Abstract
Objectives:
Colorectal perforation is associated with high morbidity and mortality rates after surgery. We investigated various clinical features of patients who underwent emergency surgery for colorectal perforation and explored the risk factors for postoperative complications and hospital mortality.
Methods:
Data from 147 patients who underwent surgery for colorectal perforation were retrospectively reviewed. We investigated various clinical and operative factors, including inflammation-based prognostic scores (IBPSs), and evaluated the risk factors for postoperative complications and hospital mortality due to colorectal perforation.
Results:
Among 147 patients, the most frequent postoperative complication was wound infection (32 cases, 21.8%), followed by intra-abdominal abscesses (27 cases, 18.4%) after surgery for colorectal perforation. Time from onset to surgery ≥ 2 days (Hazard ratio [HR] = 2.810, p = 0.0383) and prognostic nutritional index (PNI) < 30 (HR = 3.190, p = 0.0488) were identified as risk factors for intra-abdominal abscess, while neutrophil-lymphocyte ratio (NLR) < 6.15 (HR = 5.020, p = 0.0009) was identified as a risk factor for wound infection. Time from onset to surgery ≥ 2 days (HR = 7.713, p = 0.0492), severe postoperative complications (Clavien-Dindo grade ≥ IIIa) (HR = 10.98, p = 0.0281), and platelet-lymphocyte ratio (PLR) < 144 (HR = 18.84, p = 0.0190) were independent predictive factors for hospital mortality.
Conclusions:
Time from onset to surgery and IBPSs such as PNI, NLR, and PLR, may be associated with postoperative complications and hospital mortality due to colorectal perforation.
Keywords: colorectal perforation, emergency surgery, inflammation-based prognostic score, postoperative complication, mortality
Introduction
Colorectal perforation has an extremely poor prognosis due to generalized peritonitis and septic shock. Consequently, bacteremia and disseminated intravascular coagulation (DIC) can arise, leading to multiple organ failures, resulting in high mortality rates[1]. In many cases, surgical approaches, including extensive drainage and perioperative intensive treatment are required to save these patients' lives[2,3]. Despite such aggressive therapy, challenges such as high morbidity and mortality occur after surgery.
Emergency surgery in these conditions is associated with a high incidence of postoperative complications. Previous studies have reported that postoperative complications result in poor postoperative outcomes for several diseases. Hashimoto et al. have reported that postoperative complication was an independent prognostic factor for overall survival (OS) and recurrence-free survival in perforated colorectal cancer[4]. We previously studied patients with esophageal squamous cell carcinoma who underwent surgical treatment for postoperative recurrent lesions and showed that the presence of severe complications after resection for recurrent lesions (Clavien-Dindo (C-D)[5,6] grade ≥ IIIa) was one of the independent poor prognostic factors for OS[7].
Some studies have indicated that postoperative complications affect the immunological response, which improves undetected tumor viability and increases disease recurrence[8,9]. Other studies have shown that injuries associated with surgery stimulate tumor growth and dissemination[10-12]. Oh et al. reported that advanced cancer and open surgery were identified as risk factors for increased surgery-related major complications after radical colorectal cancer surgery[13]. Moreover, in cases of colorectal perforation, postoperative complications are presumed to affect survival rates after surgery; however, this hypothesis has not yet been elucidated due to the availability of only a few studies on these situations.
We previously investigated risk factors of hospital mortality after surgery for colorectal perforation in another cohort and showed that three inflammation-based prognostic scores (IBPSs) including neutrophil-lymphocyte ratio (NLR), C-reactive protein/albumin ratio (CAR) and prognostic nutritional index (PNI) were associated with poor outcomes[14]. IBPSs, which reflect malnutrition and systemic inflammatory responses, have been reported to predict outcomes in patients with malignant tumors[15-20], cardiovascular diseases[21,22], and other non-malignant diseases such as acute pancreatitis, pulmonary embolism, and infective endocarditis[23-25]. In addition to postoperative prognosis, IBPSs may be associated with postoperative complications. However, the relationship between IBPSs and gastrointestinal perforation has not been elucidated.
