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Persistent Elevation of C-Reactive Protein Following Esophagogastric Cancer Resection as a Predictor of Postoperative Surgical Site Infectious Complications

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Abstract

Background

Infectious complications, particularly in the form of anastomotic leaks (ALs) or surgical site infections (SSIs), represent a serious morbidity after esophagogastric cancer resections. Therefore, early detection is of paramount importance. Although markers of the systemic inflammatory response, including C-reactive protein (CRP) and white cell count (WCC), have been used in this regard, their relative predictive value is unclear. The aim of the present study was to examine serial postoperative WCC, albumin, and CRP and their diagnostic accuracy in case of infectious complications.

Patients and Methods

White cell count, albumin, and CRP were routinely measured postoperatively for 7 days in 136 consecutive patients who had undergone esophagogastric cancer resection. All postoperative complications were recorded. The diagnostic accuracy of the WCC, albumin, and CRP values were analyzed by receiver operating characteristics curve analysis with surgical site and remote infectious complications as outcome measures.

Results

Fifty-four (40%) patients developed infectious complications, and 17 of them developed an AL. CRP was significantly higher from postoperative day (POD) 3 onward in those patients who developed an AL. On POD 3, a threshold reading of 180 mg/l was associated with development of an AL, providing a sensitivity of 82% and a specificity of 63%. On POD 4, the same CRP threshold of 180 mg/l provided 71% sensitivity and 83% specificity.

Conclusions

Postoperative CRP measurements on PODs 3 and 4 are clinically useful in predicting surgical site infectious complications, in particular an AL, after resection for esophagogastric cancer.

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References

  1. Zafirellis KD, Fountoulakis A, Dolan K et al (2002) Evaluation of POSSUM in patients with oesophageal cancer undergoing resection. Br J Surg 89:1150–1155

    Article  PubMed  CAS  Google Scholar 

  2. Sah BK, Zhu ZG, Chen MM et al (2008) Gastric cancer surgery and its hazards: postoperative infection is the most important complication. Hepatogastroenterology 55:2259–2263

    PubMed  CAS  Google Scholar 

  3. Sah BK, Chen MM, Yan M et al (2010) Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital. World J Gastroenterol 16:98–103

    PubMed  Google Scholar 

  4. Hulscher JB, Tijssen JG, Obertop H et al (2001) Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg 72:306–313

    Article  PubMed  CAS  Google Scholar 

  5. Lagarde SM, Reitsma JB, Maris AK et al (2008) Preoperative prediction of the occurrence and severity of complications after esophagectomy for cancer with use of a nomogram. Ann Thorac Surg 85:1938–1945

    Article  PubMed  Google Scholar 

  6. Lorentz T, Fok M, Wong J (1989) Anastomotic leakage after resection and bypass for esophageal cancer: lessons learned from the past. World J Surg 13:472–477

    Article  PubMed  CAS  Google Scholar 

  7. Hankins JR, Attar S, Coughlin TR Jr et al (1989) Carcinoma of the esophagus: a comparison of the results of transhiatal versus transthoracic resection. Ann Thorac Surg 47:700–705

    Article  PubMed  CAS  Google Scholar 

  8. Urschel JD (1995) Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 169:634–640

    Article  PubMed  CAS  Google Scholar 

  9. Isguder AS, Nazli O, Tansug T et al (2005) Total gastrectomy for gastric carcinoma. Hepatogastroenterology 52:302–304

    PubMed  Google Scholar 

  10. Lo SS, Wu CW, Shen KH et al (2002) Higher morbidity and mortality after combined total gastrectomy and pancreaticosplenectomy for gastric cancer. World J Surg 26:678–682

    Article  PubMed  Google Scholar 

  11. Lerut T, Coosemans W, Decker G (2002) Anastomotic complications after esophagectomy. Dig Surg 19:92–98

    Article  PubMed  CAS  Google Scholar 

  12. Whooley BP, Law S, Alexandrou A et al (2001) Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer. Am J Surg 181:198–203

    Article  PubMed  CAS  Google Scholar 

  13. Griffin SM, Lamb PJ, Dresner SM et al (2001) Diagnosis and management of a mediastinal leak following radical oesophagectomy. Br J Surg 88:1346–1351

    Article  PubMed  CAS  Google Scholar 

  14. 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  PubMed  CAS  Google Scholar 

  15. Marra F, Steffen T, Kalak N et al (2009) Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer. Eur J Surg Oncol 35:1060–1064

    PubMed  CAS  Google Scholar 

  16. Jung SH, Yu CS, Choi PW et al (2008) Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 51:902–908

    Article  PubMed  Google Scholar 

  17. Lagarde SM, de Boer JD, ten Kate FJ et al (2008) Postoperative complications after esophagectomy for adenocarcinoma of the esophagus are related to timing of death due to recurrence. Ann Surg 247:71–76

    Article  PubMed  Google Scholar 

  18. Tsujimoto H, Ichikura T, Ono S et al (2009) Impact of postoperative infection on long-term survival after potentially curative resection for gastric cancer. Ann Surg Oncol 16:311–318

    Article  PubMed  Google Scholar 

  19. 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 22:1499–1507

    Article  PubMed  CAS  Google Scholar 

  20. Welsch T, Frommhold K, Hinz U et al (2008) Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery 143:20–28

    Article  PubMed  Google Scholar 

  21. Korner H, Nielsen HJ, Soreide JA et al (2009) Diagnostic accuracy of C-reactive protein for intraabdominal infections after colorectal resections. J Gastrointest Surg 13:1599–1606

