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

  • SSAT Poster Presentation
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Journal of Gastrointestinal Surgery

Abstract

Introduction

C-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.

Methods

A 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.

Results

A 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.

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References

  1. Midura EF, Hanseman D, Davis BR, Atkinson SJ, Abbott DE, Shah SA et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum. 2015;58(3):333-8. https://doi.org/10.1097/DCR.0000000000000249.

    Article  PubMed  Google Scholar 

  2. Tevis SE, Carchman EH, Foley EF, Heise CP, Harms BA, Kennedy GD. Does Anastomotic Leak Contribute to High Failure-to-rescue Rates? Ann Surg. 2016;263(6):1148-51. https://doi.org/10.1097/SLA.0000000000001409.

    Article  PubMed  Google Scholar 

  3. Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg. 2011;253(5):890-9. https://doi.org/10.1097/SLA.0b013e3182128929.

    Article  PubMed  Google Scholar 

  4. Artinyan A, Orcutt ST, Anaya DA, Richardson P, Chen GJ, Berger DH. Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients. Ann Surg. 2015;261(3):497-505. https://doi.org/10.1097/SLA.0000000000000854.

    Article  PubMed  Google Scholar 

  5. Tan WJ, Ng WQ, Sultana R, de Souza NN, Chew MH, Foo FJ et al. Systematic review and meta-analysis of the use of serum procalcitonin levels to predict intra-abdominal infections after colorectal surgery. Int J Colorectal Dis. 2018;33(2):171-80. https://doi.org/10.1007/s00384-017-2956-8.

    Article  PubMed  Google Scholar 

  6. Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG. 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 

  7. Gans SL, Atema JJ, van Dieren S, Groot Koerkamp B, Boermeester MA. Diagnostic value of C-reactive protein to rule out infectious complications after major abdominal surgery: a systematic review and meta-analysis. Int J Colorectal Dis. 2015;30(7):861-73. https://doi.org/10.1007/s00384-015-2205-y.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Madbouly KM, Senagore AJ, Delaney CP. Endogenous morphine levels after laparoscopic versus open colectomy. Br J Surg. 2010;97(5):759-64. https://doi.org/10.1002/bjs.6987.

    Article  CAS  PubMed  Google Scholar 

  9. Kuntz C, Wunsch A, Bay F, Windeler J, Glaser F, Herfarth C. Prospective randomized study of stress and immune response after laparoscopic vs conventional colonic resection. Surg Endosc. 1998;12(7):963-7. https://doi.org/10.1007/s004649900757.

    Article  CAS  PubMed  Google Scholar 

  10. Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES et al. Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg. 2012;255(2):216-21. https://doi.org/10.1097/SLA.0b013e31824336e2.

    Article  CAS  PubMed  Google Scholar 

  11. Tsimogiannis KE, Tellis CC, Tselepis AD, Pappas-Gogos GK, Tsimoyiannis EC, Basdanis G. Toll-like receptors in the inflammatory response during open and laparoscopic colectomy for colorectal cancer. Surg Endosc. 2012;26(2):330-6. https://doi.org/10.1007/s00464-011-1871-2.

    Article  PubMed  Google Scholar 

  12. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine. 2009;6(7):e1000097.

    Article  Google Scholar 

  13. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ journal of surgery. 2003;73(9):712-6.

    Article  Google Scholar 

  14. Cole DS, Watts A, Scott-Coombes D, Avades T. Clinical utility of peri-operative C-reactive protein testing in general surgery. Ann R Coll Surg Engl. 2008;90(4):317-21. https://doi.org/10.1308/003588408X285865.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ. 2011;342:d549. https://doi.org/10.1136/bmj.d549.

    Article  PubMed  Google Scholar 

  16. Simundic AM. Measures of Diagnostic Accuracy: Basic Definitions. EJIFCC. 2009;19(4):203-11.

    PubMed  PubMed Central  Google Scholar 

  17. Linn S, Grunau PD. New patient-oriented summary measure of net total gain in certainty for dichotomous diagnostic tests. Epidemiol Perspect Innov. 2006;3:11. https://doi.org/10.1186/1742-5573-3-11.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Adamina M, Warschkow R, Naf F, Hummel B, Rduch T, Lange J et al. Monitoring c-reactive protein after laparoscopic colorectal surgery excludes infectious complications and allows for safe and early discharge. Surg Endosc. 2014;28(10):2939-48. https://doi.org/10.1007/s00464-014-3556-0.

