In the current study, we explored the distinguishing power of combinations of various factors expecially the up and down combinations, detected with the preoperative routine laboratory work, and delineate several findings. The major finding in this research was that LCR defined as the combination of lymphocyte counts along with CRP levels, was found signifcantly lower in the patients underwent intestinal resection compared with the patients without resection. Compared with other parameters, like neutrophil count, CRP level and NLR level, LCR is a more reliable indicator of intestinal resection in patients with intussusception.
The intussusception can become strangulated, which can cause bowel ischemia and necrosis due to the blood flow blocking. The operation is highly important to avoid the intestinal ischemia and necrosis in intussusception, because a delayed response might cause unnecessary bowel resection, sepsis, and even death [11, 12], all these were serious complications following bowel ischemia and necrosis due to intussusception. The primary rationale for early operative intervention is to avoid bowel resection due to ischemia. Previous studies have suggested that approximately one-half of children admitted with intussusception required an surgical intervention, although conservative management was first attempted for a interval of 5.5 hours.
To determine the presence of ischemia, there are accumulating studies indicating various factors involve in systemic inflammatory condition. In peripheral blood, as a result of strangulation, a measurable infammatory factors could be detected, which were response and released from the local ischemic intestinal wall . In many disease conditions, various infammatory indicators have been suggested valuable in diagnosis and treatment monitoring . However, the best parameters for predicting the bowel ischemia and necrosis using peripheral blood systemic inflammatory factors examination in intussusception patients remains unclear.
In present study, we found that the surrogate marker of the severity of the infammatory response were significantly higher for CRP and leukocyte count values and lower for albumin and lymphocyte in the patients who underwent intestinal resection, compared the patients without intestinal resections, indicating the inflammatory response for the intestinal ischemia and necrosis. ROC analysis was further conducted to investigate the optimal accuracy for the involved surrogate markers. In previous research involved the inguinal hernia, LCR was indicated to be higher in the patients with strangulation and could be a predictor to indicate bowel resections. In another multivariate analysis, NLR was also found to be significantly related to hernia strangulation with obvious bowel ischemia. It was concluded that certain surrogate markers can be used to predict intestinal necrosis and had clinical correlations. Furthermore, LCR has been associated with the prognosis of specific cancer patients, like stomach cancer and colorectal cancer[7, 16, 19]. similarly, Our result with ROC analysis showed that among all these parameters, LCR was alone a good infammatory parameter, strongly related with intestinal resection. Although LCR has been researched in many infammatory conditions, to our knowledge, the use of LCR in the prediction of intestinal resection was firstly reported here in the current study.
In various clinical settings, including the present intestinal resection in our patients, the LCR value, was found the most rapid respond indicator reflecting systemic inflammatory responses. Here the LCR value represent the conbination of the immunological and inflammatory response with the intestinal ischemia due to strangulation during the preoperative period. the negative predictive value was come from the contribution of lymphocyte[21, 23]. because peripheral lymphocytes should contribute to the host cytotoxic immune response to intestinal microflora and CRP is alone a good factor as an infammatory marker. As indicated in the current study, low LCR value means an enhancement of systemic inflammatory response or impaired immunological response in patients with intussusception and could be used to assess the intestinal ischemia.
A retrospective analysis reported that the CRP and NLR levels were increase in acute pancreatitis patients. Another research suggested that NLR levels were significantly associated with patients with acute mesenteric ischemia, and underwent intestinal resection[24, 25]. In the current research, NLR, CRP, neutrophil count were found significantly increased in the patient with intestinal resection. Among them, the LCR represented the most valuable indicative marker, which, is simple and easy to calculate using routine laboratory data without anadditional technique or cost.
We acknowledged that the present results must be considered in the context of its limitations, which should be interpreted cautiously. The samples size collected in the current research was still somewhat smaller. Although the study was a single center investigation, the diagnosis of intestinal necrosis and decision on the resection depended on the opinion of individual surgeon, which should be subjective, with the possibility of over or under-classification of the degree of intestinal necrosis. In order to conduct a powerful study that specifically aimed at intestinal necrosis in intussusception, further investigation with more patients would need to be recruited to validate the role of preoperative LCR with consistent cut-off value in patients undergoing intestinal resection.
In conclusion, the current research suggested that preoperative LCR from routine hematologic parameters was a promising predictive factor for bowel resection in patients with intussusception, which should also be effective for perioperative management. To date, no other study has addressed this issue specifically in pediatric with appendicitis.