Welsch Thilo, Frommhold Klaus, Hinz Ulf, Weigand Markus A, Kleeff Jörg, Friess Helmut, Büchler Markus W, Schmidt Jan
Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany.
Surgery. 2008 Jan;143(1):20-8. doi: 10.1016/j.surg.2007.06.010.
Serum C-reactive protein (CRP) is an established discriminating factor for necrotizing pancreatitis. In this study, the CRP response with respect to inflammatory postoperative complications was examined in a large, homogeneous series of pancreatic resections in order to define a relevant clinical parameter for early detection of inflammatory postoperative complications.
688 consecutive pancreatic resections with jejunal anastomosis were screened for inflammatory postoperative complications based on a prospective database. Ninety-one patients had at least one inflammatory postoperative complication and were compared to a subgroup of 60 consecutive patients with uneventful postoperative courses.
In the postoperative setting after pancreatic resection, CRP peaked on postoperative day (POD) 3 with a median serum CRP of 132 mg/L, and gradually decreased thereafter in patients with an uncomplicated postoperative course. In complicated cases (with the exception of cholangitis), increase in CRP was significantly greater, peaked on POD 3 (median CRP 173 mg/L), and persisted thereafter, whereas white blood cell count and body temperature did not differ significantly from uneventful courses until POD 6. The median day of diagnosis of inflammatory postoperative complications was POD 9. A cutoff CRP value of 140 mg/dL on POD 4 yielded a positive predictive value of 89.1% (adjusted to the prevalence of inflammatory postoperative complications: 48.7%) with a specificity of 87.1% and a sensitivity of 69.5% for inflammatory postoperative complications.
Persistence of CRP elevation above 140 mg/dL on POD 4 is predictive of inflammatory postoperative complications and should prompt an intense clinical search for major septic processes (e.g. pancreatic fistula or abscess) if pneumonia and wound infection are unlikely or excluded.
血清C反应蛋白（CRP）是坏死性胰腺炎的一个既定鉴别因素。在本研究中，为了确定一个用于早期检测术后炎症并发症的相关临床参数，我们在一系列大型、同质的胰腺切除术中检查了CRP对术后炎症并发症的反应。
基于一个前瞻性数据库，对688例连续进行空肠吻合术的胰腺切除术患者进行术后炎症并发症筛查。91例患者至少发生了一种术后炎症并发症，并与连续60例术后病程顺利的患者亚组进行比较。
在胰腺切除术后的情况下，CRP在术后第3天（POD 3）达到峰值，血清CRP中位数为132 mg/L，此后在术后病程顺利的患者中逐渐下降。在复杂病例（胆管炎除外）中，CRP的升高明显更大，在POD 3达到峰值（CRP中位数173 mg/L），并持续升高，而白细胞计数和体温在POD 6之前与病程顺利的患者没有显著差异。术后炎症并发症的中位诊断日期为POD 9。POD 4时CRP临界值为140 mg/dL，对术后炎症并发症的阳性预测值为89.1%（根据术后炎症并发症的患病率调整：48.7%），特异性为87.1%，敏感性为69.5%。
POD 4时CRP持续高于140 mg/dL可预测术后炎症并发症，如果不太可能或已排除肺炎和伤口感染，应促使临床密切寻找主要的感染性病变（如胰瘘或脓肿）。
