Clinical impact of postoperative changes in the psoas muscle mass and Prognostic Nutritional Index for patients with biliary tract cancer: A retrospective cohort study

Clinical impact of postoperative changes in the psoas muscle mass and Prognostic Nutritional Index for patients with biliary tract cancer: A retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical impact of postoperative changes in the psoas muscle mass and Prognostic Nutritional Index for patients with biliary tract cancer: A retrospective cohort study Masashi Utsumi, Masaru Inagaki, Koji Kitada, Naoyuki Tokunaga, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9303435/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Low preoperative Psoas Muscle Index (PMI) and Prognostic Nutritional Index (PNI) values in patients with biliary tract cancer (BTC) indicate unfavorable prognoses. However, the impact of changes in PMI and PNI from pre- to postoperative on survival outcomes remains unclear. We sought to clarify whether changes in skeletal muscle mass and PNI could affect the long-term postoperative prognosis of patients with BTC who underwent curative surgery. Methods We retrospectively reviewed 168 patients who underwent BTC resection. The PMI was assessed within 1 month before surgery, and the PNI was calculated from blood samples collected within 2 weeks before surgery; postoperative assessments were performed at 4–6 months (PMI) and 6 months (PNI) after surgery. We classified patients into a large decrease and a small decrease/increase group, according to the percentage change in PMI and PNI, using the optimal cut-off point. Associations between clinicopathological characteristics, including changes in the PMI and PNI, and survival outcomes were analyzed. Results Preoperative PMI values were similar in both groups. The decrease in PNI was significantly greater in the large- than in the small-PMI-decrease group ( P = 0.004). T classification ≥ 3 (hazard ratio [95% confidence interval]) (2.11 [1.29–3.47]; P = 0.003), lymph node metastasis (1.84 [1.10–3.09]; P = 0.002), and a large PNI (≥ 11.0%; 2.14 [1.27–3.54]; P = 0.005), and PMI (≥ 6.6%; 2.00 [1.18–3.50]; P = 0.009) decrease independently predicted overall survival in multivariate analysis. T classification ≥ 3 (1.72 [1.02–2.91]; P = 0.038), lymph node metastasis (1.77 [1.03–3.05]; P = 0.039), and a large PMI decrease (≥ 6.6%; 1.90 [1.08–3.47]; P = 0.026) were independent predictors of RFS in the multivariate analysis. Conclusions Large postoperative reductions in the PMI and PNI were independent predictors of poor survival, regardless of the preoperative sarcopenia status of patients with resectable BTC. Psoas Muscle Index Survival outcomes Sarcopenia Overall survival Lymph node metastasis Figures Figure 1 Introduction Biliary tract cancer (BTC) is an aggressive malignancy that, although rare, has been increasing in incidence over the past few decades [ 1 ]. While surgical resection is the only curative treatment, recurrence is a major concern [ 2 ]. BTC is often diagnosed at an advanced stage, at which point most patients are no longer candidates for surgical resection. Despite advances in surgical techniques and adjuvant chemotherapy, the prognosis of such patients remains poor [ 3 , 4 ]. Therefore, identifying prognostic factors for patients with resectable BTC is of clinical importance. The Prognostic Nutritional Index (PNI) is a marker of nutritional status as well as systemic inflammation that is based on serum albumin concentration and total lymphocyte count. These values can be easily obtained from routine preoperative blood tests [ 5 ]. Several studies [ 6 – 8 ] have shown that PNI is a prognostic indicator in various cancers. We previously demonstrated that preoperative PNI was an independent prognostic factor for patients with BTC [ 9 ]. However, the relationship between postoperative changes in PNI and prognosis has not been reported to date. Sarcopenia, defined as the loss of skeletal muscle mass and function, has recently attracted attention in the context of various cancers. Early studies on sarcopenia focused on the loss of skeletal muscle mass at one preoperative time point and concluded that preoperative sarcopenia was associated with poor prognosis [ 10 , 11 ]. Indeed, we previously demonstrated that preoperative skeletal muscle mass loss is an independent prognostic factor for patients with BTC [ 12 ]. Recent studies investigating postoperative changes in skeletal muscle mass in cancer patients demonstrated a greater impact of postoperative muscle loss on the prognosis of these patients [ 13 – 15 ]. The Psoas Muscle Index (PMI), determined relative to the third lumbar level on computed tomography (CT), correlates with whole-body skeletal muscle mass [ 16 ]. This information may be useful for monitoring treatment interventions and evaluating prognosis in individual patients. However, the importance of postoperative changes in skeletal muscle mass in patients with resectable BTC remains poorly studied. Inflammation and sarcopenia influence carcinogenesis and cancer progression [ 17 ]. Systemic inflammation has been observed in patients with sarcopenia [ 18 ]. In patients with various types of cancer, sarcopenia accompanied by systemic inflammation correlates with poor prognosis [ 19 – 21 ]. However, to date, few studies have examined the postoperative changes in sarcopenia, in combination with systemic inflammation, in the prognosis of patients with resectable BTC. Therefore, in this study, we focused on the changes in skeletal muscle mass and PNI from the preoperative to the postoperative period. This study aimed to clarify whether changes in skeletal muscle mass and PNI could affect the long-term postoperative prognosis of patients with BTC who underwent curative surgery. Methods Ethical standards All procedures involving human participants were conducted in accordance with the ethical standards of our institutional research committee, as well as the 1964 Declaration of Helsinki and its subsequent amendments. The study design was approved by the Ethical Review Board of the National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan (approval numbers: ERBP2025042, ERBP2025040). Clinical trial number: not applicable. The requirement for obtaining written informed patient consent was waived because of the retrospective nature of the study . Patients In total, 168 consecutive patients who underwent curative surgical resection for BTC at the Department of Surgery of the National Hospital Organization Fukuyama Medical Center between July 1, 2010, and December 31, 2024, were retrospectively reviewed. Imaging and pathological examination confirmed BTC, including intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, ampullary carcinoma, gallbladder carcinoma, and distal cholangiocarcinoma. Data were collected and analyzed from June 30, 2025, to October 31, 2025, to allow for at least 6 months of follow-up. Data collection We obtained data on the following from patients’ medical records: demographic characteristics (age at surgery and sex), laboratory tests (platelet and lymphocyte counts, serum albumin, and tumor marker levels), comorbidities (diabetes mellitus, hypertension, and cardiac, lung, and cerebral diseases), preoperative cholangitis, surgical procedure (resection type), blood loss, operative time, blood transfusion, tumor–node–metastasis stage (Union for International Cancer Control classification [eighth edition]), and use of postoperative adjuvant chemotherapy were obtained from patients’ medical records. We defined curative (R0) resection as the complete removal of all macroscopic nodules with microscopically clear margins and defined R1 and R2 resections involving at least one margin as microscopic or macroscopic disease, respectively. Complications were defined according to the Clavien–Dindo classification [22]. We defined postoperative complications as complications of Clavien–Dindo grade IIIa or higher. Postoperative mortality was defined as death from any cause within 30 days of surgery. PNI and other inflammation-based prognostic scores Inflammation-based prognostic scores were calculated from the analysis of peripheral venous blood samples collected within 2 weeks prior to surgery. The Glasgow prognostic score was defined as follows: The first category (score 0) was defined as normal albumin (≥ 3.5 g/dL) and CRP (≤ 1.0 mg/dL). The second category (score 1) is defined as low albumin ( 1.0 mg/dL). The third category (score 2) is defined as low albumin ( 1.0 mg/dL) [23]. The neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios were calculated by dividing the neutrophil and platelet counts by the lymphocyte count [24, 25]. The PNI was calculated as follows [5]: PNI = 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (/mm 3 ) Regarding nutritional assessment, perioperative time-dependent changes in thePNI score were evaluated from 2 weeks pre-surgery to 6 months post-surgery (at 2 weeks preoperatively, and 1 month, 3 months, and 6 months postoperatively). The percentage decrease in PNI was defined as follows: [1 − (postoperative 6 months PNI score / preoperative PNI score)] × 100. Measurement of skeletal muscle volume To determine the PMI, preoperative CT was performed within 1 month before surgery, using a multidetector CT scanner (Aquilion CXL 64; Canon Medical Systems, Tochigi, Japan). Preoperative