title: Attempted validation of the NUn score and inflammatory markers as predictors of esophageal anastomotic leak and major complications.
abstract: The ability to predict complications following esophagectomy/extended total gastrectomy would be of great clinical value. A recent study demonstrated significant correlations between anastomotic leak (AL) and numerical values of C-reactive protein (CRP), white cell count (WCC) and albumin measured on postoperative day (POD) 4. A predictive model comprising all three (NUn score >10) was found to be highly sensitive and discriminant in predicting AL and complications. We attempted a retrospective validation in our center. Data were collected on all resections performed during a 5-year period (April 2008-2013) using prospectively maintained databases. Our biochemistry laboratory uses a maximum CRP value (156 mg/L), unlike that of the original study; otherwise all variables and outcome measures were comparable. Analysis was performed for all patients with complete blood results on POD4. Three hundred twenty-six patients underwent resection, of which 248 had POD4 bloods. There were 21 AL overall (6.44%); 16 among those with complete POD4 blood results (6.45%). There were 8 (2.45%) in-hospital deaths; 7 (2.82%) in those with POD4 results. No parameters were associated with AL or complication severity on univariate analysis. WCC was associated with AL in multivariate binary logistic regression with albumin and CRP (OR 1.23 [95% CI 1.03-1.47]; P = 0.021). When a binary variable of CRP ≥ 156 mg/L was used rather than an absolute value, no factors were significant. Mean NUn was 8.30 for AL, compared with 8.40 for non-AL (P = 0.710 independent t-test). NUn > 10 predicted 0 of 16 leaks (sensitivity 0.00%, specificity 94.4%, receiver operator curve [ROC] area under the curve [AUC] 0.485; P = 0.843). NUn > 7.65 was 93% sensitive and 21.6% specific. ROC for WCC alone was comparable with NUn (AUC 0.641 [0.504-0.779]; P = 0.059; WCC > 6.89 93.8% sensitive, 20.7% specific; WCC > 15 6.3% sensitive and 97% specific). There were no associations between any parameters and other complications. In a comparable cohort with the original study, we demonstrated a similar multivariate association between WCC alone on POD4 and subsequent demonstration of AL, but not albumin or CRP (measured up to 156 mg/L). The NUn score overall (calculated with this caveat) and a threshold of 10 was not found to have clinical utility in predicting AL or complications.
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: J M
authors.initials: JM
authors.lastname: Findlay
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: R C
authors.initials: RC
authors.lastname: Tilson
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: A
authors.initials: A
authors.lastname: Harikrishnan
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: B
authors.initials: B
authors.lastname: Sgromo
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: R E K
authors.initials: RE
authors.lastname: Marshall
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: N D
authors.initials: ND
authors.lastname: Maynard
authors.affiliation: Oxford OesophagoGastric Centre, Churchill Hospital, Oxford, UK.
authors.forename: R S
authors.initials: RS
authors.lastname: Gillies
authors.affiliation: NIHR Biomedical Research Centre, Churchill Hospital, Oxford, UK.
authors.forename: M R
authors.initials: MR
authors.lastname: Middleton
mesh_terms: D000714:Anastomosis, Surgical / Q000009:adverse effects; D057868:Anastomotic Leak / Q000097:blood / Q000209:etiology*; D019540:Area Under Curve; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis*; D016629:Esophagectomy / Q000009:adverse effects*; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects*; D006801:Humans; D007958:Leukocyte Count; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011184:Postoperative Period; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012709:Serum Albumin / Q000032:analysis*; D013997:Time Factors
chemical_list: D015415:Biomarkers; D012709:Serum Albumin; D002097:C-Reactive Protein
keywords: anastomotic leak; decision support technique; esophagectomy; gastrectomy; risk