at the department of general surgery, the affiliated hospital of Nanjing University Medical School between August 2018 and December 2020. The bacteriological concentration and the pH value in peritoneal drainage fluid were tested on the first, fourth, seventh days postoperatively. A total of 300 consecutive patients underwent rectal resection were tested. 21 patients present with AL and the overall AL rate was 7%. The bacteriological concentration in peritoneal drainage fluid of AL group was significantly higher than that in non-AL group. The AUC value was 0.98 (95% confidence intervals 0.969–1.000) according to the ROC curve. The best cut-off value was 1143/uL. The sensitivity and specificity were 100% and 93.19% respectively. There was no difference of pH value between the AL and non-AL groups. According the results of present study, a high bacteriological concentration in peritoneal drainage fluid is a good marker for predicting and diagnosing AL following rectal resection. However, owing to the limitation of the sample, there was no validation attempt in the study. A large sample study is needed to validate the conclusion.

First day postoperative values of the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and C-reactive protein as complication predictors following gastric oncologic surgery

Article

Nov 2021

Introduction The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) level are simple laboratory test parameters that can provide us with information on the inflammatory status of the organism. CRP has been shown to be a predictor of postoperative complications, whereas NLR and PLR have shown greater usefulness in the prognosis of oncologic pathologies. Aim To evaluate the associations of NLR and PLR with postoperative complications following gastric oncologic surgery and compare them with CRP. Materials and methods A prospective study was conducted on 66 patients that underwent oncologic gastric surgery, within the time frame of January 2014 and March 2019. The variables analyzed were sociodemographic data, surgical technique, tumor extension, and NLR, PLR, and CRP levels from the first day after surgery, as well as postoperative complications. Results Seventeen patients (25.8%) presented with grade III-V complications, utilizing the Clavien-Dindo classification system. Mean NLR value was 11.30 and was associated with the appearance of major complications, with statistical significance (p = 0.009). Mean PLR was266.05 and was not significantly associated with complications (p = 0.149). Fifty-four patients had a mean CRP level of 143.24 and it was not related to the appearance of major complications (p = 0.164). Conclusions The NLR is a simple and inexpensive parameter, which measured on postoperative day one, predicted the appearance of major postoperative complications in our study sample and appears to be a better predictive parameter than CRP for said complications. Further studies to confirm that trend need to be carried out.

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

Article

Apr 2021

Introduction: Postoperative anastomotic leak after rectal resection is a life-threatening complication. Late diagnosis and a severe symptomatic leak may cause almost 18 % mortality. Early diagnosis is a challenging issue because of nonspecific clinical signs in the early postoperative period. Minimally invasive rectal surgery and the implementation of ERAS protocol require appropriate markers of inflammatory complications and leak with high sensitivity. Postoperative serum C-reactive protein values seem to be the right answer for this question. Aim: The presented study aimed to determine the importance and cut-off level of serum C-reactive protein as a possible predictive factor for early anastomotic leak diagnosis in rectal surgery. Material and methods: The retrospective observational analysis of patients after resection for rectal cancer in a period of one year. The observation included risk factors (age, sex, BMI, bowel preparation and the acuteness of surgery), recording of complications and serum values of CRP. Results: The study included 178 patients. 63 patients (35,4 %) had non-complicated postoperative course. The complications were present in 115 cases (64,6 %), including surgical site infection (16,3 %) and anastomotic leak (7,3 %). The mortality was 2,2 %. CRP serum value reached the sensitivity 94,7 % and specificity 72,5 % at POD 4 with cut off value of 131,8 mg/l and the sensitivity of 84,2 % and specificity 82,4 % with cut off 175,4 mg/l, respectively. Conclusions: Postoperative serum C-reactive protein may be used as a predictor of anastomotic leakage. The examination of CRP on the 4th postoperative day may lead to early and safe discharge from the hospital after rectal resection. The implementation of the cut off values detects more than 90 % of anastomotic leaks or septic complications.

C reactive protein to albumin ratio (CAR) as predictor of anastomotic leakage in colorectal surgery

Article

Jun 2021
SURG ONCOL

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.

Usefulness of inflammatory markers in detecting esophagojejunostomy leakage

Article

May 2021

Introduction and aim Total gastrectomy is utilized in different pathologies. Esophagojejunostomy leakage is a frequent complication. Our aim was to determine the association of the neutrophil-lymphocyte ratio (NLR) with esophagojejunostomy leakage that subsequently required invasive treatment. Materials and methods A retrospective study included patients that underwent esophagojejunostomy within the time frame of 2002-2017. Patients were grouped into those with or without anastomotic leakage that had conservative treatment (group A) and those with anastomotic leakage that had invasive treatment (group B). ROC curves and the Youden index were used for the optimum cutoff values of the NLR. Results Fifty-seven patients were included. Thirty-two (56.14%) were men, and mean patient age was 61.8 ± 13.4 years. Forty-five patients were assigned to group A and 12 to group B. Mean NLR was higher for group B on postoperative day 3 (group A 9.5 ± 7.5 vs. group B 13.9 ± 4.9) (p = 0.05). Mean total leukocytes was higher in group B on postoperative day 5 (group A 7.8 ± 3.4 × 10³/mcl vs. group B 10.3 ± 4.4 × 10³/mcl) (p = 0.03). NLR and total leukocyte accuracy on postoperative day 3 was calculated with ROC curves, at 0.78 and 0.63, respectively. For the NLR and leukocyte count, sensitivity was 91.7% and 58%, specificity was 64.4% and 60%, positive predictive value was 40% and 28%, and negative predictive value was 96% and 84%, respectively. Conclusions Postoperatively, the NLR identified the total gastrectomy with esophagojejunostomy patients that subsequently required an invasive procedure secondary to esophagojejunostomy leakage.

