Abstract
The goal of this study was to determine whether C-reactive protein (CRP) levels and its ratios can be used as indicators to exclude postoperative anastomotic leak (AL) requiring intervention in patients undergoing elective laparoscopic total mesorectal excision (TME) without a diverting ileostomy for middle or low rectal cancer. We measured CRP values on postoperative days (POD) 1, 2, and 4 and CRP ratios between two PODs in 1278 consecutive patients undergoing rectal surgery. The incidence of AL requiring intervention was 5.9%, and 92% of AL occurred by POD 4. The CRP levels on POD 4 had a maximal area under the curve (AUC) of 0.956 with a negative predictive value (NPV) of 99.7% when the cutoff was established as 80 mg/l. Also, the ratio between CRP levels on POD 4 and CRP levels on POD 2 (CRP POD 4/2) was the most accurate indicator among the CRP ratios, with an AUC of 0.959 and an NPV of 99.5% when the cutoff was set at one. CRP on POD 4 < 80 mg/l and the ratio of CRP POD 4/2 < 1 can be used to rule out AL requiring intervention in patients undergoing elective laparoscopic TME without a diverting ileostomy for middle or low rectal cancer.
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References
Heald R, Husband E, Ryall R (1982) The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg. https://doi.org/10.1002/bjs.1800691019
Crippa J, Duchalais E, Machairas N et al (2020) Long-term oncological outcomes following anastomotic leak in rectal cancer surgery. Dis Colon Rectum. https://doi.org/10.1097/dcr.0000000000001634
Kang C, Halabi W, Chaudhry O et al (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg. https://doi.org/10.1001/2013.jamasurg.2
van Westreenen H, Ijpma F, Wevers K et al (2011) Reoperation after colorectal surgery is an independent predictor of the 1-year mortality rate. Dis Colon Rectum. https://doi.org/10.1097/DCR.0b013e31822c64f1
Buchs N, Gervaz P, Secic M et al (2008) Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study. Int J Colorectal Dis. https://doi.org/10.1007/s00384-007-0399-3
Karim A, Cubas V, Zaman S et al (2020) Anastomotic leak and cancer-specific outcomes after curative rectal cancer surgery: a systematic review and meta-analysis. Tech Coloproctol. https://doi.org/10.1007/s10151-020-02153-5
Rahbari N, Weitz J, Hohenberger W et al (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery. https://doi.org/10.1016/j.surg.2009.10.012
Messias B, Botelho R, Saad S et al (2020) Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery. Sci Rep. https://doi.org/10.1038/s41598-020-58780-3
Millan M, Garcia-Granero E, Flor B et al (2006) Early prediction of anastomotic leak in colorectal cancer surgery by intramucosal pH. Dis Colon Rectum. https://doi.org/10.1007/s10350-006-0504-7
Ledue T, Rifai N (2003) Preanalytic and analytic sources of variations in C-reactive protein measurement: implications for cardiovascular disease risk assessment. Clin Chem. https://doi.org/10.1373/49.8.1258
Man W, Lin H, Liu Z et al (2020) Usefulness of inflammation-based prognostic scores for predicting the risk of complications after radical resection of colorectal carcinoma. Cancer Manag Res. https://doi.org/10.2147/cmar.S234448
Zawadzki M, Czarnecki R, Rzaca M et al (2016) C-reactive protein and procalcitonin predict anastomotic leaks following colorectal cancer resections - a prospective study. Wideochir Inne Tech Maloinwazyjne. https://doi.org/10.5114/wiitm.2015.56999
Selby J, Prabhudesai A (2014) Can C-reactive protein predict the severity of a post-operative complication after elective resection of colorectal cancer? Int J Colorectal Dis. https://doi.org/10.1007/s00384-014-1977-9
MacKay GJ, Molloy RG, O’Dwyer PJ (2011) C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection. Colorectal Dis. https://doi.org/10.1111/j.1463-1318.2010.02236.x
Garcia-Granero A, Frasson M, Flor-Lorente B et al (2013) Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study. Dis Colon Rectum. https://doi.org/10.1097/DCR.0b013e31826ce825
Ge X, Cao Y, Wang H et al (2017) Diagnostic accuracy of the postoperative ratio of C-reactive protein to albumin for complications after colorectal surgery. World J Surg Oncol. https://doi.org/10.1186/s12957-016-1092-1
Mik M, Dziki L, Berut M et al (2018) Neutrophil to lymphocyte ratio and c-reactive protein as two predictive tools of anastomotic leak in colorectal cancer open surgery. Dig Surg. https://doi.org/10.1159/000456081
