Evaluating the predictive performance of nutritional indices in postoperative outcomes following pancreaticoduodenectomy in the elderly

Abstract

Aims: The aim of the study was to evaluate the prognostic significance of nutritional indices including geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), and total bilirubin-albumin ratio (TBAR) in predicting postoperative outcomes following pancreaticoduodenectomy (PD) among elderly patients. Methods: This study retrospectively analyzed 192 patients aged 65 and older who underwent PD at a single center. Postoperative complications were graded using the Clavien-Dindo classification. Postoperative survival was defined as survival beyond 90 days. All deaths that occurred during follow-up were included in the assessment of long-term mortality. In addition, the duration of hospital stay was assessed. Results: The mean age of the participants was 71.6±5.3 (range: 65–87) years. The mean follow-up time was 22.5±20.9 months (median: 15.0 months, IQR: 6.0-36.0). Postoperative complications occurred in 51.0% of patients, with pancreatic fistulae developing in 27.6%. GNRI demonstrated superior predictive accuracy for both 90-day and long-term mortality compared to PNI and TBAR. Lower GNRI scores were significantly associated with worse survival outcomes. Multivariate Analysis revealed that age, GNRI, and the presence of postoperative complications were independent predictors of 90-day mortality. GNRI was the only significant predictor of long-term mortality in the Cox regression model. Conclusion: Preoperative GNRI demonstrated superior predictive performance compared to PNI and TBAR in predicting postoperative survival following PD in elderly patients. Lower GNRI scores were strongly associated with increased mortality risk. We suggest routine screening for malnutrition using tools like GNRI to identify these vulnerable patients at increased risk of mortality following PD.

Keywords

• Elderly
• geriatrics
• geriatric nutritional risk index
• nutrition
• pancreaticoduodenectomy
• prognostic nutritional index
• survival

References

1. Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int. 2024;23(5):449-457. doi:10.1016/j.hbpd.2023.11.001
2. Giuliani T, Marchegiani G, Di Gioia A, et al. Patterns of mortality after pancreatoduodenectomy: a root cause, day-to-day analysis. Surgery. 2022;172(1):329-335. doi:10.1016/j.surg.2022.01.005
3. Merath K, Mehta R, Tsilimigras DI, et al. In-hospital mortality following pancreatoduodenectomy: a comprehensive analysis. J Gastrointest Surg. 2020;24(5):1119-1126. doi:10.1007/s11605-019-04307-9
4. Liu Z, Hayashi H, Matsumura K, et al. Biological and clinical impacts of glucose metabolism in pancreatic ductal adenocarcinoma. Cancers (Basel). 2023;15(2):498-511. doi:10.3390/cancers15020498
5. Funamizu N, Nakabayashi Y, Iida T, Kurihara K. Geriatric nutritional risk index predicts surgical site infection after pancreaticoduodenectomy. Mol Clin Oncol. 2018;9(3):274-278. doi:10.3892/mco.2018.1671
6. Kitahara H, Shoji F, Akamine T, et al. Preoperative prognostic nutritional index level is associated with tumour-infiltrating lymphocyte status in patients with surgically resected lung squamous cell carcinoma. Eur J Cardiothorac Surg. 2021;60(2):393-401. doi:10.1093/ejcts/ezab046
7. Lin JX, Tang YH, Wang JB, et al. Blood parameters score predicts long-term outcomes in stage II-III gastric cancer patients. World J Gastroenterol. 2019;25(41):6258-6272. doi:10.3748/wjg.v25.i41.6258
8. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992;111(5):518–526.

9. Clark AL, Sze S. Impact of malnutrition using geriatric nutritional risk index in heart failure with preserved ejection fraction. JACC Heart Fail. 2019;7(8):676-677. doi:10.1016/j.jchf.2019.06.002
10. Bouillanne O, Morineau G, Dupont C, et al. Geriatric nutritional risk index: a new index for evaluating at-risk elderly medical patients. Am J Clin Nutr. 2005;82(4):777-783. doi:10.1093/ajcn/82.4.777
11. Shoji F, Matsubara T, Kozuma Y, et al. Preoperative geriatric nutritional risk index: a predictive and prognostic factor in patients with pathological stage I non-small cell lung cancer. Surg Oncol. 2017;26(4): 483-488. doi:10.1016/j.suronc.2017.09.006
12. Dale W, Hemmerich J, Kamm A, et al. Geriatric assessment improves prediction of surgical outcomes in older adults undergoing pancreaticoduodenectomy: a prospective cohort study. Ann Surg. 2014; 259(5):960-965. doi:10.1097/SLA.0000000000000226
13. Ito Y, Kenmochi T, Irino T, et al. The impact of surgical outcome after pancreaticoduodenectomy in elderly patients. World J Surg Oncol. 2011; 11(9):102. doi:10.1186/1477-7819-9-102
14. Pratt WB, Gangavati A, Agarwal K, et al. Establishing standards of quality for elderly patients undergoing pancreatic resection. Arch Surg. 2009;144(10):950-956. doi:10.1001/archsurg.2009.107
15. Pineño-Flores C, Ambrona-Zafra D, Rodríguez-Pino JC, et al. Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely? Cir Esp (Engl Ed). 2022;100(3):125-132. doi:10.1016/j.cireng.2022.02.011
16. Beattie AH, Prach AT, Baxter JP, Pennington CR. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut. 2000;46(6):813-818. doi:10.1136/gut.46.6.813
17. Huang Y, Chen Y, Wei L, Hu Y, Huang L. Comparison of three malnutrition risk screening tools in identifying malnutrition according to Global leadership initiative on malnutrition criteria in gastrointestinal cancer. Front Nutr. 2022;9:959038. doi:10.3389/fnut.2022.959038
18. Reece L, Hogan S, Allman-Farinelli M, Carey S. Oral nutrition interventions in patients undergoing gastrointestinal surgery for cancer: a systematic literature review. Support Care Cancer. 2020;28(12):5673-5691. doi:10.1007/s00520-020-05673-w
19. Kim E, Kang JS, Han Y, et al. Influence of preoperative nutritional status on clinical outcomes after pancreatoduodenectomy. HPB (Oxford). 2018;20(11):1051-1061. doi:10.1016/j.hpb.2018.05.004
20. Yamamoto M, Kawaguchi Y, Ichida A, et al. Evaluation of preoperative nutritional variables to predict postoperative complications after pancreaticoduodenectomy. Nutrition. 2019;67-68S:100006. doi:10.1016/ j.nutx.2020.100006
21. Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg. 2011;98(2):268-274. doi:10.1002/bjs.7305
22. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA surgical risk study. Arch Surg. 1999;134(1): 36-42. doi: 10.1001/archsurg.134.1.36.
23. Augustin T, Burstein MD, Schneider EB, et al. Frailty predicts risk of life-threatening complications and mortality after pancreatic resections. Surgery. 2016;160(4):987-996. doi:10.1016/j.surg.2016.07.010
24. Imaoka H, Mizuno N, Hara K, et al. Evaluation of modified glasgow prognostic score for pancreatic cancer: a retrospective cohort study. Pancreas. 2016;45(2):211-217. doi:10.1097/MPA.0000000000000446