C-reactive protein identifies patients at low risk of anastomotic leak after esophagectomy.

PURPOSE: Fast-track protocols are increasingly used after digestive surgery. After esophagectomy, the gravity and the fear of anastomotic leak may be an obstacle to generalization of such protocols. C-reactive protein (CRP) might be a reliable tool to identify patients at low risk of anastomotic leak after esophagectomy, so that they can be safely included in a fast-track program. The aim of our retrospective bicentric study is to evaluate the interest of C-reactive protein measurement for the early diagnosis of anastomotic leak after esophagectomy. METHODS: Patients having undergone Ivor-Lewis procedure between January 2009 and September 2017 were included in this bicentric retrospective study. CRP values were recorded between postoperative day 3 (POD 3) and postoperative day 5 (POD 5). All postoperative complications were recorded, and the primary endpoint was anastomotic leak. RESULTS: We included 585 patients. Among them, 241 (41.2%) developed infectious complications and 69 patients (11.8%) developed anastomotic leak. CRP had the best predictive value on POD 5 (AUC = 0.74; 95% CI: 0.67-0.81). On POD 5, a cut-off value of 130 mg/L yielded a sensitivity of 87%, a specificity of 51%, and a negative predictive value of 96% for the detection of anastomotic leak. CONCLUSIONS: CRP may help in identifying patients at very low risk of anastomotic leak after esophagectomy. Patients with CRP values < 130 mg/L on POD 5 can safely undertake an enhanced recovery protocol.

CA 19-9 predicts resectability of pancreatic cancer even in jaundiced patients.

BACKGROUND: Surgical resection remains the only curative option for pancreatic adenocarcinoma. Despite recent improvements in medical imaging, unresectability is still often discovered at the time of surgery. It is essential to identify unresectable patients preoperatively to avoid unnecessary surgery. High serum CA 19-9 levels have been suggested as a marker of unresectability but considered inaccurate in patients with hyperbilirubinemia. AIM OF THE STUDY: To evaluate CA 19-9 serum levels as a predictor of unresectability of pancreatic adenocarcinomas with a special focus on jaundiced patients. METHODS: All patients presenting with histologically-confirmed pancreatic adenocarcinoma and having serum CA 19-9 levels available prior to any treatment were included in this retrospective study. The relationship between serum concentrations of CA 19-9 and resectability was studied by regression analysis and theROC curves obtained. A cut-off value of CA 19-9 was calculated. In jaundiced patients, a CA 19-9 adjusted for bilirubinemia was also evaluated. RESULTS: Of the 171 patients included, 49 (29%) were deemed resectable and 122 (71%) unresectable. Altogether, 93 patients (54%) had jaundice. The area under the ROC curve for CA 19-9 as a predictor of resectability was 0.886 (95%CI:[0.832-0.932]); in jaundiced patients it was 0.880 (95% CI [0.798-0.934]. A cut-off in CA 19-9 at 178 UI/mlyielded 85% sensitivity, 81% specificity and 91% positive predictive value for resectability. There was no correlation between the levels of bilirubin and CA 19-9 (r = 0.149). CONCLUSION: Serum CA 19-9 is a good predictive marker of unresectability of pancreatic adenocarcinoma, even in jaundiced patients. CA 19-9 levels over 178 UI/ml strongly suggest unresectable disease.

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

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.