The Predictive Value of Inflammatory Biomarkers in Esophageal Anastomotic Leaks

Retrospective Clinical Study on Early Prediction of Anastomotic Leak After Esophageal Cancer Resection Based on the Combination of Platelet Count and Neutrophil-to-Lymphocyte Ratio

OBJECTIVE

 The systemic inflammatory response may influence the occurrence of postoperative complications. This study aimed to evaluate the predictive potential of combining platelet count and neutrophil-to-lymphocyte ratio (COP-NLR) for esophagogastric anastomotic leak (AL) following esophageal cancer surgery.

METHODS

 We enrolled patients who developed AL after radical surgery for esophageal cancer and those who did not develop AL after the surgery at the First Affiliated Hospital of Chongqing Medical University, China, from June 2019 to February 2022. We analyzed the correlation between AL and several risk factors, including COP-NLR. Patients were categorized as COP-NLR 2 if both platelet count and neutrophil-to-lymphocyte ratio (NLR) were elevated, COP-NLR 1 if either parameter was elevated, and COP-NLR 0 if neither parameter showed elevation.

RESULTS

 A total of 190 patients were included in this study. The incidence of AL after esophageal cancer surgery was 14.7%. The critical values of preoperative NLR and preoperative platelet count were 2.41 (sensitivity 48.8%, specificity 92.9%, and area under the curve (AUC) 0.728) and 186 × 109/L (sensitivity 45.3%, specificity 78.9%, and AUC 0.667), respectively. According to multivariate analysis, COP-NLR was identified as an independent risk factor for AL (COP-NLR 1 vs. COP-NLR 0: odds ratio (OR) 4.98, 95% confidence interval (CI) 1.05-23.61; COP-NLR 2 vs. COP-NLR 0: OR 11.12, 95% CI 2.31-53.41).

CONCLUSION

 COP-NLR is a new predictor for AL after esophageal cancer resection.

Biomarkers associated with anastomotic leakage after esophagectomy: a systematic review

PURPOSE

Anastomotic leakage (AL) is one of the most important complications that occurs after upper gastrointestinal surgery, registering rates of 20-30% after esophagectomy. The role of systemic inflammatory biomarkers to predict anastomotic leaks is controversial and needs systematization.

METHODS

A systematic review based on the PRISMA guidelines criteria was performed. PubMed, Scopus, and Embase were queried using MESH Terms and All Fields key words to identify studies investigating a range of immune-inflammatory factors in predicting AL.

RESULTS

Twenty-four studies were included in this review. The total number of included patients was 5903, ranging in each study from 42 to 612. The included studies reported patients that underwent different techniques of esophagectomy (Ivor Lewis, McKeown, Orringer or thoracoabdominal esophagectomy) and 23 out of 24 studies included patients that underwent neoadjuvant treatment. While different biomarkers at different timepoints were analyzed, most studies have indicated postoperative biomarkers, between day 3 and day 5 to reach statistical significance.

CONCLUSIONS

Systemic inflammatory biomarkers represent potential risk stratification and predicting tools for AL after esophageal surgery, but more studies need to be conducted to validate their clinical utility.

PROFUGO study protocol: Predictive model for the early diagnosis of anastomotic leak after esophagectomy and gastrectomy

In esophagogastric surgery, the appearance of an anastomotic leak is the most feared complication. Early diagnosis is important for optimal management and successful resolution. For this reason, different studies have investigated the value of the use of markers to predict possible postoperative complications. Because of this, research and the creation of predictive models that identify patients at high risk of developing complications are mandatory in order to obtain an early diagnosis. The PROFUGO study (PRedictivO Model for Early Diagnosis of anastomotic LEAK after esophagectomy and gastrectomy) is proposed as a prospective and multicenter national study that aims to develop, with the help of artificial intelligence methods, a predictive model that allows for the identification of high-risk cases. of anastomotic leakage and/or major complications by analyzing different clinical and analytical variables collected during the postoperative period of patients undergoing esophagectomy or gastrectomy.

Association of inflammatory biomarkers with overall survival in burn patients: a systematic review and meta-analysis

INTRODUCTION

The inflammatory response to burn injuries can lead to organ dysfunction that ultimately results in increased mortality and morbidity. This meta-analysis was conducted to determine the efficacy of inflammatory biomarkers, including the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), procalcitonin (PCT), and C-reactive protein (CRP) as predictive tools of mortality among burn patients.

