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CRP daily variation : a valuable tool for excluding anastomotic leakage
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Abstract(s)
Background: A deiscência da anastomose (DA) é uma complicação importante da cirurgia de cancro colorretal. A trajetória da proteína C-reativa (PCR) após o 2º dia pós-operatório (DPO) com descida após o pico é característica da ausência de DA. O objetivo deste estudo é quantificar a descida da PCR entre o 2º-3º DPO, assegurando uma alta precoce e segura.
Métodos: Analisou-se retrospetivamente dados de doentes submetidos a cirurgia de cancro colorretal com anastomose primária durante o período de janeiro de 2012 a dezembro de 2018. Realizou-se análise univariada e multivariada, regressão logística, determinação da área sob a curva ROC (AUC) e valores cut off associados.
Resultados: 214 doentes foram estudados (Grupo A, com DA, n=25, (11,7%), Grupo B, sem DA, n=189). Na análise multivariada verificou-se associação entre a DA e o sexo masculino (p=0,016; OR 5,5), maior tempo de internamento (13 vs 7 dias, p=0,007) e mortalidade hospitalar (16% vs 4%, p=0,026). Quanto à trajetória da PCR no pós-operatório, no grupo B, a PCR atingiu o pico no 2ºDPO diminuindo posteriormente, enquanto que, no grupo A, a PCR foi significativamente maior a partir do 2ºDPO, aumentando até ao 4ºDPO. Verificou-se que a PCR teve maior utilidade diagnóstica para a DA no 4ºDPO (AUC=0,816), seguida da variação de PCR entre 3º-4ºDPO (AUC = 0,777), PCR no 3ºDPO (AUC=0,772), PCR no 5ºDPO (AUC=0,747) e variação de PCR entre 2º-3ºDPO (AUC=0,702). Uma diminuição de PCR superior a 37% entre 2º-3ºDPO (valor preditivo negativo (VPN) de 99%) e de 39% entre 3º-4ºDPO (VPN de 100%) maximizam a sensibilidade.
Conclusão: Doentes que não desenvolvem DA apresentam uma descida de PCR entre o 2º-3ºDPO. Uma diminuição de 37% entre o 2º-3ºDPO e de 39% entre o 3º-4ºDPO excluem DA e asseguram uma alta precoce segura.
Background: Anastomotic leakage (AL) is a significant complication of colorectal cancer surgery. C-reactive protein (CRP) trajectory after the 2nd post-operative day (POD) with a marked declined after peaking is characteristic of absence of AL. The aim of this study is to quantify the CRP decline between 2nd and 3rd POD to ensure a safe early discharge. Methods: This retrospective study analysed colorectal cancer patients submitted to surgery with primary anastomosis from January 2012 to December 2018. Statistical analyses included univariate and multivariate analyses, logistic regression, determination of area under the receiver operating characteristic (ROC) curve (AUC) and associated cut off values. Results: 214 patients were analysed (Group A, with AL, n=25 (11,7%) and Group B, without AL=189). On multivariate analysis we found AL was related with male sex (p=0,016; OR 5,5), prolonged postoperative length of stay (13 vs 7 days, p=0,007), and higher in-hospital mortality (16% vs 4%, p=0,026). Concerning CRP trajectory in the postoperative period, in Group B serum CRP peaked on POD2 and decline thereafter, while in Group A, CRP values were significantly higher from POD2 onwards showing an increase until POD4. The better AUC for CRP was on POD4 (AUC=0,816) followed by CRP variation between POD3-4 (AUC=0,777), CRP on POD3 (AUC=0,772), CRP on POD5 (AUC=0,747) and CRP variation between POD2-3 (AUC=0,702). A CRP decrease over 37% between POD2-3 (negative predictive value (NPV) of 99%) and a decrease of 39% between POD3-4 (NPV of 100%) maximized the sensitivity. Conclusion: Patients who do not develop AL present a CRP decline between POD2-3. A decrease of 37% between POD2-3 and a decrease of 39% CRP between POD3-4 can exclude AL and confirm an early safe discharge.
Background: Anastomotic leakage (AL) is a significant complication of colorectal cancer surgery. C-reactive protein (CRP) trajectory after the 2nd post-operative day (POD) with a marked declined after peaking is characteristic of absence of AL. The aim of this study is to quantify the CRP decline between 2nd and 3rd POD to ensure a safe early discharge. Methods: This retrospective study analysed colorectal cancer patients submitted to surgery with primary anastomosis from January 2012 to December 2018. Statistical analyses included univariate and multivariate analyses, logistic regression, determination of area under the receiver operating characteristic (ROC) curve (AUC) and associated cut off values. Results: 214 patients were analysed (Group A, with AL, n=25 (11,7%) and Group B, without AL=189). On multivariate analysis we found AL was related with male sex (p=0,016; OR 5,5), prolonged postoperative length of stay (13 vs 7 days, p=0,007), and higher in-hospital mortality (16% vs 4%, p=0,026). Concerning CRP trajectory in the postoperative period, in Group B serum CRP peaked on POD2 and decline thereafter, while in Group A, CRP values were significantly higher from POD2 onwards showing an increase until POD4. The better AUC for CRP was on POD4 (AUC=0,816) followed by CRP variation between POD3-4 (AUC=0,777), CRP on POD3 (AUC=0,772), CRP on POD5 (AUC=0,747) and CRP variation between POD2-3 (AUC=0,702). A CRP decrease over 37% between POD2-3 (negative predictive value (NPV) of 99%) and a decrease of 39% between POD3-4 (NPV of 100%) maximized the sensitivity. Conclusion: Patients who do not develop AL present a CRP decline between POD2-3. A decrease of 37% between POD2-3 and a decrease of 39% CRP between POD3-4 can exclude AL and confirm an early safe discharge.
Description
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Keywords
Deiscência da anastomose Proteína C-reativa Cirurgia colorretal Cancro colorretal