• Colorectal cancer
• Early discharge
• Inflammatory markers
• Minimally invasive surgery

• Humans
• Male
• Female
• Colorectal Neoplasms/surgery
• Colorectal Neoplasms/blood
• Postoperative Complications/etiology
• Postoperative Complications/blood
• Postoperative Complications/diagnosis
• Postoperative Complications/epidemiology
• Retrospective Studies
• Middle Aged
• Aged
• C-Reactive Protein/analysis
• Minimally Invasive Surgical Procedures/adverse effects
• Neutrophils
• Patient Discharge/statistics & numerical data
• Biomarkers/blood
• Elective Surgical Procedures/adverse effects
• ROC Curve
• Predictive Value of Tests
• Lymphocytes
• Lymphocyte Count
• Inflammation/blood
• Adult
• Colectomy/adverse effects

• Fundação D. Anna de Sommer Champalimaud e Dr. Carlos Montez Champalimaud

• Humans
• Anastomotic Leak/diagnosis
• Anastomotic Leak/etiology
• Anastomotic Leak/blood
• Female
• Male
• Middle Aged
• Prospective Studies
• Aged
• Biomarkers/blood
• Adult
• Rectal Neoplasms/surgery
• Rectal Neoplasms/diagnosis
• Rectal Neoplasms/blood

• Anastomotic leak
• C-reactive protein
• Colon cancer
• Early warning score

• CRP
• Colorectal cancer
• Complications
• Leucocytes
• Postoperative monitoring
• Vital signs

• Humans
• C-Reactive Protein/metabolism
• Retrospective Studies
• Colorectal Surgery
• Postoperative Complications/diagnosis
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• ROC Curve
• Colorectal Neoplasms/diagnosis
• Vital Signs
• Biomarkers

• anastomotic leakage
• logistic regression model
• permanent stoma
• prediction model
• rectal cancer
• rectal cancer resection
• stoma-free survival
• stoma score

• Humans
• Anastomotic Leak/etiology
• Anastomotic Leak/surgery
• Rectum/surgery
• Retrospective Studies
• Rectal Neoplasms/surgery
• Anastomosis, Surgical/methods
• Risk Factors

Colorectal anastomotic leakage (CAL), a severe postoperative complication, is associated with high morbidity, hospital readmission, and overall healthcare costs. Early detection of CAL remains a challenge in clinical practice. However, some decision models have been developed to increase the diagnostic accuracy of this event.

To develop a score based on easily accessible variables to detect CAL early.

Based on the least absolute shrinkage and selection operator method, a predictive classification system was developed [Early ColoRectAL Leakage (E-CRALL) score] from a prospective observational, single center cohort, carried out in a colorectal division from a non-academic hospital. The score performance and CAL threshold from postoperative day (POD) 3 to POD5 were estimated. Based on a precise analytical decision model, the standard clinical practice was compared with the E-CRALL adoption on POD3, POD4, or POD5. A cost-minimization analysis was conducted, on the assumption that all alternatives delivered similar health-related effects.

In this study, 396 patients who underwent colorectal resection surgery with anastomosis, and 6.3% (n = 25) developed CAL. Most of the patients who developed CAL (n = 23; 92%) were diagnosed during the first hospital admission, with a median time of diagnosis of 9.0 ± 6.8 d. From POD3 to POD5, the area under the receiver operating characteristic curve of the E-CRALL score was 0.82, 0.84, and 0.95, respectively. On POD5, if a threshold of 8.29 was chosen, 87.4% of anastomotic failures were identified with E-CRALL adoption. Additionally, score usage could anticipate CAL diagnosis in an average of 5.2 d and 4.1 d, if used on POD3 and POD5, respectively. Regardless of score adoption, episode comprehensive costs were markedly greater (up to four times) in patients who developed CAL in comparison with patients who did not develop CAL. Nonetheless, the use of the E-CRALL warning score was associated with cost savings of €421442.20, with most (92.9%) of the savings from patients who did not develop CAL.

The E-CRALL score is an accessible tool to predict CAL at an early timepoint. Additionally, E-CRALL can reduce overall healthcare costs, mainly in the reduction of hospital costs, independent of whether a patient developed CAL.