MATERIAL AND METHODS

The biomarker levels of survivors and non-survivors were consolidated according to guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Three main databases were searched electronically: PubMed, Web of Science, and Scopus, on December 8, 2022. The Newcastle-Ottawa Quality Assessment Scale (NOS) was used to evaluate and score the methodological quality of the included studies. The standard mean difference (SMD) with a 95% confidence interval (CI) was utilized.

RESULTS

Twenty-four studies were included in our systematic review and meta-analysis, (3636 total burn patients), of whom 2878 survived. We found that deceased burn patients had elevated levels of NLR (SMD = 0.60, 95% CI; 0.19-1.00, P < 0.001), CRP (SMD = 0.80, 95% CI; 0.02-1.58, P = 0.04), and PCT (SMD = 0.85, 95% CI; 0.45-1.24, P < 0.001), compared to survivors. However, we found no association between PLR and mortality among burn patients (SMD = 0.00, 95% CI; -0.14-0.15, P < 0.001). In addition, CRP was significantly higher in non-survivors (SMD = 0.80, 95% CI; 0.02-1.58, P =0.04). Similar results were also found about PCT (SMD = 0.85, 95% CI; 0.45-1.24, P < 0.001). When we analyzed the PCT data, collected in the first 24-48 hours, we found similar results; the PCT level was significantly higher in non-survivors in the immediate postinjury-period (SMD = 0.67, 95% CI; 0.31-1.02, P < 0.001). There was no publication bias among studies on the role of NLR in burn (Egger's test P = 0.91). The based cut-off values for NLR (13), CRP (71), and PCT (1.77) yielded sensitivities of 69.2%, 100%, and 93.33%, and specificities of 76%, 72.22%, and 72.22% respectively.

DISCUSSION/CONCLUSIONS

PCT is a marker of sepsis, therefore its elevated level is presumably associated with a higher incidence and severity of sepsis among non-survivors. In addition, NLR and CRP are promising biomarkers for predicting and guiding prevention against burn deaths in clinical settings.

Drainage fluid LDH and neutrophil to lymphocyte ratio as biomarkers for early detecting anastomotic leakage in patients undergoing colorectal surgery

OBJECTIVES

In this study, we investigated the role of several circulating and drainage fluid biomarkers for detecting postoperative complications (PCs) and anastomotic leakage (AL) in patients undergoing colorectal surgery.

METHODS

All consecutive patients undergoing colorectal surgery between June 2018 and April 2020 were prospectively considered. On postoperative days (POD) 1, 3, and 5, we measured lactate dehydrogenase (LDH) in drainage fluid, C-reactive protein (CRP) in serum and drainage fluid, and neutrophil to lymphocyte ratio (NLR).

RESULTS

We enrolled 187 patients. POD1 patients with AL had higher serum CRP levels, while on POD3 and on POD5 higher NLR and serum CRP. LDH and CRP in drainage fluid were also significantly higher at both time points. The area under the curves (AUCs) of serum and drainage fluid CRP were 0.752 (0.629-0.875) and 0.752 (0.565-0.939), respectively. The best cut-off for serum and drainage fluid CRP was 185.23 and 76 mg/dL, respectively. The AUC of NLR on POD3 was 0.762 (0.662-0.882) with a sensitivity and specificity of 84 and 63 %, respectively, at a cut-off of 6,6. Finally, drainage fluid LDH showed the best diagnostic performance for AL, with an AUC, sensitivity, and specificity of 0.921 (0.849-0.993), 82 %, and 90 % at a cut-off of 2,186 U/L. Trends in serum parameters between patients with or without PCs or AL were also evaluated. Interestingly, we found that NLR decreased faster in patients without PCs than in patients with PCs and patients with AL.

CONCLUSIONS

Drainage fluid LDH and NLR could be promising biomarkers of PCs and AL.

The significance of preoperative neutrophil-to-lymphocyte ratio in predicting short-term complications and survival benefits of pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

The established association between the inflammatory marker, neutrophil-lymphocyte ratio (NLR), and both long-term surgical prognosis and short-term postoperative complications is well-recognized. However, its prognostic value in pancreaticoduodenectomy (PD) is yet to be ascertained. This meta-analysis investigates the prognostic relevance of preoperative NLR in PD patients.

METHOD

We systematically searched electronic databases to identify studies exploring the relationship between pre-treatment blood NLR levels and overall survival (OS), disease-free survival (DFS), and immediate postoperative complications in PD patients. Statistical evaluations, using RevMan 5.4 and Stata 12, focused on hazard ratios (HRs) and risk ratios (RRs). Additionally, subgroup analyses, publication bias tests, and sensitivity analyses were performed.

