Over 700 Whipples for Pancreaticobiliary Malignancies: Postoperative Morbidity Is an Additional Negative Prognostic Factor for Distal Bile Duct Cancer

Using the comprehensive complication index to assess the impact of Global Leadership Initiative on Malnutrition (GLIM)-defined malnutrition on postoperative complications after resection for biliary tract cancer

PURPOSE

The Global Leadership Initiative on Malnutrition (GLIM) criteria, proposed in 2018, provide universal diagnostic standards for malnutrition, a known risk factor for postoperative complications in patients with various cancers. However, its impact on surgery for biliary tract cancer (BTC) remains unclear. This study evaluates the relationship between GLIM-defined malnutrition and postoperative complications after resection for BTC.

METHODS

The subjects of this retrospective study were patients who underwent pancreaticoduodenectomy or major hepatectomy with extrahepatic bile duct resection for BTC between January, 2013 and December, 2021. The comprehensive complication index (CCI), an indicator of postoperative complications, was calculated based on the total number and severity of postoperative complications.

RESULTS

GLIM-defined malnutrition was diagnosed in143 (71.1%) of the total 201 patients. The median CCI was significantly higher in the GLIM-defined malnutrition group than in the non-malnutrition group (37.2 vs. 28.3; P < 0.001). Multivariate logistic regression analysis revealed that GLIM-defined malnutrition (odds ratio 2.87 [95% confidence interval 1.38-5.96], P = 0.005) and intraoperative blood loss > 1,000 mL (odds ratio 3.77 [95% confidence interval 1.06-13.47], P = 0.041) were independent predictors of high morbidity (CCI ≥ 37.1).

CONCLUSION

Preoperative GLIM-defined malnutrition was closely associated with increased postoperative complications in patients who underwent resection for BTC.

CT-based skeletal muscle loss predicts long term prognosis in patients with distal cholangiocarcinoma undergone pancreaticoduodenectomy

Skeletal muscle index (SMI), as an effective indicator of nutritional status, plays an important role in the prognosis of malignancy. However, the impact of skeletal muscle changes on tumor prognosis has not been systematically elaborated. We aimed to explore the value of skeletal muscle changes in the prognosis of distal cholangiocarcinoma (DCC) patients undergone pancreaticoduodenectomy (PD). Patients who underwent PD for DCC between 2015 and 2023 were included in this study. Demographic, laboratory and follow-up information was obtained. The cross-sectional images of skeletal muscle area at the level of the third lumbar spine was obtained based on computed tomography (CT), and the SMI was calculated by skeletal muscle mass through height squared normalization. Skeletal muscle index and skeletal muscle loss (SML) were obtained before PD and three to six months after surgery. Patients were classified into two groups (High-SML and Low-SML) based on the optimal SML cut-off value. The univariate and multivariate Cox proportional hazards analysis was conducted to evaluate the influence of SML in predicting over survival (OS) and recurrence free survival (RFS) of DCC. Of the 112 patients with distal cholangiocarcinoma, 55 (49%) were diagnosed with low SMI preoperatively. The best cut-off values of SML were - 4.01% and - 5.99% for OS and RFS. In multivariate analysis, tumor size  > 2.0 cm (hazard ratio (HR) = 1.90, P = 0.017), poor differentiation (hazard ratio (HR) = 2.80, P > 0.001), higher SML (SML ≤ - 4.01%) (hazard ratio (HR) = 3.60, P  < 0.001), lymph metastasis (hazard ratio (HR) = 4.00, P  < 0.001) and vascular invasion (hazard ratio (HR) = 2.10, P  = 0.013) were independent risk factors forOS. Meanwhile, poor differentiation (hazard ratio (HR) = 1.90, P = 0.043), higher SML (SML ≤ -5.99%) (hazard ratio (HR) = 3.80, P < 0.001) and lymph metastasis (hazard ratio (HR) = 2.60, P = 0.003) was an independent risk factor forRFS. The models combining SML and clinical characteristics had excellent predictive performance for OS and RFS. The nutritional status marker SML are effective and convenient indicators for predicting the long-term prognosis of DCC after PD, and the SMLafter PD is notable. The combination of CT quantified SML and clinical features can help clinicians predict the long-term survival of DCC patients after PD.

