C-reactive protein for the early prediction of anastomotic leak after esophagectomy in both neoadjuvant and non-neoadjuvant therapy case: a propensity score matching analysis

Abstract

Background: Anastomotic leak is one of most significant causes of mortality after esophagectomy. Therefore, it is clinically valuable to detect anastomotic leak early after esophagectomy in esophageal cancer. The purpose of this study is to investigate the associations between routine postoperative laboratory findings and anastomotic leak and to analyze the laboratory findings to find out an independent predictive marker for anastomotic leak.In addition, this study compares cases treated with neoadjuvant therapy (NT) and those without (non-NT). Methods:We retrospectively assessed the medical records of 201 consecutive cases that met this study's criteria from January 2009 to December 2016. All patients underwent curative and complete esophagectomy for intra-thoracic esophageal cancer. We compiled and analyzed routine laboratory findings from the day before surgery to the eighth postoperative day on a daily basis. Routine laboratory tests consisted of 26 separate tests, including complete blood cell counts, blood chemistries, as well as erythrocyte sedimentation rate and C-reactive protein (CRP). Barium esophagogram with chest computed tomography (CT) was performed on the seventh postoperative day to evaluate the presence of an anastomotic leak.Results: A total of 45 of 201 patients underwent NT. Anastomotic leaks were found in 23 (11.4%) of 201 patients (8 patients in NT and 15 patients in non-NT). White blood cell (WBC) from the second postoperative day (P=0.031, P=0.006, P=0.007, P=0.007, P=0.041, and P=0.003, respectively) and CRP from the third postoperative day (P=0.012, P<0.001, P=0.014, P<0.001, P=0.001, and P=0.006, respectively) were associated with anastomotic leak in non-NT; however, only CRP on the third, fifth, sixth, and seventh postoperative days (P=0.041, P=0.037, P=0.002, and P=0.003, respectively) was associated with anastomotic leak in NT. The CRP level on the third postoperative day was a significant independent predictive marker of anastomotic leak (P=0.041, odd ratio (OR) 1.056, 95% confidential interval (CI): 1.002-1.113) and had a significant diagnostic cutoff value for the development of anastomotic leak (non-NT: cutoff value 17.12 mg/dL, sensitivity 69.2%, specificity 78.1%, P<0.001, area 0.822; NT: cutoff value 16.42 mg/dL, sensitivity 80.0%, specificity 70.0 %, P=0.042, area 0.7104).Conclusions: There were divergent laboratory findings reflective of anastomotic leak between patients who underwent NT and those who did not. The CRP level on the third postoperative day had a significant cutoff value for early detection of anastomotic leak after esophagectomy in both NT and non-NT groups.

Systematic use of the serum C‐reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks

“…4 Desirable qualities of a good clinical diagnostic tool should include being easily accessible, cost effective and easily interpretable. 5 C-reactive protein (CRP) has been a promising serum indicator for the detection of post-operative anastomotic leaks in colorectal surgery. It is an acute phase protein which becomes raised in the inflammatory process.…”

Postoperative Esophageal Leaks in Malignant Pathology - Optimal Management: A Systematic Review

“…In patients with recent atrial fibrillation, post-oesophagectomy was associated with infectious complications, is a clinical sign of early warning for the occurrence of anastomotic leaks (31). CRP level on the third postoperative day may be of significant value for early detection of anastomotic leaks after esophagectomy (32). Determination of amylase in the pleural fluid may be useful in assessing the integrity of an esophageal anastomosis, and successive evaluation of amylase on the 5 th to the 7 th postoperative day may be a method of detecting anastomotic leaks (33).…”

Early detection of complications: anastomotic leakage

“…The incidence of AL is about 10%, is often unpredictable in nature, and varies widely among institutions and surgeons, with a significantly higher incidence of cervical AL of 10% to 20% compared with intrathoracic AL (5)(6)(7)(8). Given the high incidence and morbidity of AL, identification of the causes and precipitating factors, techniques for prevention, early diagnosis, and management strategies is critical (9)(10)(11)(12). AL results in high mortality, requires repetitive therapeutic intervention and prolonged hospitalization, and is associated with poor oncological consequences from the interruptions or delays in adjuvant treatment (2,4,6,13).…”

“…Early diagnosis and timely therapeutic action are necessary if patients are to avoid AL-related problems (14). However, early diagnosis and recognition of AL are difficult due to the various clinical presentations, which are often indistinguishable from the symptoms caused by physiological inflammatory response, infection, and especially pneumonia after esophagectomy (9,15). In addition, these signs and symptoms may vary from clinically silent to severely septic (11).…”

“…AL usually occurs within 10 days after esophagectomy, but in some cases, it may show development as late as a few postoperative weeks (11,16). Clinical assessment alone is generally considered inadequate in early diagnosis or detection (9). Therefore, multiple methods including clinical assessments, image examinations, laboratory biomarkers, and endoscopic examinations have been proposed for early diagnosis of AL (8,9).…”