In the present study, we investigated various clinical features, including IBPSs, in patients who underwent emergency surgery for colorectal perforation and explored the risk factors for postoperative complications and hospital mortality.
Methods
Patients
In this retrospective single-center cohort study, we reviewed the data of 147 patients who underwent emergency surgery for colorectal perforation at our institute between June 2013 and November 2022.
This study was approved by the Institutional Review Board of Iizuka Hospital (23073). The study conformed to the provisions of the Declaration of Helsinki (revised in Fortaleza, Brazil, October 2013) available at https://www.wma.net/what-we-do/medical-ethics/declaration-of-helsinki/. Informed consent was obtained from the patients; an opt-out form on the study website was used when informed consent could not be obtained.
Inflammation-based prognostic scores
The NLR, platelet-lymphocyte ratio (PLR), CAR, PNI, Glasgow Prognostic Score (GPS), and prognostic index (PI) were calculated from patient records. Baseline blood data were obtained by collecting blood from the peripheral veins of each patient before surgery. NLR and PLR were defined as the absolute neutrophil count and platelet count, respectively, divided by the absolute lymphocyte count[15,16]. CAR was defined as the serum c-reactive protein (CRP) level divided by the serum albumin level[17]. The PNI was calculated using the following formula: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3)[18]. The GPS was calculated by CRP and albumin using standard thresholds (>1.0 mg/dL for CRP and <3.5 g/dL for albumin)[19]. Calculation of the PI was based on the CRP level and white blood cell count. The upper limits of the reference range for the CRP level (0.1 mg/dL) and white blood cell count (11,000/mm3) were used as cut-off values[20]. The PI was considered zero if both values were < the cut-off values and the PI was one if one of the two markers was elevated.
Statistical analyses
Differences in characteristics between the groups were evaluated using Fisher's exact test or an unpaired t-test. Survival curves were plotted according to the Kaplan-Meier method, and differences were analyzed using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards model to identify independent prognostic factors. Receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off values for IBPSs. Based on ROC curve analysis, the optimal cut-off values of NLR, PLR, CAR, PNI, GPS, and PI were 6.15, 144, 11, 30, 2, and 1, respectively, and the AUCs were 0.5241, 0.6401, 0.6182, 0.6985, 0.6617, and 0.4956, respectively. All p-values were two-sided, and p < 0.05 was considered statistically significant. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria)[26]. More precisely, it is a modified version of the R commander designed to add statistical functions frequently used in biostatistics.
Results
Characteristics of patients with colorectal perforation based on postoperative complication
Among the 147 patients, the incidence of postoperative complications was 55.8% (82 patients). The patients were divided into two groups according to the occurrence of postoperative complications. The baseline characteristics of the two groups are summarized in Table 1. There were no significant differences in the proportion of sex and mean age between the two groups. Regarding the location of the perforation, all 9 cases perforated in descending colon had postoperative complications. Diverticula were the most common cause of perforation, whereas cancer was the second most frequent cause in both groups. All patients with perforations caused by the endoscopic treatment were free of complications. Comparing the mean values of each IBPS between the two groups, the proportion of high GPS and PI was significantly higher in the group with postoperative complications (p = 0.010 and 0.006, respectively) (Table 1).
Table 1.
Baseline Demographic and Clinical Features Based on Postoperative Complication.
