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Predictive Value of Preoperative Serum C-Reactive Protein for Recurrence After Definitive Surgical Repair of Enterocutaneous Fistula
Jose L. Martinez*, Enrique Luque-De-LEóN, Eduardo Ferat-Osorio, Alicia Estrada-Castellanos
Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional SXXI, Mexico DF, Mexico
Background: Despite recent advances in the management of enterocutaneous fistulae (ECF), recurrence rates after surgical repair have not changed substantially. Serum C-reactive protein (s-CRP) has been used as an indicator of postoperative complications in abdominal surgery; however its predictive value for recurrence prior to definitive surgical attempts at closure of ECF has not been previously studied.
Aim: To determine the predictive value of preoperative s-CRP for recurrence in patients submitted to surgical repair of ECF.
Material and Methods: We analyzed all consecutive patients with postoperative ECF persistence without intra-abdominal or distant infection submitted electively to definitive surgical repair (ECF resection with primary anastomosis) during a 36 month period. Besides preoperative s-CRP (our primary independent variable), numerous other patient, disease and operative variables were assessed as factors related to recurrence (dependent variable). Univariate (UA) and Multivariate (MA) statistical analyses comparisons were performed. A receiving operating characteristic (ROC) curve and area under the curve (AUC) were used to assess s-CRP level as predictor of ECF recurrence. Significance was determined at the 95% confidence interval (95% CI, p≤0.05).
Results: Fifty patients were included with a median age of 53 y. (range, 23-86). Most (84%) were classified as enteroatmospheric fistulas and had a history of open abdomen management. Median interval between last abdominal operation and attempt at ECF surgical closure was 115 days (range, 2-1120). ECF recurred in 19 patients (38%). Conservative and surgical management of patients with recurrent ECF was successful in 9 (47%), so overall, ECF closure was attained in 40 (80%). Seven patients (14%) remain with a low-output ECF (<50 ml/day) and three (6%) ultimately died (all after ECF recurrence). UA disclosed preoperative s-CRP (p<0.01) and operative blood loss > 400 ml (p<0.05) as the only risk factors for recurrence. ECF recurrence rates were significantly higher for patients with preoperative s-CRP above >0.5 mg/dL (53% vs 11%, p<0.01). This also prevailed after multivariate analysis (p<0.01), that disclosed that patients with s-CRP levels > 0.5 mg/dL had 18 times more risk of recurrence. At this cut-off value sensitivity, specificity, positive predictive value and negative predictive value were 89.5%, 51.6%, 53.1% and 88.9%, respectively.
Conclusions: Our results suggest that as a biomarker of ongoing inflammation, s-CRP may serve as a useful parameter to predict potential failure (recurrence) in patients submitted to definitive closure of ECF. In the setting of apparently fit patients being considered for surgical treatment, it could postpone our decision, thus providing with a more objective measure to decide on the optimal timing for surgery.
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