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Inflammatory markers as early predictors of infection after colorectal surgery: the same cut-off values in laparoscopy and laparotomy?

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

C-reactive protein and procalcitonin are reliable early predictors of infection after colorectal surgery. However, the inflammatory response is lower after laparoscopy as compared to open surgery. This study analyzed whether a different cutoff value of inflammatory markers should be chosen according to the surgical approach.

Methods

A prospective, observational study included consecutive patients undergoing elective colorectal surgery in three academic centers. All infections until postoperative day (POD) 30 were recorded. The inflammatory markers were analyzed daily until POD 4. Areas under the ROC curve and diagnostic values were calculated in order to assess their accuracy as a predictor of intra-abdominal infection.

Results

Five-hundred-one patients were included. The incidence of intra-abdominal infection was 11.8%. The median levels of C-reactive protein (CRP) and procalcitonin (PCT) were lower in the laparoscopy group at each postoperative day (p < 0.0001). In patients without intra-abdominal infection, they were also lower in the laparoscopy group (p = 0.0036) but were not different in patients presenting with intra-abdominal infections (p = 0.3243). In the laparoscopy group, CRP at POD 4 was the most accurate predictor of overall and intra-abdominal infection (AUC = 0.775). With a cutoff of 100 mg/L, it yielded 95.7% negative predictive value, 75% sensitivity, and 70.3% specificity for the detection of intra-abdominal infection.

Conclusion

The impact of infection on inflammatory markers is more important than that of the surgical approach. Defining a specific cutoff value for early discharge according to the surgical approach is not justified. A patient with CRP values lower than 100 mg/L on POD 4 can be safely discharged.

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References

  1. Kingham TP, Pachter HL (2009) Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg 208:269–278

    Article  PubMed  Google Scholar 

  2. Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K et al (2005) Postoperative mortality and morbidity in French patients undergoing colorectal surgery. Arch Surg 140:278–283

    Article  PubMed  Google Scholar 

  3. Krarup PM, Jorgensen LN, Harling H, Danish Colorectal Cancer Group (2014) Management of anastomotic leakage in a nationwide cohort of colonic cancer patients. J Am Coll Surg 218:940–949

    Article  PubMed  Google Scholar 

  4. McArdle CS, McMillan DC, Hole DJ (2005) Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br J Surg 92:1150–1154

    Article  CAS  PubMed  Google Scholar 

  5. Krarup PM, Nordholm-Carstensen A, Jorgensen LN, Harling H (2014) Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: a nationwide cohort study. Ann Surg 259:930–938

    Article  PubMed  Google Scholar 

  6. Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T (2014) Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 101:424–432

    Article  CAS  PubMed  Google Scholar 

  7. Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM (2009) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Color Dis 24:569–576

    Article  CAS  Google Scholar 

  8. Hirst NA, Tiernan JP, Millner PA, Jayne DG (2014) Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. Color Dis 16:95–109

    Article  CAS  Google Scholar 

  9. Lagoutte N, Facy O, Ravoire A, Chalumeau C, Jonval L, Rat P et al (2012) C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients. J Visc Surg 149:e345–e349

    Article  CAS  PubMed  Google Scholar 

  10. Facy O, Paquette B, Orry D, Binquet C, Masson D, Bouvier A, Fournel I, Charles PE, Rat P, Ortega-Deballon P (2016) Diagnostic accuracy of inflammatory markers as early predictors of infection after elective colorectal surgery: results from the IMACORS study. Ann Surg 263:961–966

    Article  PubMed  Google Scholar 

  11. Giaccaglia V, Salvi PF, Antonelli MS, Nigri G, Pirozzi F, Casagranda B, Giacca M, Corcione F, de Manzini N, Balducci G, Ramacciato G (2016) Procalcitonin reveals early dehiscence in colorectal surgery: the PREDICS study. Ann Surg 263:967–972

    Article  PubMed  Google Scholar 

  12. Garcia-Granero A, Frasson M, Flor-Lorente B, Blanco F, Puga R, Carratalá A et al (2013) Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study. Dis Colon rectum 56:475–483

