CT Scan in the Postoperative Management of Colorectal Surgery Complications: Balancing Clinical Usefulness and OveruseAbstract
Objective To evaluate whether computed tomography (CT) was overused in the early postoperative period in oncologic colorectal surgery.
Materials and Methods We conducted a single-center retrospective study including all patients who underwent colorectal resection with an anastomosis for colorectal adenocarcinoma between 2018 and 2022. The indications and findings of postoperative abdominopelvic CT scans performed during the initial hospital stay were collected, excluding the CT scans performed after discharge.
Results A total of 1,091 patients were included. The overall morbidity rate was of 32%. Abdominopelvic CT scans were performed in 284 patients (26%), including 25% for isolated C-reactive protein (CRP) elevation without clinical signs. In total, 30% of the scans performed (n = 84) were normal, with 93% of those patients subsequently experiencing no severe postoperative complications. In cases of isolated CRP elevation, the rate of normal abdominopelvic CT scans was of 38%. In the multivariate analysis, we identified 3 factors associated with a normal abdominopelvic CT: scans performed within the first 4 postoperative days (p = 0.004), isolated CRP elevation (p = 0.010), and absence of a diverting ileostomy (p = 0.044). A predictive score based on these factors showed probabilities of a normal CT of 7%, 22%, 35%, and 54% when 0, 1, 2, or 3 factors were present respectively. Among patients with a normal scan, 39% were discharged within 24 hours, rising to 68% when the CT was performed for isolated CRP elevation.
Conclusion Postoperative abdominopelvic CT scans are frequently performed after colorectal surgery, with normal findings in about 1/3 of the cases in our experience. When normal—especially in the context of isolated CRP elevation—abdominopelvic CT scans exclude major complications and help accelerate an earlier and safe patient discharge.
Keywords
colorectal surgery; adenocarcinoma; tomography; postoperative complications
Introduction
Oncological colorectal surgery with bowel continuity restoration is associated with a significant overall morbidity rate of approximately 35%.1 Among the complications, anastomotic leakage (AL) is one of the most severe, with reported incidences ranging from 2 to 30%.2,3 Anastomotic leakage leads to increased postoperative morbidity, and it can also have negative impacts on oncological outcomes and long-term functional results.4,5
In routine practice, clinical symptoms such as fever or abdominal pain can help detect postoperative complications. However, these signs often lack specificity, limiting their diagnostic value. To enhance the detection of AL, two primary tools are now widely used: assessment of the levels of C-reactive protein (CRP) and computed tomography (CT) scans.6–8 An inflammatory marker, CRP is elevated in response to septic or inflammatory events, and it has been shown to be higher in patients with AL following colorectal surgery. Cut-off thresholds have been proposed, such as CRP levels above 100 mg/L on postoperative day (POD) 3 or 4, achieving a sensitivity of 72% and a specificity of 75% to diagnose intra-abdominal complications.9 When AL is suspected, CT scans are commonly employed to confirm the diagnosis. In this indication, abdominal CT scans have a sensitivity of 76 to 84% and a specificity of 84 to 92%.10,11
While preventing AL remains the ultimate objective, early diagnosis is equally critical, as timely intervention can reduce its morbidity.12 Anastomotic leakage has also an impact on hospital length and on economic burden.13 However, the reliance on CT scans raises concerns about potential misuse or overuse in the clinical practice. The aim of the current study was to evaluate the frequency, indications, and relevance of abdominopelvic CT scans performed postoperatively for suspected complications after surgery for a colorectal adenocarcinoma with an anastomosis.
Materials and Methods
All patients who underwent oncological colorectal surgery for a colorectal adenocarcinoma with an anastomosis performed during the same procedure between January 2017 and June 2022 at Hôpital Saint Antoine (Paris, France) were retrospectively included. Patients with ileoanal anastomosis, multiple colorectal tumors, no anastomosis, local excision of the tumor or extracolonic associated procedures, such as liver resection or adjacent organ resection, were excluded from the study.
