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Efficacy of C-Reactive Protein Measurement in Predicting Postoperative Morbidity and Pancreatic Fistula Following Pancreaticoduodenectomy
*John W Kunstman, *James M Healy, *Timothy D Murtha, Ronald R. Salem
Yale University, New Haven, CT

Objective: Enormous improvement in mortality following pancreaticoduodenectomy (PD) has not been accompanied by a corresponding improvement in postoperative morbidity. In particular, incidence of postoperative pancreatic fistula (POPF) remains high. C-reactive protein (CRP) has been investigated as a surrogate marker for anastomotic leakage following gastrointestinal surgery. This study sought to examine the utility of CRP in predicting POPF and morbidity following PD.
Design: Prospective case series
Setting: Academic tertiary center
Patients: 139 consecutive patients undergoing PD from 1/2013 to 12/2015.
Intervention: Serum CRP was assessed daily in patients undergoing PD during their primary admission
Outcome Measures: The primary outcome assessed was POPF as defined by international consensus. Secondary outcomes included overall morbidity as assessed by Clavien-Dindo classification and other events of interest. Complications were correlated with CRP levels and statistical analysis was performed.
Results: Mean CRP increased from 63 on postoperative day (POD) #1 to 205 on POD#3 among all patients. POPF occurred in 17 patients (12.2%); mean CRP was equivalent to non-POPF patients on POD#1 but increased to 271±46 versus 196±66 in non-POPF patients by POD#2 (p<0.001) and remained significantly elevated through POD#6. Incidence of POPF with CRP>250 for ≥3 days was 55% (relative risk 26.9, C.I. 7.9-91.7) versus 6.7% with CRP<180 (relative risk 0.26, C.I. 0.003-0.209). 0% of patients with CRP<170 for ≥3 days experienced POPF. Similar correlations with CRP were observed for major (Clavien≥3) complications. Among assessed patients requiring readmission, CRP>130 strongly correlated with POPF or abscess formation (p<0.001).
Conclusions: Elevated levels of CRP in patients undergoing PD demonstrates significant correlation with incidence of POPF and other major complications. This may enable early identification of morbidity and facilitate earlier discharge in appropriate patients.


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