| Factor | Postoperative complication (-) (n = 65) n (%) |
Postoperative complication (+) (n = 82) n (%) |
p-value | |
|---|---|---|---|---|
| Sex | Male | 30 (46.2) | 36 (43.9) | 0.868 |
| Female | 35 (53.8) | 46 (56.1) | ||
| Age in years | Mean | 74.8 | 73.1 | 0.411 |
| (range) | (35-98) | (35-92) | ||
| BMI | < 25 | 47 (72.3) | 70 (85.4) | 0.064 |
| ≥ 25 | 18 (27.7) | 12 (14.6) | ||
| Location | C | 1 (1.5) | 5 (6.1) | 0.003 |
| A | 5 (7.7) | 7 (8.5) | ||
| T | 10 (15.4) | 2 (2.4) | ||
| D | 0 (0.0) | 9 (11.0) | ||
| S | 37 (56.9) | 45 (54.9) | ||
| R | 12 (18.5) | 14 (17.1) | ||
| Causes of perforation | Diverticulum | 24 (36.9) | 25 (30.5) | NA |
| Cancer | 14 (21.5) | 23 (28.0) | ||
| Post-endoscopy | 11 (16.9) | 0 (0.0) | ||
| Fecal | 2 (3.1) | 4 (4.9) | ||
| Steroid | 2 (3.1) | 3 (3.7) | ||
| Ileus | 2 (3.1) | 2 (2.4) | ||
| Trauma | 1 (1.5) | 1 (1.2) | ||
| Unknown | 9 (13.9) | 24 (29.3) | ||
| Days from onset to surgery | Mean | 0.89 | 1.28 | 0.150 |
| NLR | Mean | 12.22 | 12.82 | 0.762 |
| (range) | (1.35-49.84) | (0.67-64.47) | ||
| PLR | Mean | 365.86 | 440.88 | 0.130 |
| (range) | (51.50-1159.41) | (42.73-1561.91) | ||
| CAR | Mean | 3.63 | 5.09 | 0.062 |
| (range) | (0.01-19.13) | (0.03-24.99) | ||
| PNI | Mean | 37.50 | 35.03 | 0.115 |
| (range) | (21.47-67.61) | (14.62-66.74) | ||
| GPS | 0/1 | 33 (50.8) | 24 (29.3) | 0.010 |
| 2 | 32 (49.2) | 58 (70.7) | ||
| PI | 0 | 17 (26.2) | 7 (8.5) | 0.006 |
| 1/2 | 48 (73.8) | 75 (91.5) | ||
| Surgical procedure | Resection + stoma | 30 (46.2) | 51 (62.2) | 0.023 |
| Resection + anastomosis | 14 (21.5) | 12 (14.6) | ||
| Stoma | 11 (16.9) | 17 (20.7) | ||
| Suture | 9 (13.8) | 2 (2.4) | ||
| Only drainage | 1 (1.5) | 0 (0.0) | ||
| Operative time (min) | Mean | 142.4 | 164.7 | 0.009 |
| (range) | (46-253) | (46-286) | ||
| Intraoperative blood loss (mL) | Mean | 216.0 | 384.9 | 0.008 |
| (range) | (0-930) | (0-2900) | ||
| Hospital stay (days) | Mean | 18.25 | 40.00 | <0.001 |
| (range) | (7-48) | (1-200) | ||
| Details of complication | Wound infection | 32 (21.8) | ||
| Intra-abdominal abscess | 27 (18.4) | |||
| Respiratory complication | 10 (6.8) | |||
| Wound dehiscence | 7 (4.8) | |||
| Intestinal infection | 6 (4.1) | |||
| Anastomotic leakage | 4 (2.7) | |||
| Others | 9 (6.1) | |||
| Clavien-Dindo classification (n = 82) | I | 22 (26.8) | ||
| II | 21 (25.6) | |||
| IIIa | 22 (26.8) | |||
| IIIb | 3 (3.7) | |||
| IV | 6 (7.3) | |||
| V | 8 (9.8) | |||
Data are presented as the number (%) unless otherwise stated. BMI, body mass index; C, Cecum; A, Ascending colon; T, Transverse colon; D, Descending colon; S, Sigmoid colon; R, Rectum; NLR, neutrophil-lymphocyte ratio; PLR, platelet-lymphocyte ratio; CAR, C-reactive protein/albumin ratio; PNI, prognostic nutritional index; GPS, Glasgow prognostic score; PI, prognostic index
Operative outcomes were also compared between the two groups. The mean operative time was significantly longer in the patients with postoperative complications (p = 0.009). The mean intraoperative blood loss (IBL) was significantly higher in patients with postoperative complications (p = 0.008). The mean duration of hospital stay was significantly longer in patients with postoperative complications (p < 0.001).