Procedures
A laparoscopic approach was preferred whenever possible, and no robotic surgery was performed during the inclusion period. A diverting stoma was always performed in case of low colorectal anastomosis or coloanal anastomosis. In our department, after oncological colorectal surgery, the patients underwent daily clinical evaluations, and CRP measurements were routinely performed every 48 hours starting at POD 1 or 2. The CT scans were performed based on the clinical suspicion of postoperative complications such as abdominal pain, fever, persistent paralytic ileus, or based on CRP levels higher than 100 mg/mL after POD 2.9 At our hospital, the scanners used were the Revolution HD 128 (GE HealthCare; first use in August 2022) and the SOMATOM Definition Edge (Siemens Healthineers; first use January 2018). If the renal clearance was normal, every CT scan was injected with a portal venous phase; arterial phases were added only if acute bleeding was suspected, and no rectal contrast enema was used. Enhanced recovery protocols were implemented depending on the type of surgery and the patient's condition. Our objective was to enable patients undergoing colonic surgery to be discharged home on POD 3, and patients undergoing rectal cancer surgery with low anastomosis requiring a protective ileostomy to be discharged home on POD 5.14 These objectives are contingent upon the patient's general condition and a home environment that supports early discharge, as well as the absence of postoperative complications. No colorectal resections were performed on an outpatient basis at our center.
Outcomes
All data were retrospectively collected. The CRP measurements were grouped into 3 time intervals: POD 1 to 2, POD 3 to 4, and POD 5 to 6. For patients with multiple CRP measurements within a 48-hour window, the last measurement was retained for analysis. Overall postoperative morbidity encompassed any deviation from the normal postoperative course occurring until 30 days after the surgical procedure. Morbidity was graded according to the Clavien-Dindo classification.15 Complications classified as Clavien-Dindo III or higher were considered major. Anastomotic leakage was defined as a communication between the intra- and extraluminal compartments due to a defect of the integrity of the anastomosis. Any perianastomotic abscess that occurred after the confection of the anastomosis was also considered AL. Abdominopelvic CT scans without evidence of AL, intra-abdominal or abdominal wall abscess, paralytic ileus, hematoma or other abnormalities were classified as normal. Radiological data were collected from the CT scan reports issued at the time of the scan, which served as the basis for the surgeon's decision-making regarding further management.
Statistical Analysis
The quantitative variables were reported as mean ± standard deviation (SD) values and compared using the Student's t-test for normally-distributed data. For data not following a normal distribution, the variables were presented as median and interquartile range (IQR) values and analyzed using the Mann-Whitney U test. The qualitative variables were expressed as numbers (percentages) and analyzed using the Chi-squared (χ2) test or the Fisher's exact test, as applicable. All statistical tests were two-tailed, with p-values < 0.05 considered statistically significant. Univariate analyses were conducted using binary logistic regression to identify variables associated with a normal CT scan among patients who underwent abdominopelvic CT in the postoperative course. Multivariate analyses were then performed using a backward binary logistic regression model to identify variables independently associated with a normal CT scan, including all variables with a p-value < 0.05 in the univariate analysis. A score to predict the absence of abnormality on the CT scan was developed by assigning a value of 1 to each variable that was statistically associated with the performance of a normal CT scan in the multivariate analysis. All statistical analyses were performed using the IBM SPSS Statistics for Windows (IBM Corp.) software, version 26.0.
Results
Population
Between January 2017 and June 2022, 1,355 patients underwent surgery for colorectal adenocarcinoma. After the exclusion of 20 patients operated for ileal pouch-anal anastomosis, 17 patients, for multiple colorectal tumors, 119 patients without anastomosis and 108 patients, for major extracolonic associated procedures, 1,091 (81%) patients were included in the study. Their mean age was of 66.1 ± 12.9 years, and there were slightly more male (57%) compared to female patients. Most of the patients underwent a laparoscopic procedure (n = 908; 84%). In this cohort, 463 (42%) patients underwent colorectal anastomosis, 344 (32%) patients, ileocolic anastomosis, and 208 (19%) subjects, coloanal anastomosis. Diverting loop ileostomy was performed for 325 patients (30%). Details of the patients' characteristics are shown in Table 1.