    Article  PubMed  Google Scholar 

  19. Facy O, Paquette B, Orry D, Santucci N, Rat P, Rat P 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. 2017;32(6):857-63. https://doi.org/10.1007/s00384-017-2805-9.

    Article  PubMed  Google Scholar 

  20. Mik M, Dziki L, Berut M, Trzcinski R, Dziki A. Neutrophil to Lymphocyte Ratio and C-Reactive Protein as Two Predictive Tools of Anastomotic Leak in Colorectal Cancer Open Surgery. Dig Surg. 2018;35(1):77-84. https://doi.org/10.1159/000456081.

    Article  CAS  PubMed  Google Scholar 

  21. Munoz JL, Alvarez MO, Cuquerella V, Miranda E, Pico C, Flores R et al. Procalcitonin and C-reactive protein as early markers of anastomotic leak after laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) program. Surg Endosc. 2018;32(9):4003-10. https://doi.org/10.1007/s00464-018-6144-x.

    Article  PubMed  Google Scholar 

  22. Nason GJ, Barry BD, Obinwa O, McMacken E, Rajaretnam NS, Neary PC. Early rise in C-reactive protein is a marker for infective complications in laparoscopic colorectal surgery. Surg Laparosc Endosc Percutan Tech. 2014;24(1):57-61. https://doi.org/10.1097/SLE.0b013e31828fa03e.

    Article  PubMed  Google Scholar 

  23. Pedersen T, Roikjaer O, Jess P. Increased levels of C-reactive protein and leukocyte count are poor predictors of anastomotic leakage following laparoscopic colorectal resection. Dan Med J. 2012;59(12):A4552.

    PubMed  Google Scholar 

  24. Pedrazzani C, Moro M, Mantovani G, Lazzarini E, Conci S, Ruzzenente A et al. C-reactive protein as early predictor of complications after minimally invasive colorectal resection. J Surg Res. 2017;210:261-8. https://doi.org/10.1016/j.jss.2016.11.047.

    Article  CAS  PubMed  Google Scholar 

  25. Platt JJ, Ramanathan ML, Crosbie RA, Anderson JH, McKee RF, Horgan PG et al. C-reactive protein as a predictor of postoperative infective complications after curative resection in patients with colorectal cancer. Ann Surg Oncol. 2012;19(13):4168-77. https://doi.org/10.1245/s10434-012-2498-9.

    Article  PubMed  Google Scholar 

  26. Ramanathan ML, MacKay G, Platt J, Horgan PG, McMillan DC. 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. 2015;22(3):938-43. https://doi.org/10.1245/s10434-014-4065-z.

    Article  PubMed  Google Scholar 

  27. Ramos Fernandez M, Rivas Ruiz F, Fernandez Lopez A, Loinaz Segurola C, Fernandez Cabrian JM, de la Portilla de Juan F. C Reactive Protein as a Predictor of Anastomotic Leakage in Colorectal Surgery. Comparison Between Open and Laparoscopic Surgery. Cir Esp. 2017;95:529-35.

    Article  Google Scholar 

  28. Welsch T, Muller SA, Ulrich A, Kischlat A, Hinz U, Kienle P et al. C-reactive protein as early predictor for infectious postoperative complications in rectal surgery. Int J Colorectal Dis. 2007;22(12):1499-507. https://doi.org/10.1007/s00384-007-0354-3.

    Article  CAS  PubMed  Google Scholar 

  29. Waterland P, Ng J, Jones A, Broadley G, Nicol D, Patel H et al. Using CRP to predict anastomotic leakage after open and laparoscopic colorectal surgery: is there a difference? Int J Colorectal Dis. 2016;31(4):861-8. https://doi.org/10.1007/s00384-016-2547-0.

    Article  CAS  PubMed  Google Scholar 

  30. Warschkow R, Tarantino I, Torzewski M, Naf F, Lange J, Steffen T. 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 Colorectal Dis. 2011;26(11):1405-13. https://doi.org/10.1007/s00384-011-1262-0.

    Article  PubMed  Google Scholar 

  31. Watt DG, Horgan PG, McMillan DC. Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review. Surgery. 2015;157(2):362-80. https://doi.org/10.1016/j.surg.2014.09.009.

