Langenbecks Arch Surg DOI 10.1007/s00423-014-1209-3

LETTER TO THE EDITOR

Inflammatory markers as predictors of surgical site infection after elective colorectal cancer surgery Pablo Ortega-Deballon & Nicolas Lagoutte & Olivier Facy

Received: 2 September 2013 / Accepted: 2 May 2014 # Springer-Verlag Berlin Heidelberg 2014

Abstract We raise some doubts regarding the methods, results and conclusions obtained by Takakura et al. in their article published in the August’s issue of the journal about the use of inflammatory markers as early predictors of surgical infection after colorectal cancer surgery. Keywords Procalcitonin . C-reactive protein . Surgical infection . Colorectal surgery We have read with great interest the article published by Takakura et al. in the August issue of the journal [1]. They have performed an observational study including 114 patients in order to assess the usefulness of procalcitonin (PCT) as a predictive marker of surgical site infection (SSI) in patients undergoing elective colorectal cancer surgery. They have also compared PCT to other potential markers, namely C-reactive protein (CRP), white blood cell count and temperature. The authors conclude that PCT is a better predictor than CRP and state twice that “(their) study is the first to evaluate the diagnostic value of PCT for surgical site infection in elective colorectal cancer surgery”. This is not totally true as three other groups have published similar studies with quite different conclusions [2–4]. Although these studies included some patients operated for benign diseases, most of the patients underwent cancer surgery. Moreover, the interest of CRP as a predictor of surgical infection after colorectal surgery has already been established in several prospective studies and confirmed in a recent metaanalysis [5–9]. In all those trials, the mean values of CRP at postoperative days 2, 3 or 4 were clearly higher than those obtained by Takakura et al. As a result, the cutoff values of CRP P. Ortega-Deballon (*) : N. Lagoutte : O. Facy Department of Digestive Surgical Oncology, University Hospital of Dijon, 14, rue Paul Gaffarel, 21079 Dijon Cedex, France e-mail: [email protected]

proposed at postoperative day 3 were also higher, 170 and 190 mg/l for Platt et al. and Korner et al., respectively [5, 7]. The lowest values of CRP before the third postoperative day were obtained by Guirao et al. in the second postoperative day in patients operated on by laparoscopy and in the absence of infection (132 mg/l); thus, higher than the cutoff proposed by Takakura et al. (95 mg/l) [8]. Their amazingly low values of CRP in a series where almost half of the patients have been operated by laparotomy (inducing a stronger inflammatory response) raise some doubts about the validity of their conclusion regarding the superiority of PCT over CRP in that setting. Finally, as the authors point out in the discussion, they combined patients with organ/space SSIs and those with incisional SSIs. These are complications clearly different in physiopathology, severity and management. It is more interesting to detect early and accurately the former than the second; the CRP seems to be more reliable than the PCT in that aim. Moreover, it has been pointed out that the values of PCT in patients with anastomotic leak after colorectal surgery are very different from one patient to another and that they do not correlate with the severity of the infection. This seem also to be the case in the study by Takakura et al. according to their Fig. 2 (values ranging between 0 and 6 ng/mL at the third postoperative day in patients with organ/space SSI) that disperse and irregular distribution of PCT makes it clinically unreliable [2, 3, 10]. The results of the multicentric French ongoing survey IMACORS (including 500 patients) should help to confirm the superiority of CRP over PCT in this setting. Conflicts of interest None.

References 1. Takakura Y, Hinoi T, Egi H, Shimomura M, Adachi T, Saito Y, Tanimine N, Miguchi M, Ohdan H (2013) Procalcitonin as a

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predictive marker for surgical site infection in elective colorectal cancer surgery. Langenbecks Arch Surg 398:833–839 Lagoutte N, Facy O, Ravoire A, Chalumeau C, Jonval L, Rat P, Ortega-Deballon P (2012) C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients. J Visc Surg 149:345–349 Oberhofer D, Juras J, Pavicić AM, Rancić Zurić I, Rumenjak V (2012) Comparison of C-reactive protein and procalcitonin as predictors of postoperative infectious complications after elective colorectal surgery. Croat Med J 53:612–619 Garcia-Granero A, Frasson M, Flor-Lorente B, Blanco F, Puga R, Carratala A, Garcia-Granero E (2013) Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study. Dis Colon Rectum 56: 475–483 Kørner H, Nielsen HJ, Søreide JA, Nedrebø BS, Søreide K, Knapp JC (2009) Diagnostic accuracy of C-reactive protein for intraabdominal infections after colorectal resections. J Gastrointest Surg 13:1599–1606

6. Ortega-Deballon P, Radais F, Facy O, d’Athis P, Masson D, Charles PE, Cheynel N, Favre JP, Rat P (2010) C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg 34:808–814 7. Platt JJ, Ramanathan ML, Crosbie RA, Anderson JH, McKee RF, Horgan PG, McMillan DC (2012) C-reactive protein as a predictor of postoperative infective complications after curative resection in patients with colorectal cancer. Ann Surg Oncol 19:4168–4177 8. Guirao X, Juvany M, Franch G, Navinés J, Amador S, Badía JM (2013) Value of C-reactive protein in the assessment of organ-space surgical site infections after elective open and laparoscopic colorectal surgery. Surg Infect (Larchmt) 14:209–215 9. Warschkow R, Beutner U, Steffen T, Müller SA, Schmied BM, Güller U, Tarantino I (2012) Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1832 patients. Ann Surg 256:245–250 10. Ortega-Deballon P, Facy O, Binquet C (2013) C-reactive protein and procalcitonin as predictors of anastomotic leak. Dis Colon Rectum 56:e395

Inflammatory markers as predictors of surgical site infection after elective colorectal cancer surgery.

We raise some doubts regarding the methods, results and conclusions obtained by Takakura et al. in their article published in the August's issue of th...
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