CRP is a useful negative predictive test for the development of anastomotic leakage following colorectal surgery.

ObjectiveTo quantify the sequential changes in metabolic response occurring in patients with severe sepsis after the onset of peritonitis. Summary Background DataUnderstanding the changes in energy expenditure and body composition is essential for the optimal management of severely septic patients; however, they have not been quantified in the context of modern surgical care. MethodsTwelve patients with severe sepsis secondary to peritonitis (median APACHE 11 score = 21.5) had measurements of energy expenditure and body composition as soon as they were hemodynamically stable and 5, 10, and 21 days later. Sequential measurements of acute-phase proteins and cytokine responses were also made. ResultsResting energy expenditure rose to 49% above predicted and remained elevated throughout the study period. Total energy expenditure was 1.25 x resting energy expenditure. Body fat was oxidized when energy intake was insufficient to achieve energy balance. There was a positive fluid balance of 12.5 over the first 2 days after onset of sepsis; thereafter, body water changes closely paralleled body weight changes and were largely accounted for by changes in extracellular water. During the 21-day study period, there was a loss of 1.21 kg (13%) of total body protein. During the first 10 days, 67% of the protein lost came from skeletal muscle, but after this time it was predominantly from viscera. Intracellular potassium levels were low but did not deteriorate further after hemodynamic stability had been reached. There was a reprioritization of hepatic protein synthesis that was obligatory and independent of changes in total body protein. The cytokine responses demonstrated the complexity, redundancy, and overlap of mediators. ConclusionsThe period of hypermetabolism in severely septic patients is similar to that previously described, but the fluid changes are larger and the protein loss is greater. Protein loss early on is predominantly from muscle, thereafter from viscera. Fat loss can be prevented and cell function preserved once hemodynamic stability is achieved.Patients with severe sepsis demonstrate a characteristic picture in which hypermetabolism occurs, protein and fat are consumed, and body water and salt are conserved.' These fundamental changes lie at the heart of present management of the severely septic patient; however, many of the changes described have not been quantified in the context of modem surgical care. The availability of body composition methodology, which has been adapted for use in

Increased rates of nodal examination are associated with a significantly lower 5-year mortality for Stage II and III colonic cancer, but this survival advantage appears to be minimal after the 16-node mark. The lymph node ratio has been validated as a powerful predictor of survival in Stage III cancer. Our results support the current practice of harvesting and examining as many nodes as possible during attempted curative resection.