Role of Procalcitonin as a Biomarker in Early Identification of Adverse Events Following Esophageal Atresia Surgery

Abstract

Introduction: Surgical complication following esophageal atresia repair is one of the several factors known to influence the final outcomes. Early identification of such complications may help in timely institution of therapeutic measures and translate into improved prognosis.

Objective: The objective of this study was to evaluate the role of procalcitonin in early prediction of the adverse events after surgery in patients of esophageal atresia and the temporal relationship with clinical manifestations and other inflammatory biomarkers such as C-reactive protein (CRP).

Materials and methods: This was a prospective study on consecutive patients of esophageal atresia (n = 23). Serum procalcitonin and CRP levels were assessed at baseline (prior to surgery) and on postoperative days (POD) 1, 3, 5, 7, and 14. The trends in the biomarker values and temporal relationships of deviation in trend with the clinical and conventional laboratory parameters and patient outcomes were analyzed.

Results: Baseline serum procalcitonin was elevated (n = 23; 1.7 ng/ml: min: 0.07 ng/ml-max: 24.36 ng/ml) in 18/23 (78.3%) patients. Procalcitonin nearly doubled on POD-1 (n = 22; 3.28 ng/ml: min: 0.64 ng/ml-max: 16.51 ng/ml) followed by a gradual decline. CRP was also elevated on POD-1 (three times the baseline) and depicted a delayed peak at POD-3. POD-1 procalcitonin and CRP levels correlated with survival. POD-1 procalcitonin cutoff at 3.28 ng/ml predicted mortality with a sensitivity and specificity of 100% and 57.9% (P = 0.05). Serum procalcitonin and CRP were higher for patients who sustained complications, so was the time required for hemodynamic stabilization. Procalcitonin (baseline and POD-5) and CRP (POD-3 and POD-5) values correlated with the clinical course after surgery. Baseline procalcitonin cutoff at 2.91 ng/ml predicted the possibility of a major complication with a sensitivity of 71.4% and a specificity of 93.3%. POD-5 procalcitonin cutoff at 1.38 ng/ml predicted the possibility of a major complication with a sensitivity of 83.3% and a specificity of 93.3%. Patients who sustained major complications depicted a change in serum procalcitonin trend 24-48 h ahead of clinical manifestation of an adverse event.

Conclusions: Procalcitonin is a good indicator to identify the adverse events in neonates after surgery for esophageal atresia. The procalcitonin levels in patients who sustained a major complication depicted a reversal in trend 24-48 h of clinical manifestation. POD-1 procalcitonin correlated with survival while the baseline and POD-5 serum procalcitonin predicted the clinical course.

Keywords: Adverse event; C-reactive protein; biomarker; esophageal atresia; procalcitonin; sepsis; surgical complication.

Chart 1

Mapping of study participants into groups based on clinical course

Figure 1

Trends of serum procalcitonin and C-reactive protein levels in the study cohort (box and whisker chart)

Figure 2

(a) ROC curves depicting sensitivity and specificity of serum procalcitonin at baseline between Groups A and B vs. Group C, (b) ROC curves depicting sensitivity and specificity of serum procalcitonin on POD-5 between Groups A and B vs. Group C, (c) ROC curves depicting sensitivity and specificity of serum procalcitonin on POD-1 between outcomes (mortality vs. no mortality), (d) ROC curves depicting sensitivity and specificity of serum CRP on POD-3 between Groups A and B vs. Group C, (e) ROC curves depicting sensitivity and specificity of serum CRP on POD-5 between Groups A and B vs. Group C. (f) ROC curves depicting sensitivity and specificity of serum CRP on POD-1 between outcomes (mortality vs. no mortality). CRP: C-reactive protein, POD: Postoperative days, ROC: Receiver operating characteristic

Figure 3

Trends of serum procalcitonin and C-reactive protein among patients stratified into Groups A, B, and C

Figure 4

Diagrammatic depiction of the temporal relationship of clinical indicators of underlying adverse events with the leukocyte count, CRP, and procalcitonin in individual patients substratified into Group C. CRP: C-reactive protein