Almeida A, Faria G, Moreira H et al (2012) Elevated serum C-reactive protein as a predictive factor for anastomotic leakage in colorectal surgery. Int J Surg. https://doi.org/10.1016/j.ijsu.2011.12.006
Welsch T, Muller SA, Ulrich A et al (2007) C-reactive protein as early predictor for infectious postoperative complications in rectal surgery. Int J Colorectal Dis. https://doi.org/10.1007/s00384-007-0354-3
Bilgin IA, Hatipoglu E, Aghayeva A et al (2017) Predicting value of serum procalcitonin, C-reactive protein, drain fluid culture, drain fluid interleukin-6, and tumor necrosis factor-α levels in anastomotic leakage after rectal resection. Surg Infect (Larchmt). https://doi.org/10.1089/sur.2016.222
Matthiessen P, Henriksson M, Hallbook O et al (2008) Increase of serum C-reactive protein is an early indicator of subsequent symptomatic anastomotic leakage after anterior resection. Colorectal Dis. https://doi.org/10.1111/j.1463-1318.2007.01300.x
Macarthur DC, Nixon SJ, Aitken RJ (1998) Avoidable deaths still occur after large bowel surgery. Scottish Audit of Surgical Mortality, Royal College of Surgeons of Edinburgh. Br J Surg. https://doi.org/10.1046/j.1365-2168.1998.00554.x
Parthasarathy M, Greensmith M, Bowers D et al (2017) Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients. Colorectal Dis. https://doi.org/10.1111/codi.13476
Qu H, Liu Y, Bi DS (2015) Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc. https://doi.org/10.1007/s00464-015-4117-x
Waterland P, Ng J, Jones A et al (2016) Using CRP to predict anastomotic leakage after open and laparoscopic colorectal surgery: is there a difference? Int J Colorectal Dis. https://doi.org/10.1007/s00384-016-2547-0
Neumaier M, Metak G, Scherer MA (2006) C-reactive protein as a parameter of surgical trauma: CRP response after different types of surgery in 349 hip fractures. Acta Orthop. https://doi.org/10.1080/17453670610013006
Vigushin DM, Pepys MB, Hawkins PN (1993) Metabolic and scintigraphic studies of radioiodinated human C-reactive protein in health and disease. J Clin Invest. https://doi.org/10.1172/jci116336
Ortega-Deballon P, Radais F, Facy O et al (2010) C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg. https://doi.org/10.1007/s00268-009-0367-x
Cazelles A, Giacca M, Monsinjon M et al (2021) Monitoring of C-reactive protein decreases length of stay after laparoscopic total mesorectal excision for cancer: a prospective case-matched study in 236 patients. Colorectal Dis. https://doi.org/10.1111/codi.15573
Warschkow R, Beutner U, Steffen T et al (2012) Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1832 patients. Ann Surg. https://doi.org/10.1097/SLA.0b013e31825b60f0
Singh P, Zeng I, Srinivasa S et al (2014) Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg. https://doi.org/10.1002/bjs.9354
Domínguez-Comesaña E, Estevez-Fernández S, López-Gómez V et al (2017) Procalcitonin and C-reactive protein as early markers of postoperative intra-abdominal infection in patients operated on colorectal cancer. Int J Colorectal Dis. https://doi.org/10.1007/s00384-017-2902-9
Smith SR, Pockney P, Holmes R et al (2018) Biomarkers and anastomotic leakage in colorectal surgery: C-reactive protein trajectory is the gold standard. ANZ J Surg. https://doi.org/10.1111/ans.13937
Stephensen B, Reid F, Shaikh S et al (2020) C-reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study. Br J Surg. https://doi.org/10.1002/bjs.11812
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This work was supported by Department of Finance of Jilin Province (JLSWSRCZX2020-0016) and Department of Science and Technology of Jilin Province (20200802010GH).
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JZ and QW conceived the study. DY, YZ and ML performed data collection and analysis. JZ wrote the manuscript; QW and JZ critically revised the article.
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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. The study was approved by the First Hospital of Jilin University (No. 20k085-001).
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Zhang, J., Yang, D., Zhao, Y. et al. C-reactive protein and its ratio are useful indicators to exclude anastomotic leakage requiring intervention after laparoscopic rectal surgery. Updates Surg 74, 1637–1643 (2022). https://doi.org/10.1007/s13304-022-01358-7
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DOI: https://doi.org/10.1007/s13304-022-01358-7