"The Critical 18" of postoperative white blood cell count and C-reactive protein level predicts postoperative pancreatic fistula after distal pancreatectomy.

Abstract

Background: Distal pancreatectomy (DP) carries high risk for postoperative pancreatic fistula. This study evaluates white blood cell count (WBC), C-reactive protein (CRP) and interleukin-6 (IL-6) as serum-based predictors, offering potential alternatives to drain amylase for early pancreatic fistula diagnosis.

Methods: This retrospective cohort study included adult patients who underwent elective distal pancreatectomy between 01/2014 and 12/2023. Inclusion criteria required the availability of WBC count and CRP levels during the first three postoperative days. Exclusions were prior pancreatic surgery, combined DP/enucleation, or missing data. Data collected included demographics, comorbidities, intraoperative details, and postoperative serum markers (WBC, CRP, IL-6) from postoperative day 1 to postoperative day 3.

Results: This study included 210 patients who underwent distal pancreatectomy and met all inclusion criteria. Median WBC counts were significantly higher in patients with pancreatic fistula, especially on postoperative day 2 (18.5 × 10⁹/L vs. 16.0 × 10⁹/L, p < 0,01). CRP levels peaked higher in the pancreatic fistula group on postoperative day 3 (19.8 mg/dL vs. 15.3 mg/dL, p < 0.001). IL-6 levels showed no significant difference. Receiver Operating Characteristic (ROC) analysis identified WBC on postoperative day 2 (AUC = 0.62) and CRP on postoperative day 3 (AUC = 0.65) as relevant predictors, with optimal cut-off values of 17.9 × 10⁹/L and 17.2 mg/dL, respectively, which were rounded to 18. The combined elevation of both markers, defined as the "Critical 18" was associated with a markedly higher pancreatic fistula rate (59% vs. 18% in patients without elevation of either marker).

Conclusions: In light of these findings, we propose the "The Critical 18" as a simple yet powerful tool for early risk stratification of pancreatic fistula following distal pancreatectomy. By using WBC > 18 × 10 × 9/L on postoperative day 2 and CRP > 18 mg/dl on postoperative day 3, clinicians can easily identify patients at escalating risk, offering a clear framework for guiding postoperative management and interventions.

Clinical trial number: Not applicable.