Pre-operative neutrophil/lymphocyte and platelet/lymphocyte ratios are effective in predicting complicated acute cholecystitis

Neutrophil percentage-to-albumin ratio as a predictor of conservative treatment failure in acute cholecystitis: a retrospective cohort study

BACKGROUND

While early laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, conservative management remains necessary in specific scenarios such as high-risk patients or resource-limited settings. This study evaluated the predictive value of neutrophil percentage-to-albumin ratio (NPAR), a biomarker derived from routine laboratory tests, alongside established inflammatory markers and clinical parameters in identifying patients at risk of conservative treatment failure.

METHODS

In this retrospective cohort study at 2 tertiary centers (2020-2023), we analyzed 508 patients with acute cholecystitis who received conservative management. The study period coincided with the COVID-19 pandemic when healthcare resource constraints led to increased utilization of conservative management. Using admission laboratory data, we calculated NPAR, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and assessed Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists Physical Status (ASA-PS) classification. Receiver operating characteristic analysis and logistic regression were performed to evaluate their predictive value.

RESULTS

Conservative treatment failed in 107 patients (21.1%). Risk assessment showed higher proportions of CCI ≥ 6 (32.7% vs. 22.9%; P =.008) and ASA-PS class III-IV (16.8% vs. 8.0%; P =.002) in the failed treatment group. NPAR demonstrated superior predictive performance (area under curve, 0.906 [95% CI, 0.867-0.944]) compared with NLR (0.810 [0.765-0.855]) and PLR (0.614 [0.554-0.673]). The optimal NPAR cutoff value of 21.5 showed sensitivity of 88.8% and specificity of 84.8%. In multivariable analysis, NPAR > 21.5 emerged as the strongest independent predictor (adjusted odds ratio, 19.876 [95% CI, 8.934-42.651]; P <.001), followed by fever > 37.8 °C (2.845 [1.476-5.483]; P =.002) and leukocytosis (2.234 [1.112-4.485]; P =.024). Most treatment failures (77.6%) occurred within 48 h, requiring emergency surgery (57.9%), percutaneous drainage (37.4%), or endoscopic interventions (4.7%).

CONCLUSIONS

NPAR, combined with fever and leukocytosis, provides a practical and cost-effective framework for predicting conservative treatment failure in acute cholecystitis using routine laboratory tests. Although our study was conducted during the COVID-19 pandemic, these findings remain valuable for any clinical setting where conservative treatment is considered. The 48-hour window for most treatment failures provides a practical timeframe for clinical monitoring and intervention decisions.

The Role of Different Systemic Inflammatory Indexes Derived from Complete Blood Count in Differentiating Acute from Chronic Calculus Cholecystitis and Predicting Its Severity

Purpose

This study aimed to evaluate the diagnostic value of the different Complete blood count-derived systemic inflammation indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and neutrophil to lymphocyte × platelet ratio (NLPR) in differential diagnosing the chronic calculus cholecystitis (CCC) and the acute calculus cholecystitis (ACC), as well as determining the severity of ACC.

Patients and Methods

105 CCC and 88 ACC patients were enrolled. NLR, PLR, SII, and NLPR were evaluated in both cohorts as well as in different severity levels of ACC. The severity of ACC was determined based on the Tokyo Guidelines. Receiver operating characteristic (ROC) curve and Univariate/multivariate regression analyses were conducted.

Results

The levels of NLR, PLR, SII, and NLPR were significantly higher in the ACC group compared to the CCC group. The optimal cutoff values for NLR, PLR, SII, and NLPR were determined to be 3.89, 144.7, 896.8, and 0.031 respectively. NLR>3.89 demonstrates the highest predictive capability with an AUC of 0.801 and a sensitivity of 72.73%. Multivariate analysis showed that NLR>3.89 (OR: 4.169, p = 0.004) and NLPR>0.031 (OR: 4.304, p = 0.005) were dominant in distinguishing ACC from CCC. In ACC patients, the levels of NLR, SII, and NLPR were significantly higher in the Moderate to Severe-degree ACC (MS-ACC) group than in Mild-Degree ACC (M-ACC). NLPR > 0.044 exhibited the highest predictive ability with an AUC of 0.778 and a specificity of 91.67%. Multivariate analysis showed that NLR>6.399 (OR: 10.308, p = 0.000) was a possible independent prognostic factor for accessing the severity of ACC.

