Nomogram based on albumin and neutrophil-to-lymphocyte ratio for predicting postoperative complications after pancreaticoduodenectomy

Risk stratification of postoperative pancreatic fistula and other complications following pancreatoduodenectomy. How far are we? A scoping review

PURPOSE

Pancreatoduodenectomy (PD) is a challenging procedure which is associated with high morbidity rates. This study was performed to make an overview of risk factors included in risk stratification methods both logistic regression models and models based on artificial intelligence algorithms to predict postoperative pancreatic fistula (POPF) and other complications following PD and to provide insight in the extent to which these tools were validated.

METHODS

Five databases were searched to identify relevant studies. Calculators, equations, nomograms, and artificial intelligence models that addressed POPF and other complications were included. Only PD resections were considered eligible. There was no exclusion of the minimally invasive techniques reporting PD resections. All other pancreatic resections were excluded.

RESULTS

90 studies were included. Thirty-five studies were related to POPF, thirty-five studies were related to other complications following PD and twenty studies were related to artificial intelligence predication models after PD. Among the identified risk factors, the most used factors for POPF risk stratification were the main pancreatic duct diameter (MPD) (80%) followed by pancreatic texture (51%), whereas for other complications the most used factors were age (34%) and ASA score (29.4%). Only 26% of the evaluated risk stratification tools for POPF and other complications were externally validated. This percentage was even lower for the risk models using artificial intelligence which was 20%.

CONCLUSION

The MPD was the most used factor when stratifying the risk of POPF followed by pancreatic texture. Age and ASA score were the most used factors for the stratification of other complications. Insight in clinically relevant risk factors could help surgeons in adapting their surgical strategy and shared decision-making. This study revealed that the focus of research still lies on developing new risk models rather than model validation, hampering clinical implementation of these tools for decision support.

Biomarker of severity in hospitalised patients with COVID-19: a retrospective study

BACKGROUND

The novel COVID-19 was rapidly spreading and was highly contagious. COVID-19 caused over 6 million deaths worldwide, with high mortality rates, particularly in severe cases.

OBJECTIVE

This study aimed to investigate whether serum albumin-neutrophil count to lymphocyte count ratio (NLR) score (ANS) could be used as a prognostic indicator of COVID-19 severity.

DESIGN

A retrospective study.

PARTICIPANTS

Based on the WHO diagnostic criteria, patients were classified as either non-severe (n=270) or severe (n=100).

PRIMARY AND SECONDARY OUTCOME MEASURES

NLR, serum albumin level and ANS.

MAIN RESULTS

The NLR of patients with severe disease was significantly higher than that of those with non-severe disease. Serum albumin levels were significantly lower in patients with severe disease than in those with non-severe disease. The cut-off values representing the maximum potential effectiveness of serum albumin and NLR were 33.5 g/L and 8.25, respectively, according to the Youden index. In patients with severe COVID-19, we observed that the serum albumin level, NLR and ANS were independent prognostic indicators of severe COVID-19 using logistic analysis. The relative risk of severe COVID-19 was 7.65 (95% CI 3.72 to 15.75, p<0.05) in the ANS 2 group compared with that in ANS 0.

CONCLUSIONS

ANS could be used as a prognostic indicator of COVID-19 severity.

The Role of C-reactive Protein and Procalcitonin in Predicting the Occurrence of Pancreatic Fistula in Patients who Underwent Laparoscopic Pancreaticoduodenectomy: a Retrospective Study

The occurrence of postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD) is a significant concern, yet there is currently a lack of consensus on reliable predictive methods for this complication. Therefore, the aim of this study was to assess the clinical significance of C-reactive protein (CRP) and procalcitonin (PCT) values and their reliability in early predicting the development of clinically relevant pancreatic fistula (CRPF) following LPD.A retrospective analysis was conducted using data from 120 patients who had LPD between September 2019 and December 2021. Preoperative assessment data, standard patients' demographic and clinicopathological characteristics, intra- and postoperative evaluation, as well as postoperative laboratory values on postoperative days (PODs) 1, 3, and 7, including white blood cells (WBCs), CRP, and PCT, were prospectively recorded on a dedicated database. Two clinicians separately collected and cross-checked all of the data.Among 120 patients [77 men (64%), 43 women (36%], CRPF occurred in 15 patients (11 grade B and 4 grade C fistulas). The incidence rate of CRPF was 12.3%. A comparison of the median values of WBCs, PCT, and CRP across the two groups revealed that the CRPF group had higher values on most PODs than the non-CRPF group. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and cutoff values. It was discovered that POD 3 has the most accurate and significant values for WBCs, CRP, and PCT. According to the ROC plots, the AUC for WBCs was 0.842, whereas the AUC for PCT was 0.909. As for CRP, the AUC was 0.941 (95% CI 0.899-0.983, p < 0.01) with a cutoff value of 203.45, indicating a sensitivity of 93.3% and specificity of 91.4%.Both CRP and PCT can be used to predict the early onset of CRPF following LPD, with CRP being slightly superior on POD 3.