CT at the level of the caudal end of the third lumbar vertebra was used to measure the cross-sectional area of the bilateral psoas muscles using manual tracing. The PMI was calculated as follows [26]: PMI = cross-sectional area of the bilateral psoas muscles (cm 2 ) / height squared (m 2 ) A low PMI is considered an indicator of low muscle volume. Given the documented variation in the range of the PMI between male and female subjects, distinct cut-off values were determined through the implementation of receiver operating characteristic curves. The optimal cut-off values were determined based on the best accuracy in relation to outcome [12]. The cut-off values for the PMI in men and women were 5.10 and 3.69 cm 2 /m 2 , respectively, with areas under the receiver operating characteristic curves of 0.587 and 0.625, respectively. The PMI was evaluated at two time-points: at 1-month preoperatively and 4–6 months postoperatively. The percentage decrease in the PMI was defined as follows: [1 − (postoperative PMI/preoperative PMI)] × 100. We classified the patients into two groups, i.e., a large-PMI-decrease group and a small-PMI-decrease/increase group, according to the percentage change in PMI based on the optimal cut-off point. The optimal cut-off value was selected based on the best accuracy for the outcome. Follow-up Routine follow-up was conducted for all participants until October 2025. Postoperative follow-up encompassed a comprehensive medical history review, including symptoms and physical examination findings, along with laboratory test results. Imaging studies were performed on a regular basis, at intervals of three to six months, for a minimum period of five years. Patients presenting with lymph node metastasis subsequently received postoperative adjuvant chemotherapy consisting of tegafur/gimeracil/oteracil for a period of approximately six months. Notably, none of the patients received neoadjuvant chemotherapy. Outcomes The outcomes of this study included the association between clinicopathological variables and survival rates. The terms “recurrence-free survival” (RFS) and “overall survival” (OS) were defined as the time intervals from surgical intervention to the recurrence of BTC and death or last follow-up, respectively. Statistical analysis Prior to analysis, all data were anonymized. Categorical variables are expressed as numerical values, typically expressed as percentages. Continuous variables are expressed as medians with ranges. Univariate comparisons of variables between groups were performed using Mann–Whitney U and chi-square tests. The degree of diagnostic accuracy was ascertained by calculating the area under the receiver operating characteristic curve. The cut-off values for PMI change and inflammation-based prognostic scores were determined by maximizing the Youden index, which is defined as sensitivity + specificity − 1, with OS as the endpoint. RFS and OS were estimated using the Kaplan–Meier method and were compared between patient groups by using the log-rank test. Univariate and multivariate analyses of the associations between clinicopathological variables and survival rates were performed using Cox proportional hazards models. Variables found to be significant in the univariate analyses were then entered into multivariate analyses. All statistical analyses were conducted using JMP 11 (SAS Institute, Cary, NC, USA). Statistical significance was defined as P < 0.05. Results Patient characteristics Overall patient characteristics are summarized in Table 1. The patients ranged in age from 34 to 92 years. Most patients had gallbladder carcinoma, followed by intrahepatic, distal, ampullary, and perihilar cholangiocarcinomas. The surgical procedures performed primarily included liver resection (including hemihepatectomy, subsegmentectomy, liver bed resection, sectionectomy, and trisectionectomy), followed by pancreaticoduodenectomy, cholecystectomy, hepatopancreaticoduodenectomy, and bile duct resection without hepatectomy. Postoperative complications were observed in approximately 37% of the patients, including pancreatic fistula, bile leakage, abdominal abscess, pleural effusion, chylous ascites, and abdominal bleeding. Table 1. Patient characteristics Characteristic Patients Age (years), mean ± SD (range) 73.2 ± 10.4 (34–92) Sex (male/female), N 98/70 Body mass index (kg/m 2 ), mean ± SD (range) 22.6 ± 3.4 (15.7–32.5) Preoperative laboratory data Albumin (g/dL), mean ± SD (range) 3.84 ± 0.51 (2.40–4.90) Platelet count (×10 4 /mm 3 ), mean ± SD (range) 21.80 ± 6.65 (3.37–46.30) Neutrophil count (×10 3 /mm 3 ), mean ± SD (range) 3.96 ± 1.80 (1.08–12.48) Lymphocyte count (×10 3 /mm 3 ), mean ± SD (range) 1.61 ± 0.69 (0.26–5.80) C-reactive protein (mg/dL), mean ± SD (range) 0.88 ± 1.67 (0.01–12.96) Carcinoembryonic antigen (ng/mL), mean ± SD (range) 5.19 ± 11.13 (0.52–113.06) Carbohydrate antigen 19-9 (U/mL), mean ± SD (range) 1,355.55 ± 9,798.96 (2.00–120,000.00) PNI, mean ± SD (range) 46.49 ± 6.47 (30.30–63.30) Glasgow Prognostic Score (0/1/2), N 109/42/17 C-reactive protein-to-albumin ratio, mean ± SD (range) 0.27 ± 0.56 (0.001–4.63) Platelet-to-lymphocyte ratio, mean ± SD (range) 156.8 ± 81.0 (39.0–600.0) Neutrophil-to-lymphocyte ratio, mean ± SD (range) 3.10 ± 4.11 (0.75–4.80) PMI (cm 2 /m 2 ), mean ± SD Male Female 7.00 ± 1.71 (2.53–11.80) 5.34 ± 1.21 (2.55–8.90) Type of cancer, N (%) Intrahepatic cholangiocarcinoma Gallbladder carcinoma Distal cholangiocarcinoma Ampullary carcinoma Perihilar cholangiocarcinoma 39 (23.2) 48 (28.6) 38 (22.6) 27 (16.0) 16 (9.5) Preoperative cholangitis, N (%) 67 (39.9) Comorbidities (absent/present), N 40/128 Surgical procedure, N (%) Cholecystectomy Bile duct resection without liver resection Type of liver resection Liver bed resection Subsegmentectomy Sectionectomy Hemihepatectomy Trisectionectomy Pancreaticoduodenectomy Hepatopancreaticoduodenectomy 29 (17.2) 1 (0.6) 9 (5.3) 11 (6.5) 7 (4.2) 41 (24.4) 5 (3.0) 63 (37.5) 2 (1.2) Operative time (min), mean ± SD (range) 413.7 ± 178.2 (45.0–1049.0) Blood loss (mL), mean ± SD (range) 606.5 ± 1,277.5 (0.0–13,870.0) Blood transfusion, N (%) 15 (9.1) T classification (1/2/3/4), N 37/60/63/8 Lymph node metastasis (absent/present), N 55/113 Tumor–Node–Metastasis classification (eighth edition) (0/I/II/III/IV), N 14/28/66/42/18 Resection (R0/R1/R2), N 147/18/3 Mortality, N (%) 0 (0.0) Postoperative adjuvant chemotherapy, N (%) 102 (61.4) Postoperative complications (Clavien–Dindo Grade ≥ IIIa) (absent/present), N 62/106 SD, standard deviation; N, number Association between PMI or PNI changes and postoperative outcomes The optimal cut-off value for the percentage decrease in PMI was 6.6%. After dividing patients into two groups based on a large decrease or small decrease/increase in PMI relative to the cut-off point, patients in the large-decrease and small-decrease/increase groups were 101 and 67 cases, respectively. Patients in the large- and small-PNI-decrease/increase groups, defined in a similar manner as for PMI using the optimal cut-off value for the percentage decrease in PNI of 11.0%, comprised 40 and 128 patients, respectively. We then compared the OS and RFS between these patient groups defined by decreases in the PMI and PNI (Fig. 1). The OS and RFS rates of the group with a small PMI decrease/increase were significantly higher than those of the group with a large PMI decrease (OS: P = 0.001, RFS: P = 0.002; Fig. 1A). The OS and RFS rates were significantly higher in the group with a small PNI decrease/increase than in the group with a large decrease in PNI (OS: P < 0.001, RFS: P = 0.003; Fig. 1B). Association between PMI changes and clinicopathological characteristics Table 2 summarizes the clinicopathological characteristics and short-term surgical outcomes of the patients in the groups with large and small decreases in PMI. We found no significant difference in preoperative PMI levels between the two groups. The decrease in PNI was significantly greater in the large-PMI-decrease group than in the small-PMI-decrease group ( P = 0.004). In the large-PMI-decrease group, the operative time was significantly longer than that in the small-PMI-decrease group ( P = 0.013). In the large-PMI-decrease group, the induction rate of postoperative adjuvant chemotherapy was significantly lower than that in the small-PMI-decrease group ( P = 0.014). In the large-PMI-decrease group, the rate of postoperative complications tended to be greater than that in the small-PMI-decrease group ( P = 0.059). Table 2. Perioperative characteristics by Psoas Muscle Index change group Characteristic Large-PMI-decrease group (N = 101) Small-PMI-decrease/PMI increase group (N = 67) P -value Age (years), mean ± SD 73.6± 9.7 72.6 ± 11.5 0.508 Sex (male/female), N 63/38 35/32 0.192 Body mass index (kg/m 2 ), mean ± SD 21.2 ± 3.6 22.6 ± 3.3 0.896 Carcinoembryonic antigen (ng/mL), mean ± SD 5.69 ± 13.31 4.43 ± 6.60 0.472 Carbohydrate antigen 19-9 (U/mL), mean ± SD 2,040.3 ± 12,606.4 333.5 ± 1,162.3 0.271 C-reactive protein (mg/dL), mean ± SD 0.96 ± 1.62 0.76 ± 1.75 0.454 Preoperative PNI, mean ± SD 46.26 ± 6.69 46.84 ± 6.15 0.569 Glasgow Prognostic Score (0/1/2), N 68/21/12 41/21/5 0.246 C-reactive protein-to-albumin ratio, mean ± SD 0.29 ± 0.53 0.23 ± 0.60 0.494 Platelet-to-lymphocyte ratio, mean ± SD 161.6 ± 8.5 149.7 ± 7.5 0.354 Neutrophil-to-lymphocyte ratio, mean ± SD 3.32 ± 5.07 2.76 ± 1.90 0.388 Preoperative low PMI 46 (45.5) 22 (32.8) 0.100 Preoperative cholangitis (absent/present), N 61/40 40/27 0.928 Resection (R0/R1–2), N 87/14 60/7 0.244 Operative time (min), mean ± SD 441 ± 150 371 ± 207 0.013 Blood loss (mL), mean ± SD 738 ± 536 709 ± 1917 0.398 Transfusion (no/yes), N 90/9 61/6 0.976 T classification (≥ 3), N (%) 44 (43.5) 27 (40.3) 0.674 Lymph node metastasis (absent/present), N 37 (36.6) 18 (26.8) 0.184 Tumor–Node–Metastasis classification (eighth edition) (I–II/III–IV), N 63/38 45/22 0.525 Postoperative complications (Clavien–Dindo Grade ≥ IIIa) (absent/present), N 58/43 48/19 0.059 Postoperative adjuvant chemotherapy (no/yes), N 31/69 (68.3%) 33/33 (50.0%) 0.014 Large PNI decrease (≥ 11%) 31 (31.6%) 8 (12.2%) 0.004 PNI, Prognostic Nutritional Index; PMI, Psoas Muscle Index; SD, standard deviation; N, number Univariate and multivariate analyses of clinicopathological factors associated with overall survival in patients with resected BTC Table 3 shows the relationship between clinicopathological variables and OS in patients with resected BTC. Univariate analysis showed that carbohydrate antigen 19-9 ≥ 50, a low PMI, a low PNI (< 42), T classification ≥ 3, lymph node metastasis, a large decrease in PNI (≥ 11.0%), and a large decrease in PMI (≥ 6.6%) were associated with poor OS. In multivariate analysis, T classification ≥ 3 (hazard ratio [95% confidence interval]) (2.11 [1.29–3.47]; P = 0.003), lymph node metastasis (1.84 [1.10–3.09]; P = 0.002), a large decrease in PNI (≥11.0%; 2.14 [1.27–3.54]; P = 0.005), and a large decrease in PMI (≥ 6.6%; 2.00 [1.18–3.50]; P = 0.009) were independent predictors of OS in multivariate analysis. Table 3. Clinicopathological predictors of overall survival after BTC resection Clinicopathological characteristic Univariate analysis Multivariate analysis N P -value HR (95% CI) P -value Age (years) ≥ 75 < 75 81 87 0.831 – – Sex Male Female 98 70 0.092 Body mass index (kg/m 2 ) ≥ 21 < 21 105 63 0.112 – – Carcinoembryonic antigen (ng/mL) ≥ 5 < 5 32 136 0.896 – – Carbohydrate antigen 19-9 (U/mL) ≥ 50 < 50 53 115 0.032 1.16 (0.69–1.96) 0.556 Preoperative cholangitis Present Absent 67 101 0.092 – – Preoperative PMI Low PMI High PMI 68 100 0.007 1.55 (0.97–2.46) 0.066 Preoperative PNI < 42 ≥ 42 57 121 0.015 1.54 (0.91–2.56) 0.107 Glasgow Prognostic Score 0 1–2 110 59 0.106 – – Neutrophil-to-lymphocyte ratio < 2.20 ≥ 2.20 91 77 0.503 – – Platelet-to-lymphocyte ratio < 106 ≥ 106 53 115 0.704 – – Operative time (min) ≥ 420 < 420 90 78 0.179 – – Blood loss (mL) ≥ 300 < 300 84 84 0.188 – – Transfusion No Yes 153 15 0.121 – – Postoperative complications (Clavien–Dindo Grade ≥ IIIa) Absent Present 106 62 0.092 – – T classification < 3 ≥ 3 97 71 < 0.001 2.11 (1.29–3.47) 0.003 Lymph node metastasis Present Absent 55 113 < 0.001 1.84 (1.10–3.09) 0.002 Postoperative adjuvant chemotherapy No Yes 64 104 0.051 – – Percentage decrease in PNI Large decrease (decrease percentage ≥ 11.0%) Small decrease or increase (decrease percentage < 11.0%) 40 128 < 0.001 2.14 (1.27–3.54) 0.005 Percentage decrease in PMI Large decrease (decrease percentage ≥ 6.6%) Small decrease or increase (decrease percentage < 6.6%) 101 67 0.001 2.00 (1.18–3.50) 0.009 HR, hazard ratio; CI, confidence interval PNI, Prognostic Nutritional Index; PMI, Psoas Muscle Index Univariate and multivariate analyses of clinicopathological factors associated with recurrence-free survival in patients with resected BTC Table 4 shows the relationship between clinicopathological variables and RFS in patients with resected BTC. Univariate analysis showed that BMI ≥ 21 kg/m 2 , carbohydrate antigen 19-9 ≥ 50, preoperative cholangitis, a low PMI, a low PNI (< 42), blood loss ≥ 300 ml, T classification ≥ 3, lymph node metastasis, postoperative adjuvant chemotherapy, a large PNI decrease (≥ 11.0%), and a large PMI decrease (≥ 6.6%) were associated with poor RFS. T classification ≥ 3 (hazard ratio [95% confidence interval]) (1.72 [1.02–2.91]; P = 0.038), lymph node metastasis (1.77 [1.03–3.05]; P = 0.039), a large PNI decrease (≥ 11.0%; 1.80 [1.01–3.20]; P = 0.048), and a large PMI decrease (≥ 6.6%; 1.90 [1.08–3.47]; P = 0.009) were independent predictors of RFS in the multivariate analysis. Table 4. Clinicopathological predictors of recurrence-free survival after BTC resection Clinicopathological characteristic Univariate analysis Multivariate analysis N P -value HR (95% CI) P -value Age (years) ≥ 75 < 75 81 87 0.487 – – Sex Male Female 98 70 0.063 Body mass index (kg/m 2 ) ≥ 21 < 21 105 63 0.006* 1.65 (0.93–2.95) 0.085 Carcinoembryonic antigen (ng/mL) ≥ 5 < 5 32 136 0.213 – – Carbohydrate antigen 19-9 (U/mL) ≥ 50 < 50 53 115 0.007 1.25 (0.73–2.14) 0.401 Preoperative cholangitis Present Absent 67 101 0.021 1.17 (0.71–1.95) 0.540 Preoperative PMI Low PMI High PMI 68 100 0.023 1.12 (0.66–1.87) 0.672 Preoperative PNI < 42 ≥ 42 57 121 0.004 1.60 (0.94–2.65) 0.078 Glasgow Prognostic Score 0 1–2 110 59 0.079 – – Neutrophil-to-lymphocyte ratio < 2.20 ≥ 2.20 91 77 0.796 – – Platelet-to-lymphocyte ratio < 106 ≥ 106 53 115 0.887 – – Operative time (min) ≥ 420 < 420 90 78 0.058 – – Blood loss (mL) ≥ 300 < 300 84 84 0.034 1.06 (0.64–1.82) 0.802 Transfusion No Yes 153 15 0.112 – – Postoperative complications (Clavien–Dindo Grade ≥ IIIa) Absent Present 106 62 0.391 – – T classification < 3 ≥ 3 97 71 < 0.001 1.72 (1.02–2.91) 0.038 Lymph node metastasis Present Absent 55 113 < 0.001 1.77 (1.03–3.05) 0.03 Postoperative adjuvant chemotherapy No Yes 64 104 < 0.001 1.45 (0.81–2.74) 0.212 Percentage decrease in PNI Large decrease (decrease percentage ≥ 11.0%) Small decrease or increase (decrease percentage < 11.0%) 40 128 0.004 1.80 (1.01–3.20) 0.048* Percentage decrease in PMI Large decrease (decrease percentage ≥ 6.6%) Small decrease or increase (decrease percentage < 6.6%) 101 67 0.002 1.90 (1.08–3.47) 0.026 HR, hazard ratio; CI, confidence interval; PNI, Prognostic Nutritional Index; PMI, Psoas Muscle Index Discussion The significance of skeletal muscle mass in the prognosis and outcome of various diseases has been increasingly recognized. The present study investigated how the pre- to postoperative changes in skeletal muscle mass, assessed using the PMI, as well as using the PNI in nutritional and inflammation assessment, influence survival outcomes after curative resection in patients with BTC. We found that a greater degree of reduction in PMI and PNI was significantly associated with worse survival in patients with BTC who underwent surgical curative resection. To our knowledge, no previous study has investigated the prognostic value and postoperative changes in the PNI and PMI in patients with BTC. In the present study, postoperative skeletal muscle loss was an independent factor associated with a poor prognosis. Moreover, the large PMI-decrease group had a poor prognosis, irrespective of whether they had preoperative sarcopenia. Preoperative assessment of sarcopenia is important; however, we show that postoperative evaluation of skeletal muscle loss is equally important. Preoperative sarcopenia, defined by a low PMI, was not a predictive factor for postoperative muscle depletion. Rather, postoperative complications and chemotherapy induction were more strongly associated with a large decrease in the PMI. These findings suggest the importance of controlling comorbidities and paying attention to early postoperative management. Furthermore, this study demonstrated a relationship between a marked decrease in PMI and postoperative BTC recurrence. Maeda et al. analyzed the timing of cancer recurrence and its correlation with skeletal muscle mass reduction. The findings indicated that skeletal muscle decline was most evident within the first postoperative year in patients who experienced recurrence of gastrointestinal cancer [27]. Skeletal muscle dynamics may serve as a promising early indicator of cancer recurrence. In our study, a large decrease in PMI influenced RFS. Further studies are required to validate whether skeletal muscle loss can reliably predict recurrence timing and patterns in patients with BTC. The PNI is based on serum albumin levels and total lymphocyte counts, both of which can be easily obtained from routine blood tests [5]. The PNI is a marker of nutritional status and systemic inflammation. The prognostic significance of preoperative PNI in patients with resected BTC, including proposed mechanistic explanations, has been previously described [28]. This study demonstrated that a large decrease in PNI after surgery is an independent prognostic factor for patients with BTC in terms of both OS and RFS. The results of this study also indicated that the degree of change in the PNI after surgery could be a valuable predictive marker. In various cancers, perioperative changes in PNI have been reported to be a significant prognostic factor [29-31]. A decreased PNI, although not a low preoperative PNI, was identified as an independent risk factor for OS and RFS in patients with small hepatocellular carcinomas who underwent liver resection [31]. Patients with pStage II/III colorectal cancer with lower postoperative PNI values also had worse OS and RFS [30]. Perioperative PNI changes have the potential to induce significant alterations in the tumor immune response following curative surgery for BTC. The presence of inflammatory cytokines derived from cancer