Pankreatikoduodenektomi Sonrası Gelişen Postoperatif Pankreatik Fistül İçin Erken Bir Belirteç Olarak C-Reaktif Protein

Year 2025, Volume: 7 Issue: 3, 413 - 420, 13.10.2025

Ahmet Cihangir Emral , Mustafa Kerem

https://doi.org/10.52827/hititmedj.1758344

Abstract

Amaç: Pankreatikoduodenektomi (PD) sonrası gelişen klinik olarak anlamlı postoperatif pankreatik fistül (CR-POPF), cerrahi sonrası morbiditenin en önemli nedenlerinden biri olup, sekonder komplikasyonlara da zemin hazırlamaktadır. CR-POPF’nin erken dönemde tanınması, zamanında müdahale ve uygun dren yönetimi açısından kritik öneme sahiptir. Bu çalışmanın amacı, postoperatif 3. gün (POD 3) serum C-reaktif protein (CRP) düzeylerinin CR-POPF gelişimini öngörmedeki değerini değerlendirmektir.
Gereç ve Yöntem: Mart 2020 ile Şubat 2025 arasında merkezimizde PD uygulanan 112 hasta retrospektif olarak analiz edildi. Total veya distal pankreatektomi yapılanlar, neoadjuvan tedavi alanlar, kontrolsüz diyabeti olanlar, immünsüprese hastalar ve pankreas dışı anastomoz kaçağı gelişenler çalışma dışı bırakıldı. Postoperatif 3. gün serum CRP düzeyleri, dren amilaz konsantrasyonu ve drenaj hacmi kaydedildi. CR-POPF, Uluslararası Pankreas Cerrahisi Çalışma Grubu (ISGPS) kriterlerine göre tanımlandı. ROC eğrisi analizi ile CRP düzeylerinin tanısal performansı değerlendirildi. Ayrıca, çok değişkenli lojistik regresyon analizi ile CR-POPF için bağımsız risk faktörleri belirlendi.
Bulgular: CR-POPF, 17 hastada (%15,2) gelişti. Bu hastalarda pankreas duktus çapı anlamlı şekilde daha dar ve doku yapısı daha yumuşaktı (p < 0,01). ROC analizinde, POD 3 CRP düzeyi >161 mg/L olan hastalarda CR-POPF gelişimini öngörmede AUC 0,77, sensitivite %82,4 ve spesifisite %66,3 olarak bulundu. Lojistik regresyon analizinde, dar pankreatik duktus çapı ve yumuşak pankreas dokusu CR-POPF için bağımsız risk faktörleri olarak saptandı.
Sonuç: Pankreatikoduodenektomi sonrası 3. gün serum CRP düzeylerinin yüksek olması, CR-POPF gelişimini öngörmede anlamlı bir belirteçtir. CRP düzeylerinin rutin postoperatif değerlendirmeye dahil edilmesi, erken risk sınıflamasını kolaylaştırarak hasta yönetimi ve dren çekilme zamanlamasında klinik karar sürecine katkı sağlayabilir.

Keywords

C-Reaktif Protein , Postoperatif Pankreatik Fistül , Pankreatikoduodenektomi , Dren Yönetimi

C-reactive Protein as an Early Marker for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Abstract

Objective: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains one of the most serious complications following pancreaticoduodenectomy (PD), leading to increased morbidity and secondary adverse events. Early identification of CR-POPF risk is essential for timely intervention and optimal drain management. This study aimed to evaluate the predictive value of serum C-reactive protein (CRP) levels on postoperative day 3 (POD 3) for the development of CR-POPF.
Material and Method: We retrospectively analyzed 112 patients who underwent PD between March 2020 and February 2025. Patients with distal or total pancreatectomy, neoadjuvant therapy, poorly controlled diabetes, immunosuppression, or anastomotic leaks unrelated to the pancreas were excluded. Serum CRP levels, drain amylase concentration, and drainage volume were recorded on POD 3. CR-POPF was defined according to International Study Group on Pancreatic Surgery (ISGPS) criteria. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic performance of CRP. Multivariable logistic regression was used to identify independent risk factors for CR-POPF.
Results: CR-POPF occurred in 17 patients (15.2%). These patients had significantly softer pancreatic texture and smaller duct diameters (p < 0.01). ROC analysis revealed that a POD 3 CRP level >161 mg/L predicted CR-POPF with an area under the curve (AUC) of 0.77, sensitivity of 82.4%, and specificity of 66.3%. Logistic regression identified small duct diameter and soft pancreatic texture as independent predictors of CR-POPF.
Conclusion: Elevated POD 3 serum CRP levels are significantly associated with CR-POPF development after PD. Incorporating CRP into routine postoperative assessment may enhance early risk stratification, support clinical decision-making, and guide individualized drain management strategies.

