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Postoperative C-Reactive Protein Measurement Predicts the Severity of Complications Following Surgery for Colorectal Cancer
Stephen T. Mcsorley*, Michelle L. Ramanathan, Paul G. Horgan, Donald C. Mcmillan
Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom
Background and aims:
Studies have shown that postoperative serum C-reactive protein (CRP) measurement may be useful in predicting the type of complication (e.g. infective or non-infective) following surgery for colorectal cancer (Singh et al. 2014). It may be that the magnitude of the postoperative CRP is also associated with the severity of the complication (Selby et al. 2014). The aim of the present study was to examine the relationship between daily postoperative CRP concentrations and Clavien Dindo complication grade.
Patients and Methods:
Data was recorded prospectively for patients undergoing elective, potentially curative, surgery for colorectal cancer in two hospitals between January 2011 and January 2013. Patients undergoing emergency surgery, who had received neoadjuvant treatment or with pre-existing inflammatory conditions were excluded. All patients had daily CRP measurement for the first four postoperative days. Complications were retrospectively classified by Clavien Dindo grade. Categorical data was analysed using the chi square test, the medians of groups of continuous variables were compared using the Kruskal-Wallis test. P values <0.05 were considered significant.
Results:
Of the 241 patients the majority were male (59%) and were over 65 years old (69%). The majority had colonic (86%) and node negative (65%) disease. 119 patients (49%) suffered a complication and 28 (12%) of these were Clavien-Dindo grade 3, 4 or 5. Clavien Dindo grade 3 to 5 complications were associated with a higher median CRP when compared to grade 1 to 2 complications and no complication on postoperative day 2 (234 mg/L vs. 176 mg/L vs. 123 mg/L, p<0.001), day 3 (251 mg/L vs. 208 mg/L vs. 118 mg/L, p<0.001), and day 4 (243 mg/L vs. 161mg/L vs. 98 mg/L, p<0.001). Established threshold CRP concentrations (for predicting infective type complications) on postoperative days 2 (190mg/L), 3 (170mg/L) and 4 (125mg/L) were directly associated with a Clavien Dindo complication grade 3 or higher (all p<0.001).
Conclusion:
There was a direct association between exceeding postoperative day 2, 3 and 4 CRP thresholds, established for the type of complication, and the severity of complications defined by the Clavien Dindo grade. These results would suggest that the systemic inflammatory response may be a common pathway linking the type and the severity of postoperative complications.
References:
Singh PP, Zeng ISL, Srinivasa S, Lemanu DP, Connolly AB, Hill AG. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 2014;101:339-346
Selby J, Prabhudesai A. Can C-reactive protein predict the severity of a post-operative complication after elective resection of colorectal cancer? Int J Colorectal Dis 2014;DOI 10.1007/s00384-014-1977-9
Table 1: Frequency of complication by Clavien Dindo grade
| Clavien Dindo grade | N | % | | 0 | 122 | 51 | | 1 | 22 | 9 | | 2 | 69 | 28 | | 3 | 15 | 6 | | 4 | 6 | 3 | | 5 | 7 | 3 | | Total | 241 | 100 |
Table 2: Patient characteristics by Clavien Dindo complication grade | Characteristic | All | Clavien Dindo complication grade | | 0 | 1-2 | 3-5 | P | | Age (<65/65-74/>74) | 75/74/92 | 40/37/45 | 29/29/33 | 6/8/14 | 0.695 | | Gender (male/female) | 142/99 | 65/57 | 58/33 | 19/9 | 0.183 | | TNM stage (I/II/III/IV) | 58/99/73/11 | 27/57/34/4 | 24/32/32/3 | 7/10/7/4 | 0.135 | | Site (colon/rectum) | 209/32 | 110/12 | 75/16 | 24/4 | 0.254 | | Preop mGPS (0/1/2) | 152/20/46 | 84/7/19 | 56/11/16 | 12/2/11 | 0.02 | | Preop NLR (≤5/>5) | 202/33 | 102/17 | 77/12 | 23/4 | 0.98 | | Approach (open/lap) | 129/112 | 50/72 | 59/32 | 20/8 | <0.001 | | POD2 CRP (median,range,mg/L) | 147(12-454) | 123(12-317) | 176(34-454) | 234(57-321) | <0.001 | | POD2 CRP >190mg/L (no/yes) | 151/77 | 92/22 | 48/38 | 11/17 | <0.001 | | POD3 CRP (median,range,mg/L) | 158(11-601) | 118(11-316) | 208(35-601) | 251(109-246) | <0.001 | | POD3 CRP >170mg/L (no/yes) | 120/105 | 84/30 | 31/54 | 5/21 | <0.001 | | POD4 CRP (median,range,mg/L) | 143(21-528) | 98(21-346) | 161(25-528) | 243(67-403) | <0.001 | | POD4 CRP >125mg/L (no/yes) | 84/114 | 50/36 | 30/54 | 4/24 | <0.001 |
Clavien Dindo grades; 0 = no complication, 1-2 = complication requiring minor intervention, 3-5 = complication requiring significant intervention. mGPS preoperative modified Glasgow Prognostic score (0 = CRP<10mg/L, 1 = CRP≥10mg/L and albumin ≥35g/L, 2 = CRP≥10mg/L and albumin <35g/L). NLR preoperative neutrophil lymphocyte ratio. POD postoperative day.
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