The Use of Inflammatory Biomarkers in the Early Identification of Post-operative Pancreatic Fistulae Following Pancreaticoduodenectomy

Abstract

Purpose: Pancreaticoduodenectomy(PD) is associated with a significant risk of post-operative complications, including pancreatic fistulae(POPF). The utility and interpretation of peri-operative inflammatory biomarkers in predicting such complications remains unclear. This study aimed to evaluate the role of pre-operative neutrophil-lymphocyte ratio(NLR) and post-operative c-reactive protein(CRP) in the early identification of POPF following PD. Method: An analysis of consecutive patients undergoing PD between 2012 and 2020 at a single tertiary centre was performed. Data were derived from a combination of prospective electronic databases, retrospective case-notes and computer records. Patients were excluded if data were incomplete. Results: 96 male and 80 female patients(median age 68 years) underwent PD; 67(38.1%%) for pancreatic adenocarcinoma, 45(25.6%%) for ampullary adenocarcinoma, 26(14.8%) for biliary/duodenal adenocarcinoma and 38(21.6%) for a combination of other benign/malignant indications. 63(35.8%) patients were diagnosed with POPF and 42(23.8%) with clinically-relevant POPF(CR-POPF; ISGPS Grade B/C). Median pre-operative NLR was 2.73 in POPF patients, 2.74 in CR-POPF patients and 2.66 in non-POPF patients(t-test; p>0.05). Median post-operative peak CRP was 305mg/L in POPF patients, 330mg/L in CR-POPF patients and 182mg/L in non-POPF patients(t-test; p = 0.0001). Median and mode post-operative peak CRP occurred on day 3 in POPF and CR-POPF patients, and on day 2 in non-POPF patients. Conclusion: There was a non-significant trend towards higher pre-operative NLR in patients with POPF. Patients with serum CRP that continues to rise on post-operative day 3 above approximately 300mg/L are at risk of CR-POPF. Such data may help to guide early administration of antibiotics or targeted use of cross-sectional imaging.