cells can result in the proliferation of neutrophils, suppression of lymphocytes, and increased breakdown of proteins, including albumin [32]. Therefore, in the small-PNI-decrease group, tumor-mediated immune suppression may resolve more promptly following surgery, contributing to the more favorable outcomes observed in this group. To ascertain the clinical significance of perioperative PNI changes as a clinically relevant biomarker, future studies are necessary to validate our results. An association has been demonstrated between skeletal muscle loss and a decrease in local tumor immunity [33]. The infiltrative behavior of tumor and immune cells has been shown to be pivotal in the progression of extrahepatic cholangiocarcinoma [34]. Skeletal muscle mass appears to have increasing relevance as a prognostic factor for BTC; however, further investigation is necessary to elucidate the underlying mechanisms. Some reports have described a relationship between the mechanisms of distant metastasis and sarcopenia. During the process of micrometastasis, the tumor tissue produces a variety of pro-inflammatory cytokines that activate systemic inflammation and metabolic disorders that suppress host immunity [35]. Moreover, this may lead to sarcopenia [36]. In addition, skeletal muscle loss may promote an inflammatory microenvironment that is conducive to micrometastasis formation, in part through facilitation of epithelial–mesenchymal transition. The tumor micrometastasis environment can induce microinfiltration [37]. Therefore, tumor microinfiltration, inflammation, and skeletal muscle loss may mutually enhance each other. In this study, the decrease in PNI was significantly greater in the large-PMI-decrease group than in the small-PMI-decrease group. However, it remains unclear whether skeletal muscle loss leads to an increased recurrence rate due to impaired immune function. Further studies are needed to clarify the association between postoperative muscle loss and cancer recurrence. The administration of supportive therapy, with a focus on nutrition and rehabilitation, has been demonstrated to improve outcomes following resection of BTC in patients with poor nutritional status. Kaido et al. [38] demonstrated the impact of nutritional therapy on the prognosis of sarcopenia patients who had undergone liver transplantation. Other studies have shown that preoperative rehabilitation can reduce complications after surgery for different types of cancer [39, 40]. Preoperative physical conditioning, also known as prehabilitation, is the process of improving an individual’s functional and physiological capacity and ability to tolerate surgical stress and assist in postoperative recovery [41]. In our study, the factors that contributed to postoperative skeletal muscle loss were postoperative complications and the use of chemotherapy. Thus, since postoperative skeletal muscle loss occurs in patients regardless of the presence of preoperative sarcopenia, postoperative factors such as complications and chemotherapy may be useful in identifying patients more likely to have a poor prognosis. Patients with postoperative factors need more aggressive nutritional intervention and rehabilitation. Further studies are warranted to clarify the benefits of prehabilitation and nutritional intervention in improving surgical outcomes. The present study had some limitations. First, the relationship between postoperative PMI changes and the underlying biological mechanisms remains to be elucidated. Second, this was of a retrospective nature and encompassed a population of patients exhibiting a wide range of baseline characteristics. Third, the study’s sample size was comparatively limited, and the duration of the follow-up period was short. The number of patients required for the study was not statistically predetermined. Fourth, the cut-off values for PMI and PNI percentage change were derived by maximizing the Youden index within the same dataset used for prognostic analysis; this data-driven approach may introduce overfitting and inflate apparent discriminatory performance. Prospective validation using predefined thresholds is needed. Conclusion In this study, postoperative skeletal muscle loss, based on a large decrease in the PMI and a large decrease in the PNI, was identified as an independent predictor of a poor prognosis in patients with resectable BTC. We propose that skeletal muscle loss and a decrease in the PNI between pre- and postoperative time points could provide useful information regarding the prognosis of patients after curative resection for BTC. Our results suggest that early interventions, such as providing nutritional support and implementing physical exercise programs, may optimize treatment strategies and improve patient outcomes after resection of BTC; this should be verified in future studies. Abbreviations BTC Biliary tract cancer CT Computed tomography OS Overall survival PMI Psoas Muscle Index PNI Prognostic Nutritional Index RFS Recurrence-free survival Declarations Ethics approval and consent to participate The study design was approved by the Ethical Review Board of the National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan (approval numbers: ERBP2025042, ERBP2025040). Clinical trial number: not applicable. The requirement for obtaining written informed patient consent was waived because of the retrospective nature of the study . Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Authors’ contributions Study conception and design: MU, KK, NT, RT, NO, KO, HO, RH, HM, FT, YT, SO, and MI Acquisition of data: MI, MU, KK, and NT. Analysis and interpretation of data: MU, KK, and NT Drafting of manuscript: MU Critical revision of manuscript: MI Acknowledgments We would like to thank Editage (www.editage.com) for English language editing. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest statement The authors have no conflicts of interest to declare. References Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69:7–34. Hasegawa S, Ikai I, Fujii H, Hatano E, Shimahara Y. Surgical resection of hilar cholangiocarcinoma: analysis of survival and postoperative complications. World J Surg. 2007;31:1256–63. Wang Y, Li J, Xia Y, Gong R, Wang K, Yan Z, et al. Prognostic nomogram for intrahepatic cholangiocarcinoma after partial hepatectomy. J Clin Oncol. 2013;31:1188–95. Buettner S, van Vugt JLA, Gaspersz MP, Coelen RJS, Roos E, Labeur TA, et al. Survival after resection of perihilar cholangiocarcinoma in patients with lymph node metastases. HPB (Oxford). 2017;19:735–40. Onodera T, Goseki N, Kosaki G. [Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients]. Nihon Geka Gakkai Zasshi. 1984;85:1001–5. Wang J, Bo X, Li M, Nan L, Wang C, Gao Z, et al. Prediction efficacy for clinical outcome of prognostic nutritional index in patients with resectable biliary tract cancer depends on sex and obstructive jaundice status. Ann Surg Oncol. 2021;28:430–8. Yoo YJ, Kang CM, Choi M, Rho SY, Hwang HK, Lee WJ, et al. Preoperative prognostic nutritional index as an independent prognostic factor for resected ampulla of Vater cancer. PLoS ONE. 2020;15:e0229597. Okamura Y, Ashida R, Ito T, Sugiura T, Mori K, Uesaka K. Preoperative neutrophil to lymphocyte ratio and prognostic nutritional index predict overall survival after hepatectomy for hepatocellular carcinoma. World J Surg. 2015;39:1501–9. Utsumi M, Kitada K, Tokunaga N, Yoshida Y, Narusaka T, Hamano R, et al. Comparison of inflammation-based prognostic scores in patients with biliary tract cancer after surgical resection. Anticancer Res. 2021;41:2147–55. Prado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9:629–35. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European working group on sarcopenia in older people. Age Ageing. 2010;39:412–23. Utsumi M, Inagaki M, Kitada K, Tokunaga N, Yonoki K, Sakurai Y, et al. Prognostic significance of sarcopenia and systemic inflammatory markers in biliary tract cancer: A retrospective cohort study. J Gastrointest Cancer. 2024;55:888–99. Nakamura R, Yoneyama S, Tobita R, Kurihara S, Hatori T, Numata T, et al. Effect of postoperative muscle loss after resection of non-small cell lung cancer on surgical outcomes. Anticancer Res. 2022;42:3159–68. Miyake M, Morizawa Y, Hori S, Marugami N, Shimada K, Gotoh D, et al. Clinical impact of postoperative loss in psoas major muscle and nutrition index after radical cystectomy for patients with urothelial carcinoma of the bladder. BMC Cancer. 2017;17:237. Kudou K, Saeki H, Nakashima Y, Kimura K, Ando K, Oki E, et al. Postoperative skeletal muscle loss predicts poor prognosis of adenocarcinoma of upper stomach and esophagogastric junction. World J Surg. 2019;43:1068–75. Hamaguchi Y, Kaido T, Okumura S, Kobayashi A, Hammad A, Tamai Y, et al. Proposal for new diagnostic criteria for low skeletal muscle mass based on computed tomography imaging in Asian adults. Nutrition. 2016;32:1200–5. Coussens LM, Werb Z. Inflammation and cancer. Nature. 2002;420:860–7. Bano G, Trevisan C, Carraro S, Solmi M, Luchini C, Stubbs B, et al. Inflammation and sarcopenia: A systematic review and meta-analysis. Maturitas. 2017;96:10–5. Kim H, Choi HZ, Choi JM, Kang BM, Lee JW, Hwang JW. Sarcopenia with systemic inflammation can predict survival in patients with hepatocellular carcinoma undergoing curative resection. J Gastrointest Oncol. 