    Article  PubMed  Google Scholar 

  13. Adamina M, Steffen T, Tarantino I, Beutner U, Schmied BM, Warschkow R (2015) Meta-analysis of the predictive value of C-reactive protein for infectious complications in abdominal surgery. Br J Surg 102:590–598

    Article  CAS  PubMed  Google Scholar 

  14. Cousin O-DP, Bourredjem A, Doussot A, Giaccaglia V, Fournel I (2016) Diagnostic accuracy of procalcitonin and C-reactive protein for the early diagnosis of intra-abdominal infection after elective colorectal surgery: a meta-analysis. Ann Surg 264:252–256

    Article  PubMed  Google Scholar 

  15. Schwenk W, Jacobi C, Mansmann U, Bohm B, Muller JM (2000) Inflammatory response after laparoscopic and conventional colorectal resections: results of a prospective randomized trial. Langenbeck’s Arch Surg 385:2–9

    Article  CAS  Google Scholar 

  16. Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES et al (2012) Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg 255:216–221

    Article  CAS  PubMed  Google Scholar 

  17. Dunker MS, Ten Hove T, Bemelman WA, Slors JF, Gouma DJ, Van Deventer SJ (2003) Interleukin-6, C-reactive protein, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells in patients after laparoscopic vs. conventional bowel resection: a randomized study. Dis Colon rectum 46:1238–1244

    Article  CAS  PubMed  Google Scholar 

  18. Warschkow R, Beutner U, Steffen T, Müller SA, Schmied BM, Güller U et al (2012) Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1832 patients. Ann Surg 256:245–250

    Article  PubMed  Google Scholar 

  19. Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG (2014) Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 101:339–346

    Article  CAS  PubMed  Google Scholar 

  20. Adamina M, Warschkow R, Näf F, Hummel B, Rduch T, Lange J et al (2014) Monitoring C-reactive protein after laparoscopic colorectal surgery excludes infectious complications and allows for safe and early discharge. Surg Endosc 28:2939–2948

    Article  PubMed  Google Scholar 

  21. Ramanathan ML, MacKay G, Platt J, Horgan PG, McMillan DC (2015) The impact of open versus laparoscopic resection for colon cancer on C-reactive protein concentrations as a predictor of postoperative infective complications. Ann Surg Oncol 22:938–943

    Article  PubMed  Google Scholar 

  22. Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:309–332

    Article  PubMed  Google Scholar 

  23. Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué JM, Visa J (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229

    Article  PubMed  Google Scholar 

  24. Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA (2007) Anastomotic leaks after intestinal anastomosis: it’s later than you think. Ann Surg 245:254–258

    Article  PubMed  PubMed Central  Google Scholar 

  25. Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK (2013) Variation in surgical-readmission rates and quality of hospital care. N Engl J Med 369:1134–1142

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. den Dulk M, Witvliet MJ, Kortram K, Neijenhuis PA, de Hingh IH, Engel AF et al (2013) The DULK (Dutch leakage) and modified DULK score compared: actively seek the leak. Color Dis 15:e528–e533

    Google Scholar 

  27. Frasson M, Flor-Lorente B, Rodríguez JL, Granero-Castro P, Hervás D, Alvarez Rico MA, Brao MJ, Sánchez González JM, Garcia-Granero E, ANACO Study Group (2015) Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg 262:321–330

    Article  PubMed  Google Scholar 

  28. Ortega-Deballon P, Radais F, Facy O, d'Athis P, Masson D, Charles PE et al (2010) C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg 34:808–814

    Article  PubMed  PubMed Central  Google Scholar 

  29. MacKay GJ, Molloy RG, O'Dwyer PJ (2011) C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection. Color Dis 13:583–587

    Article  CAS  Google Scholar 

  30. Warschkow R, Tarantino I, Torzewski M, Näf F, Lange J, Steffen T (2011) Diagnostic accuracy of C-reactive protein and white blood cell counts in the early detection of inflammatory complications after open resection of colorectal cancer: a retrospective study of 1,187 patients. Int J Color Dis 26:1405–1413

    Article  Google Scholar 

  31. Silvestre J, Rebanda J, Lourenço C, Póvoa P (2014) Diagnostic accuracy of C-reactive protein and procalcitonin in the early detection of infection after elective colorectal surgery—a pilot study. BMC Infect Dis 14:444

