Murase H, Matsuo Y, Nakatani E, Denda Y, Nonoyama K, Kato T, Saito K, Sato T, Morimoto M, Yamakawa Y, Sagawa H, Takiguchi S. Association between preoperative serum zinc levels and postoperative infectious complications after minimally invasive hepatectomy: A retrospective cohort study. World J Hepatol 2026; 18(6): 118905 [DOI: 10.4254/wjh.118905]
Corresponding Author of This Article
Yoichi Matsuo, MD, PhD, Professor, Department of Gastroenterological Surgery, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya 464-8547, Japan. nukemat0328@gmail.com
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Murase H, Matsuo Y, Nakatani E, Denda Y, Nonoyama K, Kato T, Saito K, Sato T, Morimoto M, Yamakawa Y, Sagawa H, Takiguchi S. Association between preoperative serum zinc levels and postoperative infectious complications after minimally invasive hepatectomy: A retrospective cohort study. World J Hepatol 2026; 18(6): 118905 [DOI: 10.4254/wjh.118905]
World J Hepatol. Jun 27, 2026; 18(6): 118905 Published online Jun 27, 2026. doi: 10.4254/wjh.118905
Association between preoperative serum zinc levels and postoperative infectious complications after minimally invasive hepatectomy: A retrospective cohort study
Hiromichi Murase, Yuki Denda, Keisuke Nonoyama, Tomokatsu Kato, Kenta Saito, Takafumi Sato, Mamoru Morimoto, Yushi Yamakawa, Hiroyuki Sagawa, Shuji Takiguchi, Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
Yoichi Matsuo, Department of Gastroenterological Surgery, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
Eiji Nakatani, Department of Biostatics, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
Co-corresponding authors: Yoichi Matsuo and Eiji Nakatani.
Author contributions: Murase H conceived and designed the study, collected and curated the data, interpreted the results, and drafted the manuscript; Matsuo Y supervised the project and critically revised the manuscript for important intellectual content; Nakatani E provided biostatistical guidance and reviewed the statistical methods and results; Denda Y, Nonoyama K and Kato T collected the data; Saito K, Sato T, Morimoto M, Yamakawa Y, Sagawa H and Takiguchi S critically reviewed the manuscript for important intellectual content; all authors read and approved the final manuscript; Matsuo Y and Nakatani E have played important and indispensable roles in the manuscript preparation as the co-corresponding authors.
Institutional review board statement: This retrospective study was reviewed and approved by the Institutional Review Board of Nagoya City Univercity (No. 60-24-0099).
Informed consent statement: The requirement for informed consent was waived by the Institutional Review Board due to the retrospective nature of the study, and an opt-out approach was used.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: The datasets used and/or analyzed during the current study are not publicly available due to ethical and privacy restrictions, but are available from the corresponding author on reasonable request and with approval from the institutional review board.
Corresponding author: Yoichi Matsuo, MD, PhD, Professor, Department of Gastroenterological Surgery, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya 464-8547, Japan. nukemat0328@gmail.com
Received: January 14, 2026 Revised: February 13, 2026 Accepted: April 23, 2026 Published online: June 27, 2026 Processing time: 163 Days and 20.6 Hours
Abstract
BACKGROUND
Minimally invasive hepatectomy (MIH) reduces surgical trauma; however, postoperative infectious complications (PICs) still occur in 10%-20% of patients and remain a clinical issue. Zinc (Zn), an essential trace element for innate and adaptive immunity, may influence postoperative infection risk.
AIM
To evaluate the association between preoperative serum Zn concentration and PIC after MIH.
METHODS
This single-center retrospective cohort study included 182 consecutive patients who underwent MIH between April 2020 and April 2025. The primary endpoint was PIC within 30 days, defined as Clavien-Dindo grade ≥ II requiring systemic antibiotic therapy. The preoperative Zn concentration was analyzed categorically (< 60, 60-69, 70-79, ≥ 80 μg/dL) and as a continuous variable. Multivariable logistic regression was performed with adjustment for age, sex, body mass index, liver function indices, comorbidities, surgical approach, operative time, and blood loss.
