Postoperative CRP Levels Can Rule out Anastomotic Leaks in Crohn’s Disease Patients

Background: In colorectal cancer, C-reactive protein (CRP) levels on postoperative days 3–4 have a strong negative predictive value for an anastomotic leak, with threshold values of ~15 on post-operative day (POD) 3 and ~13 on POD 4. In Crohn’s disease, CRP levels are perceived as unreliable in the postoperative period because of the underlying inflammatory process. The aim of this study was to determine whether postoperative CRP levels can be used to rule out anastomotic leaks in patients with Crohn’s disease and to set CRP threshold values for this population. Methods: This was a retrospective study of a population of Crohn’s disease patients who underwent surgery with bowel anastomoses at a single high-volume center between 1/2012 and 12/2017. The operations were performed by a single colorectal consultant who is an inflammatory bowel disease specialist. Results: Ninety-two operations were performed. A CRP level of 19.56 mg/dL on postoperative day 3 had an area under the curve of 0.865 (sensitivity 88%, specificity 73%) and a negative predictive value (NPV) of 98% for an anastomotic leak. Patients with an anastomotic leak showed a trend towards decreased postoperative albumin levels (p = 0.06). Conclusions: Mean CRP levels and CRP threshold values were indeed higher in the study population compared with those in colorectal cancer patients. Threshold values were set at 20.3 mg/dL on POD 3, 19.5 mg/dL on POD 4 and 16.7 mg/dL on POD 5. These values had high NPVs and can be used to rule out anastomotic leaks in patients with Crohn’s disease after surgery with bowel anastomosis.

P-OGC88 Is Routine Contrast Swallow after Ivor-Lewis Oesophagectomy Required or Justified?

Background Traditionally many Upper-GI cancer tertiary centres have carried out contrast swallow fluoroscopic studies as a routine after Ivor-Lewis “Two-Stage” Oesophagectomy. However, more recently studies have demonstrated the limited value of this test as a routine screening study. The primary outcome of our study was to assess the sensitivity of routine contrast swallow in identifying anastomotic leak post oesophagectomy and identify how the study changed management of these patients. Methods This was a single-centre retrospective study involving 2-observer data collection. Data was collected and analysed from clinical notes for all patients who underwent an Ivor-Lewis oesophagectomy for cancer between January 2011 to December 2020. Results A total of 220 patients were identified. Protocol at the centre was to obtain a routine contrast swallow in the Fluoroscopy department on the fifth post-operative day– which occurred in 211 patients (96%). A total of 19 (8.64%) patients were diagnosed with an anastomotic leak (clinically and/or radiologically), with contrast swallow imaging and/or computed tomography (CT). There was no correlation between incidence of leak and T stage (p = 0.38) and N staging (p = 0.22). Only 3 of 19 anastomotic leaks were positively identified on contrast swallow study. All patients with anastomotic leak identified by contrast swallow study were asymptomatic i.e. “subclinical”. 2 patients were managed conservatively; one underwent endoscopic stent insertion. CT scan with oral contrast was the mode of diagnosis for 16 anastomotic leaks; where 10 patients underwent a CT scan following a normal contrast swallow study due to suspicious symptoms and 6 patients underwent expedited CT scans prior to Day-5 contrast swallow study due to presence of symptoms and limitation of fluoroscopy resources. The sensitivity of the Day-5 contrast swallow study was calculated to be 15.8% (CI 3.4, 39.6) with a specificity of 98.0% (CI 95.0, 99.5). Conclusions Our data reflects that routine contrast swallow study on Day-5 post Ivor-Lewis esophagectomy has a poor sensitivity in detecting anastomotic leak and may be falsely reassuring. The vast majority of patients had no change in management as a result of contrast swallow. This adds to the growing body of evidence limiting the role of contrast swallow in this situation. We recommend that clinical judgement and use of CT and endoscopy be the surgeon’s prime tools in the diagnosis of anastomotic leak post oesophagectomy.

