Pankreatikoduodenektomili hastalarda albümin/globulin oranının postoperatif pankreas fistülünü öngörmedeki rolü

Öz

Amaç: Albümin/globulin oranı (AGR), inflamasyon ve bağışıklığın göstergelerinden biridir. Bu oran birçok malign hastalıkta da prognostik öneme sahiptir. Önceki çalışmalar, inflamatuar aracılar ile postoperatif pankreas fistülü (POPF) arasında bir ilişki olduğunu göstermiştir. Bu çalışmada, nispeten yeni bir gösterge olan AGR'nin postoperatif pankreas fistülü (POPF) ile ilişkisinin değerlendirilmesi amaçlandı. Yöntem: 2017 ve 2020 yılları arasında pankreatikoduodenektomi (PD) hastaları geriye dönük olarak analiz edildi ve iki gruba ayrıldı: (1) klinik olarak anlamlı POPF'si (CR-POPF) olan ve olmayan (2). İki grup ameliyat öncesi ve sonrası AGR ve klinik, demografik özellikler açısından karşılaştırıldı. AGR, albümin/ (toplam protein-albümin) olarak hesaplandı ve AGR için kesim noktası Youden indeksine göre belirlendi. Bulgular: PD uygulanan 121 hastanın %21'inde CR-POPF gelişti. Gruplar arasında yaş, cinsiyet, ek hastalık durumu, pankreas kanalı genişliği ve anastomoz tekniği açısından fark bulunmadı. Ameliyat öncesi ve sonrası 3. gün (POD3) albümin seviyeleri ve AGR, CR-POPF grubunda anlamlı derecede düşük bulundu. Çok değişkenli analiz, AGR ve pankreas dokusu sertliğinin POPF gelişimi için bağımsız risk faktörleri olduğunu gösterdi. Sonuç: Düşük AGR, CR-POPF gelişimi için bağımsız bir risk faktörüdür. POPF insidansını azaltmak için bu oran optimal seviyede tutulmalıdır. AGR'nin pankreatikoduodenektomi hastalarında POPF'yi öngörmede yararlı bir araç olarak kullanılması önerilmektedir.

Anahtar Kelimeler

• albumin
• albumin/globulin oranı
• pankreatikoduodenektomi
• postoperatif pankreas fistülü

The role of the albumin/globulin ratio on predicting post-operative pancreatic fistula in pancreaticoduodenectomy patients

Öz

Background: The albumin/globulin ratio (AGR) is one of several indicators of inflammation and immunity. This ratio has a prognostic significance in many malignant diseases. Previous studies have demonstrated a relationship between inflammatory mediators and post-operative pancreatic fistula (POPF). This study aimed to evaluate the relationship of AGR, a relatively new indicator, with post-operative pancreatic fistula (POPF). Methods: Pancreaticoduodenectomy (PD) patients between 2017 and 2020 were retrospectively analyzed and divided into two groups: (1) with and (2) without clinically relevant POPF (CR-POPF). The two groups were compared in terms of pre-operative–post-operative AGR and clinicodemographic characteristics. AGR was calculated as albumin/total protein–albumin, and the cutoff point for AGR was determined according to Youden’s index. Results: CR-POPF developed in 21% of 121 patients who underwent PD. No differences between the groups in terms of age, gender, comorbid disease status, pancreatic duct width, and anastomosis technique were found. Pre- and post-operative day-3 (POD3) albumin levels and AGR were found to be significantly lower in the CR-POPF group. Multivariate analysis showed that AGR and pancreatic tissue stiffness are independent risk factors for POPF development. Conclusion: Low AGR is an independent risk factor for the development of CR-POPF. To reduce the incidence of POPF, this ratio should be maintained at an optimal level. The use of AGR as a useful tool for predicting POPF in pancreaticoduodenectomy patients is suggested.

Anahtar Kelimeler

• albumin
• albumin/globulin ratio
• pancreaticoduodenectomy
• postoperative pancreatic fistula

Kaynakça

1. References 1. Peters JH, Carey LC. Historical review of pancreaticoduodenectomy. Am J Surg 1991; 161: 219–225.
2. 2. Are C, Dhir M, Ravipati L. History of pancreaticoduodenectomy: early misconceptions, initial milestones, and the pioneers. HPB 2011; 13: 377–384.
3. 3. Frymerman AS, Schuld J, Ziehen P, et al. Impact of Postoperative Pancreatic Fistula on Surgical Outcome—The Need for a Classification-driven Risk Management. J Gastrointest Surg 2010; 14: 711–718.
4. 4. Vallance AE, Young AL, Macutkiewicz C, et al. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB 2015; 17: 1040–1048.
5. 5. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017; 161: 584–591.
6. 6. Callery MP, Pratt WB, Kent TS, et al. A Prospectively Validated Clinical Risk Score Accurately Predicts Pancreatic Fistula after Pancreatoduodenectomy. J Am Coll Surg 2013; 216: 1–14.
7. 7. Mungroop TH, van Rijssen LB, van Klaveren D, et al. Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation. Ann Surg 2019; 269: 937–943.
8. 8. You Y, Han IW, Choi DW, et al. Nomogram for predicting postoperative pancreatic fistula. HPB 2019; 21: 1436–1445.

