Despite advanced surgery and perioperative management, CAP after PD or PD (rate: 40–60%) remains a cause of high morbidity in patients with pancreatic cancer16.17. The most common major POCs are the development of POPF, DGE, intra-abdominal infection, and PPH. POPF is particularly known as POC major, which is a life-threatening complication after PD or DP16.17. Several studies have reported that POPF was associated with gender, BMI, blood transfusion, pancreatic texture, preoperative biliary drainage, lower serum albumin, CRP level, and nutritional status3.18. However, a definitive risk factor for POPF remains incompletely understood.19. Generally, POCs have been associated with poor OS, likely due to delayed chemotherapy and cancer progression caused by chemokine/cytokine-induced POC-associated inflammation in several cancer types, including cancer pancreas5,20,21.
Therefore, the main goal of surgeons is to prevent these POCs, especially POPFs, in order to reduce poor survival. Previous studies have also reported pancreatic volume, completion of adjuvant chemotherapy, cancer antigen 19-9, carcinoembryonic antigen level, and prognostic index as prognostic factors in patients with pancreatic cancer.22,23,24.
Recent evidence has revealed that nutritional status such as Predictive Nutritional Index (PNI) and GNRI are strongly associated with POCs or patient outcomes25.26. NIBP is defined using serum albumin and lymphocyte count. Luan et al.25 showed that the raised NIBP is correlated with a better prognosis in ENT patients. However, AUC was compared to NIBP and GNRI using ROC curve analysis. As a result, AUC showed that GNRI was higher than NIBP (GNRI: 0.71 versus NIBP: 0.60) in this study. On the other hand, Hayama, et al.26 reported that a lower GNRI was significantly associated with poor prognosis compared to PNI in elderly patients with colorectal cancer. Thus, we believe that GNRI will be a better predictive marker than PNI.
Using nutritional status as an objective nutritional screening tool, Bouillanne et al.12 first reported that the GNRI, which includes albumin and BMI, is a prognostic factor for morbidity and mortality in hospitalized elderly patients. Subsequently, several studies have consistently shown that there is a relationship between GNRIs, POCs, and cancer prognosis, as nutritional status was strongly associated with cancer prognosis.25,27,28,29. For example, Kushiyama et al.30 reported that GNRI is associated with POC after gastrectomy. Additionally, recent reports have revealed that GNRI is an important predictor of POC and OS in patients with gastric cancer.31.32. Recent evidence has revealed that GNRI is an important prognostic factor in advanced lung disease.33 and colorectal34 cancers. Hu et al., showed that the GNRI could be a useful prognostic indicator in patients who underwent surgery35.36especially in pancreatic cancer.
Previous studies have shown that GNRI is associated with a high risk of POC, including SSI, POPF, and PPH after PD or PD8,9,10,11. Briefly, a lower GNRI value was related to a higher risk of SSI and reported as a potential marker for the development of POPF and PPH after pancreatic surgery. We recently reported the role of GNRI as a risk factor for POPF after PD in 37 patients with pancreatic tumor or invasive gastric cancer.8 and for SSI after PD in 93 patients with hepatobiliary, pancreatic, or duodenal cancer11. In the present study, we further investigated the predictive value of GNRI not only for POC but also for long-term postoperative survival after PD or PD in 139 patients with pancreatic cancer treated at another institution.
In this study, 32 patients (23.0%) developed CAP including POPF (10.8%), bile leak (2.9%), PPH (3.6%) and SSI ( 7.9%), after PD or DP, which corresponded to the CD ≥ IIIa classification and sometimes superimposed. The GNRI value 34.35. At present, our results are consistent with those of a previous study on several cancers36,37,38. Moreover, their cut-off values were close to the present study, although one of them was subject to an age restriction.39. Thus, the present study has reinforced that the GNRI may be a useful predictor of prognosis in patients with pancreatic cancer who have undergone radical surgery.
Our study has several limitations regarding the interpretation of the study results. First, there was a lack of statistical power caused by the relatively small sample size. Second, our data was collected at a single center. The third limitation lies in the retrospective nature of the study. Finally, the present study cannot break the racial line, as only Asian data were reported. Therefore, a more comprehensive large-scale prospective study should be conducted in the future to validate the results of our study.
Finally, we believe that although the GNRI can be easily acquired from routine preoperative work without an invasive procedure, it can predict OS in patients with pancreatic cancer after pancreatic resection. Therefore, future prospective randomized studies are warranted to investigate the importance of GNRI in improving outcomes in patients with pancreatic cancer after curative surgery.