Postoperative Outcomes
The overall morbidity rate was of 32%, and that of severe morbidity was of 10% (Table 1). Ileocolic anastomosis yielded the lowest overall morbidity and AL rates respectively: 27% and 6%. Coloanal and ileorectal anastomosis resulted in higher overall morbidity with 42 to 53% and 17 to 27% of AL respectively. The mean length of stay was of 7.7 days, and readmissions were required in 78 patients (7%). Among all the patients, 562 (52%) were discharged before POD 5, and 218 (20%), before POD 3. In total, 125 patients (12%) were diagnosed with AL, including 14 patients (11%) after hospital discharge. The mean time until AL diagnosis was of 6.25 ± 4.7 days, and 54 patients (43%) were diagnosed before POD 4. Overall, 51 patients (41%) were treated with antibiotics alone, 45 patients (36%) had radiological or surgical drainage, and 29 patients (23%) had an anastomotic takedown.
Computed Tomography Scan
In total, 284 (26%) patients underwent an abdominopelvic CT scan. The main reasons for the CT scan were elevated CRP for 199 patients (71%), fever for 103 patients (37%), and abdominal pain for 86 patients (31%) (Table 2). Among the 199 (71%) patients undergoing a CT scan with elevated CRP, 70 patients (25%) had no clinical signs. The mean levels of CRP levels in patients undergoing a CT scan at POD 3 to 4 and POD 5 to 6 were of 184 mg/mL and 135.5 mg/mL respectively. A total of 179 (63%) patients underwent a CT scan before POD 4. Among the 286 patients with CRP levels ≥ 130 mg/mL at POD 3 tp 4, 124 (43%) did not undergo a CT scan.
Overall, 84 patients (30%) had a normal CT scan, 59 (21%) presented fluid collection or abscess, and 49 subjects (17%) presented fluid effusion (Table 2). When comparing the indications for the scan between subjects with normal CT scans and the other patients, there were significantly more patients (37%) undergoing a CT scan for isolated elevated CRP levels without clinical signs on the normal scan compared with the other patients (20%) (p = 0.001) (Table 3). Among patients with a normal CT scan, 6 (7%) developed during the next days a severe postoperative complication, including 3 patients (4%) with an AL (2 with unexplained fever and 1 with pus in the drainage liquid, all 3 treated with antibiotics only), and 78 patients (93%) had no severe complications in the postoperative period.
Risk Factors of Normal CT-Scan
In the univariate analysis, sex, age, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) score, neoadjuvant therapy, open surgery, type of anastomosis, drainage and conversion did not influence the risk of having a normal CT scan (Table 4). In the multivariate analysis, the absence of diverting loop ileostomy (odds ratio [OR]: 1.968; 95%CI: 1.018–3.805; p = 0.04), a scan required for isolated elevated CRP (OR: 2.212; 95%CI: 1.211–4.040; p = 0.01), and a CT scan before POD 4 (OR: 2.638; 95%CI: 1.358–5.125; p = 0.004) were significatively associated with a normal CT scan. We found a strong association between the type of anastomosis and no diverting loop ileostomy (Cramér's V = 0.76; p < 0.001). Given the obvious collinearity, only "no diverting loop ileostomy" was included in the multivariate model.
Predictive Score of a Normal CT Scan
According to the results of the multivariate analysis, we generated a score to predict the probability of having a normal CT scan. The absence of diverting loop ileostomy, a CT scan ordered for elevated CRP levels without clinical sign, and a CT scan before POD 4 were each assigned 1 point as the ORs were close in value for the 3 variables. A score of 0 meant a 7% probability of having a normal CT scan, a score of 1, 22%, a score of 2, 35%, and a score of 3, 54% (Fig. 1). Patients with a score of 0 had an overall morbidity rate of 93%, with 47% of severe morbidity and 49% of AL, whereas patients with a score of 3 had an overall morbidity of 41%, with a severe morbidity of 15% and 24% of AL.
