Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratiosin Laparoscopy and Open Surgery Applications

Aziz Ari; Kenan Buyukasik

Research Article

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratiosin Laparoscopy and Open Surgery Applications

Aziz Ari^* and Kenan Buyukasik
Department of General Surgery, Istanbul Training and Research Hospital, Turkey

^*Corresponding author: Aziz Ari, Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey

Published: 14 Sep, 2018
Cite this article as: Ari A, Buyukasik K. Neutrophilto- Lymphocyte and Platelet-to- Lymphocyte Ratiosin Laparoscopy and Open Surgery Applications. World J Surg Surgical Res. 2018; 1: 1051.

Abstract

Objective: Reducing the morbidity and mortality in patients with penetrating abdominal trauma needs to determine the peritoneal penetration and identify the need for surgery. In these conditions, the Neutrophil-Lymphocyte Ratio (NLR) and the Platelet-to-Lymphocyte Ratio (PLR) which is indicators of inflammatory events may guide the surgeon. We aimed to investigate NLR and PLR in patients who undergo laparoscopy.
Method: We performed a post-hoc analysis of previously collected data concerning 29 patients undergoing abdominal laparoscopic surgeries. For each patient, we recorded preoperative characteristics, injury types, NLR and PLR value, and postoperative condition.
Results: 13 patients (44.8%) were survivors with abdominal deep organ injury. In total, 10 patients underwent open surgery, due to insufficient or incompatibility of laparoscopy. In the correlation analysis of all continuous variables, while NLR showed a positive relation with PLR (r=0,932; p< 0.00001), this correlation was not seen in those of with lactate values. Both NLR and PLR had a significant increase in the opened cases instead of the laparoscopic close way (p=0.029 and p=0.047, respectively).
Conclusion: The examination of NLR and PLR may provide cost-effective and easy-to-use information on essential surgical interventions in the first few hours of admission to the emergency.
Keywords: Neutrophil-to-lymphocyte ratio; Platelet-to-lymphocyte ratio; Penetrating abdominal trauma; Laparoscopy

Introduction

Laparoscopic applications performed by an experienced surgeon provide successful results from abdominal surgery [1]. Laparoscopic operations cause fewer side effects for many types of surgery, especially in terms of bleeding and infection [2]. Lesser tissue damage at the surgery site provides easier and faster healing for patients [3]. Intra-abdominal adhesions developing after an open surgery and causing distress until the end of life in many patients are seen less common after laparoscopic surgery that the bowel obstruction due to the bowel circulation as a result of those minimizes the second laparoscopic chances that the patient may need due to a secondary disease [4].
Recent studies have shown that the ratio of both platelet (PLR) and neutrophil count to lymphocyte count (NLR) is indicative of systemic inflammation and is associated with the prognosis in many systemic diseases, malignancies, and chronic inflammatory diseases [5-7]. These ratios have been reported as correlated with the parameters such as TNF-alpha and interleukins, which have critical functions in inflammation [8]. We consider that these hematological parameters can give powerful preliminary information in the sense of the surgical approach to the case, with their inflammatory sensitive properties, when we are unstable for choosing an open or closed surgical approach.
In this study, we analyzed the NLR and PLR values on our surgical preferences in open or laparoscopic surgery for surgical patients who were hospitalized with abdominal trauma.

Methods and Materials

This single-center retrospective study was performed after ethical committee approval and we gained an informed consent from all the patients. The study involved 74 patients, without any major systemic diseases, scheduled for abdominal trauma-related gastric, hepatic, pancreatic, intestinal and colorectal injuries. We all recorded the preoperative data (Blood pressure, pulse, etc.), the NLR and PLR values (at preoperative 1st day) in addition to lactate (indicative of ischemia or hypoxemia) and other hemogram parameters (Neutrophil, WBC, etc.), and operative conditions such as fluid leakage, liquid Support and hospital stay for each patient. Venous blood samples were analyzed in a full automatic haemogram analyzer (Abbott Cell-Dyn 1800 automated hematology analyzer, Illinois, ABD) to count blood cells. After measuring the lymphocytes, platelets, and neutrophils, the NLR and PLR were calculated manually. A device of CARE Diagnostics was used to measure the lactate (Eco twenty, CARE diagnostic Productions, Möllersdorf, Römerstr, Austria).
All variables providing normal distribution were given as mean (± standard deviation: SD), while those without a normal distribution were given as percentage and median. Data including the demo graphics between groups were done by Mann-Whitney-U test. The Kruskal Wallis test was used post-hoc analyze of tests for the injury types. The Pearson correlation evaluating the linear relationship between two continuous variables was used for NLR and PLR correlation analyzes. Statistical analyze was done SPSSv21 (data analysis software for MS Windows). P< 0.05 was accepted as statistically significant.

Results

All patient details are given in Tables-1 with p values. The mean age was 30, 4 ± 10, 3 (range, 17 to 55) years for all participants. Of 74 patients, 33 patients (44.8%) were survivors with abdominal deep organ injury (perforation in colon, 10; perforation in small intestine, 13; stomach, 5; liver laceration, 5). In total, 26 patients underwent open surgery, due to insufficient or incompatibility of laparoscopy. In the correlation analysis of all continuous variables, while NLR showed a positive relation with PLR (r=0,932; p< 0.00001), this correlation was not seen in those of with lactate values. There was no significant correlation among neither other parameters nor PLR and NLR. Both NLR and PLR had a significant increase in the opened cases instead of the laparoscopic close way (p=0.029 and p=0.047, respectively). Additionally, they indicated a similar behavior at the type of abdominal injury, which had the highest levels in the stomach, as seen in (Figure 1) and (Figure 2). However, this increase was not significant due to the high standard deviations.

