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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 28
| Issue : 1 | Page : 32-36 |
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Neutrophil–Leucocyte ratio as a predictor of bowel viability in incarcerated hernia: A cross-sectional study
TK Deepak
Department of General Surgery, Government Medical College, Thiruvananthapuram, Kerala, India
| Date of Submission | 08-May-2022 |
| Date of Decision | 15-May-2022 |
| Date of Acceptance | 17-May-2022 |
| Date of Web Publication | 14-Jul-2022 |
Correspondence Address:
Dr. T K Deepak
Department of General Surgery, Government Medical College, Thiruvananthapuram - 695 011, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ksj.ksj_17_22
Introduction: Incarcerated hernias can lead to bowel obstruction or strangulation, leading to loss of bowel viability. One of the changes occurring in our body during incarceration or strangulation of hernia is neutrophil leucocyte ratio (NLR) change. This relationship can be made use of for recognising hernia as, early or late leading to bowel ischaemia. It helps to decide safe non-operative management or early surgical intervention to prevent life-threatening complications. Primary objective of the study was to assess the predictive accuracy of preoperative neutrophil–leucocyte ratio and bowel viability amongst patients with incarcerated hernia. The secondary objective was to identify the relationship between preoperative neutrophil–lymphocyte ratio and bowel viability in incarcerated hernia. Methodology: This cross-sectional study which used diagnostic test evaluation was done with a sample size of 100 patients, after obtaining informed consent. Detailed history, physical examination and laboratory investigations were collected, and the need for bowel resection was assessed, surgery was carried out under aseptic precautions and checked for bowel viability and then comparison done with neutrophil–leucocyte ratio and data analysed using SPSS software (IBM-SPSS, New Delhi, India 2021) using Chi-square test. Results: The majority belonged to 51–60 years of age, 66 belonged to male gender and 31 patients underwent bowel resection. The mean neutrophil–leucocyte ratio was obtained as 0.84, and using the Chi-square test was found to be statistically significant in comparing relation between the ratio and bowel non-viability. The mean neutrophil–lymphocyte ratio was obtained as 11.1, and using the Chi-square test, there is a statistically significant relation between the ratio and bowel non-viability. Conclusion: Neutrophil–leucocyte ratio can be used as a predictive marker for early detection of non-viability of bowel. There is a statistically significant relation between the ratio and bowel non-viability.
Keywords: Femoral, hernia, inguinal, neutrophil–leucocyte ratio, strangulated, umbilical
How to cite this article:
Deepak T K. Neutrophil–Leucocyte ratio as a predictor of bowel viability in incarcerated hernia: A cross-sectional study. Kerala Surg J 2022;28:32-6 |
How to cite this URL:
Deepak T K. Neutrophil–Leucocyte ratio as a predictor of bowel viability in incarcerated hernia: A cross-sectional study. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:32-6. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/32/350890 |
| Introduction | |  |
Hernia is the protrusion of any viscous from its proper cavity. Abdominal wall hernias are one amongst the most common surgical problems. There are many types of abdominal wall hernias. Incarcerated hernias occur when herniated tissue become trapped and cannot be easily moved back into place. This can lead to bowel obstruction or strangulation, leading to loss of bowel viability. Various changes occur in our body during incarceration or strangulation of hernia. One amongst them is neutrophil–leucocyte ratio change. This relationship can be made use of for recognising hernia early as, early or proceeding to bowel ischaemia. Its severity helps to allow decide safe non-operative management or early surgical intervention to prevent life-threatening complications. The present study was undertaken to assess the predictive accuracy of preoperative neutrophil–leucocyte ratio and bowel viability amongst patients with incarcerated hernia and to identify the relationship between preoperative neutrophil–lymphocyte ratio and bowel viability in incarcerated hernia.