Risk factors for postoperative complication
Detailed analyses were performed for each postoperative complication. Listed in descending order of incidence, the most frequent complication was wound infection (32 cases, 21.8%), followed by intra-abdominal abscess (27 cases, 18.4%), respiratory complication (10 cases, 6.8%), wound dehiscence (7 cases, 4.8%), intestinal infection (6 cases, 4.1%), and anastomotic leakage (4 cases, 2.7%) (Table 1). We focused on four postoperative complications that were particularly frequent, including wound infection, intra-abdominal abscess, respiratory complications, and wound dehiscence, and examined the relationships between the occurrence of these complications and clinical factors.
The clinical features, IBPSs, and operative outcomes were compared between patients with and without each complication (Supplementary Table 1-4). Patients with wound infections were characterized by a lower NLR (p = 0.014), longer operative time (p = 0.019), higher IBL (p = 0.018), and longer hospital stay (p = 0.041) (Supplementary Table 1). Patients with intra-abdominal abscesses had a longer time from onset to surgery (p = 0.048), higher PLR (p = 0.001), and higher CAR (p = 0.001) (Supplementary Table 2). Patients with respiratory complications were characterized by lower body mass index (BMI) (p = 0.026), higher PLR (p = 0.003), lower PNI (p = 0.005), higher GPS (p = 0.007), and longer hospital stay (p = 0.035) (Supplementary Table 3). Patients with wound dehiscence were characterized by longer hospital stays (p < 0.001) (Supplementary Table 4).
The patients were categorized according to the C-D classification[19,20]. Patients with severe complication (C-D grade ≥ IIIa) were characterized by longer time from onset to surgery (p = 0.022), higher CAR (p = 0.013), lower PNI (p = 0.013), higher GPS (p = 0.022), higher PI (p = 0.040), higher amount of IBL (p = 0.005), and longer hospital stay (p < 0.001) (Supplementary Table 5).
Multivariate analyses were performed to identify risk factors for postoperative complications in patients with colorectal perforation. Multivariate analyses identified that NLR < 6.15 (hazard ratio [HR] = 3.380, p = 0.0070) and PI ≥ 1 (HR = 5.340, p = 0.0041) were independent risk factors for all postoperative complications in patients with colorectal perforation (Table 2). For complications with a high frequency, such as intra-abdominal abscess and wound infection, multivariate analyses were performed individually. Time from onset to surgery ≥ 2 days (HR = 2.810, p = 0.0383), and a PNI < 30 (HR = 3.190, p = 0.0488) were identified as risk factors for intra-abdominal abscess. NLR < 6.15 was identified as a risk factor for wound infection (HR = 5.020, p = 0.0009), whereas PNI < 30 was identified as a factor that decreased the occurrence of wound infection (HR = 0.176, p = 0.0291).
Table 2.
Multivariate Analyses for Risk Factors of All Postoperative Complication, Intra-Abdominal Abscess, and Surgical Site Infection.
| Factor | All complication | Intra-abdominal abscess | Wound infection | ||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | (95% CI) | p-value | OR | (95% CI) | p-value | OR | (95% CI) | p-value | |
| Age ≥ 75 y (vs < 75 y) | 0.717 | (0.347–1.480) | 0.3680 | 0.779 | (0.311–1.950) | 0.5940 | 1.130 | (0.473–2.720) | 0.7780 |
| Right side of colon (vs left) | 0.717 | (0.289–1.780) | 0.4750 | 1.770 | (0.601–5.230) | 0.3000 | 0.902 | (0.298–2.730) | 0.8540 |
| Time from onset to surgery ≥ 2 days | 1.740 | (0.726–4.170) | 0.2140 | 2.810 | (1.060–7.490) | 0.0383 | 1.300 | (0.441–3.830) | 0.6350 |
