Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 14, 2015; 21(18): 5598-5606
Published online May 14, 2015. doi: 10.3748/wjg.v21.i18.5598
Poor oncologic outcomes of hepatocellular carcinoma patients with intra-abdominal infection after hepatectomy
Dan-Yun Ruan, Ze-Xiao Lin, Yang Li, Nan Jiang, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu
Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
Yang Li, Nan Jiang, Department of Liver Surgery, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
Author contributions: Ruan DY, Lin ZX and Li Y contributed equally to this work; Ruan DY, Lin ZX, Li Y and Wu XY designed the research; Ruan DY, Lin ZX and Li Y performed the research; Wu DH, Wang TT, Chen J and Lin Q contributed new reagents/analysis tools; Jiang N, Li X analyzed the data; and Ruan DY, Lin ZX and Li Y wrote the paper.
Supported by National Natural Science Foundation of China, No. 81372374 and No. 81000959; the Combination Project of Production, Education and Research from Guangdong Province and Ministry of Education, No. 2012B091100460; and Science and Technology Planning Project of Guangdong Province, No. 2009B030801007.
Ethics approval: The study was reviewed and approved by the Third Affiliated Hospital of Sun Yat-sen University Institutional Review Board.
Informed consent: All study participants, or their legal guardian, provided written informed consent prior to study enrollment.
Conflict-of-interest: The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. The authors have not received fees for serving as a speaker for any organization, and have not received research funding from any organization. The authors are not employees of any organization and do not own stocks and/or shares in any organization. The authors do not own patents.
Data sharing: Technical appendix, statistical code, and dataset available from the corresponding author at wuxiangy@mail.sysu.edu.cn. Participants gave informed consent for data sharing. No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Xiang-Yuan Wu, MD, Professor, Chief, Department of Medical Oncology, the Third Affiliated Hospital of Sun Yat-sen University, 600 Tian He Road, Tian He District, Guangzhou 510630, Guangdong Province, China. wuxiangy@mail.sysu.edu.cn
Telephone: +86-20-85252161 Fax: +86-20-85252276
Received: November 25, 2014
Peer-review started: November 26, 2014
First decision: December 26, 2014
Revised: January 12, 2015
Accepted: February 12, 2015
Article in press: February 13, 2015
Published online: May 14, 2015
Processing time: 173 Days and 17.3 Hours
Abstract

AIM: To evaluate the impact of postoperative infectious complications on hepatocellular carcinoma following curative hepatectomy.

METHODS: We performed a retrospective analysis of 200 hepatocellular carcinoma patients who underwent hepatectomy at our institution between September 2003 and June 2011. The patients’ demographics, clinicopathological characteristics and postoperative infectious complications were analyzed. The Clavien-Dindo classification was adopted to assess the severity of complications. The dynamic change in the neutrophil-to-lymphocyte ratio, defined as the absolute neutrophil count divided by the absolute lymphocyte count, after surgery was also investigated. The observation endpoints for this study were recurrence-free survival and overall survival of the patients. Statistical analysis of the survival curves was performed using the Kaplan-Meier method and the log-rank test. The prognostic value of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis. The cutoff score for each variable was selected based on receiver operating characteristic curve analysis. All statistical tests were two-sided, and significance was set at P < 0.05.

RESULTS: The median age of the patients was 49 years, and the majority of patients were male (86%) and had been infected with hepatitis B virus (86%). The 30-d postoperative infectious complication rate was 34.0% (n = 68). Kaplan-Meier survival analysis revealed that postoperative infection was significantly correlated with tumor recurrence (P < 0.001). The postoperative intra-abdominal infection group exhibited a worse prognosis than the non-intra-abdominal infection group (P < 0.001). A significantly increased incidence of postoperative intra-abdominal infection was observed in the patients with hepatic cirrhosis (P = 0.028), concomitant splenectomy (P = 0.007) or vascular invasion (P = 0.026). The patients who had an elevated postoperative neutrophil-to-lymphocyte ratio change (> 1.643) clearly exhibited poorer recurrence-free survival than those who did not (P = 0.009), although no significant correlation was observed between overall survival and the change in the postoperative neutrophil-to-lymphocyte ratio. Based on multivariate analysis, hepatitis B surface antigen positivity, Child-Turcotte-Pugh class B, an elevated postoperative neutrophil-to-lymphocyte ratio change and intra-abdominal infection were significant predictors of poor recurrence-free survival. Hepatic cirrhosis, the maximal tumor diameter and intra-abdominal infection were significant predictors of overall survival.

CONCLUSION: Postoperative intra-abdominal infection adversely affected oncologic outcomes, and the change in postoperative neutrophil-to-lymphocyte ratio was a good indicator of tumor recurrence in hepatocellular carcinoma patients after curative hepatectomy.

Keywords: Hepatocellular carcinoma; Postoperative intra-abdominal infection; Neutrophil-to-lymphocyte ratio change; Hepatectomy; Prognosis

Core tip: Post-operative infectious complications adversely affect survival in various cancers. However, the prognostic value of postoperative infectious complications for patients with hepatocellular carcinoma remains unclear. We found that the occurrence of postoperative intra-abdominal infection was an independent predictor of tumor recurrence and poor overall survival. Postoperative neutrophil-to-lymphocyte ratio change, which indicated a systemic inflammatory response, was also an independent predictor of tumor recurrence.