Prognostic value of preoperative sarcopenia and inflammatory markers in patients undergoing pancreaticoduodenectomy

The combined role of preoperative sarcopenia and inflammatory response in patients undergoing pancreaticoduodenectomy (PD) remains unclear. This study investigates the predictive value of sarcopenia combined with inflammatory markers for postoperative overall survival (OS).

We retrospectively analyzed 318 patients who underwent PD between February 2019 and March 2025. Sarcopenia was defined by CT-derived skeletal muscle index (SMI) using sex- and BMI-specific thresholds. Inflammatory markers included NLR, PLR, LMR and CAR. Optimal cutoffs were determined via ROC curves, and prognostic factors were identified using Cox proportional hazards models. Survival analysis was performed using the Kaplan-Meier method.

Of the 318 patients, 196 (61.64%) were diagnosed with preoperative sarcopenia. Multivariable analysis showed no significant association between sarcopenia or inflammatory markers and postoperative complications evaluated in this study (P > 0.05). CA19-9 $\left(\mathrm{OR}:0.999,P=0.027\right)$ was a protective factor for POPF. SMI (OR: 1.165, P = 0.041), neutrophils (OR: 1.191, P = 0.005), and Operative blood loss (OR: 1.001, P = 0.022) were independent risk factors for 30-day readmission. Multivariable analysis identified sarcopenia $\left(\mathrm{HR}=1.935,P=0.012\right)$ as an independent predictor of OS. Based on ROC curve analysis, the optimal cutoff values for NLR and CAR were exploratorily identified as 2.705 and 0.372. Survival analysis revealed that patients with sarcopenia combined with either high NLR (>2.705) or high CAR (>0.372) had significantly shorter mean OS compared to non-sarcopenic patients with low NLR or low CAR $\left(P=0.007,P=0.001\right)$ . Specifically, the concurrent presence of sarcopenia and high NLR was associated with the highest mortality risk $\left(\mathrm{HR}=5.155,P=0.007\right)$ , followed by the combination of sarcopenia and high CAR $\left(\mathrm{HR}=2.808,P=0.001\right)$ .

Preoperative sarcopenia is an independent predictor of poor OS following PD. The coexistence of sarcopenia and a high inflammatory state (i.e., high NLR or high CAR) significantly increases the risk of mortality. Therefore, preoperative assessment of skeletal muscle mass and inflammatory status may be crucial for identifying high-risk patients.