Neutropthil-to-Lymphocyte Ratio as a Predictor of Postsurgical Intraabdominal Abscess in Children Operated for Acute Appendicitis

Blood biomarkers to distinguish complicated and uncomplicated appendicitis in pediatric patients

BACKGROUND

/Purpose: Acute appendicitis (AA) stands as the most prevalent cause of acute abdominal pain among children. The potential for morbidity escalates significantly when uncomplicated appendicitis (UA) progresses to complicated appendicitis (CA), which can encompass gangrenous, necrotic, or perforated appendicitis. Consequently, establishing an early and accurate diagnosis of AA, and effectively differentiating CA from UA, becomes paramount. This study explores the diagnostic utility of various blood biomarkers for distinguishing CA from UA in pediatric patients.

METHODS

We conducted a retrospective review of medical records pertaining to pediatric patients who underwent surgery for AA. Patients were categorized as either having UA or CA based on histopathological examination of the appendix. The data collected and analyzed included demographic information, white blood cell (WBC) count, neutrophil proportion, lymphocyte proportion, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) levels upon admission.

RESULTS

Among the 192 pediatric patients who underwent surgery for AA, 150 were diagnosed with UA, while 42 were diagnosed with CA. The CA group exhibited significantly higher neutrophil proportions, NLRs, PLRs, and CRP levels, alongside lower lymphocyte proportions (all p < 0.01) compared to the UA group. Receiver operating characteristic (ROC) curve analysis disclosed that CRP exhibited the highest specificity, sensitivity, and positive and negative predictive values for predicting CA.

CONCLUSION

CRP emerges as a valuable biomarker for differentiating complicated appendicitis from uncomplicated appendicitis.

Neutrophil-to-lymphocyte ratio as a predictor of postoperative complications and readmissions after appendectomy in children

To analyze the role of neutrophil-to-lymphocyte ratio (NLR) in predicting the development of postoperative complications and readmission after appendectomy in children. A retrospective single-centered case-control study was conducted on children who underwent appendectomy between 2017 and 2020. Demographics, time since symptoms onset, laboratory tests at admission, postoperative complications, and readmissions in the first 30 days after surgery were recorded. Sensitivity and specificity analysis of the parameters evaluated were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves. A total of 1,214 patients (765 males; 449 females) were included, with a median age at diagnosis of 10.4 years. The median time from symptom onset was 24 h. During the first 30 days after surgery, 149 postoperative complications were reported (12.3%). NLR at admission presented the highest AUC (0.753), with a cut-off point of 10.5 for maximum sensitivity (68.7%) and specificity (86.1%). Readmissions were reported in 45 cases (3.7%). NLR at admission presented an AUC of 0.794 significantly higher than neutrophils (0.696), leukocytes (0.654), and time since symptom onset (0.622), making these differences statistically significant (p < 0.001). The cut-off point of NLR > 12.4 was estimated, with a maximum sensitivity and specificity of 71.0% and 82.3% for predicting readmission. NLR is an independent predictor of postoperative complications and readmission in children with acute appendicitis. While its application in routine clinical practice has yet to be established, the NLR may provide clinicians with a tool for identifying high-risk surgical patients.

Mucosal appendicitis: How can it be differentiated from nonappendicitis?

OBJECTIVES

Mucosal appendicitis is defined by neutrophilic infiltration limited to the mucosa, with no transmural invasion; it is currently a controversial entity. The aim of our study was to determine whether mucosal appendicitis represents an early stage of acute appendicitis (AA) or should be considered a negative appendectomy.

METHODS

A retrospective study was performed of children with suspected AA who underwent surgical treatment between 2017 and 2020. The participants were divided into 2 groups according to histologic appendiceal findings: mucosal appendicitis (MA) and negative appendicitis (NA). Demographic, clinical, ultrasound, and laboratory features were compared between the groups.