• Anastomotic leakage
• Colorectal
• Surgery
• Biomarkers
• Score
• Costs

Colorectal anastomotic leakage (CAL) is one of the most dreaded complications after colorectal surgery, with an incidence that can be as high as 27%. This event is associated with increased morbidity and mortality; therefore, its early diagnosis is crucial to reduce clinical consequences and costs. Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL.

To assess the usefulness of plasma C-reactive protein (CRP) and calprotectin (CLP) as early predictors of CAL.

A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis, from March 2017 to August 2019. Patients were divided into three groups: G1 – no complications; G2 – complications not related to CAL; and G3 – CAL. Five biomarkers were measured and analyzed in the first 5 postoperative days (PODs), namely white blood cell (WBC) count, eosinophil cell count (ECC), CRP, CLP, and procalcitonin (PCT). Clinical criteria, such as abdominal pain and clinical condition, were also assessed. The correlation between biomarkers and CAL was evaluated. Receiver operating characteristic (ROC) curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL, and the area under the ROC curve (AUROC), specificity, sensitivity, positive predictive value, and negative predictive value (NPV) during this period were estimated.

In total, 25 of 396 patients developed CAL (6.3%), and the mean time for this diagnosis was 9.0 ± 6.8 d. Some operative characteristics, such as surgical approach, blood loss, intraoperative complications, and duration of the procedure, were notably related to the development of CAL. The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications (median of 21 d vs 13 d and 7 d respectively; P < 0.001). For abdominal pain, the best predictive performance was on POD4 and POD5, with the largest AUROC of 0.84 on POD4. Worsening of the clinical condition was associated with the diagnosis of CAL, presenting a higher predictive effect on POD5, with an AUROC of 0.9. WBC and ECC showed better predictive effects on POD5 (AUROC = 0.62 and 0.7, respectively). Those markers also presented a high NPV (94%-98%). PCT had the best predictive effect on POD5 (AUROC = 0.61), although it presented low accuracy. However, this biomarker revealed a high NPV on POD3, POD4, and POD5 (96%, 95%, and 96%, respectively). The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications (195.5 ± 139.9 mg/L vs 59.5 ± 43.4 mg/L; P < 0.00001). On POD5, CRP had a NPV of 98%. The mean CLP value on POD3 was significantly higher in G3 compared with G1 (5.26 ± 3.58 μg/mL vs 11.52 ± 6.81 μg/mL; P < 0.00005). On POD3, the combination of CLP and CRP values showed a high diagnostic accuracy (AUROC = 0.82), providing a 5.2 d reduction in the time to CAL diagnosis.

CRP and CLP are moderate predictors of CAL. However, the combination of these biomarkers presents an increased diagnostic accuracy, potentially decreasing the time to CAL diagnosis.

• Anastomotic leakage
• Colorectal
• Surgery
• Biomarkers
• C-reactive protein
• Calprotectin

• Abdominal Pain/complications
• Anastomotic Leak/diagnosis
• Anastomotic Leak/etiology
• Biomarkers
• C-Reactive Protein/analysis
• Colorectal Neoplasms/complications
• Colorectal Neoplasms/diagnosis
• Colorectal Neoplasms/surgery
• Early Diagnosis
• Humans
• Leukocyte L1 Antigen Complex
• Prospective Studies
• ROC Curve

• anastomotic leakage
• colorectal cancer
• risk factor

• Anastomotic leak
• Colorectal cancer
• Esophageal cancer
• Fluorescence
• Image-guided surgery
• Lymph node
• Surgery

• Anastomotic leak
• Body mass index
• Colorectal cancer
• Obesity
• Surgery

• anastomotic leak
• biomarkers
• colorectal cancer
• intestinal anastomosis
• precision medicine

• EP/K-34510/1 Engineering and Physical Sciences Research Council
• NA Bowel and Cancer Research

Anastomotic leaks (AL) are among the most serious complications due to the substantial impact on the quality of life and mortality. Inspite of the advance in diagnostic tools such as laboratory tests and radiological adjuncts, only moderate improvement has been recorded in the rate of detected leaks. The purpose of the research was to assess the perioperative risk factors for AL.

