Relatively high mortality and morbidity rates are reported after liver resection (LR). However, the early predictors of complications after LR are not clear. This study was performed to clarify the usefulness of procalcitonin (PCT) for the early prediction of complications after elective LR.
This observational study included 72 consecutive patients who underwent elective LR from December 2015 to March 2017. Patients were categorized into two groups: those with and without postoperative complications (Clavien-Dindo grade ≥II). The values of postoperative inflammatory markers (white blood cell [WBC] count, C-reactive protein [CRP] and PCT) were compared between the two groups.
CRP and PCT were significantly higher in patients with than without complications; however, the WBC count showed no difference within 5 days postoperatively. The maximum area under the receiver operating characteristic curves within 2 days after LR using the WBC count, CRP and PCT were 0.608, 0.697 and 0.860, respectively, PCT had the best predictive ability in the early postoperative period. The PCT level peaked within 2 days postoperatively in 61 patients (85%). The maximum PCT level within 2 days postoperatively (PCT1−2) was significantly higher in patients with than without complications (0.52 vs. 0.19 ng/mL, p<0.001). A cutoff PCT1−2 level of 0.35 ng/mL achieved 80% sensitivity and 83% specificity. In patients without complications, there was no difference in PCT1−2 even when the surgical procedure differed (p=0.935).
PCT1−2 is an early predictive marker after LR and can be similarly used regardless of the LR procedure.
We thank Angela Morben, DVM, ELS, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.
Author contributions: YA – Study design, data collection, data analysis, writing first draft of manuscript, critical revisions, approved final version. NT – Study design, data analysis, approved final version. MY – Study design, data collection, data analysis, approved final version. YKaw – Study design, data analysis, approved final version. TS – Study design, data collection, data analysis, approved final version. TK – Data analysis, approved final version. RK – Study design, data collection, data analysis, approved final version. YKan – Study design, data collection, data analysis, approved final version. HF – Data analysis, approved final version. EU – Study design, critical revisions, approved final version. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: Nobuhiko Taniai received grants from Teijin Pharma Limited for research for liver transplantation; these grants were outside the scope of this work.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
1. Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397–406.Search in Google Scholar
2. Spolverato G, Ejaz A, Hyder O, Kim Y, Pawlik TM. Failure to rescue as a source of variation in hospital mortality after hepatic surgery. Br J Surg 2014;101:836–46.Search in Google Scholar
3. He J, Amini N, Spolverato G, Hirose K, Makary M, Wolfgang CL, et al. National trends with a laparoscopic liver resection: results from a population-based analysis. HPB 2015;17:919–26.Search in Google Scholar
4. Yokoo H, Miyata H, Konno H, Taketomi A, Kakisaka T, Hirahara N, et al. Models predicting the risks of six life-threatening morbidities and bile leakage in 14,970 hepatectomy patients registered in the National Clinical Database of Japan. Medicine (Baltimore) 2016;95:e5466.Search in Google Scholar
5. Amini N, Margonis GA, Kim Y, Wilson A, Gani F, Pawlik TM. Complication timing impacts 30-d mortality after hepatectomy. J Surg Res 2016;203:495–506.Search in Google Scholar
6. Lee CW, Tsai HI, Sung CM, Chen CW, Huang SW, Jeng WJ, et al. Risk factors for early mortality after hepatectomy for hepatocellular carcinoma. Medicine (Baltimore) 2016;95:e5028.Search in Google Scholar
7. Hoeboer SH, Groeneveld AB, Engels N, van Genderen M, Wijnhoven BP, van Bommel J. Rising C-reactive protein and procalcitonin levels precede early complications after esophagectomy. J Gastrointest Surg 2015;19:613–24.Search in Google Scholar
8. Boleslawski E, Vibert E, Pruvot FR, Le Treut YP, Scatton O, Laurent C, et al. Relevance of postoperative peak transaminase after elective hepatectomy. Ann Surg 2014;260:815–20.Search in Google Scholar
9. Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The “50-50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 2005;242:824–8.Search in Google Scholar
10. Paugam-Burtz C, Janny S, Delefosse D, Dahmani S, Dondero F, Mantz J, et al. Prospective validation of the “fifty-fifty” criteria as an early and accurate predictor of death after liver resection in intensive care unit patients. Ann Surg 2009;249:124–8.Search in Google Scholar
