Letter to the Editor Open Access
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Mar 27, 2022; 14(3): 268-270
Published online Mar 27, 2022. doi: 10.4240/wjgs.v14.i3.268
Is it sufficient to evaluate only preoperative systemic inflammatory biomarkers to predict postoperative complications after pancreaticoduodenectomy?
Semra Demirli Atici, Erdinc Kamer, Department of General Surgery, University of Health Sciences Tepecik Training and Research Hospital, İzmir 35180, Turkey
ORCID number: Semra Demirli Atici (0000-0002-8287-067X); Erdinc Kamer (0000-0002-5084-5867).
Author contributions: Demirli Atici S and Kamer E wrote the manuscript; Kamer E reviewed and supervised the manuscript preparation; Both authors read and agreed to the published version of the manuscript.
Conflict-of-interest statement: The authors declare having no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Semra Demirli Atici, MD, Surgeon, Department of General Surgery, University of Health Sciences Tepecik Training and Research Hospital, Güney Mahallesi, 1140/1 Sokak No. 1 Yenişehir/Konak, İzmir 35180, Turkey. smrdemirli@hotmail.com
Received: November 21, 2021
Peer-review started: November 21, 2021
First decision: December 27, 2021
Revised: January 7, 2022
Accepted: March 6, 2022
Article in press: March 6, 2022
Published online: March 27, 2022
Processing time: 124 Days and 8.3 Hours


Postoperative morbidity and mortality rates are still very high among patients undergoing pancreaticoduodenectomy (PD). However, mortality rates secondary to morbidities that are detected early and well-managed postoperatively are lower among patients undergoing PD. Since early detection of complications plays a very important role in the management of these patients, many ongoing studies are being conducted on this subject. Recent endoscopic retrograde cholangiopancreatography and biliary drainage history of the patient study group is important for comparison of C-reactive protein (CRP), an inflammatory parameter evaluated in the retrospective study by Coppola et al published in the World Journal of Gastrointestinal Surgery and titled “Utility of preoperative systemic inflammatory biomarkers in predicting postoperative complications after pancreaticoduodenectomy: Literature review and single center experience”. Therefore, it may be more appropriate to compare CRP values in randomized patients.

Key Words: Pancreaticoduodenectomy, Biliary drainage, Complications, C-reactive protein, CRP, Postoperative pancreatic fistula, Preoperative inflammatory markers

Core Tip: Predicting the complications that may develop after pancreaticoduodenectomy is very important in the management of patients. Preoperative and intraoperative scoring of patients with the combination of many parameters, such as pancreatic structure, pancreatic duct diameter, preoperative biliary drainage history and laboratory parameters, can guide the estimation of postoperative morbidity and management. Inflammatory biomarkers are easily affected by preoperative treatment. In order to discuss such situations, we think that it would be more appropriate to prospectively randomize patients in whom dynamic changes of inflammatory parameters can be observed with reported risk factors, including not only C-reactive protein value but also other inflammatory parameters, rather than these preoperative values.


Coppola et al[1] recently published a retrospective study on the role of preoperative inflammatory markers to detect the predictive efficiency of postoperative morbidity and mortality in pancreaticoduodenectomy (PD) patients.

Most patients diagnosed with pancreatic cancer undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic purposes. Preoperative biliary drainage (PBD) can be performed in addition to ERCP in these patients, who may also present with the complaint of obstructive jaundice[2].

PBD itself, duration of the PBD and the ERCP procedure can each increase the inflammatory response[3,4]. Coppola et al[1] found that preoperative C-reactive protein (CRP) level of > 8.81 mg/dL was a high-risk factor for general complications and abdominal collection, which was associated with the inflammatory parameters examined prior to PD operations. Unfortunately, the authors did not report the number of PBD procedures performed on the individual patients included in their study, nor did they provide information on the duration of time before the ERCP procedure was performed for any. This missing information may preclude our ability to make conclusions on the effectiveness of the baseline CRP value, since the recent history of ERCP and the history of PBD are unknown for the study’s patients. A history of PBD will cause an increased inflammatory response. In addition, increased postoperative complication rates have been demonstrated in relation to a history of PBD and duration of biliary drainage. Prospective randomized controlled trials would be more instructive in determining the efficacy of preoperative inflammatory markers and their importance in the rates of postoperative complications due to PD.


Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: Association of Surgeons of Great Britain & Ireland (ASGBI); Association of Coloproctology of Great Britain and Ireland (ACPGBI).

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Turkey

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B, B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Shah OJ, India; Xu X, China S-Editor: Wu YXJ L-Editor: A P-Editor: Wu YXJ

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