| Methodology | | |
It was a cross-sectional study – diagnostic test evaluation done for 1 year, after approval of thesis protocol in the department of general surgery of a tertiary care centre. All patients who attended with symptoms and signs of incarcerated hernia were included in the study. Those who did not give consent, children <13 years and known cases any inflammatory disease or infectious disease causing change in white blood cell (WBC) counts, known case of neutropenia, neutrophilia, leucocytosis, leucopenia, lymphocytosis or lymphopenia were excluded from the study. The sample size calculation done using the formula.
n = 4pq/d2N
p = sensitivity of NLR as predictor of bowel resection = 50
q = 100 − p = 50
d = precision = 2
N = proportion of bowel resection in incarcerated hernia = 25
Using this formula, sample size needed for this study was calculated as 100
After obtaining written informed consent, the participants were assessed by a detailed history, physical examination and needed laboratory investigations. When available, their past investigations were also assessed. After obtaining anaesthesia fitness, surgery was carried out under aseptic precautions. The need for bowel resection was assessed and preoperative bowel viability determined and comparison done with neutrophil–leucocyte ratio and neutrophil–lymphocyte ratio and analysed by Chi-square test.
| Results | | |
Age distribution
Majority of the patients belonged to the 5th and 6th decades of life [Table 1]. Sixty-six percentage were males against 34% females. About 89% of patients had pain.
The duration of symptoms ranged from <6 h to more than 24 h. Majority had pain between 12 and 24 h [Table 2]. Ninety-seven percentage of the hernias were irreducible. Vomiting was present in 58%. Constipation was noted in 42%. Abdomen was distended in 60%. Muscle guarding was seen in 69%. Abdomen was rigid in 73%. Skin discolouration was noted in 15%. Seventy-eight percentage of patients had tenderness on palpating abdomen. Bowel sounds were absent in 49%. During exploration, bowels were non-viable in 31%.
The neutrophil–leucocyte ratio using receiver operating characteristic (ROC) curve (Youden's index method), optimum cut-off value was found as 0.84, with a sensitivity of 83.87, specificity of 76.81, +ve LR of 3.62, -ve LR of 0.21, +ve PV of 61.9 and -ve PV of 91.4 [Table 3], [Table 4], [Table 5] and [Figure 1]. | Figure 1: ROC of neutrophil–leucocyte ratio with bowel viability. ROC: Receiver operating characteristic
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 | Table 3: Receiver operating characteristic curve of neutrophil-leucocyte ratio with bowel viability
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 | Table 4: Relationship between neutrophil-leucocyte ratio and non-viability of bowel
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Using Chi-square test, neutrophil–leucocyte ratio >0.84 showed significant relation with prediction of non-viability of bowel (P < 0.01), as detailed in [Table 4].
The neutrophil–lymphocyte ratio using ROC curve (Youden's index method), optimum cut-off value was found as 11.1, with a sensitivity of 67.74, specificity of 79.71, +ve LR of 3.34, -ve LR of 0.4, +ve PV of 60 and -ve PV of 84.6 [Table 6], [Table 7] and [Figure 2]. | Table 5: Relationship between neutrophil-leucocyte ratio and non-viability of bowel
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 | Table 6: Receiver operating characteristic curve of neutrophil-lymphocyte ratio with bowel viability
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 | Table 7: Relationship between neutrophil-lymphocyte ratio and non-viability of bowel
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 | Figure 2: ROC of neutrophil–lymphocyte ratio with bowel viability. ROC: Receiver operating characteristic
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Using Chi-square test, neutrophil–lymphocyte ratio >11.1 has significant relation with prediction of non-viability of bowel (P < 0.01), as shown in [Table 8]. | Table 8: Relationship between neutrophil-lymphocyte ratio and non-viability of bowel
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| Discussion | | |
Abdominal wall hernias constitute a large group of cases encountered by surgeons. Strangulated hernia is a common emergency case, which is managed by immediate surgical intervention. The management depends upon the viability of the contents of the hernia sac. There are many factors which are affected by systemic inflammation, and many markers are used to assess the extent of inflammation. Similarly, neutrophil–leucocyte ratio and neutrophil–lymphocyte ratio have been used as predictors in many conditions.[1],[2]
In case of a systemic inflammation, there will be a surge in neutrophil count, besides the overall rise in leucocyte count, the normal ratio of neutrophils to leucocytes will be altered due to more half-life of neutrophils than other leucocytes in circulation. Therefore, this ratio will be different from normal levels in case of an ongoing inflammation. A study done by Agiasotelli et al.[1] to predict the relation between neutrophil–leucocyte ratio and survival in acute-on-chronic liver failure event identified that neutrophil/leucocyte ratio will be influenced by the degree of systemic inflammation the patient has. Many of the patients with infection developed systemic inflammatory response syndrome or sepsis. Therefore, the severity of inflammation, lack of its resolution and severity of organ failure are the factors associated with significantly higher risk of death.