9. 9. Tabchouri N, Bouquot M, Hermand H, et al. A Novel Pancreatic Fistula Risk Score Including Preoperative Radiation Therapy in Pancreatic Cancer Patients. J Gastrointest Surg 2021; 25: 991–1000.
10. 10. Aydin A, Kaçmaz O, Öterkuş M, et al. MPV, RDW, LAKTAT, NA ve Albumin Düzeyleriyle Yoğun Bakım Hasta Mortalitesi Arasındaki İlişki. Dicle Tıp Derg 2022; 168–175.
11. 11. Boonpipattanapong T, Chewatanakornkul S. Preoperative Carcinoembryonic Antigen and Albumin in Predicting Survival in Patients With Colon and Rectal Carcinomas: J Clin Gastroenterol 2006; 40: 592–595.
12. 12. Siddiqui A, Heinzerling J, Livingston EH, et al. Predictors of early mortality in veteran patients with pancreatic cancer. Am J Surg 2007; 194: 362–366.
13. 13. Li X-H, Gu W-S, Wang X-P, et al. Low Preoperative albumin-to-globulin ratio Predict Poor Survival and Negatively Correlated with Fibrinogen in Resectable Esophageal Squamous Cell Carcinoma. J Cancer 2017; 8: 1833–1842.
14. 14. Fujiwara Y, Shiba H, Shirai Y, et al. Perioperative Serum Albumin Correlates with Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. ANTICANCER Res 2015; 5.
15. 15. Oki S, Toriyama Y, Okugawa Y, et al. Clinical burden of preoperative albumin-globulin ratio in esophageal cancer patients. Am J Surg 2017; 214: 891–898.
16. 16. Azab B, Kedia S, Shah N, et al. The value of the pretreatment albumin/globulin ratio in predicting the long-term survival in colorectal cancer. Int J Colorectal Dis 2013; 28: 1629–1636.
17. 17. Shinde R, Bhandare MS, Chaudhari V, et al. Preoperative Albumin-Globulin Ratio and Its Association with Perioperative and Long-Term Outcomes in Patients Undergoing Pancreatoduodenectomy. Dig Surg 2021; 38: 275–282.
18. 18. Hackert T, Hinz U, Pausch T, et al. Postoperative pancreatic fistula: We need to redefine grades B and C. Surgery 2016; 159: 872–877.
19. 19. Eshmuminov D, Schneider MA, Tschuor C, et al. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB 2018; 20: 992–1003.
20. 20. Gruppo M, Angriman I, Martella B, et al. Perioperative albumin ratio is associated with postoperative pancreatic fistula: Serum albumin predicts pancreatic fistula. ANZ J Surg 2018; 88: E602–E605.
21. 21. Xu W, Peng X, Jiang B. Hypoalbuminemia after pancreaticoduodenectomy does not predict or affect short-term postoperative prognosis. BMC Surg 2020; 20: 72.
22. 22. Lee B, Han H, Yoon Y, et al. Impact of preoperative malnutrition, based on albumin level and body mass index, on operative outcomes in patients with pancreatic head cancer. J Hepato-Biliary-Pancreat Sci 2021; 28: 1069–1075.
23. 23. Azab BN, Bhatt VR, Vonfrolio S, et al. Value of the pretreatment albumin to globulin ratio in predicting long-term mortality in breast cancer patients. Am J Surg 2013; 206: 764–770.
24. 24. Mungroop TH, Klompmaker S, Wellner UF, et al. Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation. Ann Surg 2021; 273: 334–340.
25. 25. Lapshyn H, Petruch N, Thomaschewski M, et al. A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy. Pancreatology 2021; 21: 957–964.
26. 26. Sakamoto T, Yagyu Y, Uchinaka E, et al. Predictive Significance of C-reactive Protein-to-albumin Ratio for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. Anticancer Res 2019; 39: 6283–6290.
27. 27. Fuks D, Piessen G, Huet E, et al. Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg 2009; 197: 702–709.
28. 28. Dutch Pancreatic Cancer Group, Gerritsen A, Molenaar IQ, et al. Preoperative Characteristics of Patients with Presumed Pancreatic Cancer but Ultimately Benign Disease: A Multicenter Series of 344 Pancreatoduodenectomies. Ann Surg Oncol 2014; 21: 3999–4006.
29. 29. Yildirim OY, Özer N. Effect of Anastomosis Technique on Pancreatic Fistula Formation in Proximal Pancreaticoduodenectomy. J Coll Physicians Surg Pak 2020; 30: 480–484.
30. 30. Yang YM, Tian XD, Zhuand Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol 2005; 11: 2456.