    Article  PubMed  Google Scholar 

  32. Fink-Neuboeck N, Lindenmann J, Bajric S, Maier A, Riedl R, Weinberg AM et al. Clinical impact of interleukin 6 as a predictive biomarker in the early diagnosis of postoperative systemic inflammatory response syndrome after major thoracic surgery: A prospective clinical trial. Surgery. 2016;160(2):443-53. https://doi.org/10.1016/j.surg.2016.04.004.

    Article  PubMed  Google Scholar 

  33. McSorley ST, Khor BY, MacKay GJ, Horgan PG, McMillan DC. Examination of a CRP first approach for the detection of postoperative complications in patients undergoing surgery for colorectal cancer: A pragmatic study. Medicine (Baltimore). 2017;96(7):e6133. https://doi.org/10.1097/MD.0000000000006133.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Holl S, Fournel I, Orry D, Facy O, Cheynel N, Rat P et al. Should CT scan be performed when CRP is elevated after colorectal surgery? Results from the inflammatory markers after colorectal surgery study. Journal of visceral surgery. 2017;154(1):5-9. https://doi.org/10.1016/j.jviscsurg.2016.07.003.

    Article  CAS  PubMed  Google Scholar 

  35. Benedetti M, Ciano P, Pergolini I, Ciotti S, Guercioni G, Ruffo G et al. Early diagnosis of anastomotic leakage after colorectal surgery by the Dutch leakage score, serum procalcitonin and serum C-reactive protein: study protocol of a prospective multicentre observational study by the Italian ColoRectal Anastomotic Leakage (iC). G Chir. 2019;40(1):20-5.

    CAS  PubMed  Google Scholar 

  36. Kornmann V, van Ramshorst B, van Dieren S, van Geloven N, Boermeester M, Boerma D. Early complication detection after colorectal surgery (CONDOR): study protocol for a prospective clinical diagnostic study. Int J Colorectal Dis. 2016;31(2):459-64. https://doi.org/10.1007/s00384-015-2468-3.

    Article  PubMed  Google Scholar 

  37. Barbic J, Ivic D, Alkhamis T, Drenjancevic D, Ivic J, Harsanji-Drenjancevic I et al. Kinetics of changes in serum concentrations of procalcitonin, interleukin-6, and C- reactive protein after elective abdominal surgery. Can it be used to detect postoperative complications? Coll Antropol. 2013;37(1):195-201.

    CAS  PubMed  Google Scholar 

  38. Persec J, Persec Z, Husedzinovic I. Postoperative pain and systemic inflammatory stress response after preoperative analgesia with clonidine or levobupivacaine: a randomized controlled trial. Wien Klin Wochenschr. 2009;121(17-18):558-63. https://doi.org/10.1007/s00508-009-1221-8.

    Article  CAS  PubMed  Google Scholar 

  39. Cabellos Olivares M, Labalde Martinez M, Torralba M, Rodriguez Fraile JR, Atance Martinez JC. C-reactive protein as a marker of the surgical stress reduction within an ERAS protocol (Enhanced Recovery After Surgery) in colorectal surgery: A prospective cohort study. J Surg Oncol. 2018;117(4):717-24. https://doi.org/10.1002/jso.24909.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada

    Tiffany Paradis, Anudari Zorigtbaatar, Maude Trepanier, Julio F. Fiore Jr, Gerald M. Fried, Liane S. Feldman & Lawrence Lee

  2. Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada

    Maude Trepanier, Julio F. Fiore Jr, Gerald M. Fried, Liane S. Feldman & Lawrence Lee

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Contributions

Conception or design: JF, GMF, LSF, LL

Data acquisition, analysis, or interpretation of data: TP, AZ, MT, JF, GMF, LSF, LL

Manuscript drafting: TP, AZ, MT, LL

Critical revision: JF, GMF, LSF, LL

Final approval of the version to be published: TP, AZ, MT, JF, GMF, LSF, LL

Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: TP, AZ, MT, JF, GMF, LSF, LL

Corresponding author

Correspondence to Lawrence Lee.

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Conflict of Interest

LL is the recipient of an investigator-initiated grant from Johnson & Johnson. JF has received investigator-initiated grants from Merck and personal fees for consulting from Shionogi. LSF receives consulting fees from Merck and Abbott. TP, AZ, MT, and GMF have no conflicts of interests to disclose.

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Paradis, T., Zorigtbaatar, A., Trepanier, M. et al. Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery. J Gastrointest Surg 24, 1392–1401 (2020). https://doi.org/10.1007/s11605-020-04599-2

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  • DOI: https://doi.org/10.1007/s11605-020-04599-2

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