Conclusion

Systemic inflammation indexes can be useful in predicting the risk of ACC and MS-ACC. NLR demonstrates the best distinguishing power and sensitivity for distinguishing ACC from CCC, while NLPR shows the best predictive power and specificity for predicting the severity of ACC.

Medical management or surgery for acute cholecystitis: Enhancing treatment selection with decision trees

BACKGROUND

This study aimed to create an algorithm using the decision tree method to classify patients with suspected acute cholecystitis into those who may improve with medical treatment, those who should undergo surgery for acute cholecystitis, and those with complicated cholecystitis, using laboratory parameters alone.

METHODS

A total of 1,352 patients treated for acute cholecystitis at our hospital over four years were retrospectively analyzed. Patients were divided into groups based on whether they received medical treatment or surgery. Various demographic and laboratory parameters were recorded. A decision tree algorithm was used to classify patients based on these parameters. Statistical analyses were performed using SPSS, and the decision tree's performance was evaluated with 10-fold cross-validation. An additional decision tree was created for gangrenous cholecystitis using the same methods.

RESULTS

The decision tree identified the platelet-to-lymphocyte ratio (PLR) as the most critical parameter for distinguishing between patients requiring surgery and those suitable for conservative treatment. The algorithm demonstrated an 82.17% diagnostic accuracy for predicting operative need and a 73.86% accuracy for identifying gangrenous cholecystitis. C-reactive protein (CRP) levels, platelet (PLT) values, white blood cell (WBC) counts, and patient age were also significant factors in the decision-making process. The neutrophil-to-lymphocyte ratio (NLR) was the most useful for diagnosing necrosis.

CONCLUSION

The decision tree algorithm effectively differentiates between uncomplicated and complicated cholecystitis using easily obtainable laboratory parameters. This method offers a cost-effective, rapid alternative to imaging studies, facilitating timely and appropriate treatment decisions, ultimately improving patient outcomes and reducing healthcare costs.

Can neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, prognostic nutrition index, and albumin be used to predict cholecystectomy morbidity in super-elderly patients?

BACKGROUND

This study aimed to evaluate the usability of neutrophil-lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), prognostic nutritional index (PNI), and serum albumin level in predicting cholecystectomy morbidity in elderly patients (85 years and older) who underwent cholecystectomy for acute cholecystitis.

METHODS

This retrospective study included super-elderly patients who underwent cholecystectomy due to acute cholecystitis at a tertiary health centre between January 2010 and January 2021. The patients were divided into two groups according to the presence of postoperative complications (morbidity). The differences between the two groups were evaluated. In addition, the role of NLR, PLR, PNI, and serum albumin level in predicting cholecystectomy morbidity for acute cholecystitis in super-elderly patients was assessed via ROC analysis.

RESULTS

Of 30 patients who met the study criteria, 22 (73.3%) were female, and the mean age of all patients was 87.43±2.66 years (range 85-94 years). 7 (23.3%) patients had at least one comorbid disease during the preoperative period. The mean value of NLR, PLR, albumin, and PNI were 8.31, 153.76, 3.45, and 48.37, respectively. The morbidity rate of the study was 23.3%. The area under the curve (AUC) for NLR was 0.466 ([95% confidence interval [CI]: 0.259-0.672]; P=0.787), and the AUC for PLR was 0.429 ([95% CI: 0.201-0.656]; P=0.573). These two factors were not suitable for predicting morbidity. The AUC for PNI was 0.780 ([95% CI: 0.568-0.991]; P=0.027), and the AUC for albumin was 0.894 ([95% CI: 0.770-1.000]; P=0.002). At the cut-off value of 3.05 g/dL, the sensitivity and specificity of albumin were 91.3% and 71.4%, respectively, while the sensitivity and specificity of PNI at the 41.70 cut-off value were 82.6% and 71.4%, respectively.

CONCLUSION

This study found that PNI and albumin can be used as predictive factors with high sensitivity and specificity for predicting cholecystectomy morbidity for acute cholecystitis in super-elderly patients. However, NLR and PLR had no significance in predicting cholecystectomy morbidity.