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Does C-reactive Protein Have a Predictive Role in the Early Diagnosis of Postoperative Complications After Bariatric Surgery? Systematic Review and Bayesian Meta-analysis

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Abstract

Background

Postoperative leak and intra-abdominal infections are common after bariatric surgery with a significant impact on perioperative outcomes, hospital length of stay, and readmission rates. In the era of enhanced recovery programs, with patients being discharged from the hospital 24–36 h after surgery and potentially before developing any complications, an early indicator of postoperative complications may be decisive. The aim of this study was to evaluate the predictive role of the C-reactive protein (CRP) in the early diagnosis of complications in patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods

PubMed, Embase, and Web of Science databases were consulted. A systematic review and a fully Bayesian meta-analysis were conducted.

Results

Seven studies met the inclusion criteria for a total of 1401 patients. Overall, 57.7% underwent LSG while 42.3% underwent LRYGB. The pooled prevalence of postoperative complications was 9.8% (95% CI = 5–16%). The estimated pooled CRP cut-off value on postoperative day 1 (POD1) was 6.1 mg/dl with a significant diagnostic accuracy and a pooled area under the curve of 0.92 (95% credible interval (CrI) 0.73–0.98). The positive and negative likelihood ratios were 13.6 (95% CrI 8.40–15.9) and 0.16 (95% CrI 0.04–0.31), respectively.

Conclusion

A CRP value lower than the derived cut-off of 6.1 mg/dl on POD1, combined with reassuring clinical signs, could be useful to rule out early postoperative leak and complications after LSG and LRYGB. In the context of enhanced recovery after surgery protocols, the integration of a CRP-based diagnostic algorithm as an additional complementary instrument may be valuable to reduce cost and improve outcomes and patient care.

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References

  1. Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.

    Article  CAS  Google Scholar 

  2. Gamme G, Dang JT, Switzer N, et al. Evaluating the safety of bariatric surgery for weight loss in class I obesity: a propensity-matched analysis of North American data. Surg Obes Relat Dis. 2019;15(4):629–35. https://doi.org/10.1016/j.soard.2019.01.024.

    Article  PubMed  Google Scholar 

  3. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    Article  CAS  Google Scholar 

  4. Livingston EH. Complications of bariatric surgery. Surg Clin North Am. 2005;85(4):853–68.vii.

    Article  PubMed  Google Scholar 

  5. Buchwald H, Estok R, Fahrbach K, et al. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery. 2007;142(4):621–32.

    Article  PubMed  Google Scholar 

  6. Aiolfi A, Asti E, Rausa E, et al. Trans-gastric ERCP after Roux-en-Y gastric bypass: systematic review and meta-analysis. Obes Surg. 2018;28(9):2836–43.

    Article  PubMed  Google Scholar 

  7. Khorgami Z, Petrosky JA, Andalib A, et al. Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery. Surg Obes Relat Dis. 2017;13(2):273–80.

    Article  PubMed  Google Scholar 

  8. Ruiz-Tovar J, Garcia A, Ferrigni C, et al. Impact of implementation of an enhanced recovery after surgery (ERAS) program in laparoscopic Roux-en-Y gastric bypass: a prospective randomized clinical trial. Surg Obes Relat Dis. 2018;28:3374–9.

    Article  Google Scholar 

  9. Villard MA, Helm MC, Kindel TL, et al. C-reactive protein as a predictor of post-operative complications in bariatric surgery patients. Surg Endosc. 2018; https://doi.org/10.1007/s00464-018-6534-0.

    Article  PubMed  Google Scholar 

  10. Romain B, Chemaly R, Meyer N, et al. Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity. Langenbeck's Arch Surg. 2014;399(4):503–8.

    Article  Google Scholar 

  11. Csendes A, Burgos AM, Roizblatt D, et al. Inflammatory response measured by body temperature, C-reactive protein and white blood cell count 1, 3, and 5 days after laparotomic or laparoscopic gastric bypass surgery. Obes Surg. 2009;19(7):890–3.

    Article  PubMed  Google Scholar 

  12. Warschkow R, Tarantino I, Folie P, et al. C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity. J Gastrointest Surg. 2012;16(6):1128–35.

    Article  PubMed  Google Scholar 

  13. Albanopoulos K, Alevizos L, Natoudi M, et al. C-reactive protein, white blood cells, and neutrophils as early predictors of postoperative complications in patients undergoing laparoscopic sleeve gastrectomy. Surg Endosc. 2013;27(3):864–71.

    Article  PubMed  Google Scholar 

  14. Pike TW, White AD, Snook NJ, et al. Simplified fast-track laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2015;25(3):413–7.

    Article  PubMed  Google Scholar 

  15. Muñoz JL, Ruiz-Tovar J, Miranda E, et al. C-reactive protein and procalcitonin as early markers of septic complications after laparoscopic sleeve gastrectomy in morbidly obese patients within an enhanced recovery after surgery program. J Am Coll Surg. 2016;222(5):831–7.

    Article  PubMed  Google Scholar 

  16. Williams MR, McMeekin S, Wilson RJ, et al. Predictive value of C-reactive protein for complications post-laparoscopic Roux-En-Y gastric bypass. Obes Surg. 2017;27(3):709–15.

    Article  PubMed  Google Scholar 

  17. Kröll D, Nakhostin D, Stirnimann G, et al. C-reactive protein on postoperative day 1: a predictor of early intra-abdominal infections after bariatric surgery. Obes Surg. 2018;28(9):2760–6.

    Article  PubMed  Google Scholar 

  18. Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement. PLoS Med. 2009;(6):7, e1000097.