2022;13:744–53. Peng H, Tan X. The prognostic significance of sarcopenia and the neutrophil-to-lymphocyte ratio in elderly patients with esophageal squamous cell carcinoma. Cancer Manag Res. 2021;13:3209–18. Feliciano EMC, Kroenke CH, Meyerhardt JA, Prado CM, Bradshaw PT, Kwan ML, et al. Association of systemic inflammation and sarcopenia with survival in nonmetastatic colorectal cancer: Results from the C SCANS study. JAMA Oncol. 2017;3:e172319. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96. Proctor MJ, Talwar D, Balmar SM, O'Reilly DS, Foulis AK, Horgan PG, et al. The relationship between the presence and site of cancer, an inflammation-based prognostic score and biochemical parameters. Initial results of the Glasgow Inflammation Outcome Study. Br J Cancer. 2010;103:870–6. Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol. 2005;91:181–4. Smith RA, Bosonnet L, Raraty M, Sutton R, Neoptolemos JP, Campbell F, et al. Preoperative platelet-lymphocyte ratio is an independent significant prognostic marker in resected pancreatic ductal adenocarcinoma. Am J Surg. 2009;197:466–72. Okumura S, Kaido T, Hamaguchi Y, Fujimoto Y, Masui T, Mizumoto M, et al. Impact of preoperative quality as well as quantity of skeletal muscle on survival after resection of pancreatic cancer. Surgery. 2015;157:1088–98. Maeda Y, Miyamoto Y, Ohuchi M, Ogawa K, Hiyoshi Y, Yoshida N, et al. Impact of preoperative skeletal muscle mass on prognosis and postoperative change in patients with gastrointestinal cancer. World J Surg. 2025;49:1600–10. Utsumi M, Kitada K, Tokunaga N, Kato T, Narusaka T, Hamano R, et al. A combined prediction model for biliary tract cancer using the prognostic nutritional index and pathological findings: a single-center retrospective study. BMC Gastroenterol. 2021;21:375. Hayasaka K, Notsuda H, Onodera K, Watanabe T, Watanabe Y, Suzuki T, et al. Prognostic value of perioperative changes in the prognostic nutritional index in patients with surgically resected non-small cell lung cancer. Surg Today. 2024;54:1031–40. Tatsuta K, Sakata M, Kojima T, Akai T, Shimizu M, Morita Y, et al. Impact of perioperative prognostic nutritional index changes on the survival of patients with stage II/III colorectal cancer. Ann Gastroenterol Surg. 2024;8:817–25. Peng W, Li C, Wen TF, Yan LN, Li B, Wang WT, et al. Postoperative prognostic nutritional index change is an independent predictor of survival in patients with small hepatocellular carcinoma. Am J Surg. 2016;212:122–7. Coffelt SB, Wellenstein MD, de Visser KE. Neutrophils in cancer: neutral no more. Nat Rev Cancer. 2016;16:431–46. Daitoku N, Miyamoto Y, Hiyoshi Y, Tokunaga R, Sakamoto Y, Sawayama H, et al. Preoperative skeletal muscle status is associated with tumor-infiltrating lymphocytes and prognosis in patients with colorectal cancer. Ann Gastroenterol Surg. 2022;6:658–66. Kitano Y, Okabe H, Yamashita YI, Nakagawa S, Saito Y, Umezaki N, et al. Tumour-infiltrating inflammatory and immune cells in patients with extrahepatic cholangiocarcinoma. Br J Cancer. 2018;118:171–80. Miyamoto Y, Hanna DL, Zhang W, Baba H, Lenz HJ. Molecular pathways: Cachexia signaling-a targeted approach to cancer treatment. Clin Cancer Res. 2016;22:3999–4004. Muscaritoli M, Anker SD, Argiles J, Aversa Z, Bauer JM, Biolo G, et al. Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) cachexia-anorexia in chronic wasting diseases and nutrition in geriatrics. Clin Nutr. 2010;29:154–9. Prado CM, Baracos VE, McCargar LJ, Reiman T, Mourtzakis M, Tonkin K, et al. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009;15:2920–6. Kaido T, Ogawa K, Fujimoto Y, Ogura Y, Hata K, Ito T, et al. Impact of sarcopenia on survival in patients undergoing living donor liver transplantation. Am J Transpl. 2013;13:1549–56. Benzo R, Wigle D, Novotny P, Wetzstein M, Nichols F, Shen RK, et al. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer. 2011;74:441–5. Mayo NE, Feldman L, Scott S, Zavorsky G, Kim DJ, Charlebois P, et al. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery. 2011;150:505–14. Pouwels S, Hageman D, Gommans LN, Willigendael EM, Nienhuijs SW, Scheltinga MR, et al. Preoperative exercise therapy in surgical care: a scoping review. J Clin Anesth. 2016;33:476–90. Additional Declarations No competing interests reported. Supplementary Files theapprovaldocuments1.pdf theapprovaldocuments2.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 May, 2026 Reviewers agreed at journal 15 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviewers invited by journal 06 May, 2026 Editor invited by journal 14 Apr, 2026 Editor assigned by journal 08 Apr, 2026 Submission checks completed at journal 08 Apr, 2026 First submitted to journal 02 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9303435","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":640010814,"identity":"1b7229a2-a51f-4042-b54d-283939df9a91","order_by":0,"name":"Masashi Utsumi","email":"data:image/png;base64,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","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Masashi","middleName":"","lastName":"Utsumi","suffix":""},{"id":640010815,"identity":"6d25ce1c-6e72-427c-ab13-c22d0355274a","order_by":1,"name":"Masaru Inagaki","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Masaru","middleName":"","lastName":"Inagaki","suffix":""},{"id":640010816,"identity":"3ecceead-bdb9-4814-9d49-975e6dffc5fb","order_by":2,"name":"Koji Kitada","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Kitada","suffix":""},{"id":640010817,"identity":"879b6c16-d3aa-483d-91bc-0214c3657c7e","order_by":3,"name":"Naoyuki Tokunaga","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Naoyuki","middleName":"","lastName":"Tokunaga","suffix":""},{"id":640010818,"identity":"da81603e-e9bd-42cd-bf9d-0427be2511f8","order_by":4,"name":"Naoki Onoda","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Naoki","middleName":"","lastName":"Onoda","suffix":""},{"id":640010819,"identity":"e5ec97e3-514e-4a82-b0b3-9b8eb17cf29b","order_by":5,"name":"Koki Omoto","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Koki","middleName":"","lastName":"Omoto","suffix":""},{"id":640010820,"identity":"7c430d96-3f1c-43f1-8323-c3c2ae5826ed","order_by":6,"name":"Hiroki Okabayashi","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Hiroki","middleName":"","lastName":"Okabayashi","suffix":""},{"id":640010821,"identity":"7bd4122f-5aad-49e8-b457-7163f8ca36f6","order_by":7,"name":"Ryusei Takahashi","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ryusei","middleName":"","lastName":"Takahashi","suffix":""},{"id":640010822,"identity":"76dbe72e-c7ba-44c0-8374-57e16621b8ee","order_by":8,"name":"Ryosuke Hamano","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ryosuke","middleName":"","lastName":"Hamano","suffix":""},{"id":640010823,"identity":"849628f0-55f4-4a44-a35d-43eaa99c85fb","order_by":9,"name":"Hideaki Miyaso","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Hideaki","middleName":"","lastName":"Miyaso","suffix":""},{"id":640010824,"identity":"3302cf67-27b0-442d-9758-b3f1d41f5110","order_by":10,"name":"Fuminori Teraishi","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Fuminori","middleName":"","lastName":"Teraishi","suffix":""},{"id":640010825,"identity":"8416c233-7576-4546-b970-cd85727fd19d","order_by":11,"name":"Yosuke Tsunemitsu","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Yosuke","middleName":"","lastName":"Tsunemitsu","suffix":""},{"id":640010826,"identity":"65373e39-667a-4293-931e-fed6f4788c8b","order_by":12,"name":"Shinya Otsuka","email":"","orcid":"","institution":"NHO Fukuyama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Shinya","middleName":"","lastName":"Otsuka","suffix":""}],"badges":[],"createdAt":"2026-04-02 12:54:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9303435/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9303435/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109405881,"identity":"64947ce8-1af4-4e0f-8bd2-4968f56b4771","added_by":"auto","created_at":"2026-05-17 13:20:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160038,"visible":true,"origin":"","legend":"\u003cp\u003e1A: The overall survival rate and recurrence-free survival rate according to the percentage decrease in PMI.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;1B: The overall survival rate and recurrence-free survival rate according to the percentage decrease in PNI. PMI, Psoas Muscle Index; PNI\u003cstrong\u003e \u003c/strong\u003ePrognostic Nutritional Index\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9303435/v1/03cf2510ed282318ebfb49c6.png"},{"id":109405860,"identity":"bb5d6e5f-ed2a-4ee5-adb9-4ac393dc3b69","added_by":"auto","created_at":"2026-05-17 13:20:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":414917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9303435/v1/31f83d79-5811-4144-9283-dcc9fac7e08a.pdf"},{"id":109337805,"identity":"5cc744ad-3123-4b6f-acea-d7952a884ef2","added_by":"auto","created_at":"2026-05-15 17:47:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":41818,"visible":true,"origin":"","legend":"","description":"","filename":"theapprovaldocuments1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9303435/v1/76c2369fa78202238889ee46.pdf"},{"id":109405515,"identity":"69aa6bc9-bf0a-4593-beb9-c8e48b3a7af0","added_by":"auto","created_at":"2026-05-17 13:18:37","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":41587,"visible":true,"origin":"","legend":"","description":"","filename":"theapprovaldocuments2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9303435/v1/a36bd6768eb5647c55db9502.