Journal of Gastrointestinal Surgery

, Volume 20, Issue 8, pp 1482–1492 | Cite as

C-Reactive Protein and Procalcitonin as Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery

  • A. GiardinoEmail author
  • G. Spolverato
  • P. Regi
  • I. Frigerio
  • F. Scopelliti
  • R. Girelli
  • Z. Pawlik
  • P. Pederzoli
  • C. Bassi
  • G. Butturini
Original Article



The association between postoperative inflammatory markers and risk of complications after pancreaticoduodenectomy (PD) is controversial. We sought to assess the diagnostic value of perioperative C-reactive protein (CRP) and procalcitonin (PCT) levels in the early identification of patients at risk for complications after PD.


In 2014, 84 patients undergoing elective PD were enrolled in a prospective database. Clinicopathological characteristics, CRP and PCT, as well as short-term outcomes, such as complications and pancreatic fistula, were analyzed. Complications and pancreatic fistula were defined based on the Clavien-Dindo classification and the International Study Group on Pancreatic Fistula (ISGPF) classification, respectively. High CRP and PCT were classified using cut-off values based on ROC curve analysis.


The majority (73.8 %) of patients had pancreatic adenocarcinoma. CRP and PCT levels over the first 5 postoperative days (POD) were higher among patients who experienced a complication versus those who did not (p < 0.001). Postoperative CRP and PCT levels were also higher among patients who developed a grade B or C pancreatic fistula (p < 0.05). A CRP concentration >84 mg/l on POD 1 (AUC 0.77) and >127 mg/l on POD 3 (AUC 0.79) was associated with the highest risk of overall complications (OR 6.86 and 9.0, respectively; both p < 0.001). Similarly patients with PCT >0.7 mg/dl on POD 1 (AUC 0.67) were at higher risk of developing a postoperative complication (OR 3.33; p = 0.024). On POD 1, a CRP >92 mg/l (AUC 0.72) and a PCT >0.4 mg/dl (AUC 0.70) were associated with the highest risk of pancreatic fistula (OR 5.63 and 5.62, respectively; both p < 0.05).


CRP and PCT concentration were associated with an increased risk of developing complications and clinical relevant pancreatic fistula after PD. Use of these biomarkers may help identify those patients at highest risk for perioperative morbidity and help guide postoperative management of patients undergoing PD.


C-reactive protein Procalcitonin Pancreatic surgery Complications Pancreatic fistula 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Supplementary material

11605_2016_3171_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 20 kb)


