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Anastomotic leakage after colorectal surgery: Can it be detected earlier and more easily?
Journal of Visceral Surgery (2012) 149, e287—e288
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EDITORIAL
Anastomotic leakage after colorectal surgery: Can it be detected earlier and more easily?
Anastomotic leak is the most feared complication of colo-rectal surgery and its history is as old as intestinal surgery. Even if it seems illusory to think that this multifactorial complication can be eliminated [1], we must nevertheless do everything possible to improve its prognosis. The increased morbidity and mortality of this complication are partly linked to patient related factors, but also to the promptness of diagnosis [2]. But beyond the rate of reintervention, after elective colorectal surgery [3], it is the quality of management of this complication that matters, according to the well-known concept of ‘‘failure to rescue’’ [4]. An integrated institutional approach is considered an important factor in the management of complications to reduce their mortality. With specific regard to colorectal surgery, it has been shown that mortality is related less to the incidence of complications than to the quality of management of severe complications such as anastomotic leak [5]. Management begins with early detection of anastomotic leak or fistula at its onset. The diagnosis is often difficult to make due to the absence of specific criteria, and often depends on a combination of clinical signs and laboratory findings suggestive of a post-operative complication, that lead to the performance of diagnostic imaging (computerized tomography). The surgeon’s ‘‘gut feeling’’ is not sufficient to make the diagnosis; it has a sensitivity and specificity of about 50% [6]; we might as well say that the surgeon’s ‘‘gut-feeling’’ is wrong half of the time. There has been little published data on the use of diagnostic scores to dectect anastomotic leakage. To our best knowledge, only one score has been published: the ‘‘leakage score’’ of den Dulk et al. [7] was established by retrospective analysis of 1066 patients and then validated in a prospective study of 223 patients. This score is based on clinical findings and laboratory tests; its use resulted in a decrease in the delay in diagnosis of anastomotic leakage and in a reduction in the mortality specifically related to this complication. These results should nonetheless be validated by other studies in a setting of routine use where the daily collection of the multiple criteria may be difficult Is there another simpler diagnostic method that is more reproducible than this score? A recent meta-analysis including more than 1800 patients [8] showed that measurement of C-reactive protein (CRP) might prove to be a simple diagnostic test to detect infectious complications after colorectal surgery; a threshold value of CRP on the fourth postoperative day (D4) of 13.5 mg/dl has a sensitivity of 68% and a specificity of 83% (CL95%: 77—90%) and a negative predictive value of 89%. In this issue of the Journal of Visceral Surgery, Lagoutte et al. [9] compared CRP and procalcitonin (PCT) as markers for post-operative infectious complications. The authors concluded that PCT was not a useful test. CRP was a better predictor of infectious complications at D4. Their study was thus a ‘‘negative’’ study that showed no major
1878-7886/$ — see front matter © 2012 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2012.10.009
e288 significant benefit of PCT as a marker. But the low number of patients who actually had anastomotic leaks (n = 13) prevents a definitive conclusion even though it points the way to further studies involving a larger number of patients. The characteristics of PCT with its anti-bacterial specificity and short half-life should theoretically make it a good marker for post-operative infectious complications. The early publications on the utility of PCT emphasized its capacity to distinguish between viral and bacterial infection in pediatrics [10]. Since then, as in the study of Lagoutte et al., few proofs have emerged to support the notion that PCT is better than CRP as a marker of post-operative inflammatory response. The results of the IMACORS study conducted at Dijon (ClinicalTrials.gov Identifier: NCT01510314) should allow us to say whether PCT is better than CRP in the detection of post-operative complications. Over the last several years, the challenge for the surgical community has been (and remains) to find ways to improve the quality of care and risk-management. Numerous tools have been developed: evaluations of professional practice (EPP), morbidity and mortality review (MMR), safety checklists in the operating room, physician accreditation, etc. The use of laboratory markers to aid in early diagnosis of anastomotic leaks is simply another tool that might allow an improvement in the management of complications and a reduction in their severity and associated mortality. With the same goal of improving quality of care, the Fédération de chirurgie viscérale et digestive (FCVD) has developed a tool for MMR focused on unplanned re-interventions called Projet Apollo (http://projet-apollo.fr). This ambitious program aims to sensitize surgeons to the importance of ongoing apprenticeship, learning through error-analysis, and the availability of a simple computerized tool that allows them to discuss patients who suffered complications (such as anastomotic leak) and to include their cases in a national database. This database will give them the ability to anonymously compare the evolution of their surgical results with the mean national experience. The prevention and management of anastomotic leakage after colorectal surgery remains a challenge for surgeons. The quality of care and the prevention of associated risks can be improved by early diagnosis and by pedagogical programs of improvement for surgeons (MMR, EPP, etc.); this is just as important as the implementation of diagnostic modalities, whether in the form of scores or simple laboratory tests. With our current state of knowledge, the detection of anastomotic leakage after colorectal surgery is still based on a bundle of evidence where CRP (but not PCT at present) has a role to play. Some authors have written that leakage may develop beyond the classical period of 4 to 6 days, i.e. ‘‘it’s later than you think’’ [11], but it is not clear whether it is the leak or the diagnosis that occurs ‘‘later than you think’’.