Keywords

C-Reactive Protein , Postoperative Pancreatic Fistula , Pancreaticoduodenectomy , Drain Management

References

• Serene TEL, G SV, Padmakumar JS et al. Predictive value of post-operative drain amylase levels for post-operative pancreatic fistula. Ann Hepatobiliary Pancreat Surg 2018;22(4):397-404.
• Büchler MW, Friess H, Wagner M, et al. Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883-889.
• Liu Y, Li Y, Wang L, et al. Predictive value of drain pancreatic amylase concentration for postoperative pancreatic fistula on postoperative day 1 after pancreatic resection: An updated meta-analysis. Medicine (Baltimore) 2018;97(38):e12487.
• Hashimoto D, Satoi S, Yamamoto T, et al. Validation of the triple-checked criteria for drain management after pancreatectomy. J Hepatobiliary Pancreat Sci 2022;29(2):271-281.
• Koek S, Wiegele S, Ballal M. Drain fluid amylase and lipase as a predictive factor of postoperative pancreatic fistula. ANZ J Surg 2022;92(3):414-418.
• Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013;216(1):1-14.
• Kawai M, Tani M, Terasawa H et al. Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 2006;244(1):1-7.
• Bassi C, Molinari E, Malleo G, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg 2010;252(2):207-214.
• Yang J, Huang Q, Wang C. Postoperative drain amylase predicts pancreatic fistula in pancreatic surgery: A systematic review and meta-analysis. Int J Surg 2015;22:38-45.
• Rajab IM, Hart PC, Potempa LA. How C-Reactive Protein Structural Isoforms With Distinctive Bioactivities Affect Disease Progression. Front Immunol 2020;11:2126.
• Sproston NR, Ashworth JJ. Role of C-Reactive Protein at Sites of Inflammation and Infection. Front Immunol 2018;9:754.
• Singh PP, Zeng IS, Srinivasa S, et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 2014;101(4):339-346.
• Ortega-Deballon P, Facy O, Rat P. C-reactive protein to rule out infections after major abdominal surgery. Int J Colorectal Dis 2016;31(3):779-780.
• Guilbaud T, Birnbaum DJ, Lemoine C, et al. C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy. J Gastrointest Surg 2018;22(5):818-830.
• Ma J, Jiang P, Ji B, et al. Post-operative procalcitonin and C-reactive protein predict pancreatic fistula after laparoscopic pancreatoduodenectomy. BMC Surg 2021;21(1):171.
• Chen G, Yi H, Zhang J. Diagnostic value of C-reactive protein and procalcitonin for postoperative pancreatic fistula following pancreatoduodenectomy: a systematic review and meta-analysis. Gland Surg 2021;10(12):3252-3263.
• Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;161(3):584-591.
• Emral AC, Çetinkaya G, Dikmen K, Kerem M. The Predictive Effect of “Real Amylase Value”: A More Accurate Predictor for Postoperative Pancreatic Fistula. ANZ J Surg. 2025;doi.org/10.1111/ans.70276.
• Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142(5):761-768.
• Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142(1):20-25.
• Nebbia M, Capretti G, Nappo G, Zerbi A. Updates in the management of postoperative pancreatic fistula. Int J Surg 2024;110(10):6135-6144.
• Welsch T, Frommhold K, Hinz U, et al. Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery 2008;143(1):20-28.
• Mintziras I, Maurer E, Kanngiesser V, Bartsch DK. C-reactive protein and drain amylase accurately predict clinically relevant pancreatic fistula after partial pancreaticoduodenectomy. Int J Surg 2020;76:53-58.
• Wu AGR, Mohan R, Fong KY, et al. Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis. Langenbecks Arch Surg 2023;408(1):317.
• Zhu S, Yin M, Xu W, et al. Early Drain Removal Versus Routine Drain Removal After Pancreaticoduodenectomy and/or Distal Pancreatectomy: A Meta-Analysis and Systematic Review. Dig Dis Sci 2024;69(9):3450-3465.