RESULTS

A total of 1269 patients with suspected appendicitis in whom appendectomy was performed were included, with a median age of 10.5 years. Mucosal appendiceal inflammation was histologically confirmed in 30 cases (MA group), while no inflammation or other pathologic findings were observed in 25 cases (NA group), with no differences in demographic, clinical, or ultrasound features between the groups. Those in the MA group presented with significantly higher leukocyte and neutrophil counts and higher neutrophil to lymphocyte ratios (NLRs) than those in the NA group (P < .001). The NLR was the parameter with the highest area under the curve (0.736) for the diagnosis of MA. A cutoff of 3.20 was established, with a maximum sensitivity and specificity of 62.5% and 78.9%, respectively.

CONCLUSIONS

Mucosal appendicitis presents with laboratory and histologic inflammatory features that can be distinguished from nonappendicitis and should therefore be considered a pathologic entity within the spectrum of AA. Preoperative leukocyte and neutrophil counts and NLRs may help reduce the number of negative appendectomies.

Neutrophil-to-Lymphocyte Ratio as a Predictor of the Need for Surgical Treatment in Children's Intussusception

OBJECTIVE

 Neutrophil-to-lymphocyte ratio (NLR) is an emerging inflammatory marker in abdominal pathologies. Ileocolic intussusception (ICI) involves a progressive intestinal inflammation, and the effectiveness of nonsurgical treatment (enema) might be related to the inflammation degree, although no previous studies have investigated this relationship. Our aim is to identify predictors of the need for surgical treatment in ICI.

MATERIALS AND METHODS

 A single-center, retrospective, case-control study was performed in children with ICI, who were treated with initial nonsurgical management between 2005 and 2019. Patients were divided in two groups: A (effective enema) and B (need for surgery). Admission demographic and clinical and laboratory data were analyzed. Specificity and sensitivity of the different parameters as predictors of the need for surgical treatment were determined by receiver operating characteristic (ROC) curves.

RESULTS

 A total of 511 patients were included (410: group A; 101: group B), without statistically significant demographic differences. Group B presented significantly higher frequency of vomiting, bloody stools, and longer median time since symptoms onset (24 vs. 8 hours; p < 0.001). Group B presented higher median laboratory inflammatory markers than group A: NLR (6.8 vs. 1.8; p < 0.001), neutrophils (10,148 vs. 7,468; p < 0.001), and C-reactive protein (CRP; 28.2 vs. 4.7; p < 0.001). In ROC curve analysis, NLR had an area under the curve of 0.925, higher than neutrophil count (0.776; p = 0.001), CRP (0.670; p = 0.001), and time since symptoms onset (0.673; p = 0.001). It was estimated a cut-off point of NLR greater than 4.52 (sensitivity: 73.2%; specificity: 94.5%).

CONCLUSION

 High NLR values imply a high degree of bowel inflammation and might anticipate the need for surgical treatment in ICI in children.

LEVEL OF EVIDENCE

 III.

The role of the neutrophil-to-lymphocyte ratio in avoiding negative appendectomies

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory biomarker that is easily calculated with data from the differential white blood cell count. The aim of our study was to analyse the role of the NLR in the detection of negative appendectomies and to compare its usefulness with other clinical, sonographic and laboratory factors previously described.

METHODS

We conducted a retrospective study in patients aged less than 16 years who underwent appendectomy in our hospital between 2017 and 2020. We divided patients into 2 groups based on appendiceal histological findings: NA group (negative appendicitis: absence of appendiceal inflammation) and PA group (positive appendicitis: presence of inflammation in any layer of the appendiceal wall). We analysed demographic, clinical, sonographic and laboratory characteristics.

RESULTS

We included a total of 1269 patients, 1244 in the PA group and 25 in the NA group, with no differences between groups in demographic characteristics. The proportion of patients that presented with nausea and vomiting was significantly smaller in the NA group compared to the PA group (P < .001), and there were no other differences in symptoms. The appendiceal diameter on ultrasound was significantly smaller in the NA group (8.1 ± 2.1 vs. 9.7 ± 2.8 mm; P < .001). The white blood cell and neutrophil counts and the NLR were significantly higher in the PA group (P < .001), as was the level of C-reactive protein (18.6 vs. 2.6; P = .005). The ROC curve analysis revealed that the NLR was the parameter with the highest AUC (0.879) for the diagnosis of negative appendicitis, with a cut-off point of 2.65 for a maximum sensitivity of 84.2% and specificity of 83.8%.

