title: Poor oncologic outcomes of hepatocellular carcinoma patients with intra-abdominal infection after hepatectomy.
abstract: OBJECTIVE
  To evaluate the impact of postoperative infectious complications on hepatocellular carcinoma following curative hepatectomy.
  
  
  METHODS
  We performed a retrospective analysis of 200 hepatocellular carcinoma patients who underwent hepatectomy at our institution between September 2003 and June 2011. The patients' demographics, clinicopathological characteristics and postoperative infectious complications were analyzed. The Clavien-Dindo classification was adopted to assess the severity of complications. The dynamic change in the neutrophil-to-lymphocyte ratio, defined as the absolute neutrophil count divided by the absolute lymphocyte count, after surgery was also investigated. The observation endpoints for this study were recurrence-free survival and overall survival of the patients. Statistical analysis of the survival curves was performed using the Kaplan-Meier method and the log-rank test. The prognostic value of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis. The cutoff score for each variable was selected based on receiver operating characteristic curve analysis. All statistical tests were two-sided, and significance was set at P < 0.05.
  
  
  RESULTS
  The median age of the patients was 49 years, and the majority of patients were male (86%) and had been infected with hepatitis B virus (86%). The 30-d postoperative infectious complication rate was 34.0% (n = 68). Kaplan-Meier survival analysis revealed that postoperative infection was significantly correlated with tumor recurrence (P < 0.001). The postoperative intra-abdominal infection group exhibited a worse prognosis than the non-intra-abdominal infection group (P < 0.001). A significantly increased incidence of postoperative intra-abdominal infection was observed in the patients with hepatic cirrhosis (P = 0.028), concomitant splenectomy (P = 0.007) or vascular invasion (P = 0.026). The patients who had an elevated postoperative neutrophil-to-lymphocyte ratio change (> 1.643) clearly exhibited poorer recurrence-free survival than those who did not (P = 0.009), although no significant correlation was observed between overall survival and the change in the postoperative neutrophil-to-lymphocyte ratio. Based on multivariate analysis, hepatitis B surface antigen positivity, Child-Turcotte-Pugh class B, an elevated postoperative neutrophil-to-lymphocyte ratio change and intra-abdominal infection were significant predictors of poor recurrence-free survival. Hepatic cirrhosis, the maximal tumor diameter and intra-abdominal infection were significant predictors of overall survival.
  
  
  CONCLUSIONS
  Postoperative intra-abdominal infection adversely affected oncologic outcomes, and the change in postoperative neutrophil-to-lymphocyte ratio was a good indicator of tumor recurrence in hepatocellular carcinoma patients after curative hepatectomy.
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Dan-Yun
authors.initials: DY
authors.lastname: Ruan
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Ze-Xiao
authors.initials: ZX
authors.lastname: Lin
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Yang
authors.initials: Y
authors.lastname: Li
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Nan
authors.initials: N
authors.lastname: Jiang
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Xing
authors.initials: X
authors.lastname: Li
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Dong-Hao
authors.initials: DH
authors.lastname: Wu
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Tian-Tian
authors.initials: TT
authors.lastname: Wang
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Jie
authors.initials: J
authors.lastname: Chen
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Qu
authors.initials: Q
authors.lastname: Lin
authors.affiliation: Dan-Yun Ruan, Ze-Xiao Lin, Xing Li, Dong-Hao Wu, Tian-Tian Wang, Jie Chen, Qu Lin, Xiang-Yuan Wu, Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
authors.forename: Xiang-Yuan
authors.initials: XY
authors.lastname: Wu
mesh_terms: D000328:Adult; D000368:Aged; D019540:Area Under Curve; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018655:Lymphocyte Count; D008214:Lymphocytes; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009504:Neutrophils; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013530:Surgical Wound Infection / Q000097:blood / Q000175:diagnosis / Q000382:microbiology* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Hepatectomy; Hepatocellular carcinoma; Neutrophil-to-lymphocyte ratio change; Postoperative intra-abdominal infection; Prognosis