A sufficient decrease in C-reactive protein (CRP) levels after elective colorectal surgery can predict an uneventful recovery. The study found that patients who developed early complications had higher CRP levels on the second postoperative day compared to uncomplicated patients. A decrease in CRP levels between the second and fifth postoperative days of less than 36% for open surgery and 48% for laparoscopic surgery indicated a risk of developing late complications. Monitoring CRP levels in the early postoperative period can help identify patients at risk of septic complications and guide safe discharge from the hospital.

1. A suficient decrease of C-reactive protein (CRP) after elective
colorectal surgery is a good marker of uneventful outcome.
Montserrat Juvany, Xavier Guirao, Sara
Amador, Ruben Hernando, Guzmán Franch*,
Miquel Casal, Josep Maria Badia.
Hospital General de Granollers, Barcelona.
*Hospital Universitario de Salamanca,
Salamanca.
Spain.
24th European Congress on Surgical Infection, 28th May, Leon.

2. Introduction
Complications in colo-rectal surgery
• Surgical site infection (SSI):
– Wound
– Organ-space
o Anastomotic leakage is the main cause (2-24%)
o It is associated with a postoperative mortality (7 to 25%)
o Delayed diagnosis and treatment might be associated with a
worse prognosis
o Previous observations have demonstrated that clinical
parameters of SIRS are not so useful as they are in
communitary organ-space infections
24th European Congress on Surgical Infection, 28th May, Leon.

3. Introduction
C- reactive protein (CRP)
• IL-6 dependent protein produced in the liver
• Appears in blood at 4 hour after the inflammatory stimulus
• Peaks at 48 hours
400
CRP 300
(mg/L)
200
100
0
Preop 24h 48h 120h 240h
24th European Congress on Surgical Infection, 28th May, Leon.

4. Objective
• To evaluate the utility
of CRP in the early
diagnosis of major
septic complications
after elective
colorectal surgery
24th European Congress on Surgical Infection, 28th May, Leon.

5. Material and methods
• Prospective
• Elective colo-rectal surgery
with primmary anastomosis
• 33 months (January 07-Sept
09)
• Analysis
– CRP: 2nd and 5th po days
• Data: mean ± SD
• Statistics:
– Student-t test
– Receiver operative curve
(ROC) test
24th European Congress on Surgical Infection, 28th May, Leon.

6. Material and methods
• Main variable: MAJOR
SURGICAL SITE
INFECTIONS
Major Minor
Surgical site • Deep wound • Superficial
infections (SSI) infection wound infection
• Organ-space
infection
No Surgical site • Cardiac arrest • Urinary infection
infections (no SSI) • Pneumonia • Phlebitis
• Ileus
24th European Congress on Surgical Infection, 28th May, Leon.

7. Results
Age (y) 68.3 ± 11.4
Gender (%) M: 61
F: 39
ASA (%) - I: 4 - III: 33
n=208 - II: 59 - IV: 4
IQ (%) - Right colect: 34 - Left colect: 9
- Sigmoidect: 27 - Hartmann rev: 6
- Rectum res: 22 - Subtotal colect: 2
Aproach (%) Open: 50
Laparoscopic: 50
24th European Congress on Surgical Infection, 28th May, Leon.

8. Results
n=208
n=113 n=95
no complics complics
n=38 n=57
minor major
n=48 n=9
SSI no SSI
NO MAJOR MAJOR
COMPLICATIONS COMPLICATIONS EXCLUDED
(n=151) (n=48)
LATE ≥5th EARLY
PO day <5th PO day
(n=38) (n=10)
24th European Congress on Surgical Infection, 28th May, Leon.

9. Results
CRP values on the 2nd postoperative day are higher in early
complicated patients in comparison to non-complicated patients
Early complicated Non-complicated
(n=10) (n=151)
CRP at the 2nd 241  109 156  76 p<0.005
PO day (mg/L)
The best cut-off point in the ROC curve test is a CRP
on the 2nd PO day higher than:
201 mg/L
NPV=0.98
24th European Congress on Surgical Infection, 28th May, Leon.

10. Results
CRP at the 2nd and the 5th PO days is higher in late complicated
patients (vs non-complicated) and the fall down is lower (D% CRP 2-5)
350
300
250
217  79 218  94
CRP (mg/L)
200
Late-complicated
150
157  48
100
57  48
50
Non-complicated
0
D0 D2 D5
Late complicated Non-complicated
(n=38) (n=151)
D % CRP 2-5 8  52 % -63  24% P<0.0001
24th European Congress on Surgical Infection, 28th May, Leon.

11. Results
¿Which is the best cut off point of D% CRP 2-5?
ROC curve
(n=189)
-39 %
PPV=0.62
NPV=0.97
¿Are there any differences considering
the approach of the surgery?
Laparoscopic approach
produces lower levels of CRP
Open (n=92)
(less surgical stress and
Laparoscopic (n=97)
contraregulation response)
-36% -48% and because of this it is
PPV=0.77 PPV=0.44
necessary a bigger falling
NPV=0.96 NPV=1
down of the CRP to be able to
exclude major complications.
24th European Congress on Surgical Infection, 28th May, Leon.

12. Conclusion
• A decrease of CRP between the 2nd and the 5th
postoperative days higher than 36% in open
surgery and 48% in laparoscopic are useful to
exclude major septic complications and to
discharge patients safely.
24th European Congress on Surgical Infection, 28th May, Leon.

13. 24th European Congress on Surgical Infection, 28th May, Leon.

14. Thanks to Dr Guirao for giving me the opportunity to collaborate in the study
24th European Congress on Surgical Infection, 28th May, Leon.