In a study conducted by Xie et al.[2] on 'increased neutrophil–leucocyte ratio of peripheral blood in chronic heart failure patients with renal dysfunction' the neutrophil/leucocyte ratio has been recognised as an independent risk factor for both renal dysfunction and heart failure. In the study, they investigated whether neutrophil/leucocyte ratio may be used as an indicator to reflect the effect of renal dysfunction on heart function in patients with congestive heart failure.
The neutrophil–lymphocyte ratio (NLR) is an inflammatory biomarker that can be used as an indicator of systemic inflammation; the NLR is defined by the absolute number of neutrophils divided by the absolute number of lymphocytes. It is a simple measure that does not add extra costs to the patient other than the routinely performed complete blood count laboratory examinations. The NLR has also been used as a guide for the prognosis of various diseases, such as cancer, community pneumonia and sepsis.[3] Studies by Imtiaz et al. suggest that co-morbid conditions are associated with higher level of systemic inflammation as measured by NLR.[4]
Neutrophilia, which can suppress lymphocytes, is a form of inflammatory response.[2] Neutrophil–lymphocyte ratio (NLR) was first used to diagnose appendicitis in 1995. Ishizuka et al.[5] discovered that NLR was more closely associated with gangrenous appendicitis than with WBC count and C-reactive protein. Studies by Jung et al. found that neutrophil–lymphocyte ratio (≤5.6/>5.6) was associated with perforated appendicitis in elderly patients.[6] Some studies have reported that NLR can predict the prognosis of patients with certain types of cancer, such as gastric cancer, as per studies conducted by Nakayama et al.[7] in non-small cell lung cancer as per studies conducted by Diem et al.[8] and colon cancer. NLR may be important in colon cancer as well as in groin hernia. Overall, NLR seems to be important in the prediction of severity of certain diseases. Studies by Xie et al.[2] confirmed that incarcerated groin hernia patients with neutrophil–lymphocyte ratio ≥11.5, independent of WBC count and neutrophil count, had much higher risk for bowel resection. NLR has also been used in the diagnosis of adult strangulated inguinal hernias.[9] In another study by Zhou et al., ROC curve analysis was used to analyse three laboratory indices, NLR, WBC and neutrophils, and showed that NLR has the highest AUC (0.778) and was described as possibly the best index in diagnosing strangulated inguinal hernia.[10]
Huang Z et al. reported that NLR >6.5 was significantly related to the presence of a strangulated inguinal hernia in their study, the NLR value was related to the presence of an ischaemic bowel. As the intestine becomes necrotic, the systemic inflammatory response increases. Sepsis occurs when an infection leads to widespread immune activation, causing diffuse abnormalities in circulation and multiple organ failures.[11] NLR is a readily available biomarker in clinical practice. Compared with other prognostic biomarkers, NLR measurement is easy to perform and also cost-effective, which makes it a distinct biomarker in the clinical setting. Changes in NLR indicate the balance between neutrophil and lymphocyte counts, and also indicator of systemic inflammation. Although several conditions can influence NLR values, including medications and co-morbidities that alter the neutrophil and lymphocyte counts, NLR has been confirmed and used widespread as a useful indicator for the prognosis of several diseases.