Comprehensive analysis of the association between inflammation indexes and complications in patients undergoing pancreaticoduodenectomy

Background

During clinical practice, routine blood tests are commonly performed following pancreaticoduodenectomy (PD). However, the relationship between blood cell counts, inflammation-related indices, and postoperative complications remains unclear.

Method

We conducted a retrospective study, including patients who underwent PD from October 2018 to July 2023 at the First Hospital of Chongqing Medical University, and compared baseline characteristics and clinical outcomes among different groups. Neutrophil count (NC), platelet count (PLT), lymphocyte count (LC), systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and the product of platelet count and neutrophil count (PPN) were derived from postoperative blood test results. We investigated the association between these indicators and outcomes using multivariable logistic regression and restricted cubic spline analysis. The predictive performance of these indicators was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and decision curve analysis (DCA).

Result

A total of 232 patients were included in this study. Multivariate logistic regression and restricted cubic spline analysis showed that all indicators, except for PLT, were associated with clinical postoperative pancreatic fistula (POPF). SII, NLR, and NC were linked to surgical site infection (SSI), while SII, NLR, and PLR were correlated with CD3 complication. PLT levels were related to postoperative hemorrhage. SII (AUC: 0.729), NLR (AUC: 0.713), and NC (AUC: 0.706) effectively predicted clinical POPF.

Conclusion

In patients undergoing PD, postoperative inflammation-related indices and blood cell counts are associated with various complications. NLR and PLT can serve as primary indicators post-surgery for monitoring complications.

Five-year follow-up after pancreatoduodenectomy performed for malignancy: A single-centre study

Backgrounds/Aims

The aim of this study was to describe short- and long-term outcomes of patients who underwent pancreatoduodenectomy (PD) at a typical United Kingdom hepatopancreatobiliary unit.

Methods

A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA), or distal cholangiocarcinoma (CC) from September 1st, 2006 to May 31st, 2015 was carried out. The following information was obtained: demographics, comorbidities, preoperative investigations, neoadjuvant treatment, operative details, postoperative management, complications, adjuvant treatment, five-year recurrence, and five-year survival. Effects of selected preoperative variables on short- and long-term outcomes were investigated.

Results

Of 271 included patients, 57.9% had PDAC, 25.8% had AA, and 16.2% had CC. In total, 67.9% experienced morbidity and 17.3% developed a Clavien-Dindo grade ≥ III complication. The 90-day mortality was 3.3%. Clinically-relevant postoperative pancreatic fistula, bile leak, gastrojejunal leak, postpancreatectomy haemorrhage and delayed gastric emptying affected 8.1%, 4.1%, 0.0%, 9.2%, and 19.9% of patients, respectively. American Society of Anesthesiologists grade III-VI correlated with overall morbidity (p = 0.002) and major morbidity (p = 0.009), but not 90-day mortality or five-year survival. The same pattern was observed in patients with a preoperative serum bilirubin > 29 μmol/L and/or a neutrophil/lymphocyte ratio > 3.1. Five-year cancer recurrence and five-year survival were 68.3% and 22.5%, respectively. PDAC patients had higher five-year recurrence but lower five-year survival rates (both p = 0.001).

Conclusions

In our series, the majority of patients experienced a complication. However, few patients experienced major morbidity. Surgical risk factors did not affect five-year survival.

Preoperative C-Reactive Protein-to-Albumin Ratio Predicts Postoperative Pancreatic Fistula following Pancreatoduodenectomy: A Single-Center, Retrospective Study

Postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) is a potentially lethal complication, and it is clinically important to determine its risk preoperatively. Although C-reactive protein-to-albumin ratio (CAR) is reported to be a prognostic marker for postoperative complications in several cancers, no evidence is currently available regarding the association between preoperative CAR and POPF following PD for periampullary tumors. This study examined whether preoperative CAR could predict POPF following PD. Clinical data were retrospectively retrieved from Ehime University Hospital. The optimal cut-off value for CAR was determined using receiver operating characteristic (ROC) curve analysis. This study enrolled 203 consecutive patients undergoing PD for periampullary tumors. The CAR value was significantly higher in the POPF group than in the non-POPF group (p < 0.001). According to the ROC curve analysis, the optimal cut-off value for CAR was 0.09. Patients with CAR ≥ 0.09 had higher incidence rates of POPF than their counterparts. CAR ≥ 0.09 was a risk factor for POPF in the multivariate logistic regression analysis (odds ratio 34.5, 95% confidence interval 11.75-101.38, p < 0.001). This is the first report demonstrating an association between CAR and POPF following PD. Preoperative CAR is an independent predictive marker for POPF following PD.

