Post on 03-Jun-2015
24th European Congress on Surgical Infection, 28th May, Leon.
A suficient decrease of C-reactive protein (CRP) after elective
colorectal surgery is a good marker of uneventful outcome.
Montserrat Juvany, Xavier Guirao, Sara Amador, Ruben Hernando, Guzmán Franch*,
Miquel Casal, Josep Maria Badia.
Hospital General de Granollers, Barcelona. *Hospital Universitario de Salamanca,
Salamanca.
Spain.
24th European Congress on Surgical Infection, 28th May, Leon.
• Surgical site infection (SSI):
– Wound
– Organ-space
o Anastomotic leakage is the main cause (2-24%)
o It is associated with a postoperative mortality (7 to 25%)
o Delayed diagnosis and treatment might be associated with a worse prognosis
o Previous observations have demonstrated that clinical parameters of SIRS are not so useful as they are in communitary organ-space infections
Introduction
Complications in colo-rectal surgery
24th European Congress on Surgical Infection, 28th May, Leon.
C- reactive protein (CRP)
• IL-6 dependent protein produced in the liver
• Appears in blood at 4 hour after the inflammatory stimulus
• Peaks at 48 hours
100
200
300
400
CRP (mg/L)
24h 120h 240h Preop 48h
0
Introduction
24th European Congress on Surgical Infection, 28th May, Leon.
• To evaluate the utility of CRP in the early diagnosis of major septic complications after elective colorectal surgery
Objective
24th European Congress on Surgical Infection, 28th May, Leon.
Material and methods
• Prospective
• Elective colo-rectal surgery with primmary anastomosis
• 33 months (January 07-Sept 09)
• Analysis
– CRP: 2nd and 5th po days
• Data: mean ± SD
• Statistics:
– Student-t test
– Receiver operative curve (ROC) test
24th European Congress on Surgical Infection, 28th May, Leon.
• Main variable: MAJOR SURGICAL SITE INFECTIONS
Material and methods
Major Minor
Surgical site
infections (SSI)
• Deep wound
infection
• Organ-space
infection
• Superficial
wound infection
No Surgical site
infections (no SSI)
• Cardiac arrest
• Pneumonia
• Urinary infection
• Phlebitis
• Ileus
24th European Congress on Surgical Infection, 28th May, Leon.
n=208
Age (y) 68.3 ± 11.4
Gender (%) M: 61
F: 39
ASA (%) - I: 4
- II: 59
- III: 33
- IV: 4
IQ (%) - Right colect: 34
- Sigmoidect: 27
- Rectum res: 22
- Left colect: 9
- Hartmann rev: 6
- Subtotal colect: 2
Aproach (%) Open: 50
Laparoscopic: 50
Results
24th European Congress on Surgical Infection, 28th May, Leon.
n=208
n=95 complics
n=113 no complics
n=38 minor
n=57 major
n=48 SSI
n=9 no SSI
NO MAJOR
COMPLICATIONS
(n=151)
MAJOR
COMPLICATIONS
(n=48)
EARLY
<5th PO day
(n=10)
EXCLUDED
LATE ≥5th
PO day
(n=38)
Results
24th European Congress on Surgical Infection, 28th May, Leon.
CRP values on the 2nd postoperative day are higher in early complicated patients in comparison to non-complicated patients
Early complicated
(n=10)
Non-complicated
(n=151)
CRP at the 2nd
PO day (mg/L)
241 109 156 76 p<0.005
The best cut-off point in the ROC curve test is a CRP on the 2nd PO day higher than:
201 mg/L
NPV=0.98
Results
24th European Congress on Surgical Infection, 28th May, Leon.
CRP at the 2nd and the 5th PO days is higher in late complicated
patients (vs non-complicated) and the fall down is lower (D% CRP 2-5)
Late complicated
(n=38)
Non-complicated
(n=151)
D % CRP 2-5 8 52 % -63 24% P<0.0001
0
50
100
150
200
250
300
350
D0 D2 D5
CR
P (
mg
/L)
217 79
157 48
218 94
57 48
Results
Late-complicated
Non-complicated
24th European Congress on Surgical Infection, 28th May, Leon.
-39 % PPV=0.62
NPV=0.97
ROC curve (n=189)
Results
¿Which is the best cut off point of D% CRP 2-5?
¿Are there any differences considering the approach of the surgery?
Open (n=92)
-36% PPV=0.77
NPV=0.96
Laparoscopic (n=97)
-48% PPV=0.44
NPV=1
Laparoscopic approach produces lower levels of CRP (less surgical stress and contraregulation response) and because of this it is necessary a bigger falling down of the CRP to be able to
exclude major complications.
24th European Congress on Surgical Infection, 28th May, Leon.
• A decrease of CRP between the 2nd and the 5th postoperative days higher than 36% in open surgery and 48% in laparoscopic are useful to exclude major septic complications and to discharge patients safely.
Conclusion
24th European Congress on Surgical Infection, 28th May, Leon.
24th European Congress on Surgical Infection, 28th May, Leon. Thanks to Dr Guirao for giving me the opportunity to collaborate in the study