RESULT

Our analysis encompassed 18 retrospective studies, with NLR cutoff values ranging from 2 to 3.8. The meta-analysis revealed that PD patients with elevated NLR had diminished OS and DFS, evidenced by an HR of 1.35 (95% CI: 1.11-1.64, p ​= ​0.003) and 1.62 (95% CI: 1.15-2.27, p ​= ​0.005), respectively. Moreover, NLR emerged as an independent determinant of immediate postoperative complications, indicated by an OR of 1.91 (95% CI: 1.01-3.59, p ​= ​0.013) and an HR of 2.15 (95% CI: 1.23-3.73, p ​< ​0.01).

CONCLUSION

NLR serves as a significant prognostic indicator for both OS and DFS following PD and is a reliable predictor of postoperative complications. Preoperative Neutrophil-to-Lymphocyte Ratio (NLR) is a significant prognostic indicator for overall survival (OS) and disease-free survival (DFS) in patients undergoing pancreaticoduodenectomy (PD).

Systematic review of the significance of neutrophil to lymphocyte ratio in anastomotic leak after gastrointestinal surgeries

INTRODUCTION

The inflammatory response is thought to be a critical initiator of epigenetic alterations. The neutrophil to lymphocyte ratio (NLR), a biomarker of inflammation, is computed by dividing the number of neutrophils by the number of lymphocytes. The primary goal of this systematic review and meta-analysis was to evaluate the pre-operative NLR of gastrointestinal surgery patients who had an anastomotic leak (AL) in comparison to those who did not AL.

METHODS

We performed a comprehensive search for relevant papers published before May 4, 2022, using PubMed, Scopus, and Web of Science. Standardized mean difference (SMD) with a 95% confidence interval (CI) was pooled in meta-analysis to yield a summary estimate. We utilized the random-effects model to create pooled effects since we discovered a substantial heterogeneity level. For evaluating quality, the Newcastle-Ottawa scale (NOS) was implemented.

RESULTS

The research comprised 12 studies with a total of 2940 individuals who had GI operations, 353 of whom went on to develop AL. We discovered that patients who had GI surgeries and acquired AL had significantly higher NLR levels than those who did not (random-effects model: SMD = 0.75, 95% CI = 0.11-1.38, p = 0.02). Patients with AL showed significantly higher NLR levels than control group in retrospective studies (SMD = 0.93, 95% CI = 0.20-1.66, p=0.01) but not in prospective studies (SMD = - 0.11, 95% CI = - 0.65-0.43, p = 0.69), according to the subgroup analysis based on research design. Subgroup analysis based on ethnicity yielded that white patients with AL exhibited significantly higher NLR values than the control group (SMD = 1.35, 95% CI = 0.01-2.68, p = 0.04) but this result was not applied to East Asian patients (SMD = 0.14, 95% CI = -0.13-0.41, p = 0.29).

CONCLUSION

Our research suggests a potential association between preoperative NLR and postoperative AL. However, it is essential to acknowledge the variability in the findings, with significantly higher NLR levels observed in retrospective studies and among white patients, but not consistently replicated in prospective studies and among East Asian patients. Further investigations with larger and more diverse cohorts are warranted to validate these findings and explore potential factors contributing to the observed discrepancies.

Tumour extracellular vesicles induce neutrophil extracellular traps to promote lymph node metastasis

Lymph nodes (LNs) are frequently the first sites of metastasis. Currently, the only prognostic LN assessment is determining metastatic status. However, there is evidence suggesting that LN metastasis is facilitated by the formation of a pre-metastatic niche induced by tumour derived extracellular vehicles (EVs). Therefore, it is important to detect and modify the LN environmental changes. Earlier work has demonstrated that neutrophil extracellular traps (NETs) can sequester and promote distant metastasis. Here, we first confirmed that LN NETs are associated with reduced patient survival. Next, we demonstrated that NETs deposition precedes LN metastasis and NETs inhibition diminishes LN metastases in animal models. Furthermore, we discovered that EVs are essential to the formation of LN NETs. Finally, we showed that lymphatic endothelial cells secrete CXCL8/2 in response to EVs inducing NETs formation and the promotion of LN metastasis. Our findings reveal the role of EV-induced NETs in LN metastasis and provide potential immunotherapeutic vulnerabilities that may occur early in the metastatic cascade.