This study was achieved at MUH and MIH/Egypt within the period between January 2016 and January 2019 for the candidates who underwent bowel anastomosis for small intestinal (except duodenal one) and colorectal pathology. The collected data were analyzed using SPSS of V-26.

This study included 315 cases, among them, 27 cases (8.57%) developed AL. The percentage of covering stoma was significantly higher in the non-leakage group vs leakage one (24.3% vs 11.1% respectively). lower albumin, operative timing, perforation, and covering stoma were shown as significant risk factors for leakage, but with multivariate analysis for these factors, the emergency operation, and serum albumin level was the only independent risk factors that revealed the significance consequently (p = 0.043, p = 0.015). The analysis of different predictors of AL on the third day showed that the cut-off point in RR was 29 with 83% sensitivity and 92% specificity in prediction of leakage, the cut-off point in RR was 118 with 74% sensitivity and 87% specificity in prediction of leakage and the cut-off point in CRP was 184.7 with 82% sensitivity and 88% specificity in prediction of AL and all had statistically significant value.

The preoperative serum albumin level and the emergency operations are independent risk factors for anastomotic leakage. Moreover, leakage should be highly suspected in cases with rising respiratory rate, heart rate, and CRP levels.

• Anastomosis
• Intestinal
• Leakage
• Predictors

• Anastomotic Leak/blood
• Anastomotic Leak/diagnosis
• Biomarkers/blood
• C-Reactive Protein/analysis
• Colon/surgery
• Elective Surgical Procedures/adverse effects
• Humans
• Italy
• Logistic Models
• Procalcitonin/blood
• Prospective Studies
• ROC Curve
• Rectum/surgery
• Sample Size

• Anastomotic leakage
• anterior resection
• contrast enema
• rectal cancer

• Anastomotic leak (AL)
• leaks
• management
• rectal surgery

• clinical audit
• colorectal surgery
• gastrointestinal tumours
• quality In health care

• Attitude of Health Personnel
• Colorectal Neoplasms/pathology
• Colorectal Neoplasms/surgery
• Delphi Technique
• Digestive System Surgical Procedures/standards
• Humans
• Netherlands
• Outcome Assessment, Health Care
• Practice Patterns, Physicians'/statistics & numerical data
• Surgeons/standards

• Anastomotic leakages
• validation studies
• colorectal carcinoma

• Adult
• Aged
• Aged, 80 and over
• Anastomotic Leak/epidemiology
• Anastomotic Leak/prevention & control
• Colorectal Neoplasms/surgery
• Colorectal Surgery/adverse effects
• Female
• Humans
• Male
• Middle Aged
• ROC Curve
• Risk Assessment

• Anastomotic leakage
• Colrectal surgery
• Postoperative complications

After major abdominal surgery (MAS), 20 % of patients endure major complications, which require invasive treatment and are associated with increased morbidity and mortality. A quality control algorithm after major abdominal surgery aimed at early identification of patients at risk of developing major complications can decrease associated morbidity and mortality. Literature studies show promising results for C-reactive protein (CRP) as an early marker for postoperative complications, however clinical significance has yet to be determined.

A multicenter, stepped wedge, prospective clinical trial including all adult patients planned to undergo elective MAS. The first period consists of standard postoperative monitoring, which entails on demand additional examinations. This is followed by a period with implementation of postoperative control according to the PRECious protocol, which implicates standardized measurement of CRP levels. If CRP levels exceed 140 mg/L on postoperative day 3,4 or 5, an enhanced CT-scan is performed.

Primary outcome in this study is a combined primary outcome, entailing all morbidity and mortality due to postoperative complications. Complications are graded according to the Clavien-Dindo classification. Secondary outcomes are hospital length of stay, patients reported outcome measures (PROMs) and cost-effectiveness. Data will be collected during admission, three months and one year postoperatively. Approval by the medical ethics committee of the VU University Medical Center was obtained (ID 2015.114).

the PRECious trial is a stepped-wedge, multicenter, open label, prospective clinical trial to determine the effect of a standardized postoperative quality control algorithm on postoperative morbidity and mortality, and cost-effectiveness.

www.ClinicalTrials.gov, NCT02102217. Registered 5 February 2015.

The online version of this article (doi:10.1186/s13063-015-0903-y) contains supplementary material, which is available to authorized users.