RESULTS
Median preoperative Zn concentration was 72.0 μg/dL. PIC occurred in 39/182 patients (21.4%), with about 90% being intra-abdominal events. Zn concentration was lower with vs without infection (65.2 μg/dL vs 72.0 μg/dL, respectively; P = 0.015). Each 1-μg/dL increase in Zn was associated with a lower infection risk [odds ratio (OR) = 0.964; 95%CI: 0.938-0.991; P = 0.009]. Zn ≥ 80 μg/dL was independently protective (OR = 0.318; 95%CI: 0.112-0.904; P = 0.032), whereas blood loss and hypoalbuminemia were not independent predictors. Severe infection occurred in 9 patients (4.9%); lower Zn and longer operative time were independent risk factors. Infection rates decreased with increasing Zn strata: 34.4% (< 60 μg/dL), 23.9% (60-69 μg/dL), 22.2% (70-79 μg/dL), and 10.0% (≥ 80 μg/dL).
CONCLUSION
Low preoperative serum Zn was associated with postoperative infection after MIH. Zn measurement may aid risk stratification; prospective studies should validate cutoffs and test whether optimization improves outcomes.
Core Tip: In 182 minimally invasive hepatectomies (MIH), lower preoperative Zinc (Zn) concentration was associated with a higher incidence of postoperative infectious complications. Zn ≥ 80 μg/dL independently protected against infection (adjusted odds ratio = 0.318); infection rates declined stepwise with increasing Zn categories. Because Zn is measurable and modifiable preoperatively, assessment and correction may represent a simple strategy to reduce infections after MIH. Prospective studies are required.
Citation: Murase H, Matsuo Y, Nakatani E, Denda Y, Nonoyama K, Kato T, Saito K, Sato T, Morimoto M, Yamakawa Y, Sagawa H, Takiguchi S. Association between preoperative serum zinc levels and postoperative infectious complications after minimally invasive hepatectomy: A retrospective cohort study. World J Hepatol 2026; 18(6): 118905
Minimally invasive hepatectomy (MIH) has been increasingly adopted worldwide and provides reduced surgical trauma and faster recovery compared with open liver resection[1-3]. Although MIH can reduce the incidence of postoperative infectious complications (PICs), postoperative infections remain an important clinical issue[4,5]. Among surgical site infections (SSIs), organ/space infections, such as intra-abdominal abscesses, have a considerable impact on morbidity, length of hospital stay, and mortality[6]. Although recent reports indicate that laparoscopic liver resection reduces the incidence of deep SSIs compared with open procedures[4], approximately 10% of patients still develop postoperative infections after MIH[5,7]. Therefore, identification of patient-related and potentially modifiable risk factors is warranted, even in the setting of MIH.
Nutritional and immunological status are well-recognized determinants of surgical outcomes[8]. Malnutrition is common among surgical inpatients (30%-50%) and is strongly associated with adverse events and increased morbidity and mortality[9]. Hypoalbuminemia, a classical marker of malnutrition, has been linked to delayed wound healing and higher postoperative complication rates[10]. Composite indices that integrate nutritional and immunological status, such as the prognostic nutritional index (PNI), have shown prognostic utility after hepatectomy, and a low preoperative PNI has been associated with increased complications[11,12]. However, a single biomarker that specifically predicts postoperative infection after MIH and is amenable to intervention has not yet been established.
Zinc (Zn) is an essential trace element with central roles in innate and adaptive immunity as well as in tissue repair[13,14]. Experimental and clinical evidence consistently indicates that Zn deficiency impairs wound healing and host defense, thereby increasing susceptibility to infection[15]. Zn deficiency is also frequently observed in older adults and in patients with malignancies[13,16-18], groups that overlap considerably with candidates for hepatic resection. In addition, in distal pancreatectomy, low preoperative Zn has been independently associated with higher rates of postoperative pancreatic fistula, delayed healing, and greater complication severity[19], supporting the clinical relevance of Zn in wound healing and infection control.
On the basis of these considerations, we hypothesized that preoperative serum Zn concentration would predict PICs after MIH and would be related to infection severity. To verify this hypothesis, we conducted a retrospective analysis of perioperative and nutritional data to examine the associations between preoperative Zn levels and PICs, including both overall infections (CD grade ≥ II) and severe infections (CD grade ≥ IIIa), while accounting for surgical invasiveness and baseline nutritional status.