Editorial
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg 2010;145:148—51. [2] Alves A, Panis Y, Pocard M, Regimbeau JM, Valleur P. Management of anastomotic leakage after nondiverted large bowel resection. J Am Coll Surg 1999;189:554—9. [3] Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz O. Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics. BMJ 2011;343:d4836. [4] Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009;361:1368—75. [5] Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, Faiz O. Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection. Br J Surg 2011;98:1775—83. [6] Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 2009;24:569—76. [7] den Dulk M, Noter SL, Hendriks ER, et al. Improved diagnosis and treatment of anastomotic leakage after colorectal surgery. Eur J Surg Oncol 2009;35:420—6. [8] Warschkow R, Beutner U, Steffen T, Muller SA, Schmied BM, Guller U, Tarantino I. Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1832 patients. Ann Surg 2012;256:245—50. [9] Lagoutte N, Facy O, Ravoir A, Chalumeau C, Rat P, OrtegaDeballon P. C-Reactive Protein and Procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients. J Visc Surg. [10] Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004;39:206—17. [11] Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it’s later than you think. Ann Surg 2007;245:254—8.
A. Dupré , K. Slim ∗ Service de chirurgie digestive, CHU d’Estaing, 1 place Lucie-Aubrac, 63003 Clermont-Ferrand, France ∗ Corresponding
author. Phone: +33 04 73316083; fax: +33 04 73750533. E-mail address: [email protected] (K. Slim) Available online 23 October 2012
Available online at
www.sciencedirect.com
EDITORIAL
Anastomotic leakage after colorectal surgery: Can it be detected earlier and more easily?
Anastomotic leak is the most feared complication of colo-rectal surgery and its history is as old as intestinal surgery. Even if it seems illusory to think that this multifactorial complication can be eliminated [1], we must nevertheless do everything possible to improve its prognosis. The increased morbidity and mortality of this complication are partly linked to patient related factors, but also to the promptness of diagnosis [2]. But beyond the rate of reintervention, after elective colorectal surgery [3], it is the quality of management of this complication that matters, according to the well-known concept of ‘‘failure to rescue’’ [4]. An integrated institutional approach is considered an important factor in the management of complications to reduce their mortality. With specific regard to colorectal surgery, it has been shown that mortality is related less to the incidence of complications than to the quality of management of severe complications such as anastomotic leak [5]. Management begins with early detection of anastomotic leak or fistula at its onset. The diagnosis is often difficult to make due to the absence of specific criteria, and often depends on a combination of clinical signs and laboratory findings suggestive of a post-operative complication, that lead to the performance of diagnostic imaging (computerized tomography). The surgeon’s ‘‘gut feeling’’ is not sufficient to make the diagnosis; it has a sensitivity and specificity of about 50% [6]; we might as well say that the surgeon’s ‘‘gut-feeling’’ is wrong half of the time. There has been little published data on the use of diagnostic scores to dectect anastomotic leakage. To our best knowledge, only one score has been published: the ‘‘leakage score’’ of den Dulk et al. [7] was established by retrospective analysis of 1066 patients and then validated in a prospective study of 223 patients. This score is based on clinical findings and laboratory tests; its use resulted in a decrease in the delay in diagnosis of anastomotic leakage and in a reduction in the mortality specifically related to this complication. These results should nonetheless be validated by other studies in a setting of routine use where the daily collection of the multiple criteria may be difficult Is there another simpler diagnostic method that is more reproducible than this score? A recent meta-analysis including more than 1800 patients [8] showed that measurement of C-reactive protein (CRP) might prove to be a simple diagnostic test to detect infectious complications after colorectal surgery; a threshold value of CRP on the fourth postoperative day (D4) of 13.5 mg/dl has a sensitivity of 68% and a specificity of 83% (CL95%: 77—90%) and a negative predictive value of 89%. In this issue of the Journal of Visceral Surgery, Lagoutte et al. [9] compared CRP and procalcitonin (PCT) as markers for post-operative infectious complications. The authors concluded that PCT was not a useful test. CRP was a better predictor of infectious complications at D4. Their study was thus a ‘‘negative’’ study that showed no major