    Article  PubMed  PubMed Central  Google Scholar 

  32. Ortega-Deballon P, Facy O, Binquet C (2013) C-reactive protein and procalcitonin as predictors of anastomotic leak. Dis Colon rectum 56:e395

    Article  PubMed  Google Scholar 

  33. Holl S, Fournel I, Orry D, Facy O, Cheynel N, Rat P, Ortega-Deballon P (2016) Should CT scan be performed when CRP is elevated after colo-rectal surgery? Results from the Inflammatory Markers After COloRectal Surgery study. J Visc Surg (in press)

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Acknowledgments

The authors thank the data monitoring board (Cassandra Porebski, Emilie Galizzi, Sandrine Vinault, Alexandra Felin, Amandine Martin, Fanny Lachaux, Donya Souhiel Da Costa, Joelle Fritsch, Chrystelle Cappe), the safety monitoring board (Aurélie Grandvuillemin, Pharm.D.), the administrative support team (Evelyne Phu and Maud Carpentier), and the staff of the participant surgical departments for their help and Mr. Philip Bastable for the language revision of the manuscript. C. Binquet had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Author information

Authors and Affiliations

  1. Department of Digestive Surgery, Dijon University Hospital, 14, Rue Paul Gaffarel, 21079, Dijon Cedex, France

    Olivier Facy, Nicolas Santucci, Paul Rat, Patrick Rat & Pablo Ortega-Deballon

  2. INSERM, U866, Dijon, France

    Olivier Facy, Nicolas Santucci, Paul Rat, Patrick Rat, Christine Binquet & Pablo Ortega-Deballon

  3. University of Bourgogne-Franche-Comté, UMR866, Dijon, France

    Olivier Facy, Nicolas Santucci, Paul Rat, Patrick Rat, Christine Binquet & Pablo Ortega-Deballon

  4. Department of Digestive Surgery, Besançon University Hospital, Besançon, France

    Brice Paquette

  5. Department of Surgery, Anticancer Centre “Georges-François Leclerc”, Dijon, France

    David Orry

  6. INSERM, CIC1432, Dijon, France

    Christine Binquet

  7. Clinical Investigation Centre, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, Dijon, France

    Christine Binquet

Authors
  1. Olivier Facy
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  2. Brice Paquette
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  3. David Orry
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  4. Nicolas Santucci
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  5. Paul Rat
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  6. Patrick Rat
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  7. Christine Binquet
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  8. Pablo Ortega-Deballon
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Corresponding author

Correspondence to Olivier Facy.

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Financial disclosure

Support was provided by the Groupement de Coopération Sanitaire Grand-Est, the Regional Council of Burgundy, and by a grant from BRAHMS France SAS.

List of investigators (in alphabetical order)

University Hospital of Dijon: Christine Binquet, M.D., Ph.D, MPH; Pierre-Emmanuel Charles, M.D., Ph.D; Nicolas Cheynel, M.D., Ph.D.; Giovanni Di Giacomo, M.D.; Olivier Facy, M.D., Ph.D.; Isabelle Fournel, M.D., Ph.D.; David Masson, Pharm.D, Ph.D.; Pablo Ortega-Deballon, M.D., Ph.D.; Patrick Rat, M.D.

University Hospital of Besançon: Bruno Heyd, M.D.; Georges Mantion, M.D.; Brice Paquette, M.D.

“Georges F Leclerc” Anticancer Centre: Jean Fraisse, M.D.; David Orry, M.D.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

The study was funded by the Groupement de Coopération Sanitaire Grand-Est, the Regional Council of Burgundy, a grant from Brahms France SAS, and French Government grant managed by the French National Research Agency (ANR) under the “Investissements d’Avenir” program with reference ANR-11-LABX-0021-01-LipSTIC Labex.

ClinicalTrials.gov number: NCT01510314.

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Facy, O., Paquette, B., Orry, D. et al. Inflammatory markers as early predictors of infection after colorectal surgery: the same cut-off values in laparoscopy and laparotomy?. Int J Colorectal Dis 32, 857–863 (2017). https://doi.org/10.1007/s00384-017-2805-9

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  • DOI: https://doi.org/10.1007/s00384-017-2805-9

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