Lymphopenia following pancreaticoduodenectomy is associated with pancreatic fistula formation

다국어 초록 (Multilingual Abstract)

Backgrounds/Aims: Post-operative pancreatic fistulas (POPF) are a major source of morbidity following pancreaticoduodenectomy (PD). This study aims to investigate if persistent lymphopenia, a known marker of sepsis, can act as an additional marker of POPF with clinical implications that could help direct drain management. Methods: A retrospective chart review of all patients who underwent PD in a single hospital network from 2008 to 2018. Persistent lymphopenia was defined as lymphopenia beyond post-operative day #3. Results: Of the 201 patients who underwent PD during the study period 161 patients had relevant laboratory data, 81 of whom had persistent lymphopenia. 17 patients with persistent lymphopenia went on to develop a POPF, compared to 7 patients without. Persistent lymphopenia had a negative predictive value of 91.3%. Multivariate analysis revealed only persistent lymphopenia as being independently associated with POPF (HR 2.57, 95% CI 1.07-6.643, p=0.039). Patients with persistent lymphopenia were more likely to have a complication requiring intervention (56.8% vs 35.0%, p＜0.001). Conclusions: Persistent lymphopenia is a readily available early marker of POPF that holds the potential to identify clinically relevant POPF in patients where no surgical drain is present, and to act as an adjunct of drain amylase helping to guide drain management.

목차 (Table of Contents)

• INTRODUCTION
• MATERIALS AND METHODS
• RESULTS
• DISCUSSION
• REFERENCES

참고문헌 (Reference)

1 Park JE, "Understanding the role of immune regulation in wound healing" 187 : 11S-16S, 2004

2 Hotchkiss RS, "The pathophysiology and treatment of sepsis" 348 : 138-150, 2003

3 Bassi C, "The 2016 update of the International Study Group(ISGPS)definition and grading of postoperative pancreatic fistula : 11 years after" 161 : 584-591, 2017

4 Lee SR, "Significance of drain fluid amylase check on day 3 after pancreatectomy" 89 : 497-502, 2019

5 Hotchkiss RS, "Sepsis-induced apoptosis causes progressive profound depletion of B and CD4+ T lymphocytes in humans" 166 : 6952-6963, 2001

6 Templeton AJ, "Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors : a systematic review and meta-analysis" 106 : dju124-, 2014

7 Serene TEL, "Predictive value of post-operative drain amylase levels for post-operative pancreatic fistula" 22 : 397-404, 2018

8 Drewry AM, "Persistent lymphopenia after diagnosis of sepsis predicts mortality" 42 : 383-391, 2014

9 Pedrazzoli S, "Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): a systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015" 96 : e6858-, 2017

10 Munford RS, "Normal responses to injury prevent systemic inflammation and can be immunosuppressive" 163 : 316-321, 2001

11 You Y, "Nomogram for predicting postoperative pancreatic fistula" 21 : 1436-1445, 2019

12 Witzigmann H, "No need for routine drainage after pancreatic head resection : the dual-center, randomized, controlled PANDRA trial(ISRCTN04937707)" 264 : 528-537, 2016

13 Venet F, "Management of sepsis-in-duced immunosuppression" 34 : 97-106, 2018

14 Wang Q, "Is routine drainage necessary after pancreaticoduodenectomy?" 20 : 8110-8118, 2014

15 Heffernan DS, "Failure to normalize lymphopenia following trauma is associated with increased mortality, independent of the leukocytosis pattern" 16 : R12-, 2012

16 Seykora TF, "Evolving the paradigm of early drain removal following pancreatoduodenectomy" 23 : 135-144, 2019

17 Schäfer M, "Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis" 236 : 137-148, 2002

18 Kawai M, "Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection : prospective study for 104 consecutive patients" 244 : 1-7, 2006

19 Le Tulzo Y, "Early circulating lymphocyte apoptosis in human septic shock is associated with poor outcome" 18 : 487-494, 2002

20 Venet F, "Early assessment of leukocyte alterations at diagnosis of septic shock" 34 : 358-363, 2010

21 McMillan MT, "Drain management after pancreatoduodenectomy : reappraisal of a prospective randomized trial using risk stratification" 221 : 798-809, 2015

22 Dindo D, "Classification of surgical complications : a new proposal with evaluation in a cohort of 6336 patients and results of a survey" 240 : 205-213, 2004

23 Girardot T, "Apoptosis-induced lymphopenia in sepsis and other severe injuries" 22 : 295-305, 2017

24 Van Buren G 2nd, "A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage" 259 : 605-612, 2014

25 Callery MP, "A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy" 216 : 1-14, 2013

26 Miller BC, "A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy" 18 : 172-179, 2014