| IBL ≥ 700 (ml) (vs < 700) | 2.510 | (0.790–7.960) | 0.1190 | 0.861 | (0.235–3.150) | 0.8220 | 3.250 | (0.979–10.80) | 0.0543 |
| NLR < 6.15 (vs ≥ 6.15) | 3.380 | (1.400–8.170) | 0.0070 | 2.380 | (0.848–6.650) | 0.0998 | 5.020 | (1.930–13.10) | 0.0009 |
| PLR < 144 (vs ≥ 144) | 1.180 | (0.427–3.270) | 0.7480 | 0.709 | (0.197–2.560) | 0.5990 | 0.738 | (0.248–2.200) | 0.5850 |
| CAR ≥ 11 (vs < 11) | 1.080 | (0.273–4.280) | 0.9110 | 0.863 | (0.198–3.750) | 0.8440 | 2.860 | (0.460–17.70) | 0.2600 |
| PNI < 30 (vs ≥ 30) | 1.420 | (0.512–3.960) | 0.4970 | 3.190 | (1.010–10.10) | 0.0488 | 0.176 | (0.037–0.838) | 0.0291 |
| PI ≥ 1 (vs < 1) | 5.340 | (1.700–16.80) | 0.0041 | 2.130 | (0.409–11.10) | 0.3700 | 3.780 | (0.995–14.30) | 0.0509 |
OR, odds ratio; CI, confidence interval; IBL, intraoperative blood loss; NLR, neutrophil-lymphocyte ratio; PLR, platelet-lymphocyte ratio; CAR, C-reactive protein/albumin ratio; PNI, prognostic nutritional index; PI, prognostic index
Characteristics of patients with colorectal perforation based on hospital mortality
The patients were divided into two groups according to hospital mortality: 137 (93.2%) survivors and 10 (6.8%) non-survivors. The baseline characteristics of survivors and non-survivors are summarized in Supplementary Table 6. There were no significant differences in mean age, location, or cause of perforation between survivors and non-survivors. Comparing the mean values of each IBPS between survivors and non-survivors, the CAR was significantly poor in non-survivors than in survivors (p = 0.050). The mean time from onset to surgery was significantly longer in non-survivors than in survivors (p = 0.001) (Supplementary Table 6).
Operative outcomes according to hospital mortality
Operative outcomes were compared between survivors and non-survivors (Supplementary Table 7). There was no significant difference in mean operative times between the two groups (survivors, 156.1 min versus non-survivors, 138.2 min, p = 0.294). The mean amount of IBL was significantly higher in non-survivors than in survivors (survivors, 285.2 mL, versus non-survivors, 652.9 mL, p = 0.003). The occurrence of postoperative complications was higher in non-survivors than in survivors (survivors, 52.6% versus non-survivors, 100.0%; p = 0.002). Intra-abdominal abscesses tended to be more frequent in non-survivors (survivors, 16.8% vs. non-survivors, 40.0%; p = 0.087). The ratio of severe complications (C-D ≥IIIa) was more remarkable in non-survivors (survivors, 21.9% versus non-survivors, 90.0%; p < 0.0001). The median survival time of the non-survivors was 17.5 days after surgery.
Prognostic factors for hospital mortality
Univariate and multivariate analyses were performed to identify prognostic factors for hospital mortality in patients with colorectal perforation. Univariate analyses showed that time from onset to surgery ≥ 2 days, severe postoperative complications (C-D ≥ IIIa), PLR < 144, CAR ≥ 11, and PNI < 30 were associated with postoperative hospital mortality (p < 0.05). Multivariate analyses identified that time from onset to surgery ≥ 2 days (hazard ratio [HR] = 7.713, p = 0.0492), severe postoperative complications (C-D ≥ IIIa) (HR = 10.98, p = 0.0281), and PLR < 144 (HR = 18.84, p = 0.0190) were independent predictive factors for hospital mortality in patients with colorectal perforation (Table 3).
Table 3.
Univariate and Multivariate Analyses for Hospital Mortality of Colorectal Perforation.