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical impact of postoperative changes in the psoas muscle mass and Prognostic Nutritional Index for patients with biliary tract cancer: A retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBiliary tract cancer (BTC) is an aggressive malignancy that, although rare, has been increasing in incidence over the past few decades [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While surgical resection is the only curative treatment, recurrence is a major concern [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. BTC is often diagnosed at an advanced stage, at which point most patients are no longer candidates for surgical resection. Despite advances in surgical techniques and adjuvant chemotherapy, the prognosis of such patients remains poor [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, identifying prognostic factors for patients with resectable BTC is of clinical importance.\u003c/p\u003e \u003cp\u003eThe Prognostic Nutritional Index (PNI) is a marker of nutritional status as well as systemic inflammation that is based on serum albumin concentration and total lymphocyte count. These values can be easily obtained from routine preoperative blood tests [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Several studies [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] have shown that PNI is a prognostic indicator in various cancers. We previously demonstrated that preoperative PNI was an independent prognostic factor for patients with BTC [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the relationship between postoperative changes in PNI and prognosis has not been reported to date.\u003c/p\u003e \u003cp\u003eSarcopenia, defined as the loss of skeletal muscle mass and function, has recently attracted attention in the context of various cancers. Early studies on sarcopenia focused on the loss of skeletal muscle mass at one preoperative time point and concluded that preoperative sarcopenia was associated with poor prognosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Indeed, we previously demonstrated that preoperative skeletal muscle mass loss is an independent prognostic factor for patients with BTC [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Recent studies investigating postoperative changes in skeletal muscle mass in cancer patients demonstrated a greater impact of postoperative muscle loss on the prognosis of these patients [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The Psoas Muscle Index (PMI), determined relative to the third lumbar level on computed tomography (CT), correlates with whole-body skeletal muscle mass [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This information may be useful for monitoring treatment interventions and evaluating prognosis in individual patients. However, the importance of postoperative changes in skeletal muscle mass in patients with resectable BTC remains poorly studied.\u003c/p\u003e \u003cp\u003eInflammation and sarcopenia influence carcinogenesis and cancer progression [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Systemic inflammation has been observed in patients with sarcopenia [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In patients with various types of cancer, sarcopenia accompanied by systemic inflammation correlates with poor prognosis [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, to date, few studies have examined the postoperative changes in sarcopenia, in combination with systemic inflammation, in the prognosis of patients with resectable BTC.\u003c/p\u003e \u003cp\u003eTherefore, in this study, we focused on the changes in skeletal muscle mass and PNI from the preoperative to the postoperative period. This study aimed to clarify whether changes in skeletal muscle mass and PNI could affect the long-term postoperative prognosis of patients with BTC who underwent curative surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eEthical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants were conducted in accordance with the ethical standards of our institutional research committee, as well as the 1964 Declaration of Helsinki and its subsequent amendments. The study design was approved by the Ethical Review Board of the National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan (approval numbers: ERBP2025042, ERBP2025040). Clinical trial number: not applicable. The requirement for obtaining written informed patient consent was waived because of the retrospective nature of the study\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 168 consecutive patients who underwent curative surgical resection for BTC at the Department of Surgery of the National Hospital Organization Fukuyama Medical Center between July 1, 2010, and December 31, 2024, were retrospectively reviewed. Imaging and pathological examination confirmed BTC, including intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma,\u0026nbsp;ampullary carcinoma, gallbladder carcinoma, and distal cholangiocarcinoma.\u0026nbsp;Data were collected and analyzed from\u0026nbsp;June\u0026nbsp;30, 2025, to\u0026nbsp;October\u0026nbsp;31, 2025, to allow for at least\u0026nbsp;6\u0026nbsp;months\u0026nbsp;of follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained data on the following from patients’ medical records: demographic characteristics (age at surgery and sex), laboratory tests (platelet and lymphocyte counts, serum albumin, and tumor marker levels), comorbidities (diabetes mellitus, hypertension, and cardiac, lung, and cerebral diseases), preoperative cholangitis, surgical procedure (resection type), blood loss, operative time, blood transfusion, tumor–node–metastasis stage (Union for International Cancer Control classification [eighth edition]), and use of postoperative adjuvant chemotherapy were obtained from patients’ medical records. We defined curative (R0) resection as the complete removal of all macroscopic nodules with microscopically clear margins and defined R1 and R2 resections involving at least one margin as microscopic or macroscopic disease, respectively. Complications were defined according to the Clavien–Dindo classification [22]. We defined postoperative complications as complications of Clavien–Dindo grade IIIa or higher. Postoperative mortality was defined as death from any cause within 30 days of surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePNI and other inflammation-based prognostic scores\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInflammation-based prognostic scores were calculated from the analysis of peripheral venous blood samples collected within 2 weeks prior to surgery. The Glasgow prognostic score was defined as follows: The first category (score 0) was defined as normal albumin (≥ 3.5 g/dL) and CRP (≤ 1.0 mg/dL). The second category (score 1) is defined as low albumin (\u0026lt; 3.5 g/dL) or high CRP (\u0026gt; 1.0 mg/dL). The third category (score 2) is defined as low albumin (\u0026lt; 3.5 g/dL) and high CRP (\u0026gt; 1.0 mg/dL) [23]. The neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios were calculated by dividing the neutrophil and platelet counts by the lymphocyte count [24, 25]. The PNI was calculated as follows [5]:\u003c/p\u003e\n\u003cp\u003ePNI = 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n\u003cp\u003eRegarding nutritional assessment, perioperative time-dependent changes in thePNI score were evaluated from 2 weeks pre-surgery to 6 months post-surgery (at 2 weeks preoperatively, and 1 month, 3 months, and 6 months postoperatively). The percentage decrease in PNI was defined as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[1 − (postoperative 6 months PNI score / preoperative PNI score)] × 100.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurement of skeletal muscle volume\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the PMI, preoperative CT was performed within 1 month before surgery, using a multidetector CT scanner (Aquilion CXL 64; Canon Medical Systems, Tochigi, Japan). Preoperative CT at the level of the caudal end of the third lumbar vertebra was used to measure the cross-sectional area of the bilateral psoas muscles using manual tracing. The PMI was calculated as follows [26]:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePMI = cross-sectional area of the bilateral psoas muscles (cm\u003csup\u003e2\u003c/sup\u003e) / height squared (m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n\u003cp\u003eA low PMI is considered an indicator of low muscle volume. Given the documented variation in the range of the PMI between male and female subjects, distinct cut-off values were determined through the implementation of receiver operating characteristic curves. The optimal cut-off values were determined based on the best accuracy in relation to outcome [12]. The cut-off values for the PMI in men and women were 5.10 and 3.69 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e, respectively, with areas under the receiver operating characteristic curves of 0.587 and 0.625, respectively.