Figure 1

Figure 1
Platelet-to-Lymphocyte Ratio.

Figure 2

Figure 2
Neutrophil-to-Lymphocyte Ratio.

Table 1

Age (years) Gender (M/F) SBP (mmHg) DBP (mmHg) Pulse WBC NEUT LYMP PLT Hematocrit Lactate PLR NLR Fluid leakage Liquid Support Hospital Stay

Parameters	Yes	No
31 ± 11	29 ± 10	0,568
25 / 8	32 / 9	0,258
121 ± 10	108 ± 10	0,001
79±3	76 ± 4	0,023
88 ± 6	93 ± 6	0,016
11.8 ± 4,5	15 ± 5,7	0,166
8.7 ± 3,1	11.2 ± 4,8	0,143
2.3 ± 0,9	2 ± 1,3	0,258
254 ± 155	254 ± 70	0,907
38.1 ± 3,9	35.5 ± 4,4	0,421
1.91 ± 0,5	3.26 ± 1,5	0,009
128 ± 68	212 ± 99	0,245
5.1 ± 2,2	10.6 ± 4,9	0,161
272 ± 188	819 ± 449	0,001
1906 ± 633	2423 ± 312	0,001
4 ± 1	7 ± 1	0,0001

Table 1: Demographics with significance according to whether GIS injury existed or not.

Table 1
Demographics with significance according to whether GIS injury existed or not.

Discussion

The open surgical approach and the laparoscopic approach provide two very different clinical outcomes, which are of great importance for patients in their future lives. The recent studies showed that PLR and NLR could be beneficial in predicting prognosis of several inflammatory diseases [9]. Our study was an important contest in the sense whether NLR and PLR values have the potential of influencing preoperational surgical decision-making. Especially in the patients hard to decide for open or close surgical application, these two parameters should be evaluated very well before the operation. Laparoscopy for gastrointestinal perforations leads to shorter residence times, decreased morbidity, and shorter incision length compared with an open surgery [4,10,11]. A laparos-copic procedure in colon repair is probably the first clinical approach, particularly where feasible in terms of surgeon experience [12]. Intra-abdominal adhesions developing after an open surgery and causing distress until the end of life in many patients are seen less common after laparoscopic surgery that the bowel obstruction due to the bowel circulation as a result of those minimizes the second laparoscopic chances that the patient may need due to a secondary disease [3,13]. In a study of Bleir et al. [14], the time of laparoscopic approach was better and hospital stay was lesser in the laparoscopic way [14]. Similarly, Coimbria shared hospital stays as shorter in the laparoscopy than being in the laparotomy [15]. Also in our study, postoperative hospital stay in the open surgery was longer than that in a laparoscopic way. Meanwhile, hematological parameters can give powerful preliminary information in the sense of the surgical approach to the case, with their inflammatory sensitive properties, when we are unstable for choosing an open or closed surgical approach.
Nowadays, some authors report NLR as a predictor of inflammation and helpful in predicting gastrointestinal systems [16]. Markay et al. [17] a suggested NLR as a cautionary parameter for a possible appendicitis situation [17]. Another study measured high NLR levels in the pediatric vasculitis accompanying bleeding of gastrointestinal organs [18]. Park et al. [19] suggested that bleeding originated from the gastrointestinal system were associated with the high NLR [19]. Our results support these reports of NLR. In the patients with severe problems such as more fluid leakage, the additional necessity for liquid support, lengthened hospital stay period had higher NLR levels than others. The NLR was found significantly higher in the open-treated cases than the laparoscopically-treated patients.
There is little work in this regard, but it is reported that NLR has more diagnostic coherence than traditional diagnostic laboratory tests, which are only white blood cells [20]. The high PLR value indicates a reduced number of lymphocytes or an increasing number of platelets. In many different cases, platelets can secrete inflammatory mediators such as growth factors and consequently both stimulate tumor angiogenesis and cell growth [21]. As a convenient and costeffective blood-derived marker, PLR, which takes into account the inflammatory response, immune response, and coagulation status, has been widely investigated as a useful prognostic factor in the disease-related digestive system [22]. NLR had a positive correlation with PLR, but this correlation was not seen in those of with lactate values. Both NLR and PLR had a significant increase in the opened cases instead of the laparoscopic close way. Similarly, as in our study, among the all the open-treated cases, gastric injuries had higher NLR and PLR values than the other gastrointestinal locations. However, we considered that difference without any significance in this study was a result of the small number of participants.
In this study, there area few limitations due to numbers of the participants. A total of 74 patients were included in the current study. We performed the study in a single state hospital. Hence, we found different NLR and PLR in different injury types, but no significant existed. All results for NLR and PLR needs strong validation studies with large numbers of participants to cover all community.

Conclusion

As a result, both NLR and PLR can be a useful predictor of the high possibility that the patients need open-surgery instead of the laparoscopic approach. Both NLR and PLR had a significant increase in the opened cases instead of the laparoscopic close way. Gastric injuries had higher NLR and PLR values than the other gastrointestinal perforations. The examination of NLR and PLR may provide cost-effective and easy-to-use information on essential surgical interventions in the first few hours of admission to the emergency.

Research Article