In the present study, 100 patients were evaluated, out of which, 31 patients had to undergo bowel resection. Analysing the data and from ROC curve (using Youden's index), optimum cut-off value for using neutrophil–leucocyte ratio as a predictive marker was calculated as 0.84. In the study group, 31% of population had to undergo bowel resection. In them, 83.9% had neutrophil–leucocyte ratio above 0.84 and 16.1% had neutrophil–leucocyte ratio below 0.84. The two groups were compared and P value was calculated. The P < 0.001, making it significant.
Similarly, analysing the data and from ROC curve (using Youden's Index), optimum cut-off value for using NLR as a predictive marker was calculated as 11.1. Of the population who had to undergo bowel resection, 67.7% had NLR above 11.1 and 32.3% had NLR below 11.1. The two groups were compared and P value was calculated. The P value was (<0.001), making it significant.
| Conclusion | | |
From this study, we come to a conclusion that the neutrophil–leucocyte ratio and the non-viability of bowel in incarcerated hernia are statistically significant, the higher ratio suggests that the bowel is non-viable, therefore, the neutrophil–leucocyte ratio can be used as a predictor for bowel viability.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Agiasotelli D, Alexopoulou A, Vasilieva L, Kalpakou G, Papadaki S, Dourakis SP. Evaluation of neutrophil/leukocyte ratio and organ failure score as predictors of reversibility and survival following an acute-on-chronic liver failure event: Predictors of long-term survival in ACLF. Hepatol Res 2016;46:514-20.  |
| 2. | Xie X, Feng S, Tang Z, Chen L, Huang Y, Yang X. Neutrophil-to-lymphocyte ratio predicts the severity of incarcerated groin hernia. Med Sci Monit 2017;23:5558-63. |
| 3. | Martins EC, Silveira L da F, Viegas K, Beck AD, Fioravantti Júnior G, Cremonese RV, et al. Neutrophil-lymphocyte ratio in the early diagnosis of sepsis in an Intensive Care Unit: A case-control study. Rev Bras Ter Intensiva 2019;31:64-70. |
| 4. | Imtiaz F, Shafique K, Mirza SS, Ayoob Z, Vart P, Rao S. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med 2012;5:2. |
| 5. | Ishizuka M, Shimizu T, Kubota K. Neutrophil-to-lymphocyte ratio has a close association with gangrenous appendicitis in patients undergoing appendectomy. Int Surg 2012;97:299-304. |
| 6. | Jung SK, Rhee DY, Lee WJ, Woo SH, Seol SH, Kim DH, et al. Neutrophil-to-lymphocyte count ratio is associated with perforated appendicitis in elderly patients of emergency department. Aging Clin Exp Res 2017;29:529-36. |
| 7. | Nakayama Y, Gotohda N, Shibasaki H, Nomura S, Kinoshita T, Hayashi R. Usefulness of the neutrophil/lymphocyte ratio measured preoperatively as a predictor of peritoneal metastasis in patients with advanced gastric cancer. Surg Today 2014;44:2146-52. |
| 8. | Diem S, Schmid S, Krapf M, Flatz L, Born D, Jochum W, et al. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as prognostic markers in patients with non-small cell lung cancer (NSCLC) treated with nivolumab. Lung Cancer 2017;111:176-81. |
| 9. | Chen P, Yang W, Zhang J, Wang C, Yu Y, Wang Y, et al. Analysis of risk factors associated bowel resection in patients with incarcerated groin hernia. Medicine (Baltimore) 2020;99:e20629. |
| 10. | Zhou H, Ruan X, Shao X, Huang X, Fang G, Zheng X. Clinical value of the neutrophil/lymphocyte ratio in diagnosing adult strangulated inguinal hernia. Int J Surg 2016;36:76-80. |
| 11. | Huang Z, Fu Z, Huang W, Huang K. Prognostic value of neutrophil-to-lymphocyte ratio in sepsis: A meta-analysis. Am J Emerg Med 2020;38:641-7. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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