11. Hyder O, Pulitano C, Firoozmand A, Dodson R, Wolfgang CL, Choti MA, et al. A risk model to predict 90-day mortality among patients undergoing hepatic resection. J Am Coll Surg 2013;216:1049–56.Search in Google Scholar
12. Roberts KJ, Bharathy KG, Lodge JP. Kinetics of liver function tests after a hepatectomy for colorectal liver metastases predict post-operative liver failure as defined by the International Study Group for Liver Surgery. HPB 2013;15:345–51.Search in Google Scholar
13. Hayashi Y, Takayama T, Yamazaki S, Moriguchi M, Ohkubo T, Nakayama H, et al. Validation of perioperative steroids administration in liver resection: a randomized controlled trial. Ann Surg 2011;253:50–5.Search in Google Scholar
14. Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C. High serum procalcitonin concentrations in patients with sepsis and infection. Lancet 1993;341:515–8.Search in Google Scholar
15. Wrenger S, Kahne T, Bohuon C, Weglohner W, Ansorge S, Reinhold D. Amino-terminal truncation of procalcitonin, a marker for systemic bacterial infections, by dipeptidyl peptidase IV (DP IV). FEBS Lett 2000;466:155–9.Search in Google Scholar
16. Morgenthaler NG, Struck J, Fischer-Schulz C, Seidel-Mueller E, Beier W, Bergmann A. Detection of procalcitonin (PCT) in healthy controls and patients with local infection by a sensitive ILMA. Clin Lab 2002;48:263–70.Search in Google Scholar
17. Gendrel D, Raymond J, Assicot M, Moulin F, Iniguez JL, Lebon P, et al. Measurement of procalcitonin levels in children with bacterial or viral meningitis. Clin Infect Dis 1997;24:1240–2.Search in Google Scholar
18. Hedlund J, Hansson LO. Procalcitonin and C-reactive protein levels in community-acquired pneumonia: correlation with etiology and prognosis. Infection 2000;28:68–73.Search in Google Scholar
19. Ugarte H, Silva E, Mercan D, De Mendonca A, Vincent JL. Procalcitonin used as a marker of infection in the intensive care unit. Crit Care Med 1999;27:498–504.Search in Google Scholar
20. Peters RP, Twisk JW, van Agtmael MA, Groeneveld AB. The role of procalcitonin in a decision tree for prediction of bloodstream infection in febrile patients. Clin Microbiol Infect 2006;12:1207–13.Search in Google Scholar
21. Liaudat S, Dayer E, Praz G, Bille J, Troillet N. Usefulness of procalcitonin serum level for the diagnosis of bacteremia. Eur J Clin Microbiol Infect Dis 2001;20:524–7.Search in Google Scholar
22. van Nieuwkoop C, Bonten TN, van’t Wout JW, Kuijper EJ, Groeneveld GH, Becker MJ, et al. Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: a prospective observational study. Crit Care 2010;14:R206.Search in Google Scholar
23. Meisner M, Tschaikowsky K, Palmaers T, Schmidt J. Comparison of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations at different SOFA scores during the course of sepsis and MODS. Crit Care 1999;3:45–50.Search in Google Scholar
24. Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010;375:463–74.Search in Google Scholar
25. Reith HB, Mittelkotter U, Debus ES, Kussner C, Thiede A. Procalcitonin in early detection of postoperative complications. Dig Surg 1998;15:260–5.Search in Google Scholar
26. Garcia-Granero A, Frasson M, Flor-Lorente B, Blanco F, Puga R, Carratala A, et al. Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study. Dis Colon Rectum 2013;56:475–83.Search in Google Scholar
27. Giaccaglia V, Salvi PF, Cunsolo GV, Sparagna A, Antonelli MS, Nigri G, et al. Procalcitonin, as an early biomarker of colorectal anastomotic leak, facilitates enhanced recovery after surgery. J Crit Care 2014;29:528–32.Search in Google Scholar
28. Kassir R, Blanc P, Bruna Tibalbo LM, Breton C, Lointier P. C-reactive protein and procalcitonin for the early detection of postoperative complications after sleeve gastrectomy: preliminary study in 97 patients. Surg Endosc 2015;29:1439–44.Search in Google Scholar
29. Giardino A, Spolverato G, Regi P, Frigerio I, Scopelliti F, Girelli R, et al. C-reactive protein and procalcitonin as predictors of postoperative inflammatory complications after pancreatic surgery. J Gastrointest Surg 2016;20:1482–92.Search in Google Scholar
30. Kerin Povsic M, Ihan A, Beovic B. Post-operative infection is an independent risk factor for worse long-term survival after colorectal cancer surgery. Surg Infect (Larchmt) 2016;17:700–12.Search in Google Scholar
31. Ren H, Ren J, Hu Q, Wang G, Gu G, Li G, et al. Prediction of procalcitonin for postoperative intraabdominal infections after definitive operation of intestinal fistulae. J Surg Res 2016;206:280–5.Search in Google Scholar
