PREdiction of Complications: A Step-up Approach, CRP First Followed by CT-scan Imaging to Ensure Quality Control After Major Abdominal Surgery

Major Abdominal Surgery (MAS) may be defined as a surgical resection performed on colorectal, hepato-pancreatico-biliary and upper-GI organs with either primary anastomosis and/or ostomy. In patients undergoing MAS postoperative complications are reported in up to 40% of patients. Around 20% of all MAS patients have a major complication, which requires invasive treatment such as reoperation, percutaneous drainage and intensive care admission. Major complications further increase morbidity and mortality after major abdominal surgery, leading to longer intensive care and hospital stay, unplanned open procedures and creation of ostomies and possible increased cancer recurrence rates and costs.

In current postoperative practice median time to clinical diagnosis of a postoperative complication is approximately eight days. A delay in diagnosis of complications increases morbidity and mortality related to major complications. Whereas early diagnosis of postoperative septic complications, before clinical deterioration, is associated with a decrease in the associated morbidity and mortality. An early detection of septic complications is challenging and may clinically and serologically, as well while using imaging techniques, be hard to distinguish from the physiological and postoperative systemic inflammatory response syndrome (SIRS). Furthermore clinical risk assessment appears to have a low predictive value for major complications such as anastomotic leak. This further stresses the need for a standardized Quality Control algorithm after MAS.

Noteworthy is that nowadays no standard Quality Control tests or protocols are available after MAS to differentiate between a normal and a complicated postoperative course.

In the search for a marker in early diagnosis of postoperative complications several biomarkers have been assessed, such as interleukin 6 (IL-6), Tumour necrosis factor α (TNF-α), procalcitonin, white blood cell count (WBC) and C-reactive protein (CRP).

WBC showed no significant differences between patients with an uncomplicated versus complicated postoperative course. WBC is therefore not useful in a standardized quality control algorithm. Procalcitonin, IL-6 and TNF-α have been assessed as markers of postoperative sepsis. However, compared to CRP they achieve similar results in predicting major complications after MAS. Moreover, taking into account the higher cost and limited availability of testing for procalcitonin, IL-6 and TNF-α levels, we further focussed on the use of CRP in a postoperative standardized quality control algorithm.