CONCLUSION

The NLR is the preoperative parameter that best discriminates patients without acute appendicitis. Values of less than 2.65 should make clinicians contemplate diagnoses other than appendicitis.

Neutrophil/lymphocyte ratio as a predictor of severe postoperative edema and ecchymosis in open rhinoplasty surgery

Purpose: This study investigated the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR) and severe postoperative edema and ecchymosis after open rhinoplasty. Materials and Methods: The study was carried out retrospectively in 165 ASA I-II patients aged 18-45 years who underwent open rhinoplasty in the Department of Plastic and Reconstructive Surgery. The patients were grouped based on their scores on the edema and ecchymosis scales. The degree of edema and ecchymosis was considered “minimal” (Group M) in those scoring 0-2 points and “severe” (Group S) in those scoring 3-4 points. Periorbital edema and ecchymosis of the patients in both groups were scored based on the digital photographs taken on the 1st postoperative day. Results: There was no significant difference in the demographic and clinical characteristics of the patients grouped according to the degree of edema and ecchymosis. The optimal cut-off value of NLR was 2.1 (AUC = 0.747, Sensitivity = 0.666, Specificity = 0.707) for edema and 1.5 (AUC = 0.747, Sensitivity = 0.869, Specificity = 0.470) for ecchymosis. Multivariable analyzes for the development of edema and ecchymosis identified NLR (4.67 [2.38-9.40] and 6.54 [3.02-15.08, respectively) as a statistically significant independent prognostic factor. Conclusion: This study identified preoperative NLR as a predictor value of severe postoperative edema and ecchymosis after open rhinoplasty.

The role of neutrophil-to-lymphocyte ratio as a predictor of testicular torsion in children

INTRODUCTION

Doppler ultrasound constitutes the gold standard for the diagnosis of testicular torsion (TT), although sometimes the spermatic cord twisting and absence of testicular flow are difficult to visualize. To date, no laboratory markers have been shown to be useful for preoperative TT diagnosis.

OBJECTIVE

Our aim is to analyze the role of the neutrophil-to-lymphocyte ratio (NLR) as a predictor of pediatric TT.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with ultrasound suspicion of TT, in whom surgical testicular examination was performed between 2016 and 2020. Patients were divided into two groups according to the intraoperative findings: TT group (testicular torsion), defined as spermatic cord twisting on itself around its longitudinal axis at least 360°, and non-TT group (no torsion). Demographics, clinical, ultrasound and laboratory features at admission were analyzed. Sensitivity and specificity were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves.

RESULTS

A total of 159 patients were included (117 TT group; 42 non-TT group), with no demographic or clinical differences. TT group patients presented significantly shorter median time since symptoms onset (4 vs. 8 h; p < 0.012). Laboratory inflammatory test were significantly higher in TT group: Leukocytes (10,900 × 10³/μl vs. 7,980 × 10³/μl; p < 0.001), neutrophils (8,050 × 10³/μl vs. 3,350 × 10³/μl; p < 0.001) and NLR (4.6 vs. 1.1; p < 0.001). In ROC curve analysis, NLR presented the highest AUC (0.903), significantly higher than all other laboratory and ultrasound parameters. NLR of 2.3 was the cut-off point with maximum sensitivity (86.9%) and specificity (94.8%).

DISCUSSION

This is, to the best of our knowledge, the first study to analyze the usefulness of NLR in predicting the diagnosis of TT in patients with clinical and ultrasound suspicion. The limitations are mainly derived from being a single-center retrospective study. For this reason, multicenter studies with a higher number of patients and prospective design may be useful to minimize these biases. The sample size of our study, although not large, has allowed us to identify significant differences between the distinct parameters analyzed as predictors of TT. However, the absence of other similar studies in pediatric patients has hindered the comparison of our results.

CONCLUSION

NLR should be considered as a predictor of pediatric TT in cases with nuclear ultrasound suspicion that may help to anticipate the urgent surgical treatment in these patients.