Author: Zaina Hamza, Special Writer, MedPage Today November 4, 2021

French researchers found that adding C-reactive protein (CRP) levels to four commonly used clinical criteria can more accurately predict which patients undergoing laparoscopic colorectal surgery can be safely discharged from the hospital.

In an analysis of 287 patients, among patients who met clinical criteria and had a CRP level of less than 150 mg/dL, only 2 out of 15 anastomotic leaks were missed, while among patients who did not meet all 5 criteria, 15 There were 13 missed diagnoses of anastomotic leaks (HR 0.15, 95% CI 0.03-0.69), reported by Eddy Cotte, MD and colleagues at the University Hospital of Lyon South, France.

"The scariest and most serious complication after colorectal surgery is anastomotic leakage (ALs)," Cotte and co-authors wrote on JAMA Surgery. "In order for patients to be discharged safely, doctors must be convinced that the possibility of AL after discharge is almost zero."

For all criteria, the negative predictive value (NPV) for excluding anastomotic leakage was high, the four clinical criteria were 98.4% (95% CI 95.3-99.7%), and the CRP level alone was 96.9% (95% CI 93.3%- 98.8%) ), the sum of all five criteria is 98.4% (95% CI 94.5-99.8%).

"In the specific case of AL, the most important indicator is neither NPV nor accuracy," the organization wrote. "What is important is the absolute number or proportion of patients who are considered unlikely to develop AL and continue to develop AL (i.e. false negative rate)."

Here, the false negative rate of the five criteria is 13.3% (95% CI 0-40.5%), and the false negative rate of the four clinical criteria is 20% (95% CI 4.3-48.1%). Only the false negative rate of CRP level The negative rate was 40% (95% CI 16.3%-67.7%).

The four clinical criteria include tolerance to solid foods; normal bowel function; adequate control of pain with oral analgesics, measured on the visual analog pain scale below 5 (out of 10); and maintained throughout the hospital stay No fever.

"Clinical standards have always been standards that will always be followed," said Allen Kamrava, MD, of the Cedars-Sinai Medical Center in Beverly Hills, California, who was not involved in the study. "The only new issue is CRP."

Kamrava added that they will not send home patients who have body temperature, are unable to eat, or have insufficient pain control.

"Any standards that help determine the safe way to discharge patients after laparoscopic colorectal surgery are important," said David Greenwald, MD, of Mount Sinai Hospital in New York City and outgoing dean of the American College of Gastroenterology.

"Laparoscopic colorectal surgery is still the first choice for many patients because the recovery time is shorter and the results are the same," said Greenwald, who was not involved in the study.

In their study, the researchers analyzed the data of 287 adults who underwent laparoscopic colorectal surgery at the University Hospital of Lyon South, France from February 2012 to July 2017.

The main results evaluated the diagnostic performance of the five discharge criteria that ruled out postoperative anastomotic leakage-defined as leakage, effusion around the anastomosis, or air-liquid levels around the anastomosis observed on a CT scan.

When the patient was discharged from the hospital within 3 days after surgery without complications or no need for re-admission, the patient was discharged successfully. Follow-up was within 30 days after surgery.

The median age of the patients was 58 years, and slightly more than half of the women. Common surgical indications include diverticulitis (48%), cancer (29%), and Crohn’s disease-induced end ileitis (12%). The median operation time was 192 minutes.

Overall, 128 patients met all five discharge criteria, of which 76 (59%) were discharged within 3 days after surgery. Among the remaining patients in this group, nearly two-thirds were not discharged due to concerns of patients or doctors.

Another 125 patients did not meet all the criteria, 32 of them (26%) were discharged within 3 days after surgery, and 34 patients had missing data.

There were no deaths, 10 patients were re-admitted to the hospital, 6 met all the criteria, and 4 did not meet all the criteria. There were 17 anastomotic leakages, 15 of which did not meet all criteria.

The researchers acknowledge that the analysis has several limitations, including the lack of CRP data for nearly 12% of patients. The study population is also heterogeneous, requiring different types of surgery according to the condition, including patients with benign and malignant pathological results.

Zaina Hamza is a full-time writer for MedPage Today, covering gastroenterology and infectious diseases. She is based in Chicago.

Cotte disclosed funding from Takeda and Ethicon and its relationship with Intuitive.

A co-author reported an affiliation with Gamida.

Source reference: Tavernier C et al. "Evaluation Criteria for Safe and Early Discharge After Laparoscopic Colorectal Surgery" JAMA Surg 2021; DOI: 10.1001/jamasurg.2021.5551.

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