Distal Bile Duct Cancer: Radical (R0 > 1 mm) Resection Achieves Favorable Survival

OBJECTIVE

Evaluation of the outcome after resection for distal bile duct cancer (DBC) with focus on the impact of microscopic histopathological resection status R0 (>1 mm) versus R1 (≤1 mm) vs R1 (direct).

SUMMARY BACKGROUND DATA

DBC is a rare disease for which oncologic resection offers the only chance of cure.

METHODS

Prospectively collected data of consecutive patients undergoing pancreaticoduodenectomy for DBC were analyzed. Histopathological resection status was classified according to the Leeds protocol for pancreatic ductal adeno carcinoma (PDAC) (PDAC; R0 >1 mm margin clearance vs R1 ≤1 mm vs R1 direct margin involvement).

RESULTS

A total of 196 patients underwent pancreaticoduodenectomy for DBC. Microscopic complete tumor clearance (R0>1 mm) was achieved in 113 patients (58%). Median overall survival (OS) of the entire cohort was 37 months (5- and 10-year OS rate: 40% and 31%, respectively). After R0 resection, median OS increased to 78 months with a 5-year OS rate of 52%. Negative prognostic factors were age >70 years ( P < 0.0001, hazard ratio (HR) 2.48), intraoperative blood loss >1000 mL ( P = 0.0009, HR 1.99), pN1 and pN2 status ( P = 0.0052 and P = 0.0006, HR 2.14 and 2.62, respectively) and American Society of Anesthesiologists score >II ( P = 0.0259, HR 1.61).

CONCLUSIONS

This is the largest European single-center study of surgical treatment for DBC and the first to investigate the prognostic impact of the revised PDAC resection status definition in DBC. The results show that this definition is valid in DBC and that "true" R0 resection (>1 mm) is a key factor for excellent survival. In contrast to PDAC, there was no survival difference between R1 (≤1 mm) and R1 (direct).

The consistencies and inconsistencies between distal cholangiocarcinoma and pancreatic ductal adenocarcinoma: A systematic review and meta-analysis

Objective

To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological features and long-term prognosis.

Methods

PubMed, the Cochrane Library, and EMBASE were searched to find comparative studies between DCCA and PDCA. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.

Results

Eleven studies with 4,698 patients with DCCA and 100,629 patients with PDCA were identified. Pooled results indicated that patients with DCCA had a significantly higher rate of preoperative jaundice (p = 0.0003). Lymphatic metastasis (p < 0.00001), vascular invasion (p < 0.0001), and peri-neural invasion (p = 0.005) were more frequently detected in patients with PDCA. After curative pancreaticoduodenectomy (PD), a significantly higher R0 rate (p < 0.0001) and significantly smaller tumor size (p < 0.00001) were detected in patients with DCCA. Patients with DCCA had a more favorable overall survival (OS) (p < 0.00001) and disease-free survival (DFS) (p = 0.005) than patients with PDCA. However, postoperative morbidities (p = 0.02), especially postoperative pancreatic fistula (POPF) (p < 0.00001), more frequently occurred in DCCA.

Conclusion

Patients with DCCA had more favorable tumor pathological features and long-term prognosis than patients with PDCA. An early diagnosis more frequently occurred in patients with DCCA. However, postoperative complications, especially POPF, were more frequently observed in patients with DCCA.

Association of Preoperative Platelet-to-Lymphocyte Ratio with Poor Outcome in Patients with Distal Cholangiocarcinoma

BACKGROUND

Several preoperative systemic inflammatory parameters, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and Glasgow Prognostic Score, have been reported to be associated with the prognosis of solid tumors. However, there are conflicting survival data regarding these parameters in cholangiocarcinoma.

OBJECTIVES

In this study, we performed a retrospective cohort analysis of patients with distal cholangiocarcinoma (DCC) who underwent surgical resection to evaluate the prognostic value of a cluster of preoperative hematological inflammatory parameters for survival.

