Procalcitonin and C-reactive protein - early predictors of low colorectal anastomotic leakage

Aim of investigation. To determine diagnostic value of procalcitonin (PCT) and C-reactive protein (CRP) at anastomotic leakage (AL) following lower anterior resection (LAR) of the rectum. Material and methods. Overall 100 patients underwent surgery for epithelial tumors of rectum in the period 2013-2016 yy in the volume of LAR with the formation of anastomosis and preventive stoma. In patients without clinical symptoms radiopaque study was performed in order to identify asymptomatic AL on day 7 after the surgery. AL rate, difference in PCT and CRP levels in patients with AL and consistent anastomosis were assessed along with sensitivity, specificity, positive and negative predictive value of these markers. Results. AL was diagnosed in 20% (20 of 100) of patients: in 11% (11 of 100) - with clinical manifestations, in 9% (9 of 100) - without clinical symptoms (contrast leakage according to X-ray study). In the group of patients with anastomotic leak, the median of C-reactive protein level differed from that in patients with uncompromised integrity of anastomosis at 3rd day after surgery (156 mg/L vs 81 mg/L, respectively - t-test, p=0.0004) and postoperative day 6 (136 mg/L vs. 52 mg/L, respectively - t-test, p <0.0001). In patients with AL the median procalcitonin level was significantly higher compared to the group of uncomplicated course: at the day 3 it was 0.50 ng/mL versus 0.10 ng/mL, respectively - Mann-Whitney test, p<0.0001, at the day 6:1.16 vs. 0.10 ng/mL, respectively - Mann-Whitney test, p<0.0001. Conclusion. Anastomotic leakage rate was 20%, but only 11% of the patients had AL-related clinical manifestations. Changes in PCT and CRP levels in postoperative period correlated to the presence of AL.

низкая передняя резекция, колоректальный анастомоз, несостоятельность, прокальцитонин, С-реактивный белок

1. Гланц С. Медико-биологическая статистика. М.: Практика, 1999:167 с.

2. Половинкин В. В., Порханов В. А., Хмелик С. В. и др. Превентивная стома после низких передних резекций прямой кишки: улучшаем результаты или перестраховываемся? Колопроктология 2016; 1:16-21.

3. Тарасов М. А., Рыбаков Е. Г., Пикунов Д. Ю. Факторы риска развития несостоятельности аппаратных колоректальных анастомозов при низких передних резекциях прямой кишки. Лечение и профилактика 2014; 3:66-73.

4. Bakker I. S., Grossmann I., Henneman D., et al. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014; 101: 424-32.

5. Bertelsen C. A., Andreasen A. H., Jørgensen T., et al. Danish Colorectal Cancer Group. Anastomotic leakage after anterior resection for rectal cancer: risk factors. Colorectal Dis 2010; 12(1):37-43.

6. Blumetti J., Chaudhry V., Cintron J. R., et al. Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program. World J Surg 2014; 38:985-91.

7. Clark I. A. The advent of the cytokine storm. Immunol Cell Biol 2007; 85(4):271-3.

8. Eberhard O. K., Haubitz M., Brunkhorst F., et al. Discrimination of invasive bacterial infection and activation of systemic autoimmune disease by procalcitonin. J Am Soc Nephrol 1996; 7:1384.

9. Garcia-Granero A., Frasson M., Flor-Lorente B., et al. Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study. Dis Colon Rectum 2013; 56(4):47583.

10. Giaccaglia V., Salvi P. F., Cunsolo G. V., et al. Procalcitonin, as an early biomarker of colorectal anastomotic leak, facilitates enhanced recovery after surgery. J Crit Care 2014; 29:528-32.

11. Greco M., Capretti G., Beretta L., et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 2014; 38:153141.

12. Haverkamp M. P., de Roos M.AJ., Ong K. H. The ERAS protocol reduces the length of stay after laparoscopic colectomies. Surg Endosc 2012; 26:361-7.

13. Kisialeuski M., Pedziwiatr M., Matłok M., et al. Enhanced recovery after colorectal surgery in elderly patients. Videosurgery Miniinv 2015; 10: 30-6.

14. Korner H., Nielsen H. J., Soreide J. A., et al. Diagnostic accuracy of C-reactive protein for intraabdominal infections after colorectal resections. J Gastrointest Surg 2009; 13: 1599-606.

15. Krarup P. M., Jorgensen L. N., Andreasen A. H., Harling H. A nationwide study on anastomotic leakage after colonic cancer surgery. Colorectal Dis 2012; 14:661-7.

16. Kube R., Mroczkowski P., Granowski D., et al. Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumourfree survival. Eur J Surg Oncol 2010; 36:120-4.

17. Lagoutte N., Facy O., Ravoire A., et al. C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients. J Visc Surg 2012; 149:345-9.

18. Law W. I., Chu K. W., Ho J. W., et al. Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg .2000; 179:92-6.

19. Meisner M., Tschaikowsky K., Hutzler A., et al. Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med 1998; 24:680-4.

20. Merkel S., Wang W. Y., Schmidt J., et al. Locoregional recurrence in patients with anastomotic leakage after anterior resection for rectal carcinoma. Colorectal Dis 2001; 3:154-60.

21. Montagnana M., Minicozzi A. M., Salvagno G. L., et al. Postoperative variation of C-reactive protein and procalcitonin in patients with gastrointestinal cancer. Clin Lab. 2009; 55:187-92

22. Platell C., Barwood N., Dorfmann G., et al. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007; 9:71.

23. Rahbari N. N., Weitz J., Hohenberger W., et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 2010; 147(3):339-51.

24. Rose J., Schneider C., Yildirim C., et al. Complications in laparoscopic colorectal surgery: results of a multicentre trial. Tech Coloproctol 2004; 8:25-8.

25. Singh P. P., Zeng I.SL, Srinivasa S., et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 2014; 101:339-46.

26. Sriskandan S., Altmann D. M. The immunology of sepsis. J Pathol 2008; 214(2):211-23.

27. Takayuki A., Masashi T., Seiichiro Y., et al. Risk factors for anastomotic leakage following intersphincteric resection for very low rectal adenocarcinoma. J Gastrointest Surg 2010; (14):104-11.

28. Welsch T., Müller S. A., Ulrich A., et al. C-reactive protein as early predictor for infectious postoperative complications in rectal surgery. Int J Colorectal Dis 2007; 22:1499-507.

29. Zawadzki M., Czarnecki R., Rzaca M., et al. C-reactive protein and procalcitonin predict anastomotic leaks following colorectal cancer resections a prospective study. Wideochir Inne Tech Maloinwazyjne 2016; 10(4):567-73.