MATERIALS AND METHODS
Study design and patient population
This retrospective single-center study included 182 patients who underwent MIH (either laparoscopic or robot-assisted) at our institution between April 2020 and April 2025. Patients who underwent concomitant extrahepatic bile duct resection with biliary reconstruction were excluded.
Data collection and definitions
Patient demographics (age, sex), comorbidities (chronic kidney disease, diabetes mellitus, smoking, alcohol consumption), and clinical classifications [American Society of Anesthesiologists-Physical Status (ASA-PS) and Child–Pugh classification] were collected. Pathological diagnoses were categorized as metastatic liver tumor, hepatocellular carcinoma, cholangiocarcinoma, benign tumor, or other. Liver function was assessed by the indocyanine green retention rate at 15 minutes (ICG-R15). The PNI was calculated as PNI = 10 × albumin (g/dL) + 0.005 × total lymphocyte count (/mm3), and a cutoff of 45 was used for descriptive comparisons[20]. Nutritional status was also evaluated using the controlling nutritional status (CONUT) score, with a score of ≥ 2 defined as malnutrition[21-23]. Body mass index (BMI) was calculated as weight (kg)/height2 (m2). Laboratory tests performed within 30 days prior to surgery were considered preoperative values. When multiple tests were available, the result closest to the operation date was used. During the interval between blood draw and surgery, no clinical events with the potential to alter patient status were observed, including infection, transfusion or albumin infusion, initiation of Zn supplementation, changes in nutritional therapy, or additional surgical or endoscopic procedures. Perioperative antibiotic prophylaxis was administered according to our institutional protocol, consisting of cefazolin initiated intraoperatively and continued through postoperative day 1. No patients in this cohort received immunosuppressive medications, and preoperative biliary drainage was not performed.
Hypoalbuminemia was defined as serum albumin < 3.5 g/dL (reference range, 3.5-5.0 g/dL)[24,25]. Based on the Japanese practical guidelines, serum Zn concentrations are categorized as deficiency (< 60 μg/dL) and marginal/possible deficiency (60-80 μg/dL), with ≥ 80 μg/dL regarded as within the normal range in this framework. To capture both overt and borderline deficiency, we defined low Zn status as < 80 μg/dL[26]. For descriptive analyses, Zn was further categorized as < 60, 60-69, 70-79, and ≥ 80 μg/dL.
Surgical variables included operative approach (laparoscopic vs. robot-assisted), extent of resection (anatomical vs partial), operative time, and estimated blood loss. Difficulty of MIH was evaluated using the Iwate criteria.
Postoperative complications were classified according to the CD system. Grade II complications were defined as those requiring pharmacologic treatment, such as systemic antibiotics or blood transfusion. Grade III complications required surgical, endoscopic, or radiologic intervention; grade IIIa denoted intervention not requiring general anesthesia. In this study, postoperative infection was defined as CD grade ≥ II requiring systemic antibiotic therapy, and severe complications were defined as CD grade ≥ IIIa. PIC were diagnosed clinically based on fever and/or elevated inflammatory markers together with imaging findings. Intra-abdominal fluid collection was considered infectious when CT findings suggested infection and systemic antibiotics were administered, with or without percutaneous drainage. Bile leakage was counted as an infectious complication only when accompanied by clinical signs of infection and requiring systemic antibiotics. Severe infection was defined as CD grade ≥ IIIa, i.e., infection requiring an invasive intervention such as percutaneous drainage. When drainage was performed, microbiological cultures were routinely obtained when feasible.
Statistical analysis
Continuous variables are presented as median (interquartile range), and categorical variables as n (%). Group comparisons used the Mann–Whitney U test for continuous variables and the χ2 test or Fisher’s exact test for categorical variables, as appropriate. Two-sided P < 0.05 was considered statistically significant. Association with postoperative infection were evaluated using logistic regression. Because they represent alternative specifications of the same predictor, Zn as a continuous variable and Zn dichotomized at 80 μg/dL were not entered simultaneously in the same model; each specification was evaluated in a separate model. Operative time was modeled per 1 hour and estimated blood loss per 100 mL. For binary variables with zero cell counts in 2 × 2 contingency tables, odds ratios and 95%CI were estimated using Firth’s penalized likelihood logistic regression to reduce small-sample bias. Trend analyses across ordered Zn categories (< 60, 60-69, 70-79, ≥ 80 μg/dL) were performed using the Cochran-Armitage test for trend (two-sided).