METHOD

Fifty-three patients with DCC who underwent pancreaticoduodenectomy with curative intent were enrolled. The optimal cutoff values of hematological inflammatory parameters, including the absolute lym-phocyte count, NLR, PLR, and LMR, were determined by time-dependent receiver operating characteristic analysis. -Results: The univariate analysis for overall survival (OS) of conventional factors and hematological inflammatory parameters identified that portal vein invasion and PLR had p values of ≤0.1. The univariate analysis for disease-free survival (DFS) identified that lymph node metastasis, PLR, lymphocyte count, and number of positive lymph nodes (≥3) had p values of ≤0.1. These factors were incorporated into the full model and variables were selected using the backward stepwise method. The multivariate analysis identified portal vein invasion and high PLR as independent prognostic factors for OS (p = 0.033 and 0.039, respectively) and high PLR and number of positive lymph nodes (≥3) as independent prognostic factors for DFS (p = 0.016 and 0.004, respectively).

CONCLUSIONS

Preoperative PLR assessment may be useful for detecting high-risk DCC patients undergoing surgical resection for aggressive adjuvant therapy.

Neutrophil-to-lymphocyte ratio as a predictor of postoperative morbidity in patients with distal cholangiocarcinoma

Systemic inflammatory-, immunological- and nutritional-based indices, such as the neutrophil-to-lymphocyte ratio (NLR), the prognostic nutritional index (PNI) and the Glasgow prognostic score (GPS), are drawing considerable research attention to predict the long-term prognosis of many types of cancer. Recently, these parameters have also been reported to be useful in predicting postoperative morbidity in several fields, including colorectal and otolaryngological cancer. However, while distal cholangiocarcinoma exhibits a high morbidity rate, its risk factors of morbidity have not yet been established. This is because previous studies have analyzed distal cholangiocarcinoma as periampullary tumors combined with pancreatic head cancer. Therefore, the aim of the present study was to investigate the application of the NLR, the PNI and the GPS in evaluating risk factors for postoperative morbidity in patients with distal cholangiocellular or ampullary carcinoma. Eighty-four patients who underwent pancreaticoduodenectomy (PD) for distal cholangiocellular or ampullary carcinoma at the Department of Surgery in Kitasato University Hospital between 2008 and 2016 were enrolled. Associations between perioperative characteristics (NLR, PNI and GPS) and postoperative complications (Clavien-Dindo classification grade III or higher) were retrospectively analyzed. In the univariate analysis, neutrophil and lymphocyte counts, body mass index (BMI) and the NLR were associated with postoperative complications (P<0.05). In the multivariate analysis, BMI [>23.0 kg/m²; odds ratio (OR): 3.80, 95.0% confidence interval (CI): 1.35–11.83; P=0.011] and the NLR (>2.0; OR: 6.77, 95.0% CI: 2.44–21.13; P<0.001) were independent risk factors for postoperative complications. BMI and the NLR are valuable predictors of postoperative morbidity following PD in patients with distal cholangiocarcinoma. It would be beneficial to determine treatment strategies for distal cholangiocarcinoma based on the NLR to reduce postoperative complications.

Relevant prognostic factors influencing outcome of patients after surgical resection of distal cholangiocarcinoma

Background

Distal cholangiocarcinoma (DCC) is a rare but over the last decade increasing malignancy and is associated with poor prognosis. According to the present knowledge curative surgery is the only chance for long term survival. This study was performed to evaluate prognostic factors for the outcome of patients undergoing curative surgery for distal cholangiocarcinoma.

Methods

75 patients who underwent surgery between January 2000 and December 2014 for DCC in curative intention were analysed retrospectively. Potential prognostic factors for survival were investigated including the extent of surgery using purposeful selection of covariates in multivariable Cox regression modeling.

Results

Preoperative biliary stenting (Hazard ratio (HR): 2.530; 95%-CI: 1.146–6.464, p = 0.020), the extent of surgery in case of positive histological venous invasion (HR: 1.209; 95%-CI: 1.017–1.410, p = 0.032), lymph node staging (HR: 2.183; 95%-CI: 1.250–3.841, p = 0.006), perineural invasion (HR: 2.118; 95%-CI: 1.147–4.054, p = 0.016) and postoperative complications graded in points according to Clavien-Dindo (HR: 1.395; 95%-CI: 1.148–1.699, p = 0.001) were indentified as independent significant risk factors for survival. Patients receiving preoperative biliary stenting showed prolonged duration between onset of symptoms and date of operation (p = 0.048).

Conclusions

Preoperative biliary stenting reduces survival possibly due to delayed surgery. The extent of surgery is not an independent risk factor for survival except for patients with concomitant histological venous invasion. Oncological factors and postoperative surgical complications are independent prognostic factors for survival.