\u003c/p\u003e\n\u003cp\u003eThe PMI was evaluated at two time-points: at 1-month preoperatively and 4–6 months postoperatively. The percentage decrease in the PMI was defined as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[1 − (postoperative PMI/preoperative PMI)] × 100.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe classified the patients into two groups, i.e., a large-PMI-decrease group and a small-PMI-decrease/increase group, according to the percentage change in PMI based on the optimal cut-off point. The optimal cut-off value was selected based on the best accuracy for the outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRoutine follow-up was conducted for all participants until October 2025. Postoperative follow-up encompassed a comprehensive medical history review, including symptoms and physical examination findings, along with laboratory test results. Imaging studies were performed on a regular basis, at intervals of three to six months, for a minimum period of five years.\u0026nbsp;Patients presenting with lymph node metastasis subsequently received postoperative adjuvant chemotherapy consisting of tegafur/gimeracil/oteracil for a period of approximately six months. Notably, none of the patients received neoadjuvant chemotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe outcomes of this study included the association between clinicopathological variables and survival rates. The terms “recurrence-free survival” (RFS) and “overall survival” (OS) were defined as the time intervals from surgical intervention to the recurrence of BTC and death or last follow-up, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to analysis, all data were anonymized. Categorical variables are expressed as numerical values, typically expressed as percentages. Continuous variables are expressed as medians with ranges. Univariate comparisons of variables between groups were performed using Mann–Whitney \u003cem\u003eU\u003c/em\u003e and chi-square tests. The degree of diagnostic accuracy was ascertained by calculating the area under the receiver operating characteristic curve. The cut-off values for PMI change and inflammation-based prognostic scores were determined by maximizing the Youden index, which is defined as sensitivity + specificity − 1, with OS as the endpoint. RFS and OS were estimated using the Kaplan–Meier method and were compared between patient groups by using the log-rank test. Univariate and multivariate analyses of the associations between clinicopathological variables and survival rates were performed using Cox proportional hazards models. Variables found to be significant in the univariate analyses were then entered into multivariate analyses. All statistical analyses were conducted using JMP 11 (SAS Institute, Cary, NC, USA). Statistical significance was defined as P \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall patient characteristics are summarized in Table 1. The patients ranged in age from 34 to 92 years. Most patients had gallbladder carcinoma, followed by intrahepatic, distal, ampullary, and perihilar cholangiocarcinomas. The surgical procedures performed primarily included liver resection (including hemihepatectomy, subsegmentectomy, liver bed resection, sectionectomy, and trisectionectomy), followed by pancreaticoduodenectomy, cholecystectomy, hepatopancreaticoduodenectomy, and bile duct resection without hepatectomy. Postoperative complications were observed in approximately 37% of the patients, including pancreatic fistula, bile leakage, abdominal abscess, pleural effusion, chylous ascites, and abdominal bleeding. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Patient characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73.2\u0026nbsp;\u0026plusmn; 10.4\u0026nbsp;(34\u0026ndash;92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex (male/female), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e98/70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.6 \u0026plusmn; 3.4\u0026nbsp;(15.7\u0026ndash;32.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePreoperative laboratory data\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Albumin (g/dL), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.84\u0026nbsp;\u0026plusmn; 0.51\u0026nbsp;(2.40\u0026ndash;4.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Platelet count (\u0026times;10\u003csup\u003e4\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.80\u0026nbsp;\u0026plusmn; 6.65\u0026nbsp;(3.37\u0026ndash;46.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Neutrophil count (\u0026times;10\u003csup\u003e3\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.96 \u0026plusmn;\u0026nbsp;1.80\u0026nbsp;(1.08\u0026ndash;12.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Lymphocyte count (\u0026times;10\u003csup\u003e3\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.61\u0026nbsp;\u0026plusmn; 0.69 (0.26\u0026ndash;5.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;C-reactive protein (mg/dL), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.88 \u0026plusmn;\u0026nbsp;1.67\u0026nbsp;(0.01\u0026ndash;12.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Carcinoembryonic antigen (ng/mL), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.19\u0026nbsp;\u0026plusmn; 11.13\u0026nbsp;(0.52\u0026ndash;113.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Carbohydrate antigen 19-9 (U/mL), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1,355.55\u0026nbsp;\u0026plusmn;\u0026nbsp;9,798.96\u0026nbsp;(2.00\u0026ndash;120,000.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;PNI, mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.49\u0026nbsp;\u0026plusmn; 6.47\u0026nbsp;(30.30\u0026ndash;63.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Glasgow Prognostic Score (0/1/2), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e109/42/17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;C-reactive protein-to-albumin ratio, mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.27 \u0026plusmn;\u0026nbsp;0.56\u0026nbsp;(0.001\u0026ndash;4.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Platelet-to-lymphocyte ratio, mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e156.8\u0026nbsp;\u0026plusmn; 81.0\u0026nbsp;(39.0\u0026ndash;600.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Neutrophil-to-lymphocyte ratio, mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.10\u0026nbsp;\u0026plusmn; 4.11\u0026nbsp;(0.75\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePMI (cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e), mean \u0026plusmn; SD\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Male\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.00 \u0026plusmn; 1.71 (2.53\u0026ndash;11.80)\u003c/p\u003e\n \u003cp\u003e5.34 \u0026plusmn; 1.21 (2.55\u0026ndash;8.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eType of cancer, N (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Intrahepatic cholangiocarcinoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Gallbladder carcinoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Distal cholangiocarcinoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ampullary carcinoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Perihilar cholangiocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39\u0026nbsp;(23.2)\u003c/p\u003e\n \u003cp\u003e48\u0026nbsp;(28.6)\u003c/p\u003e\n \u003cp\u003e38\u0026nbsp;(22.6)\u003c/p\u003e\n \u003cp\u003e27\u0026nbsp;(16.0)\u003c/p\u003e\n \u003cp\u003e16 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative cholangitis, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67\u0026nbsp;(39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eComorbidities (absent/present), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40/128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSurgical procedure, N (%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cholecystectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Bile duct resection without liver resection\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Type of liver resection\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Liver bed resection\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Subsegmentectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Sectionectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Hemihepatectomy \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Trisectionectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Pancreaticoduodenectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hepatopancreaticoduodenectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29\u0026nbsp;(17.2)\u003c/p\u003e\n \u003cp\u003e1 (0.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u0026nbsp;(5.3)\u003c/p\u003e\n \u003cp\u003e11 (6.5)\u003c/p\u003e\n \u003cp\u003e7 (4.2)\u003c/p\u003e\n \u003cp\u003e41\u0026nbsp;(24.4)\u003c/p\u003e\n \u003cp\u003e5\u0026nbsp;(3.0)\u003c/p\u003e\n \u003cp\u003e63\u0026nbsp;(37.5)\u003c/p\u003e\n \u003cp\u003e2 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOperative time (min), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e413.7\u0026nbsp;\u0026plusmn; 178.2\u0026nbsp;(45.0\u0026ndash;1049.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBlood loss (mL), mean \u0026plusmn; SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e606.5\u0026nbsp;\u0026plusmn; 1,277.5\u0026nbsp;(0.0\u0026ndash;13,870.