Normal computed tomography (CT) scan prediction score. Under each score are reported the corresponding number of patients, overall morbidity, severe morbidity, and anastomotic leakage rate.
Impact on the Length of Stay
Among the patients who underwent a CT scan in the postoperative course (n = 284), 39% were discharged from the hospital in the next 24 hours. If the CT scan was required for isolated high CRP levels without clinical signs and the result was a normal scan, 68% of them were discharged in the next 24 hours. Among patients without any postoperative complication (n = 747, (68%)), the median CRP levels were significantly higher in those who underwent a CT scan compared with those who did not, both at POD 1to 2 (114 [IQR: 75–157] mg/L versus 80 [IQR: 51–115] mg/L; p < 0.001) and at POD 3 to 4 (133 [IQR: 95–195] mg/L versus 82 [IQR: 54–114] mg/L; p < 0.001). The median length of stay was also significantly longer in patients who underwent a CT scan (5 [IQR: 4–8] days) compared with those who did not (4 [IQR: 3–6] days; p < 0.001).
Discussion
In our cohort of 1,091 patients, 284 (26%) underwent a CT scan. Among those patients, 30% did not identified any complication, and 93% (78/84) of "with a normal CT-Scan" did not experience any major postoperative complication, suggesting that in selected cases—particularly in patients with elevated CRP without any clinical signs—a normal CT scan may help safely expedite hospital discharge. A predictive score based on 3 independent factors—absence of diverting loop ileostomy, CT scan performed before POD 4, and indication based solely on elevated CRP—was developed; higher scores were associated with a greater likelihood of normal CT findings and lower morbidity, potentially helping guide imaging decisions and discharge planning.
In the current study, 26% of the patients underwent a CT scan during the hospital stay. These data are rarely reported, but they are quite similar to those of 3 other studies evaluating CT scans and AL: 21% of patients in the study by Doeksen et al.16 on CT after the confection of a colorectal anastomosis, 33% in the study by Talboom et al.11 on CT after low anterior resection for rectal cancer, and 32% in the study by Holl et al.10 on CT and CRP. In the present study, main reason for a CT scan was elevated CRP levels at POD 3 to 4 or POD 5 to 6, associated or not with clinical signs such as abdominal pain or fever. However, 25% (70/284) of the patients underwent CT for elevated CRP levels without clinical signs. In our hospital, no specific protocol or algorithm was used for CT scans and CRP levels after surgery, as 43.3% (124/286) of patients with CRP levels ≥ 130 mg/mL did not undergo CT. Holl et al.10 proposed an algorithm with a CT scan at POD 4 if CRP levels > 125 mg/mL in patients without clinical signs of intra-abdominal infection after colorectal surgery, which resulted in a rate of 44.6% of normal scans and 26.8% of CT-scan diagnosed AL.10 In their study,10 28% of the patients with a normal CT scan had been diagnosed with AL, and the scans had a sensitivity of 76.7% for the detection of intra-abdominal infection. Among the 284 patients that underwent CT in the present study, 84 (29,6%) had normal scans, which included 3 patients (4%) who were diagnosed with an AL afterwards. These three patients were managed with antibiotics, without radiological or surgical procedures. The literature7,10,16,17 has shown that CT scans have a good negative predictive value (NPV), ranging from 77 to 100%, and a quite good sensitivity, ranging from 56 to 82%. It also appears that using rectal contrast enema could improve the sensitivity and NPV of AL detection.7,17,18 Even if the NPV of the CT scan is high, there are false-negative results, and delay in AL diagnosis is associated with higher morbidity.19,20 Moreover, the sensitivity of the CT scan is lower in early PODs compared with late PODs, and patients are more likely to present a normal scan in early PODs, but this does not completely rule out postoperative complications.16