| Factor | Univariate analysis | Multivariate analysis | ||||
|---|---|---|---|---|---|---|
| HR (95% CI) | p-value | HR (95% CI) | p-value | |||
| Age ≥ 75 y (vs < 75 y) | 0.278 | (0.059–1.311) | 0.1058 | 0.408 | (0.064–2.618) | 0.3445 |
| Right side of colon (vs left) | 0.459 | (0.058–3.626) | 0.4605 | 0.369 | (0.033–4.106) | 0.4176 |
| Time from onset to surgery ≥ 2 days | 8.423 | (2.174–32.64) | 0.0020 | 7.713 | (1.008–59.04) | 0.0492 |
| Postoperative complication (C-D ≥ IIIa) | 24.33 | (3.082–192.0) | 0.0025 | 10.98 | (1.293–93.23) | 0.0281 |
| IBL ≥ 700 (ml) (vs < 700) | 4.127 | (1.164–14.63) | 0.0282 | 2.144 | (0.233–19.76) | 0.5009 |
| NLR ≥ 6.15 (vs < 6.15) | 0.607 | (0.176–2.097) | 0.4300 | 0.462 | (0.068–3.156) | 0.4309 |
| PLR < 144 (vs ≥ 144) | 5.194 | (1.501–17.98) | 0.0093 | 18.84 | (1.619–219.3) | 0.0190 |
| CAR ≥ 11 (vs < 11) | 6.214 | (1.752–22.04) | 0.0047 | 5.992 | (0.408–87.93) | 0.1914 |
| PNI < 30 (vs ≥ 30) | 7.792 | (2.014–30.14) | 0.0029 | 2.625 | (0.187–36.95) | 0.4744 |
| PI ≥ 1 (vs < 1) | 1.515 | (0.192–11.97) | 0.6936 | 0.457 | (0.023–9.282) | 0.6105 |
HR, hazard ratio; CI, confidence interval; C-D, Clavien–Dindo classification; IBL, intraoperative blood loss; NLR, neutrophil-lymphocyte ratio; PLR, platelet-lymphocyte ratio; CAR, C-reactive protein/albumin ratio; PNI, prognostic nutritional index; PI, prognostic index
Discussion
In this study, clinical features including IBPSs and operative outcomes were evaluated according to the occurrence of various postoperative complications in patients who underwent emergency surgery for colorectal perforation. Moreover, we explored risk factors of postoperative complications and identified that NLR < 6.15 and PI ≥ 1 were independent risk factors for all postoperative complications. In addition, time from onset to surgery ≥ 2 days and PNI < 30 were identified as risk factors for intra-abdominal abscesses.
A comparison of patient characteristics based on postoperative complications revealed that the duration of hospital stay was prolonged along with other complications. Prolonged hospitalization is a natural consequence of postoperative complications requiring additional treatment. In addition, worse values were correlated with the occurrence of postoperative complications. Since IBPSs reflect a systemic inflammatory response, immunosuppression, and malnutrition, the poor patient condition may have contributed to the increased risk of postoperative complications. However, only in terms of NLR, unlike expectation, a lower value was associated with a higher risk of postoperative complications.
Comparing the values of NLR separately in each category of complications, the mean values of NLR in patients with intra-abdominal abscess, respiratory complications, and wound dehiscence were higher than those in patients without these complications, whereas the mean value of NLR in patients with wound infection was significantly lower than that in patients without wound infection, and a lower NLR was identified as an independent risk factor for wound infection. These results suggest that a lower NLR is associated with wound infections rather than other typical complications. The reason for the lower mean NLR in patients with wound infections remains unclear. In previous studies, Fuss J et al. have reported that high NLR correlated with an increased occurrence of postoperative complications in patients with colorectal cancer[27], and Ida M et al. showed that high NLR was independently associated with postoperative complications after pancreaticoduodenectomy or distal pancreatectomy[28]. Kelly ME et al. showed that mean NLR was statistically higher in patients with postoperative complications after surgery for acute appendicitis[29]. These studies consistently suggest that higher NLR was correlated with the risk of postoperative complications, and this seems to contradict our results. However, details of complications were not specified in these studies, and even in our analyses, only wound infection had an inconsistent tendency with respect to NLR. Regarding the relationship between wound healing and NLR, Vatankhah N et al. suggested that higher NLR was associated with higher odds of nonhealing in diabetic foot ulcers[30]. Consistent with the above studies, higher NLR was generally associated with worse events after surgery.
Patients with wound infection had longer operative times and higher amounts of IBL. Moreover, the proportion of BMI ≥ 22 in patients with wound infection was higher than that in patients without wound infection (56.2% vs 43.5%). These results suggest that postoperative wound infection may be more affected by surgical stress and obesity than by malnutrition and systemic inflammatory response, which are reflected in IBPSs.
