The critical 18 of postoperative white blood cells and C-reactive protein predicts postoperative pancreatic fistula after distal pancreatectomy

Background: Distal pancreatectomy (DP) carries high risk for postoperative pancreatic fistula (POPF). This study evaluates WBC, CRP, and IL-6 as serum-based predictors, offering potential alternatives to drain amylase for early POPF diagnosis.

Material and methods: This retrospective cohort study included adult patients who underwent elective DP between 01/2014 and 12/2023. 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 POD1 to POD5 ([Fig. 1]).

Fig. 1  

Results: This study included 363 patients who underwent DP and met all inclusion criteria. Median WBC counts were significantly higher in patients with POPF B/C), especially on POD 2 (18.1×10⁹/L vs. 15.8×10⁹/L, p=0.002). CRP levels also peaked higher in the POPF group on POD3 (18.9 mg/dL vs. 15.3 mg/dL, p=0.001). IL-6 levels showed no significant difference. ROC analysis identified WBC on POD2 and CRP on POD3 (AUC=0.63 each) as meaningful predictors. Among 210 patients with complete data, simultaneous elevation of both marker, termed “The Critical 18”, was associated with a 59% POPF rate versus 18% when neither was elevated.

Conclusion: In light of these findings, we propose the "The Critical 18" as a simple yet powerful tool for early risk stratification of POPF B/C following DP. By using WBC>18 x 10x9/L on POD 2 and CRP>18 mg/dl on POD 3, clinicians can easily identify patients at escalating risk, offering a clear framework for guiding postoperative management and interventions.

 

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Publication History

Article published online:
04 September 2025