NEUTROPHIL-TO-LYMPHOCYTE RATIO AS AN INFECTIOUS COMPLICATIONS BIOMARKER IN COLORECTAL SURGERY (own data, systematic review and meta-analysis)

Article

Full-text available

Dec 2020

C-reactive protein as early predictor of anastomotic leakage after surgery for colorectal cancer. Systematic review and meta-analysis

Article

Jan 2020
Khirurgiia

Objective: Systematic review and meta-analysis of data on C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after surgery for colorectal cancer. Material and methods: Literature searching was performed in Medline, Elibrary, Scopus, Web of Science databases. Literature request consisted of keywords «CRP», «colorectal surgery», «anastomotic leakage» for the period 2008-2018. Meta-analysis included 2 manuscripts for the second postoperative day, 7 articles for the third postoperative day and 6 articles for the fourth postoperative day. ROC-analysis was made to determine optimal prognostic values. Results: ROC-curve for the second postoperative day - AUC 0.758; optimal CRP value - 154 mg/l (sensitivity 70.1%, specificity 55.6%), 95% confidence interval 0.698-0.819. ROC-curve for the third postoperative day - AUC 0.715; optimal CRP value - 144.5 mg/l (sensitivity 79.1% specificity 60.3%), 95% confidence interval 0.68-0.75. ROC-curve for the fourth postoperative day - AUC 0.767; optimal CRP value - 122.91 mg/l (sensitivity 72.3% specificity 60%), 95% confidence interval 0.73-0.804. Conclusion: Increased CRP is an early predictor of AL after surgery for colorectal cancer. CRP level ≥144.5 mg/l on the third postoperative day can predict AL (sensitivity 79%, specificity 60%).

Utilidad de marcadores de inflamación para detectar fugas de anastomosis esofagoyeyunal

Article

Full-text available

Aug 2020

Resumen Introducción y objetivo La gastrectomía total se utiliza en diversas enfermedades. La fuga de la anastomosis esofagoyeyunal es una complicación frecuente. El objetivo es determinar la asociación del índice neutrófilo/linfocito (INL) con los casos de fuga de la anastomosis esofagoyeyunal que requerirán tratamiento invasivo. Material y métodos Estudio retrospectivo que incluyó pacientes sometidos a gastrectomía total en 2002-2017. Se agruparon los pacientes con o sin fuga de anastomosis que recibieron manejo conservador en un grupo (Grupo A), y aquellos con fuga que recibieron procedimiento invasivo en otro grupo (Grupo B). Se utilizaron curvas ROC y la prueba de Youden para los valores de corte óptimos del INL. Resultados Se incluyeron 57 pacientes; 32 (56.14%) eran hombres y la edad media fue de 61.8 ± 13.4 años. Se asignaron 45 pacientes al Grupo A y 12 pacientes al Grupo B. La media de INL fue mayor para el Grupo B en el día 3 postoperatorio (9.5 ± 7.5 Grupo A vs. 13.9 ± 4.9 Grupo B) (p = 0.05); la media de leucocitos totales fue mayor en el grupo B en el día 5 postoperatorio (7.8 ± 3.4 × 10³/μl Grupo A vs. 10.3 ± 4.4 × 10³/μl Grupo B) (p = 0.03). La precisión del INL y los leucocitos totales en el día 3 postoperatorio fue calculada con curvas ROC, siendo de 0.78 y 0.63, respectivamente. La sensibilidad fue del 91.7 y el 58%, la especificidad, del 64.4 y el 60%, el valor predictivo positivo, del 40 y el 28% y el valor predictivo negativo, del 96 y el 84% para el INL y los leucocitos, respectivamente. Conclusiones En el periodo postoperatorio, el INL predice qué pacientes sometidos a gastrectomía total con anastomosis esofagoyeyunal requerirán algún procedimiento invasivo secundario a fuga de la anastomosis esofagoyeyunal.

Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery

Article

Apr 2020

IntroductionC-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery.MethodsA systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3–5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy.ResultsA total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2–19.3) in laparoscopic studies and 21.0% (95% CI 11.9–30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5.Conclusions The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.

Neutrophil-lymphocyte (NLR), lymphocyte-monocyte (LMR), and platelet-lymphocyte ratios (PLR) as predictors of anastomotic dehiscence in colorectal surgery.

Poster

Full-text available

Oct 2017

Neutrophil to Lymphocyte Ratio and C-Reactive Protein as Two Predictive Tools of Anastomotic Leak in Colorectal Cancer Open Surgery?

Abstract

No full-text available

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