In the present study, multivariate analysis showed that the time from onset to surgery ≥ 2 days, severe postoperative complications (C-D ≥ IIIa), and a PLR < 144 were independent prognostic factors for hospital mortality. Time from onset to surgery ≥ 2 days was also a risk factor for the occurrence of intra-abdominal abscess. It can be expected that sepsis and DIC are more likely to occur as time passes from the onset and the risk of postoperative complications and hospital mortality increases.
PLR generally reflects chronic inflammation, and previous studies have reported that higher PLR values are correlated with poor prognosis in many diseases[16,30,31]. However, lower PLR was an independent prognostic factor for hospital mortality in the present study. Colorectal perforation is likely to become a severe condition, and DIC could be caused, particularly in patients who died after surgery. In patients with DIC, thrombosis occurs particularly in the microcirculation. This accounts for the inappropriate deposition of fibrin and platelets in the microcirculation, with subsequent organ ischemia, resulting in the characteristic hypofibrinogenemia and thrombocytopenia observed in the circulating blood[32]. Accordingly, this sequence may have resulted in lower PLR values due to thrombocytopenia.
In summary, in various IBPS, lower PNI was identified as a risk factor for intra-abdominal abscess, while lower NLR was associated with the occurrence of wound infection. Moreover, lower PLR was an independent prognostic factor for hospital mortality by reflecting a severe condition such as DIC. Therefore, each IBPS has different characteristics and roles.
However, this study has a potential limitation. This was a retrospective, single-center study. However, colorectal perforation can occur suddenly and usually requires emergency surgery. Therefore, it is challenging to design a prospective study on colorectal perforation. Few studies have investigated the risk factors of postoperative outcomes after surgery for colorectal perforations. Therefore, the accumulation of findings from retrospective studies is valuable.
Improving values of IBPSs before surgery is challenging, due to the emergency setting. Our results suggest that better management such as more thorough intraperitoneal and wound irrigation, increasing the number of drainage tubes, and more careful postoperative observation may be recommended for patients with poor PNI and NLR values.
Conclusions
In the present study, the most frequent postoperative complication was wound infection, followed by intra-abdominal abscesses after surgery for colorectal perforation. Time from onset to surgery ≥ 2 days and PNI < 30 were identified as risk factors for intra-abdominal abscesses, while NLR < 6.15 and PNI ≥ 30 were identified as risk factors for wound infection. Time from onset to surgery ≥ 2 days, severe postoperative complications (C-D ≥ IIIa), and a PLR < 144 were independent predictive factors for hospital mortality. Overall, our study will help in the better management of postoperative complications and hospital mortality in patients with colorectal perforation.
Conflicts of Interest
There are no conflicts of interest.
Source of Funding
Dr. Kensuke Kudou was supported by grants from the Kaibara Morikazu Medical Science Promotion Foundation in 2019, the Uehara Memorial Foundation in 2020, the Grant of The Clinical Research Promotion Foundation in 2020, and the Fukuoka Public Health Promotion Organization Cancer Research Fund in 2021.
Author Contributions
Kudou K.: study conception and design, acquisition of data, analysis of data and interpretation, statistical analysis, and drafting of manuscript
Kajiwara S., Motomura T., Yukaya T., Nakanoko T., Kuroda Y., Okamoto M.: acquisition of data
Koga T., Yamashita Y.: final approval.
Approval by Institutional Review Board (IRB)
This study was approved by the Institutional Review Board of Iizuka Hospital (23073). The study conformed to the provisions of the Declaration of Helsinki (revised in Fortaleza, Brazil, October 2013) available at https://www.wma.net/what-we-do/medical-ethics/declaration-of-helsinki/.
Supplementary Files
Acknowledgements
We thank the Kaibara Morikazu Medical Science Promotion Foundation, the Uehara Memorial Foundation, the Clinical Research Promotion Foundation, and the Fukuoka Public Health Promotion Organization Cancer Research Fund for providing financial support. We also thank Editage Group (https://www.editage.jp/) for editing the draft of this manuscript.
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