The role of preoperative albumin and white blood cell count in surgical site infections following whipple surgery

Whipple surgery is associated with a high risk of surgical sites infections (SSIs). Nutritional deficiency has been associated with an increased risk of wound infections. This study aims at exploring the role of preoperative albumin levels in predicting the risk of SSIs following Whipple surgery. A total of 23,808 individuals were identified from the ACS-NSQIP database from years 2011 to 2017. The primary exposure was pre-operative albumin while the secondary exposure was white blood cell (WBC) count. The primary outcome was divided into superficial and deep surgical site infections (S/D SSI) and organ-space SSI. All statistical analyses were conducted using IBM Statistical Package for Social Sciences version 26. Levels of pre-operative serum albumin less than 3.73 g/L, dirty and contaminated wounds and longer operative time were associated with increased odds for developing S/D SSIs (OR = 1.14, OR = 1.17, OR = 1.06, respectively, p-value < 0.05). Pre-operative WBC level (/L) was associated with a risk of developing an organ-space SSI but not S/D SSI (OR = 1.02, p-value  0.003). This study demonstrates the predictive role of pre-operative albumin in developing S/D SSIs and highlights the need to develop therapeutic strategies to optimize the pre-operative nutritional health status of patients undergoing Whipple surgery.

Predictive value of albumin combined with neutrophil-to-lymphocyte ratio for efficacy and safety profiles in patients with pancreatic ductal adenocarcinoma receiving liposomal irinotecan plus 5-fluorouracil and leucovorin

Liposomal irinotecan plus 5-fluorouracil and leucovorin (nal-IRI + 5-FU/LV) treatment has demonstrated survival benefits but noticeable side effects in patients with pancreatic ductal adenocarcinoma (PDAC) that is refractory to gemcitabine-based therapy. This study aimed to explore whether combining albumin with the neutrophil-to-lymphocyte ratio (NLR), herein known as the albumin and neutrophil-to-lymphocyte ratio score (ANS), could be utilized as a simple tool to predict survival and safety profiles in such patient groups. We retrospectively enrolled 434 consecutive PDAC patients treated with nal-IRI + 5-FU/LV between 2018 and 2020 at nine medical centers in Taiwan. Patients were divided into three groups: ANS 0 (high albumin and low NLR), ANS 1 (low albumin or high NLR), and ANS 2 (low albumin and high NLR), for comparison. The median overall survival times for the ANS 0, 1, and 2 groups were 8.7 months (95% confidence interval (CI), 7.0-10.3 months), 5.2 months (95% CI, 4.3-6.0 months), and 2.6 months (95% CI, 1.9-3.3 months), respectively. The ANS was found to be an independent variable for overall survival and time-to-treatment failure in multivariate analyses. Patients in the ANS 2 group had significantly higher incidences of grade 3 or higher treatment-related adverse events than those in the other two groups. The present study showed that the ANS was an independent prognosticator in PDAC patients receiving nal-IRI + 5-FU/LV therapy. The ANS can be a simple predictor of survival outcome and safety profiles in PDAC patients treated with nal-IRI + 5-FU/LV.

Preoperative NLR and PLR are predictive of clinically relevant postoperative pancreatic fistula

Background

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a dreaded complication following pancreatic surgery. Several scores attempt to predict CR-POPF occurrence to better manage outcomes in patients undergoing pancreaticoduodenectomy (PD). In our study, we investigate the prognostic role of several demographic and clinico-pathological variables. We focus on clinical biomarkers, the Neutrophil-to-Lymphocytes Ratio (NLR) and Platelet-to-Lymphocyte ratio (PLR), which can be easily used in predicting CR-POPF occurrence.

Methods

Patients who underwent a PD with curative intent at our institution, between 2008 and 2018 were reviewed. Statistical analysis was conducted to determine the association between various demographic and clinico-pathological variables, with the occurrence of clinically significant POPF.

Results

117 patients underwent a PD at our institution. Statistically significant associations on multivariate analysis were observed for the absence of preoperative diabetes mellitus, a pathological stage ≥III, an elevated NLR (> 4) and an elevated PLR (> 158).

Conclusion

The NLR and PLR are predictive of CR-POPF occurrence following PD. These readily available biomarkers can add value to risk stratification tools to assess CR-POPF occurrence and individualize patient care plans.