32. Zielinska-Borkowska U, Dib N, Tarnowski W, Skirecki T. Monitoring of procalcitonin but not interleukin-6 is useful for the early prediction of anastomotic leakage after colorectal surgery. Clin Chem Lab Med 2017;55:1053–9.Search in Google Scholar
33. Medina-Fernandez FJ, Diaz-Lopez C, Briceno J. A different approach to the use of C-reactive protein and procalcitonin in postoperative infectious complications. Ann Surg 2017;266:e98–9.Search in Google Scholar
34. Munoz JL, Ruiz-Tovar J, Miranda E, Berrio DL, Moya P, Gutierrez M, et al. C-reactive protein and procalcitonin as early markers of septic complications after laparoscopic sleeve gastrectomy in morbidly obese patients within an enhanced recovery after surgery program. J Am Coll Surg 2016;222:831–7.Search in Google Scholar
35. Itatsu K, Sugawara G, Ebata T, Yokoyama Y, Igami T, Kainuma M, et al. The diagnostic value of procalcitonin for major hepatectomy with biliary reconstruction in hepato – biliary tumor (in Japanese with English abstract). J Jpn Soc Surg Infect 2012;9:315–20.Search in Google Scholar
36. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13.Search in Google Scholar
37. Perez SB, Rodriguez-Fanjul J, Garcia IJ, Hernando JM, Iriondo Sanz M. Procalcitonin is a better biomarker than C-reactive protein in newborns undergoing cardiac surgery: the PROKINECA study. Biomark Insights 2016;11:123–9.Search in Google Scholar
38. Klingele M, Bomberg H, Schuster S, Schafers HJ, Groesdonk HV. Prognostic value of procalcitonin in patients after elective cardiac surgery: a prospective cohort study. Ann Intensive Care 2016;6:116.Search in Google Scholar
39. Facy O, Paquette B, Orry D, Binquet C, Masson D, Bouvier A, et al. Diagnostic accuracy of inflammatory markers as early predictors of infection after elective colorectal surgery: results from the IMACORS study. Ann Surg 2016;263:961–6.Search in Google Scholar
40. Popov D, Yaroustovsky M, Lobacheva G. Prevention of infectious complications after heart surgery in children: procalcitonin-guided strategy. Kardiochir Torakochirurgia Pol 2014;11:140–4.Search in Google Scholar
41. Kaido T, Ogawa K, Fujimoto Y, Mori A, Hatano E, Okajima H, et al. Perioperative changes of procalcitonin levels in patients undergoing liver transplantation. Transpl Infect Dis 2014;16:790–6.Search in Google Scholar
42. Asakura T, Ito H, Yoshida Y, Negishi H, Kobayashi S, Koizumi S, et al. Usefulness of serum procalcitonin (PCT) measurement for predicting early infectious complications after pancreatoduodenectomy (PD). J Jpn Soc Surg Infect 2010;7:583–8.Search in Google Scholar
43. Dorge H, Schondube FA, Dorge P, Seipelt R, Voss M, Messmer BJ. Procalcitonin is a valuable prognostic marker in cardiac surgery but not specific for infection. Thorac Cardiovasc Surg 2003;51:322–6.Search in Google Scholar
44. Meisner M, Rauschmayer C, Schmidt J, Feyrer R, Cesnjevar R, Bredle D, et al. Early increase of procalcitonin after cardiovascular surgery in patients with postoperative complications. Intensive Care Med 2002;28:1094–102.Search in Google Scholar
45. Mokart D, Merlin M, Sannini A, Brun JP, Delpero JR, Houvenaeghel G, et al. Procalcitonin, interleukin 6 and systemic inflammatory response syndrome (SIRS): early markers of postoperative sepsis after major surgery. Br J Anaesth 2005;94:767–73.Search in Google Scholar
46. Sarbinowski R, Arvidsson S, Tylman M, Oresland T, Bengtsson A. Plasma concentration of procalcitonin and systemic inflammatory response syndrome after colorectal surgery. Acta Anaesthesiol Scand 2005;49:191–6.Search in Google Scholar
47. Meisner M, Tschaikowsky K, Hutzler A, Schick C, Schuttler J. Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med 1998;24:680–4.Search in Google Scholar
48. Kerbaul F, Guidon C, Lejeune PJ, Mollo M, Mesana T, Gouin F. Hyperprocalcitonemia is related to noninfectious postoperative severe systemic inflammatory response syndrome associated with cardiovascular dysfunction after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2002;16:47–53.Search in Google Scholar
49. Odermatt J, Friedli N, Kutz A, Briel M, Bucher HC, Christ-Crain M, et al. Effects of procalcitonin testing on antibiotic use and clinical outcomes in patients with upper respiratory tract infections. An individual patient data meta-analysis. Clin Chem Lab Med 2018;561:170–7.Search in Google Scholar
50. Kretzschmar M, Kruger A, Schirrmeister W. Procalcitonin following elective partial liver resection – origin from the liver? Acta Anaesthesiol Scand 2001;45:1162–7.Search in Google Scholar
The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2018-0196).
©2018 Walter de Gruyter GmbH, Berlin/Boston