  1. 1.
    Fu S, Shen S, Li S, Hu W, Hua Y, Kuang M, et al. Risk factors and outcomes of postoperative pancreatic fistula after pancreatico-duodenectomy: an audit of 532 consecutive cases. BMC Surgery, 2015. 15–34.Google Scholar
  2. 2.
    Paniccia A, Hosokawa P, Henderson W, Schulick RD, Edil BH, Mccarter MD, et al. Characteristics of 10-Year Survivors of Pancreatic Ductal Adenocarcinoma. JAMA Surg, 2015. 80045: p1–10.Google Scholar
  3. 3.
    Joliat G, Petermann D, Demartines N, Schäfer M. Prediction of Complications After Pancreaticoduodenectomy Validation of a Postoperative Complication Score. Pancreas, 2015. 44(8): p1323–8.CrossRefGoogle Scholar
  4. 4.
    Nagai S, Fujii T, Kodera Y, Kanda M, Sahin TT, Kanzaki a, et al. Recurrence pattern and prognosis of pancreatic cancer after pancreatic fistula. Ann Surg Oncol, 2011. 2329: p18–37.Google Scholar
  5. 5.
    Petermann D, Demartines N, Schafer M. Severe postoperative complications adversely affect long-term survival after R1 resection for pancreatic head adenocarcinoma. World J Surg, 2013. 37: p1901–8.CrossRefGoogle Scholar
  6. 6.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery, 2005. 138: p8–13.CrossRefGoogle Scholar
  7. 7.
    Chen J, Feng J, Wang X, Cai S, Dong J, Chen Y, et al. Risk scoring system and predictor for clinically relevant pancreatic fistula after pancreaticoduodenectomy. World J Gastroenterol, 2015. 21(19): p5926–33.Google Scholar
  8. 8.
    Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, et al. A Prognostic Score to Predict Major Complications After Pancreaticoduodenectomy. Ann. Surg, 2011. 254: p702–8.CrossRefGoogle Scholar
  9. 9.
    Welsch T, Müller SA, Ulrich A, Kischlat A. C-reactive protein as early predictor for infectious postoperative complications in rectal surgery. Surgery, 2007: p1499–507.Google Scholar
  10. 10.
    Facy O, Binquet C, Masson D, Fournel I, Rat P, Ortega-deballon P. Diagnostic Accuracy of Inflammatory Markers As Early Predictors of Infection After Elective Colorectal Surgery-Results From the IMACORS Study. Ann Surg, 2015. p1–6.Google Scholar
  11. 11.
    Lagoutte N, Facy O, Ravoire A, Chalumeau C, Jonval L, Rat P, et al. C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery : Pilot study in 100 patients. J. Visc. Surg, 2012. 149: p345–9Google Scholar
  12. 12.
    Warschkow R, Tarantino I, Schmied BM, Steffen T. Diagnostic study and meta-analysis of C-reactive protein as a predictor of postoperative inflammatory complications after gastroesophageal cancer surgery. Langhenbecks Arch Surg, 2012. p727–36.Google Scholar
  13. 13.
    Oberhofer D. Comparison of C-reactive protein and procalcitonin as predictors of postoperative infectious complications after elective colorectal surgery. CMJ, 2012. p612–9.Google Scholar
  14. 14.
    Giaccaglia V, Salvi ÃPF, Antonelli ÃMS, Giacca M, Corcione F, Balducci G, et al. Procalcitonin Reveals Early Dehiscence in Colorectal Surgery The PREDICS Study. Ann Surg, 2015. 20(10): p1-6Google Scholar
  15. 15.
    Bianchi RA, Silva NA, Natal ML. Utility of base deficit , lactic acid , microalbuminuria , and C-reactive protein in the early detection of complications in the immediate postoperative evolution. Clin Biochem, 2004. 37: p404–7.Google Scholar
  16. 16.
    Siassi M, Riese J, Steffensen R, Meisner M, Thiel S, Hohenberger W, et al. Mannan-binding lectin and procalcitonin measurement for prediction of postoperative infection. Crit Care, 2005. 9: p 483–9Google Scholar
  17. 17.
    Bogar L, Molnar Z, Tarsoly P, Kenyeres P, Marton S. Serum procalcitonin level and leukocyte antisedimentation rate as early predictors of respiratory dysfunction after oesophageal tumour resection. Crit Care, 2006. 10(4): p2–6.CrossRefGoogle Scholar
  18. 18.
    Meyer ZC, Schreinemakers JMJ, Waal RAL De. Searching for predictors of surgical complications in critically ill surgery patients in the intensive care unit : a review. Surg. Today, 2015. p1091–101.Google Scholar
  19. 19.
    Mokart D, Merlin M, Sannini A, Brun JP, Delpero JR, Houvenaeghel G, et al. Procalcitonin , interleukin 6 and systemic inflammatory response syndrome ( SIRS ): early markers of postoperative sepsis after major surgery. B J Anaesth, 2005. 94: p767–73.Google Scholar
  20. 20.
    Silvestre J, Rebanda J, Lourenço C, Póvoa P. Diagnostic accuracy of C-reactive protein and procalcitonin in the early detection of infection after elective colorectal surgery – a pilot study. BMC Infectious Disease, 2014. 1–8.Google Scholar
  21. 21.
    Falcoz P et al. Usefulness of procalcitonin in the early detection of infection after thoracic surgery . Eur J Cardiothoracic Surg, 2005. 27: p1074–8.CrossRefGoogle Scholar
  22. 22.
    Garcia-granero A, Frasson MDM, D BFP, Blanco F, Ph D, Puga R, et al. Procalcitonin and C-Reactive Protein as Early Predictors of Anastomotic Leak in Colorectal Surgery: A Prospective Observational Study. Dis Colon Rectum 2013. 56: p475–83.Google Scholar
  23. 23.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospective validated clinical score accurately predicts pancreatic fistula after pancreaticoduodenectomy. J Am Coll Surg, 2013. 216(1):1–14CrossRefPubMedGoogle Scholar
  24. 24.
    Miller BC, Christein JD, Behrman SW, Drebin JA, Pratt WB, Callery MP, Vollmer CM Jr. A multi-institutional external validation of the fistula risk score for pancreaticoduodenectomy. J Gastrointest Surg. 2014. 18(1):172–79CrossRefPubMedGoogle Scholar
  25. 25.
    Vallance AE, Young AL, Macutkiewicz C, Roberts KJ, Smith AM. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. Hpb J, 2015. 17: p1040–8.CrossRefGoogle Scholar
  26. 26.
    Dindo D, Demartines N, Clavien P. Classification of Surgical Complications. Ann Surg 2004. 240: p205–13.CrossRefGoogle Scholar
  27. 27.
    Kanda M, Fujii T, Takami H, Suenaga M, Inokawa Y, Yamada S. Novel diagnostics for aggravating pancreatic fistulas at the acute phase after pancreatectomy. World J Gatroenterol, 2014. 20: p8535–44.CrossRefGoogle Scholar
  28. 28.
    Welsch T, Frommhold K, Hinz U, Weigand MA. Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery, 2008. 143: p20–8.CrossRefGoogle Scholar
  29. 29.
    Warschkow R, Ukegjini K, Tarantino I, Steffen T, Lukas MS, Mu SA. Diagnostic study and meta-analysis of C-reactive protein as a predictor of postoperative inflammatory complications after pancreatic surgery. J Hepatobiliary Pancreatic Sci, 2012. 19: p492–500.CrossRefGoogle Scholar
  30. 30.
    Bianchi RA, Haedo AS, Romero MC. Role of Plasma Procalcitonin determination in the post-operative follow-up of cephalic pancreaticoduodenectomy. Cir Esp, 2006. 79: p356–60.CrossRefGoogle Scholar
  31. 31.
    Hoeboer SH, Groeneveld ABJ, Engels N, Genderen M Van. Rising C-Reactive Protein and Procalcitonin Levels Precede Early Complications After Esophagectomy. J Gastrointes Surg, 2015. 19: p613–24.Google Scholar
  32. 32.
    Meisner M, Rauschmayer C, Schmidt J, Feyrer R, Cesnjevar R, Bredle D, et al. Early increase of procalcitonin after cardiovascular surgery in patients with postoperative complications. Intensive Care Med, 2002. 28: p1094–102.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2016

Authors and Affiliations

  • A. Giardino
    • 1
    Email author
  • G. Spolverato
    • 1
  • P. Regi
    • 1
  • I. Frigerio
    • 1
  • F. Scopelliti
    • 1
  • R. Girelli
    • 1
  • Z. Pawlik
    • 2
  • P. Pederzoli
    • 1
  • C. Bassi
    • 3
  • G. Butturini
    • 1
  1. 1.Hepato-Pancreato-Biliary Surgery UnitCasa di Cura PederzoliPeschiera del GardaItaly
  2. 2.The Johns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Department of Surgery – Pancreas InstituteUniversity of VeronaVeronaItaly

Personalised recommendations