Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Oct 27, 2021; 13(10): 1216-1225
Published online Oct 27, 2021. doi: 10.4240/wjgs.v13.i10.1216
Utility of preoperative systemic inflammatory biomarkers in predicting postoperative complications after pancreaticoduodenectomy: Literature review and single center experience
Alessandro Coppola, Vincenzo La Vaccara, Lorenza Caggiati, Ludovico Carbone, Silvia Spoto, Massimo Ciccozzi, Silvia Angeletti, Roberto Coppola, Damiano Caputo
Alessandro Coppola, Department of Surgery, University Campus Bio-Medico di Roma, Rome 00128, Italy
Vincenzo La Vaccara, Lorenza Caggiati, Ludovico Carbone, Roberto Coppola, Damiano Caputo, Department of General Surgery, University Campus Bio-Medico di Roma, Rome 00128, Italy
Silvia Spoto, Department of Internal Medicine, University Campus Bio-Medico di Roma, Rome 00128, Italy
Massimo Ciccozzi, Medical Statistics and Epidemiology Unit, University Campus Bio-Medico di Roma, Rome 00128, Italy
Silvia Angeletti, Unit of Clinical Laboratory Science, University Campus Bio-Medico di Roma, Rome 00128, Italy
Author contributions: Caputo D and Coppola A designed the research study; Caggiati L and Ludovico C collected the data; Caputo D, Ciccozzi M, Angeletti S and Spoto S analyzed and interpreted data; Caputo D, Coppola A and Caggiati L drafted the article; Caputo D, Spoto S, Angeletti S and Coppola R made critical revision of the article; All the authors gave the final approval of the version to be published.
Institutional review board statement: The local Ethical Committee approved the study (28/19 OSS ComEt CBM).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors declare that they do not have any conflict of interest.
Data sharing statement: Dataset will be available from the corresponding author at according to local laws.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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:
Corresponding author: Damiano Caputo, FACS, MD, Associate Professor, Surgeon, Department of General Surgery, University Campus Bio-Medico di Roma, Via Alvaro del Portillo, 200, Rome 00128, Italy.
Received: January 25, 2021
Peer-review started: January 25, 2021
First decision: May 3, 2021
Revised: May 10, 2021
Accepted: July 13, 2021
Article in press: July 13, 2021
Published online: October 27, 2021

The role of preoperative inflammatory biomarkers (PIBs) in predicting postoperative morbidity has been assessed in colorectal and otorhinolaryngeal surgery. However, data regarding the role that preoperative inflammatory biomarkers have on morbidity after pancreaticoduodenectomiy (PD) are less consistent.


To assess the utility of PIBs in predicting postoperative complications after pancreaticoduodenectomy.


A database of 317 consecutive pancreaticoduodenectomies performed from April 2003 to November 2018 has been retrospectively analyzed. Data regarding preoperative neutrophil-to-lymphocyte ratio (NLR), derived NLR and C-reactive protein (CRP), and postoperative complications of 238 cases have been evaluated. Exclusion criteria were: age < 18-years-old, previous neoadjuvant treatment, absence of data about PIBs, concomitant hematological disorders, and presence of active infections at the moment of the surgery. PIBs were compared using Mann-Whitney’s test and receiver operating characteristic (ROC) analysis was performed to define the cutoffs. The positive predictive value (PPV) was computed to evaluate the probability to develop complication. P-values < 0.05 were considered statistically significant.


According to the literature findings, only four papers have been published reporting the relation between the inflammatory biomarkers and PD postoperative morbidity. A combination of preoperative and postoperative inflammatory biomarkers in predicting complications after PD and the utility of preoperative NLR in the development of postoperative pancreatic fistula (POPF) have been reported. The combination of PIBs and postoperative day-1 drains amylase has been reported to predict the incidence of POPF. According to our results, CRP values were significantly different between patients who had/did not have postoperative complications and abdominal collections (P < 0.05). Notably, patients with preoperative CRP > 8.81 mg/dL were at higher risk of both overall complications and abdominal collections (respectively P = 0.0037, PPV = 0.95, negative predictive value [NPV] = 0.27 and P = 0.016, PPV = 0.59, NPV = 0.68). Preoperative derived neutrophil-to-lymphocyte ratio (dNLR) (cut off > 1.47) was also a predictor of abdominal collection (P = 0.021, PPV = 0.48, NPV = 0.71). Combining CRP and dNLR, PPV increased to 0.67. NLR (cut off > 1.65) was significantly associated with postoperative hemorrhage (P = 0.016, PPV = 0.17, NPV = 0.98).


PIBs may predict complications after PD. During postoperative care, PIB levels could influence decisions regarding the timing of drains removal and the selection of patients who might benefit from second level diagnostic exams.

Keywords: Preoperative inflammatory markers, Pancreaticoduodenectomy, Complications, Neutrophil-to-lymphocyte ratio, Derived neutrophil-to-lymphocyte ratio

Core Tip: Inflammatory markers are involved in cancer’s pathogenesis and growth. In addition, their role in predicting post-operative complications in colorectal and otorhinolaryngeal surgery has been reported. Here, the role of preoperative inflammatory biomarkers in predicting postoperative complication after pancreaticoduodenectomy has been investigated.