We investigated the risk factors of having a normal CT scan, and there was a significant association with three factors in the multivariate analysis: no diverting loop ileostomy, CT scan for elevated CRP levels without clinical signs, and CT scan before POD 4. In our unit, diverting loop ileostomy was proposed for patients with a high risk of AL due to the type of anastomosis (coloanal anastomosis, for example) or due to patient characteristics; thus, patients without ileostomy were less likely to present AL, and this could explain the association with normal CT scans when this exam was ordered. High CRP levels are associated with AL in colorectal surgery.6,8,21 A recent meta-analysis21 established that a cut-off CRP value of 148 mg/mL at POD 3 or 124 mg/mL at POD 4 had a sensitivity and a specificity from 95% to 100% for AL. Ar strategy other than using cut-off values could be to assess postoperative changes in CRP levels to predict AL.6 However, the positive predictive value (PPV) of the CRP is low, which could explain why many patients (44% in the current study) will undergo a CT scan that will be normal.6,21 The levels of CRP seem more appropriate to rule out AL, and CRP values < 100 mg/mL at POD 3 could enable hospital discharge with a 3% readmission rate.8,9,22 Several studies have also assessed the use of other inflammatory markers, such as procalcitonin (PCT), or CRP levels and other inflammatory markers in drain fluid. If PCT is a valid inflammatory marker, it has not shown better results in de the detection of AL compared with CRP.22 Inflammatory markers in drain fluid could be promising, but they need to be evaluated in larger scale studies.8,23,24,25
In the current work, 63% (179/284) of the CT scans were performed before POD 4, since early diagnosis and treatment of AL is a major issue.20 In a previous work,26 our team showed that, among patients who developed AL, this complication was diagnosed in 33% (156 patients) before POD 4, in a cohort of 834 patients with coloanal or colorectal anastomosis between 2012 and 2017, compared with 43% (54/125) in the current study. In that previous work,26 the rate of success of the antibiotic treatment alone was of 35% (54/156 patients) compared with 40% (51/125) in the present study. We found that the CT scans could have been used for earlier hospital discharge, as 39% (33/84) of the patients with a normal scan were discharged in the next 24 hours, and up to 68% (21/31) when the scan was ordered for elevated CRP levels without clinical signs of intra-abdominal infection. Another action could be to keep the patient in hospital to control the CRP levels and clinical evolution during the next 2 days without performing a scan in case of favorable evolution. Using three factors associated in the multivariate analysis with the risk of having a normal CT scan, we created a score to calculate the probability of that. If scores of 3 yield 54% of probability of having a normal CT scan, there are still 15% of severe complications and 24% of AL diagnosed later in the postoperative period, suggesting that an early normal CT scan cannot rule out the occurrence of a postoperative complication later. For such patients in whom an early discharge can be proposed, alternative management could be an early appointment with the physician for CRP level control, and a CT scan could be ordered if the CRP levels have not decreased.
The present study has limitations. It was a single-center retrospective study, so the postoperative management analyzed is the one recommended in our unit and practices differ among centers; other colorectal surgeons may perform fewer CT scans compared with us, notably in case of isolated elevated CRP levels. Additionally, the practices can also be influenced by the medical system of each country regarding the cost and availability of a CT scans and the cost of a day in hospital. Second, in the current study, a normal CT scan was defined on the report written by the radiologist; therefore, there can be a bias regarding the interpretation according to the practician analyzing the images.
Conclusion
At our colorectal unit, postoperative CT was performed in 1 out of 4 patients, with normal findings in nearly 1/3 of the cases. When performed early or for isolated CRP elevation, a normal CT can supports earlier and safe discharge. Further studies should define the optimal indications to ensure a safe and cost-effective postoperative strategy.
Data Availability
Data will be available upon request to the corresponding author.
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Edited by
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Editor-in-Chief:
Henrique Sarubbi Fillmann.