  19. Whiting PF, Rutjes AW, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36.

    Article  PubMed  Google Scholar 

  20. Aiolfi A, Tornese S, Bonitta G, et al. Roux-en-y gastric bypass: systematic review and Bayesian network meta-analysis comparing open, laparoscopic, and robotic approach. Surg Obes Relat Dis. 2019; https://doi.org/10.1016/j.soard.2019.03.006.

    Article  PubMed  Google Scholar 

  21. Steinhauser S, Schumacher M, Rucker G. Modelling multiple thresholds in meta-analysis of diagnostic test accuracy studies. BMC Med Res Methodol. 2016;16:97.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Zwinderman AH, Bossuyt PM. We should not pool diagnostic likelihood ratios in systematic reviews. Stat Med. 2008;27(5):687–97.

    Article  PubMed  Google Scholar 

  23. Plummer M, Best N, Cowles K, et al. CODA: convergence diagnosis and output analysis for MCMC. R. News. 2006;6:7–11.

    Google Scholar 

  24. Bob Carpenter, Andrew Gelman, Matthew D. Hoffman, Daniel Lee, Ben Goodrich, Michael Betancourt, Marcus Brubaker, Jiqiang Guo, Peter Li, and Allen Riddell. Stan: a probabilistic programming language. J Stat Softw 2017;76(1). https://doi.org/10.18637/jss.v076.i01

  25. R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing. Vienna, Austria: Author; 2016. Accessed 5 April 2016. http://www.R-project.org/.

  26. Jakob T, Cal P, Deluca L, et al. Shorter than 24-h hospital stay for sleeve gastrectomy is safe and feasible. Surg Endosc. 2016;30(12):5596–600.

    Article  PubMed  Google Scholar 

  27. Awad S, Carter S, Purkayastha S, et al. Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre. Obes Surg. 2014;24(5):753–8.

    Article  PubMed  Google Scholar 

  28. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS®) society recommendations: 2018. World J Surg. 2019;43(3):659–95.

    Article  CAS  PubMed  Google Scholar 

  29. Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204(1):47–55.

    Article  PubMed  Google Scholar 

  30. Pepys MB, Hirschfield GM. C-reactive protein: a critical update. J Clin Invest. 2003;111:1805–12. https://doi.org/10.1172/JCI18921.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Singh PP, Zeng IS, Srinivasa S, et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg. 2014;101(4):339–46. https://doi.org/10.1002/bjs.9354.

    Article  CAS  PubMed  Google Scholar 

  32. Aiolfi A, Asti E, Rausa E, et al. Use of C-reactive protein for the early prediction of anastomotic leak after esophagectomy: systematic review and Bayesian meta-analysis. PLoS One. 2018;13(12):e0209272.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Wener MH, Daum PR, McQuillan GM. The influence of age, sex, and race on the upper reference limit of serum C-reactive protein concentration. J Rheumatol. 2000;27(10):2351–9.

    CAS  PubMed  Google Scholar 

  34. Holdstock C, Lind L, Engstrom BE, et al. CRP reduction following gastric bypass surgery is most pronounced in insulin-sensitive subjects. Int J Obes. 2005;29(10):1275–80.

    Article  CAS  Google Scholar 

  35. Pittet D, Rangel-Frausto S, Li N, et al. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock: incidence, morbidities and outcomes in surgical ICU patients. Intensive Care Med. 1995;21:302–9.

    Article  CAS  PubMed  Google Scholar 

  36. Haga Y, Beppu T, Doi K, et al. Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery. Crit Care Med. 1997;25:1994–2000.

    Article  CAS  PubMed  Google Scholar 

  37. Akobeng AK. Understanding diagnostic tests 2: likelihood ratios, pre- and post-test probabilities and their use in clinical practice. Acta Paediatr. 2007;96:487–91. https://doi.org/10.1111/j.1651-2227.2006.00179.x.

    Article  PubMed  Google Scholar 

  38. Halkin A, Reichman J, Schwaber M, et al. Likelihood ratios: getting diagnostic testing into perspective. QJM. 1998;91:247–58.

    Article  CAS  PubMed  Google Scholar 

  39. Frees EW. Longitudinal and panel data: analysis and applications in the social sciences. New York: Cambridge University Press; 2004.

    Book  Google Scholar 

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Authors and Affiliations

  1. Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant’Ambrogio, University of Milan, Milan, Italy

    Davide Bona, Gianluca Bonitta, Marta Cavalli, Emanuele Rausa, Silvia Cirri & Alberto Aiolfi

  2. Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istitituto Clinico Sant’Ambrogio, University of Milan, Milan, Italy

    Giancarlo Micheletto & Valerio Panizzo

Authors
  1. Davide Bona
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  2. Giancarlo Micheletto
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  3. Gianluca Bonitta
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  4. Valerio Panizzo
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  6. Emanuele Rausa
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  7. Silvia Cirri
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  8. Alberto Aiolfi
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Contributions

AA, ER, and MC did the literature search. DB and AA formed the study design. Data collection was done by AA, VP, MC, ER, and DB. AA and GB analyzed the data. AA, GB, and DB interpreted the data. DB and AA wrote the manuscript. DB, GM, and AA critically reviewed the manuscript.

Corresponding author

Correspondence to Davide Bona.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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The authors declare that they have no conflict of interest.

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Bona, D., Micheletto, G., Bonitta, G. et al. Does C-reactive Protein Have a Predictive Role in the Early Diagnosis of Postoperative Complications After Bariatric Surgery? Systematic Review and Bayesian Meta-analysis. OBES SURG 29, 3448–3456 (2019). https://doi.org/10.1007/s11695-019-04013-0

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