Early detection of anastomotic leakage in colon cancer surgery: the role of early warning score and C-reactive protein

Gyung Mo Son

doi:10.3393/ac.2024.00661.0094

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Editorial Early detection of anastomotic leakage in colon cancer surgery: the role of early warning score and C-reactive protein: Gyung Mo Son^1,2; Annals of Coloproctology 2024;40(5):415-416.
DOI: https://doi.org/10.3393/ac.2024.00661.0094
Published online: October 16, 2024

¹Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea

²Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea

Correspondence to: Gyung Mo Son, MD, PhD, FACS Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea Email: skm1711@pusan.ac.kr

• Received: September 27, 2024 • Accepted: September 27, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Anastomotic leakage (AL) is one of the most common complications of colon cancer surgery with an incidence of approximately 10% [1]. Despite careful surgical techniques and preventive measures, AL persists, making early detection critical for improving patient outcomes [2]. Surgeons routinely monitor patients postoperatively and assess vital signs and symptoms such as fever and abdominal pain [3]. However, these symptoms can be nonspecific and may result from various postoperative complications. This highlights the need for more objective and reliable evaluation methods.

This study proposes a predictive tool that combines the clinical early warning score (EWS) with C-reactive protein (CRP) levels to enhance the early detection of AL [4]. Due to the extensive nature of colon cancer surgeries, which often involve radical lymph node dissection and wide mobilization of the colon, CRP levels frequently exceed the normal postoperative range, complicating the use of CRP as a standalone predictor. Nonetheless, rapid increases in CRP, particularly at levels exceeding 200 mg/L, are associated with a higher risk of complications, including AL [5].

The EWS is a valuable tool for detecting early signs of inflammatory complications such as AL and incorporating vital signs such as respiratory rate, oxygen saturation, supplemental oxygen requirement, temperature, systolic blood pressure, and heart rate [6]. These parameters reflect the systemic inflammatory response often observed in postoperative complications, prompting surgeons to investigate a range of potential issues, including pneumonia, urinary tract infections, wound infections, ischemic and infectious colitis, abdominal abscesses, and AL. Common diagnostic evaluations include physical examination, chest radiography, abdominal computed tomography scans, urinalysis, blood chemistry, blood cultures, and endoscopy, particularly when abdominal tenderness is present [3].

However, early-stage AL often presents with vague symptoms and subtle systemic inflammatory responses, leading to potential diagnostic delays. This issue is particularly prominent in patients aged >70 years, where the inflammatory response may be attenuated or delayed [7]. Thus, integrating CRP levels with the EWS provides a more robust approach, enhancing the early detection of AL, even when the initial clinical signs are subtle, especially in ambiguous cases.

Among laboratory tests, CRP is a well-established marker of acute inflammation, offering a reliable indicator of the body's response to postoperative complications. This study suggests that an EWS of 2.4 combined with a CRP level of 180 mg/L on postoperative day 3 provides a critical threshold for detecting the risk of AL [4]. Patients who meet these criteria warrant further diagnostic evaluations, which can facilitate early diagnosis and treatment, potentially mitigating the impact of this serious complication.

Efforts to enhance AL detection include the daily monitoring of amylase and lipase levels in the drainage fluid, which can serve as additional follow-up tests [8]. However, economic costs must be considered when selecting laboratory screening evaluations for AL detection. It is essential to establish a cost-effective and systematic diagnostic pathway that includes sensitive daily tests tailored to detect leaks efficiently without imposing unnecessary financial burdens on healthcare systems [9]. Continued research is required to refine these diagnostic protocols to balance their sensitivity, specificity, and cost-effectiveness.

Surgeons are dedicated to minimizing postoperative complications through meticulous surgical techniques and implementation of early recovery and rehabilitation programs [10]. The integration of EWS monitoring, careful physical examinations, and laboratory evaluations, such as CRP, can significantly enhance the early detection of AL, enabling prompt intervention. This proactive approach not only improves patient recovery, but also reduces the risk of severe postoperative complications, ultimately lowering mortality rates and enhancing patient safety.

In conclusion, combining EWS with CRP levels represents a promising strategy for early identification of AL in colon cancer surgery. This approach supports timely decision making and improves patient outcomes by providing a more objective measure of complication risk. As healthcare continues to evolve, integrating predictive tools, such as EWS and CRP, will be pivotal in advancing the safety and efficacy of surgical care.

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Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study was supported by a 2024 research grant from Pusan National University Yangsan Hospital (Yangsan, Korea).

REFERENCES

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