    Article  PubMed  Google Scholar 

  22. Woeste G, Muller C, Bechstein WO et al (2010) Increased serum levels of C-reactive protein precede anastomotic leakage in colorectal surgery. World J Surg 34:140–146

    Article  PubMed  Google Scholar 

  23. 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 34:808–814

    Article  PubMed  Google Scholar 

  24. Mackay GJ, Molloy RG, O’Dwyer PJ (2010) C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection. Colorectal Dis. E-pub ahead of print

  25. Deitmar S, Anthoni C, Palmes D et al (2009) Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection? Zentralbl Chir 134:83–89

    Article  PubMed  CAS  Google Scholar 

  26. Sobin LH, Wittekind C (eds) (2002) TNM classification of malignant tumours, 6th edn. Wiley, Hoboken

    Google Scholar 

  27. Siewert JR, Stein HJ (1996) Adenocarcinoma of the gastroesophageal junction. Classification, pathology and extent of resection. Dis Esophagus 9:173–182

    Google Scholar 

  28. Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78:355–360

    Article  PubMed  CAS  Google Scholar 

  29. Carstairs V, Morris R (1990) Deprivation and health in Scotland. Health Bull (Edinb) 48:162–175

    CAS  Google Scholar 

  30. Hole DJ, McArdle CS (2002) Impact of socioeconomic deprivation on outcome after surgery for colorectal cancer. Br J Surg 89:586–590

    Article  PubMed  CAS  Google Scholar 

  31. Robertson EA, Zweig MH (1981) Use of receiver operating characteristic curves to evaluate the clinical performance of analytical systems. Clin Chem 27:1569–1574

    PubMed  CAS  Google Scholar 

  32. Zweig MH, Campbell G (1993) Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem 39:561–577

    PubMed  CAS  Google Scholar 

  33. Soreide K (2009) Receiver-operating characteristic curve analysis in diagnostic, prognostic and predictive biomarker research. J Clin Pathol 62:1–5

    Article  PubMed  Google Scholar 

  34. Moyes LH, Leitch EF, McKee RF et al (2009) Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer. Br J Cancer 100:1236–1239

    Article  PubMed  CAS  Google Scholar 

  35. McMillan DC (2008) An inflammation-based prognostic score and its role in the nutrition-based management of patients with cancer. Proc Nutr Soc 67:257–262

    Article  PubMed  Google Scholar 

  36. Peisajovich A, Marnell L, Mold C et al (2008) C-reactive protein at the interface between innate immunity and inflammation. Expert Rev Clin Immunol 4:379–390

    Article  PubMed  CAS  Google Scholar 

  37. Coventry BJ, Ashdown ML, Quinn MA et al (2009) CRP identifies homeostatic immune oscillations in cancer patients: a potential treatment targeting tool? J Transl Med 7:102

    Article  PubMed  Google Scholar 

  38. Du Clos TW, Mold C (2004) C-reactive protein: an activator of innate immunity and a modulator of adaptive immunity. Immunol Res 30:261–277

    Article  PubMed  CAS  Google Scholar 

  39. Sander LE, Sackett SD, Dierssen U et al (2010) Hepatic acute-phase proteins control innate immune responses during infection by promoting myeloid-derived suppressor cell function. J Exp Med 207:1453–1464

    Article  PubMed  CAS  Google Scholar 

  40. Fietta AM, Morosini M, Passadore I et al (2009) Systemic inflammatory response and downmodulation of peripheral CD25 + Foxp3 + T-regulatory cells in patients undergoing radiofrequency thermal ablation for lung cancer. Hum Immunol 70:477–486

    Article  PubMed  CAS  Google Scholar 

  41. Wichmann MW, Huttl TP, Winter H et al (2005) Immunological effects of laparoscopic vs open colorectal surgery: a prospective clinical study. Arch Surg 140:692–697

    Article  PubMed  Google Scholar 

  42. Motoyama S, Miura M, Hinai Y et al (2010) C-reactive protein −717C>T genetic polymorphism associates with esophagectomy-induced stress hyperglycemia. World J Surg 35:1001–1007

    Article  Google Scholar 

  43. Ramos M, Khalpey Z, Lipsitz S et al (2008) Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg 248:585–591

    PubMed  Google Scholar 

  44. Ambiru S, Kato A, Kimura F et al (2008) Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect 68:230–233

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. University Department of Surgery, Faculty of Medicine, University of Glasgow, Royal Infirmary, Glasgow, UK

    Sumanta Dutta, Grant M. Fullarton, Matthew J. Forshaw, Paul G. Horgan & Donald C. McMillan

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  1. Sumanta Dutta
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  2. Grant M. Fullarton
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  3. Matthew J. Forshaw
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  4. Paul G. Horgan
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  5. Donald C. McMillan
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Correspondence to Sumanta Dutta.

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Dutta, S., Fullarton, G.M., Forshaw, M.J. et al. Persistent Elevation of C-Reactive Protein Following Esophagogastric Cancer Resection as a Predictor of Postoperative Surgical Site Infectious Complications. World J Surg 35, 1017–1025 (2011). https://doi.org/10.1007/s00268-011-1002-1

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