Establishment and external validation of neutrophil-to-lymphocyte ratio in excluding postoperative pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Factors excluding postoperative pancreatic fistula (POPF), facilitating early drain removal and hospital discharge represent a novel approach in patients undergoing enhanced recovery after pancreatic surgery. This study aimed to establish the relevance of neutrophil-to-lymphocyte ratio (NLR) in excluding POPF after pancreatoduodenectomy (PD).

METHODS

A prospectively maintained database of patients who underwent PD at two high-volume centres was used. Patients were divided into three cohorts (training, internal, and external validation). The primary endpoints of this study were accuracy, optimal timing, and cutoff values of NLR for excluding POPF after PD.

RESULTS

From 2012 to 2020, in a 2:1 ratio, 451 consecutive patients were randomly sampled as training (n = 301) and validation (n = 150) cohorts. Additionally, the external validation cohort included 197 patients between 2018 and 2020. POPF was diagnosed in 135 (20.8 per cent) patients. The 90-day mortality rate was 4.1 per cent. NLR less than 8.5 on postoperative day 3 (OR, 95 per cent c.i.) was significantly associated with the absence of POPF in the training (2.41, 1.19 to 4.88; P = 0.015), internal validation (5.59, 2.02 to 15.43; P = 0.001), and external validation (5.13, 1.67 to 15.76; P = 0.004) cohorts when adjusted for relevant clinical factors. Postoperative outcomes significantly differed using this threshold.

CONCLUSION

NLR less than 8.5 on postoperative day 3 may be a simple, independent, cost-effective, and easy-to-use criterion for excluding POPF.

Anastomotic Rings and Inflammation Values as Biomarkers for Leakage of Stapled Circular Colorectal Anastomoses

Reliable markers to predict or diagnose anastomotic leakage (AL) of stapled circular anastomoses following colorectal resections are an important clinical need. Here, we aim to quantitatively investigate the morphology of anastomotic rings as an early available prognostic marker for AL and compare them to established inflammatory markers. We perform a prospective single-center cohort study, including patients undergoing stapled circular anastomosis between August 2020 and August 2021. The predictive value of the anastomotic ring configuration and the neutrophil-to-lymphocyte ratio (NLR) regarding anastomotic leakage is examined by ROC analyses and compared to the C-reactive protein (CRP) as an established marker. We included 204 patients, of which 19 suffered from anastomotic leakage (LEAK group), while in 185 patients the anastomoses healed well (HEAL group). The minimal height of the anastomotic rings as a binary classifier had a good ROC-AUC of 0.81 but was inferior to the NLR at postoperative day (POD) 5, with an excellent ROC-AUC of 0.93. Still, it was superior to the NLR at POD 3 (0.74) and the CRP at POD 3 (ROC-AUC 0.54) and 5 (ROC-AUC 0.70). The minimal height of the anastomotic rings as indicator for technically insufficient anastomoses is a good predictor of AL, while postoperatively the NLR was superior to the CRP in prediction of AL.

Peripheral blood inflammation indices are effective predictors of anastomotic leakage in elective esophageal surgery

BACKGROUND

This study investigated the predictive value of peripheral inflammatory indices, including neutrophil count, lymphocyte count, platelet count, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), in anastomotic leakage during elective esophageal surgery.

METHODS

This retrospective study included all patients who underwent esophagectomy for esophageal squamous cell carcinoma from 2016 to 2020 in our institution. The peripheral blood inflammatory indices were obtained on preoperative days 1-7 (PRD 1-7), and postoperative days 1-3 (POD 1-3) and 4-7 (POD 4-7). Univariate, multivariate logistic, and receiver operating characteristic curve analyses were conducted to evaluate the diagnostic value of these peripheral blood inflammatory indices.

RESULTS

A total of 198 patients were included in the study, and 25 (13%) patients experienced anastomotic leakage. Multivariate analyses identified diet, neutrophil count, and PLR on POD 1-3, and NLR on POD 4-7 as independent factors associated with anastomotic leakage. Using the receiver operating characteristic curve, the variable with the best area under curve was a neutrophil cutoff count of 4.1 [0.737; 95% CI: 0.639-0.835], with a sensitivity and specificity of 60.0% and 66.5%, respectively. This was followed by an NLR cutoff value of 9.5 on POD 4-7 (0.628; 95% CI: 0.505-0.752) and a cutoff PLR value of 220.1 on POD 1-3 (0.643; 95% CI: 0.536-0.750). Diet showed a poor result on the receiver operating characteristic curve analysis.

CONCLUSIONS

Neutrophil count and PLR on POD 1-3 and NLR on POD 4-7 were shown to have predictive value for anastomotic leakage in elective esophageal surgery.