Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study.

BACKGROUND: Although the early diagnosis of anastomotic leak is a key point in reducing its clinical consequences, in daily practice, anastomotic leak diagnosis is often late. OBJECTIVE: The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery. DESIGN: This is a prospective observational study. SETTINGS: This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital. PATIENTS: A series of 205 consecutive patients who underwent elective colorectal surgery in a specialized unit was prospectively analyzed. The following data were collected: demographic, surgical, ASA class, POSSUM, and morbidity. During the first 5 postoperative days, procalcitonin, C-reactive protein, leukocytes, platelets, and vital signs were evaluated daily. INTERVENTIONS: Daily assessment of clinical variable and serological data were conducted in the first 5 postoperative days. MAIN OUTCOME MEASURES: The primary outcome measure was the area under the curve at receiving operating characteristic curve analysis of the different variables in relation to the anastomotic leak. RESULTS: Anastomotic leak was detected in 17 (8.3%) patients; 11(5.4%) of the patients had a major anastomotic leak (need for drainage or reoperation). None of the variables evaluated were shown to be reliable in the early detection of anastomotic leak, considering both minor and major (maximum area under the curve <0.80). In contrast, when considering only major anastomotic leaks, procalcitonin and C-reactive protein were reliable predictors on postoperative days 3 to 5 (p < 0.0001, area under the curve >0.80). The best combination was procalcitonin at postoperative day 5 (area under the curve = 0.86), with a cutoff of 0.31 ng/mL, resulting in a 100% sensitivity, 72% specificity, 100% negative predictive value, and 17% positive predictive value. LIMITATIONS: Only symptomatic patients were investigated to rule out anastomotic leakage. CONCLUSIONS: Procalcitonin and C-reactive protein are both reliable predictors of major anastomotic leak after colorectal resection, although procalcitonin is more accurate. Raised procalcitonin and C-reactive protein serum concentration on postoperative days 3 to 5 renders necessary a careful evaluation of the patient before discharge.

Giant pancreatic insulinoma. The bigger the worse? Report of two cases and literature review.

INTRODUCTION: Giant pancreatic insulinomas are rare endocrine tumors. We describe 2 cases reviewing the current literature. PRESENTATION OF CASE: We report herein 2 female patients affected by giant insulinomas of 14cm and 6cm, respectively. Symptomatic hypoglycemia episodes occurred during 4 months in first case and 3 years in the second one until diagnosis. Both patients were successfully treated performing a distal pancreatectomy with splenic preservation in the first case and a Whipple's procedure in the second one. DISCUSSION: Up to now only 7 cases have been reported previously. Insulinomas larger than 3cm accounts for less than 5% of all. This literature review shows that despite the size hypoglycemic symptoms varies from 1 day to 3 years and only 1 out of 9 cases reported presented lymph nodes metastases. No recurrences have been described. CONCLUSION: One of the cases here described (14cm) is the largest presented in the literature. Despite the size, giant insulinoma is related apparently neither to metastases nor to the recurrences.

Pathological evaluation of mesocolic resection quality and ex vivo methylene blue injection: what is the impact on lymph node harvest after colon resection for cancer?

BACKGROUND: Although the National Quality Forum has endorsed the harvest of ≥12 lymph nodes as a standard quality indicator for colon cancer surgery, this minimum quantity is not reached in many centers. OBJECTIVE: The aim of this study was to assess the impact of the implementation of a mesocolon evaluation pathological protocol and ex vivo arterial methylene blue injection on the number of nodes harvested after colon cancer resection. DESIGN: A prospective series was compared with a historical group. SETTINGS: This study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital. PATIENTS: From June 2009 to December 2009, all the specimens after colon resection for cancer were analyzed with the use of a "mesocolon quality pathological evaluation" protocol. Moreover, a consecutive series of specimens was analyzed after arterial ex vivo injection of methylene blue. We compared the study groups with our previous series (2005-2009). INTERVENTIONS: The "mesocolon quality pathological evaluation" protocol was used with or without arterial methylene blue ex vivo injection. MAIN OUTCOME MEASURE: The primary outcome measure was the number of lymph nodes harvested. RESULTS: The mean number (SD) of lymph nodes collected was 20.6 (10.5), 37.1 (12.8), and 47.6 (12.9) (p < 0.0001) in the control, protocol, and methylene blue groups. In the control group, the minimum number of 12 and 18 lymph nodes collected was not reached in 92 (15.9%) and 258 (44.6%) patients. In contrast, all patients in the protocol and methylene blue groups had more than 18 lymph nodes collected. The multivariate analysis confirmed the application of the "mesocolon quality pathological evaluation" protocol and the methylene blue ex vivo injection, along with the type of resection and the length of the specimen, to be independent factors determining the number of nodes collected. LIMITATIONS: The patients are not randomly selected and are compared with a retrospective series. CONCLUSION: The implementation of a "mesocolon quality pathological evaluation" protocol along with the arterial ex vivo injection of methylene blue can significantly increase the number of nodes isolated after colonic resection, reaching a 100% rate of specimens with more than 12 nodes.