All statistical analyses were performed with EZR (Jichi Medical University, Tochigi, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). EZR is a modified version of R Commander designed to add statistical functions frequently used in biostatistics.
RESULTS
Baseline characteristics of the study population
A total of 182 patients were included. The median age was 67.8 years, and 56.0% were male. Most patients were ASA-PS class 2 (86.3%). Malignancy accounted for 93.4% of indications (47.8% metastatic liver tumors, 34.6% hepatocellular carcinoma, 8.2% cholangiocarcinoma). The median BMI was 22.62 kg/m2 (20.37-24.86). Median albumin and PNI were 4.05 g/dL (3.80-4.30) and 47.0 (44.12-50.50), respectively; 9.9% had albumin < 3.5 g/dL, and 29.1% had PNI < 45. The median serum Zn level was 72.0 μg/dL (63.0-80.1), and 72.5% had Zn < 80 μg/dL. Robotic procedures constituted 52.2% of cases; anatomical resections, 63.2%. Median ICG-R15, Iwate score, operative time, and blood loss were 10.0% (8.0%-15.0%), 6.0 (5.0-8.0), 387.0 (269.8-478.0) minutes and 120.5 (61.3-284.5) mL, respectively (Table 1).
Table 1 Baseline characteristics of the total cohort and subgroups with and without infection, n (%)/mean ± SD/median (interquartile range).
Among the 39 postoperative infectious events, intra-abdominal fluid collection was most frequent (26/39, 66.7%), followed by abdominal abscess (5/39, 12.8%) and bile leakage (4/39, 10.3%). Superficial SSIs, postoperative cholangitis, and postoperative pneumonia were uncommon (2/39, 5.1%; 1/39, 2.6%; and 1/39, 2.6%, respectively). Overall, intra-abdominal events (fluid collection/abscess/bile leakage) accounted for 89.7% (35/39) of infections, and 23.1% (9/39) were abscesses or bile leaks that typically required drainage (Supplementary Table 1).
Risk factors for CD grade ≥ II infections
Among 182 patients, PIC occurred in 39 (21.4%) at CD grade ≥ II (Table 2). Preoperative serum Zn concentration was associated significantly with infection. Zn concentrations were lower in the infection group than in the non-infection group (median 65.2 μg/dL vs 72.0 μg/dL, respectively; P = 0.015), and when modeled continuously, each 1 μg/dL increase in Zn was associated with a lower odd of infection [odds ratio (OR) = 0.964; 95%CI: 0.938-0.991; P = 0.0087]. Using the 80-μg/dL cutoff also showed a significant difference (OR = 0.32; 95%CI: 0.117-0.873; P = 0.0261). Operative time (per 1 hour) and estimated blood loss (per 100 mL) were associated with infection (OR = 1.17; 95%CI: 1.00-1.37; P = 0.0446; and OR = 1.09; 95%CI: 1.00-1.19; P = 0.038, respectively). Albumin level was of borderline significance; ≤ 3.5 g/dL had an OR of 2.62 (95%CI: 0.943-7.30; P = 0.065). Other covariates were not significant.
Table 2 Results of univariable and multivariable logistic regression analyses for postoperative infection.
To avoid multicollinearity arising from alternative specifications of the same predictor, Zn concentration was not entered simultaneously as both a continuous and a dichotomized (80 μg/dL) variable in the same model; instead, each specification was evaluated in a separate model. Covariates were Zn, albumin, estimated blood loss, and operative time.
When Zn was modeled as a continuous variable, each 1 μg/dL increase was independently associated with a lower odds of infection (OR = 0.964; 95%CI: 0.937–0.991; P = 0.0094). In the same model, operative time (OR = 1.12; 95%CI: 0.932–1.34; P = 0.228), estimated blood loss (OR = 1.08; 95%CI: 0.975-1.20; P = 0.140), and albumin level ≤ 3.5 g/dL (OR = 2.28; 95%CI: 0.793-6.57; P = 0.126) were not significant.
With Zn concentration entered as a binary variable using an 80-μg/dL cutoff, Zn concentration ≥ 80 μg/dL showed an independent protective association (OR = 0.318; 95%CI: 0.112-0.904; P = 0.0316), while the remaining covariates did not reach significance.
