ArticlePatient safety in surgery2026
"The Critical 18" of postoperative white blood cell count and C-reactive protein level predicts postoperative pancreatic fistula after distal pancreatectomy.
Article in Patient safety in surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundDistal 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.
methodsThis 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.
resultsThis 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).
conclusionsIn 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.
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