P-OGC68 Prophylactic Endoluminal Vacuum Therapy (EVT) following oesophagectomy

Background Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for the management of anastomotic leaks following oesophagectomy. However, patients are often critically unwell with mediastinitis and established sepsis by the time the leak is diagnosed. This results in a protracted recovery period regardless of the effectiveness of EVT in treating the leak. Prophylactic EVT to protect the anastomosis following oesophagectomy may reduce the incidence of anastomotic leak, and/or mediastinitis and sepsis if the anastomosis does fail. We report the outcomes of two patients considered high risk for anastomotic leak who were managed with prophylactic EVT following esophagectomy for cancer. Methods Two patients received prophylactic EVT following oesophagectomy between May and July 2021. The patients were considered high risk for anastomotic leak due to technical concerns with, or complications during, the operation. In both cases the oesophagogastric anastomosis (OGA) was fashioned with a circular stapler. The endoluminal vacuum device (EVD) was constructed using an 18F nasogastric tube and a piece of open cell foam, and placed intraluminally across the anastomosis under endoscopic guidance at the time of surgery. Continuous negative pressure (125mmHg) was applied. Information relating to treatment and outcome was recorded prospectively. Results Patient-1, a 72-year-old female, ASA 2, underwent minimally invasive oesophgectomy for an adenocarcinoma at the gastro-oesophageal junction. After creating the stapled OGA, inspection revealed the proximal (oesophageal) tissue doughnut was complete but attenuated. Patient 2, a 67-year-old male, ASA 3, underwent a hybrid Ivor Lewis oesophgectomy for a lower 1/3 oesophageal adenocarcinoma. Surgery was complicated by significant intra-abdominal bleeding requiring blood transfusion and pressor support. In both cases, endoscopic assessment of the anastomosis following removal of the prophylactic EVD was performed day seven post-operatively. The anastomoses were healthy with no evidence of a leak, dehiscence, or early stricture formation. Conclusions In this limited case series, prophylactic EVT of the OGA following oesophagectomy was delivered safely with no complications related to insertion of the EVD or delivery of EVT. This intervention should be considered in cases where the risk of anastomotic leak is high. An intraluminal EVD situated across the OGA may minimise the extent of extraluminal contamination, and the systemic consequences of sepsis associated with this, should an anastomotic breakdown occur. Further studies are required to determine the safety of prophylactic EVT following oesophagectomy, and whether this improves surgical outcomes by reducing the incidence and impact of anastomotic leaks.

P-OGC79 Post-operative NUn score as a prognostic tool for anastomotic leak after Oesophagectomy

Background Anastomotic leak (AL) after esophagectomy is still quite high with incidence reported between 5 and 20%. Early detection of AL will enable patient rescue and the remedial measures may decrease the associated significant morbidity and improve quality of life. Oesophagectomy is also associated with other infective complications such as respiratory infections and collections in the abdomen or chest. Noble and Underwood (NUn) published the NUn score combining blood-borne markers of systemic inflammatory response to define risk of anastomotic leak and major complications following oesophageal resection. This study aims to validate the ability of NUn score to identify AL specifically. Methods A total of 113 patients who underwent esophagectomy for oesophageal cancer over 11 years from 2011 to early 2021 in our centre were selected for this study from a prospectively maintained database. Patients with leaks (n = 11) were identified by reviewing their case records, electronic records, endoscopy and radiological results. Patients with missing values were excluded. Postoperative 7-day (POD) biochemical data that included white cell count (WCC), C-reactive protein (CRP) and Albumin were used to calculate NUn score. Sensitivity and Specificity of NUn score with a cut-off value of > 10 was calculated using the ROC curve analysis using SPSS. Results A total of 99 patients were included, among which 10 patients had anastomotic leaks (AL). Overall mean of NUn of patients with AL was 10.25 vs 9.95 without AL. NUn scores for day 1 to 7 are shown in the table in figure 1. NUn with the highest AUC was Day 7 (0.664 [CI 0.499 – 0.829]; p = 0.09), with 70% sensitivity and 57.3% specificity. The trends in WCC, CRP and albumin levels over 7 days were also not helpful in differentiating patients with AL. Conclusions In this study, the trends in rising WCC, CRP and decreasing albumin were not helpful in diagnosing anastomotic leaks specifically. The NUn score had a sensitivity of 70% on day 7. Procalcitonin, blood urea nitrogen or interleukin levels may help, and further studies are being planned. This study shows that current biochemical parameters can complement but not replace careful and regular medical examination and early radiological or endoscopic evaluation if an AL is suspected.