1878-7886/$ — see front matter © 2012 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2012.10.009
e288 significant benefit of PCT as a marker. But the low number of patients who actually had anastomotic leaks (n = 13) prevents a definitive conclusion even though it points the way to further studies involving a larger number of patients. The characteristics of PCT with its anti-bacterial specificity and short half-life should theoretically make it a good marker for post-operative infectious complications. The early publications on the utility of PCT emphasized its capacity to distinguish between viral and bacterial infection in pediatrics [10]. Since then, as in the study of Lagoutte et al., few proofs have emerged to support the notion that PCT is better than CRP as a marker of post-operative inflammatory response. The results of the IMACORS study conducted at Dijon (ClinicalTrials.gov Identifier: NCT01510314) should allow us to say whether PCT is better than CRP in the detection of post-operative complications. Over the last several years, the challenge for the surgical community has been (and remains) to find ways to improve the quality of care and risk-management. Numerous tools have been developed: evaluations of professional practice (EPP), morbidity and mortality review (MMR), safety checklists in the operating room, physician accreditation, etc. The use of laboratory markers to aid in early diagnosis of anastomotic leaks is simply another tool that might allow an improvement in the management of complications and a reduction in their severity and associated mortality. With the same goal of improving quality of care, the Fédération de chirurgie viscérale et digestive (FCVD) has developed a tool for MMR focused on unplanned re-interventions called Projet Apollo (http://projet-apollo.fr). This ambitious program aims to sensitize surgeons to the importance of ongoing apprenticeship, learning through error-analysis, and the availability of a simple computerized tool that allows them to discuss patients who suffered complications (such as anastomotic leak) and to include their cases in a national database. This database will give them the ability to anonymously compare the evolution of their surgical results with the mean national experience. The prevention and management of anastomotic leakage after colorectal surgery remains a challenge for surgeons. The quality of care and the prevention of associated risks can be improved by early diagnosis and by pedagogical programs of improvement for surgeons (MMR, EPP, etc.); this is just as important as the implementation of diagnostic modalities, whether in the form of scores or simple laboratory tests. With our current state of knowledge, the detection of anastomotic leakage after colorectal surgery is still based on a bundle of evidence where CRP (but not PCT at present) has a role to play. Some authors have written that leakage may develop beyond the classical period of 4 to 6 days, i.e. ‘‘it’s later than you think’’ [11], but it is not clear whether it is the leak or the diagnosis that occurs ‘‘later than you think’’.
Editorial
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg 2010;145:148—51. [2] Alves A, Panis Y, Pocard M, Regimbeau JM, Valleur P. Management of anastomotic leakage after nondiverted large bowel resection. J Am Coll Surg 1999;189:554—9. [3] Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz O. Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics. BMJ 2011;343:d4836. [4] Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009;361:1368—75. [5] Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, Faiz O. Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection. Br J Surg 2011;98:1775—83. [6] Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 2009;24:569—76. [7] den Dulk M, Noter SL, Hendriks ER, et al. Improved diagnosis and treatment of anastomotic leakage after colorectal surgery. Eur J Surg Oncol 2009;35:420—6. [8] Warschkow R, Beutner U, Steffen T, Muller SA, Schmied BM, Guller U, Tarantino I. Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1832 patients. Ann Surg 2012;256:245—50. [9] Lagoutte N, Facy O, Ravoir A, Chalumeau C, Rat P, OrtegaDeballon P. C-Reactive Protein and Procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients. J Visc Surg. [10] Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004;39:206—17. [11] Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it’s later than you think. Ann Surg 2007;245:254—8.
A. Dupré , K. Slim ∗ Service de chirurgie digestive, CHU d’Estaing, 1 place Lucie-Aubrac, 63003 Clermont-Ferrand, France ∗ Corresponding
author. Phone: +33 04 73316083; fax: +33 04 73750533. E-mail address: [email protected] (K. Slim) Available online 23 October 2012