In this retrospective study, it revealed that jaundiced patients with periampullary tumors is more prone to loss weight and have higher nutrition risk scores. when introduced CT images as an evaluation modality, it showed significant difference between jaundice and non-jaundice patients in TAMA and SMI. While morphometric parameters such as sarcopenia and visceral obesity were not predictive factors of POPF and other major complications after pancreaticoduodenectomy.
Recent years, the incidence of biliopancreatic carcinoma is increasing and surgical resection still remains the curative therapy. Nevertheless, the high incidence of morbidity and mortality about 40% and 5% respectively threaten patients’ recovery. It had been thought that perioperative management and the TNM-stage of tumor were vital factors affected the recovery and prognosis[17–18], but it is gradually drawing attention that patient individual characteristic such as combined-disease, nutritional status may play an important role as well. BMI, nutrition risk score(NRS-2002,PG-SGA score) are the common nutrition appraisal tools, but BMI reflects the overall nutrition status and might cause some bias. For example, an obese patient may have excessive adipose accumulation while the muscle may atrophy or be infiltrated by fat[19–20]. Our institution also conducted body composition analysis by bioelectrical impedance(BIA), but the result maybe inconsistent[21–22]. Nowadays, CT acts as a new tool assessing the body composition is gaining its popularity for its accuracy and reliability. Several study on hepatocellular carcinoma, gastric and colorectal carcinoma showed that preoperative sarcopenia and visceral obesity have significant impact on postoperative complication and overall survival rate[6, 24].
Jaundice is the common symptom of bilio-pancreatic disease for the outlet of the bile tract is obstructed, dyspepsia and weight loss were general complaints of these patients as well. Clugston et al’s study showed that jaundiced group were significantly malnourished and thus the surgery-related mortality and duration of stay after intervention were differed from non-jaundiced group, which was similar to our results in some extents. We further evaluated the nutrition status of the included patients according to the area of muscle and adipose tissue at the L3 vertebral body level. The TAMA and SMI were higher in non-jaundiced group and was consistent with its higher nutrition risk score. Several points may account for it. First of all, bile is an important substance to promote fat digestion, insufficient production of bile can lead to steatorrhea and vitamin deficiency. Secondly, dysfunction of kupffer cell, proliferation and translocation of gut normal bacterium and accumulation of bacterium in bile make the body be in inflammatory state and prone to suffer from cholangitis, which leads to the increased consumption of protein[27–28]. Last but not least, impaired hepatocellular function results in insufficient protein synthesis, gluconeogenesis, and ketogenesis disorders. Although there is no consensus on routine biliary drainage before operation, it is wise to adopt biliary drainage and reuse to maintain the normal enterohepatic circulation in malnourished patients and morphometric parameters from CT images could be a reference.
When the body composition parameters of three different pathologic types of periampullary tumors classified as benign tumors, pancreatic carcinoma and non-pancreatic carcinoma were compared, no significant difference were observed. Pancreas is the exocrine organ of great importance through secreting several enzymes assisting the digestion, and more than 50% of patients with pancreatic ductal carcinoma suffered from weight loss compared to the percentage about 10% in ampullary cancer group[30–31]. Causes of high incidence of weight loss in pancreatic carcinoma group can be attributed to tissue-fibrosis, exocrine and endocrine insufficiency, obstruction of duodenum and cancer induced cachexia[32–33]. Contrary to the original hypothesis, patients with resectable pancreatic carcinoma experienced less muscle loss compared with unresectable or borderline resectable group, which had been indentified in Sandini et al’s study that loss of muscle tissue is associated with tumor resectability.
In the univariate analysis ,diameter of MPD is the only factor associated with POPF which has been validated in previous study. However, out of expectation, we did not find sarcopenia, visceral obesity and sarcopenic obesity impact the morbidity. It was doubtful that whether sarcopenia relate to the POPF. Kosei et al’s study showed that sarcopenia was the risk factor of postoperative infectious complications for the cancer impaired immune function, but more research insisted that sarcopenia alone may not predict the clinical outcome in that it only reflects the depleted mass not the quality of muscle[37–38]. A clinical prospective study conducted by Huang et al proposed sarcopenia should be defined as low muscle mass, low strength and physical performance.In their results, low muscle mass(OR 3.853, 95% CI 1.446–10.263, P = 0.007)(be regarded as sarcopenia in most study)and sarcopenia(OR 4.758, 95% CI 1.627–13.917, P = 0.004)were independent risk factors for the postoperative morbidity, while sarcopenia had better predictive power when the two functional tests were added.
It had been identified in a series of studies that excessive visceral not subcutaneous adipose tissue was the risk factor of postoperative morbidities. On the one hand, increased adipose mass may add extra difficulties to the operation[41–42], on the other hand, visceral adipose tissue is considered to be an active organ producing some cytokines and pro-inflammatory adipocytokines such as leptin, TNF-α, IL-1, and IL-6 leading to the delayed healing of wound especially the pancreaticoenteric anastomosis[43–45]. Nevertheless, The results of this study were inconsistent with our expectations that visceral obesity or sarcopenic obesity did not impact the outcome. It can be attributed to the indefinite cutoff point of visceral obesity and sarcopenic obesity between different population or nations, so further studies need to be conducted.
The present study has various limitations. First, it was a retrospective study based on available data, so we can not evaluate the function of muscle such as handgrip strength and 6-m usual gait speed, which was adopted in limited research and further prospective studies of functional tests ought to be conducted. Second, the study was a small study from a single center, to validated the value of body composition parameters on complications, multicenter researches are indispensable.
In conclusion, the results of our study showed that jaundiced patients may experience more weight loss in the early stage of disease, while the parameters of body composition such as sarcopenia and visceral obesity did not show significant predictive value on postoperative complications and further multicenter studies are needed.