Risk factors for CD grade ≥ IIIa infections
Among 182 patients, PIC occurred in 9 (4.9%) at CD grade ≥ IIIa (Table 3). Baseline characteristics of patients stratified by the presence of CD grade ≥ IIIa infection are shown in Supplementary Table 2. Patients who developed grade ≥ IIIa infection tended to have a lower BMI and albumin level, lower serum Zn concentration, and longer operative time compared with those without such complications.
Table 3 Results of univariable and multivariable logistic regression analyses comparing Clavien–Dindo grade IIIa–negative and grade IIIa–positive groups.
Preoperative Zn was lower in the infection group than the non-infection group (55.1 μg/dL vs 71.4 μg/dL, respectively; P = 0.006) and was associated with infection (OR per 1 μg/dL 0.93; 95%CI: 0.882-0.981; P = 0.007). Operative time (per 1 hour) was also associated with infection (OR = 1.55; 95%CI: 1.13-2.13; P = 0.006). Lower albumin level was associated with infection (median 3.8 g/dL vs 4.1 g/dL, P = 0.035; OR per 1 g/dL 0.148; 95%CI: 0.0241-0.912; P = 0.039), and lower BMI was similarly associated (OR = 0.766; 95%CI: 0.603-0.973; P = 0.029). Estimated blood loss was not significant (OR = 1.06; 95%CI: 0.923-1.21; P = 0.429).
Including albumin level, Zn concentration (continuous), operative time, and blood loss, Zn concentration remained independently associated with a lower odd of infection (OR per 1 μg/dL 0.939; 95%CI: 0.882-0.999; P = 0.0456), and operative time remained independently associated with a higher odd (OR = 1.58; 95%CI: 1.09-2.30; P = 0.0157). Blood loss and albumin level were not significant (OR = 1.06; 95%CI: 0.923-1.21, P = 0.429; OR = 0.543; 95%CI: 0.0705-4.19, P = 0.558, respectively).
Infection rates and baseline characteristics by Zn level
Infection rates decreased with increasing preoperative Zn concentration, being 34.4% (< 60 μg/dL), 23.9% (60-69 μg/dL), 22.2% (70-79 μg/dL), and 10.0% (≥ 80 μg/dL) (Table 4). Patients with Zn concentrations ≥ 80 μg/dL were younger (63.16 years vs 69.61 years, P = 0.001) and had higher albumin levels (4.20 g/dL vs 3.99 g/dL, P = 0.001) and PNI (48.87 vs 46.80, P = 0.007) than those with Zn concentrations < 80 μg/dL, whereas other baseline and operative variables did not differ significantly (Table 5).
Table 4 Preoperative serum zinc level-specific infection rates, n (%).
This study aimed to identify risk factors for PIC after MIH. Preoperative serum Zn concentration was independently associated with PIC defined as CD grade ≥ II, and higher Zn levels were associated with lower infection rates. In analyses restricted to severe complications (CD ≥ IIIa), multivariable logistic regression identified lower Zn (modeled as a continuous variable) and longer operative time as independent predictors. These findings indicate that, while operative time is a procedure-dependent factor, Zn is an objectively measurable preoperative biomarker, suggesting its utility as an assessment item in perioperative management.
Associations between Zn deficiency and postoperative infection have been reported in abdominal and general surgery cohorts[27]. However, evidence specific to hepatectomy[28,29] remains limited, and few reports have focused on minimally invasive techniques. Although the effect of Zn has been examined in hepatectomy cohorts including open procedures, the degree of surgical invasiveness varies across open techniques; therefore, we restricted our analysis to MIH to evaluate the effect of Zn. Our results showed that, even within MIH, preoperative serum Zn remained independently associated with infection outcomes after adjustment (e.g., Zn ≥ 80 μg/dL vs < 80 μg/dL: Adjusted OR = 0.318; 95%CI: 0.112-0.904; P = 0.032). Serum Zn is influenced by albumin binding. The correlation between Zn and albumin was moderate (Spearman ρ = 0.368, P < 0.001), and we judged that simultaneous inclusion was statistically acceptable and did not materially impair estimation of main effects. Because residual confounding and reverse causation cannot be completely excluded, we adjusted for age, malignancy, albumin level or PNI, Iwate score, operative time, diabetes, C-reactive protein, and related covariates. Even after such adjustment, indices frequently reported in surgical fields-hypoalbuminemia[30], low PNI[20], and high CONUT score[23]-did not retain significance in our cohort. A likely explanation is that overall nutritional status was relatively good (hypoalbuminemia < 3.5 g/dL: 10%; PNI < 45: 30%), whereas Zn alone showed a clear between-group difference. These findings suggest that Zn may sensitively reflect subtle immune dysfunction and impaired wound healing that albumin level or PNI may fail to capture.
Although the number of severe infections (CD ≥ IIIa) was small, and the precision of estimates was limited, multivariable analysis identified low Zn concentration (continuous) and prolonged operative time as independent factors, consistent with the primary analysis. In CD ≥ IIIa events, procedure-related contributors are relatively more prominent than in CD ≥ II events, whereas among patient-related factors that are measurable and modifiable preoperatively, Zn concentration was the most promising. Thus, in addition to managing technical factors, such as operative time, combining preoperative Zn assessment with corrective strategies appears reasonable.
Biologically, Zn regulates neutrophil function, cytokine production, T-cell responses, and natural killer-cell development and differentiation[29-31], thereby shaping both innate and adaptive immunity. Zn also contributes to epithelial and mucosal barrier integrity and to wound healing through antioxidant and anti-inflammatory actions[32]. In the context of liver resection, postoperative infections, particularly intra-abdominal abscesses often develop when contaminated bile or postoperative fluid collections persist in a surgically injured field, where local ischemia/hypoxia and impaired tissue integrity can facilitate bacterial growth. Under hypoxia and surgical stress, Zn may support tissue repair and liver regeneration[33,34]. Taken together, we hypothesize that low preoperative Zn may increase susceptibility to post-hepatectomy infections by compromising systemic and local host defenses and by delaying restoration of tissue and barrier integrity, rather than indicating a single causal pathway. These mechanisms are consistent with our observation that lower preoperative Zn was associated with postoperative infection and that risk decreased in a dose-responsive manner as Zn increased.
Although MIH is less invasive, SSIs and intra-abdominal abscesses remain clinically important and can affect prognosis, length of hospital stay, and medical costs[4,35-38]. Our findings suggest the clinical utility of incorporating Zn measurement into perioperative assessment as a risk stratification marker. Patients with Zn concentrations < 80 μg/dL may represent a subgroup at increased risk for PIC and could be considered for closer perioperative monitoring and optimization of overall nutritional status; however, whether Zn-targeted interventions (including supplementation) reduce infectious complications requires confirmation in prospective studies. Lower Zn and longer operative time were associated with severe infection; however, this analysis is exploratory given the small number of events. Zn deficiency is reported to worsen in older adults, patients with malignancy, and those with hypoalbuminemia[28,31], a trend also observed in our cohort. Therefore, preoperative Zn measurement may be particularly informative in high-risk subgroups, such as older adults, patients with malignancy, and those with borderline albumin/PNI.
This study has several limitations. First, the data were collected retrospectively, and selection and information bias cannot be excluded. Second, this was a single-center study with a limited sample size, and the number of CD ≥ IIIa infections was small (n = 9), which may lead to model overfitting, separation (including zero-cell counts), and imprecise estimates despite the use of Firth’s penalized likelihood; therefore, findings from the severe infection analysis should be interpreted as exploratory. Third, although the 80 μg/dL threshold was guideline-informed, the optimal serum Zn cutoff for predicting PIC after MIH has not been established and requires prospective validation. Fourth, microbiological confirmation was not uniformly available for non-drained cases; thus, some outcome misclassification cannot be completely excluded. Prospective multicenter validation and interventional trials are warranted to establish external validity.
CONCLUSION
Low preoperative serum Zn levels were independently associated with PIC following MIH. Preoperative Zn assessment may help identify patients at increased risk. Prospective studies are warranted to validate the optimal cutoff, clarify causal pathways, and determine whether Zn optimization reduces postoperative infections.
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P-Reviewer: Ke Y, MD, PhD, Director, Professor, Research Dean, China; Wang JL, PhD, Associate Professor, China S-Editor: Liu H L-Editor: A P-Editor: Wang CH