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBlood transfusion, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u0026nbsp;(9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT\u0026nbsp;classification\u0026nbsp;(1/2/3/4), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37/60/63/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLymph node metastasis (absent/present), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55/113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTumor\u0026ndash;Node\u0026ndash;Metastasis classification (eighth edition) (0/I/II/III/IV), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14/28/66/42/18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eResection (R0/R1/R2), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e147/18/3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMortality, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative adjuvant chemotherapy, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e102\u0026nbsp;(61.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative complications (Clavien\u0026ndash;Dindo Grade \u0026ge; IIIa) (absent/present), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62/106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD, standard deviation; N, number\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between PMI or PNI changes and postoperative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe optimal cut-off value for the percentage decrease in PMI was 6.6%. After dividing patients into two groups based on a large decrease or small decrease/increase in PMI relative to the cut-off point, patients in the large-decrease and small-decrease/increase groups were 101 and 67 cases, respectively. Patients in the large- and small-PNI-decrease/increase groups, defined in a similar manner as for PMI using the optimal cut-off value for the percentage decrease in PNI of 11.0%, comprised 40 and 128 patients, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe then compared the OS and RFS between these patient groups defined by decreases in the PMI and PNI (Fig. 1). The OS and RFS rates of the group with a small PMI decrease/increase were significantly higher than those of the group with a large PMI decrease (OS: \u003cem\u003eP\u003c/em\u003e = 0.001, RFS: \u003cem\u003eP\u003c/em\u003e = 0.002; Fig. 1A). The OS and RFS rates were significantly higher in the group with a small PNI decrease/increase than in the group with a large decrease in PNI (OS: \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001, RFS: \u003cem\u003eP\u003c/em\u003e = 0.003; Fig. 1B).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between PMI changes and clinicopathological characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 summarizes the clinicopathological characteristics and short-term surgical outcomes of the patients in the groups with large and small decreases in PMI. We found no significant difference in preoperative PMI levels between the two groups. The decrease in PNI was significantly greater in the large-PMI-decrease group than in the small-PMI-decrease group (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.004). In the large-PMI-decrease group, the operative time was significantly longer than that in the small-PMI-decrease group (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.013). In the large-PMI-decrease group, the induction rate of postoperative adjuvant chemotherapy was significantly lower than that in the small-PMI-decrease group (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.014). In the large-PMI-decrease group, the rate of postoperative complications tended to be greater than that in the small-PMI-decrease group (\u003cem\u003eP\u003c/em\u003e = 0.059). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Perioperative characteristics by Psoas Muscle Index change group\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLarge-PMI-decrease group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N = 101)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSmall-PMI-decrease/PMI increase group (N = 67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73.6\u0026plusmn; 9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72.6 \u0026plusmn; 11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex (male/female), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63/38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35/32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.2 \u0026plusmn; 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.6 \u0026plusmn; 3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarcinoembryonic antigen (ng/mL), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.69 \u0026plusmn; 13.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.43 \u0026plusmn; 6.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarbohydrate antigen 19-9 (U/mL), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,040.3 \u0026plusmn; 12,606.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e333.5 \u0026plusmn; 1,162.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.271\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC-reactive protein (mg/dL), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.96 \u0026plusmn; 1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.76 \u0026plusmn; 1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative\u0026nbsp;PNI, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.26 \u0026plusmn; 6.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.84 \u0026plusmn; 6.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGlasgow Prognostic Score (0/1/2),\u003cem\u003e\u0026nbsp;\u003c/em\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68/21/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41/21/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC-reactive protein-to-albumin ratio, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.29 \u0026plusmn; 0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.23 \u0026plusmn; 0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.494\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlatelet-to-lymphocyte ratio, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e161.6 \u0026plusmn; 8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e149.7 \u0026plusmn; 7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeutrophil-to-lymphocyte ratio, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.32 \u0026plusmn; 5.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.76 \u0026plusmn; 1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative low PMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative cholangitis (absent/present), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61/40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40/27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.928\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eResection (R0/R1\u0026ndash;2), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87/14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOperative time (min), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e441 \u0026plusmn; 150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e371 \u0026plusmn; 207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBlood loss (mL), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e738 \u0026plusmn; 536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e709 \u0026plusmn; 1917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTransfusion (no/yes), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e90/9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61/6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT\u0026nbsp;classification\u0026nbsp;(\u0026ge; 3), N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.674\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLymph node metastasis (absent/present), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTumor\u0026ndash;Node\u0026ndash;Metastasis classification (eighth edition) (I\u0026ndash;II/III\u0026ndash;IV), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63/38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative complications (Clavien\u0026ndash;Dindo Grade \u0026ge; IIIa) (absent/present), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58/43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative adjuvant chemotherapy (no/yes), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31/69 (68.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33/33 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLarge PNI decrease (\u0026ge; 11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePNI, Prognostic Nutritional Index; PMI, Psoas Muscle Index; SD, standard deviation; N, number\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnivariate and multivariate analyses of clinicopathological factors associated with overall survival in patients with resected BTC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 shows the relationship between clinicopathological variables and OS in patients with resected BTC. Univariate analysis showed that carbohydrate antigen 19-9 \u0026ge; 50, a low PMI, a low PNI (\u0026lt; 42), T classification \u0026ge; 3, lymph node metastasis, a large decrease in PNI (\u0026ge; 11.0%), and a large decrease in PMI (\u0026ge; 6.6%) were associated with poor OS. In multivariate analysis, T classification \u0026ge; 3 (hazard ratio [95% confidence interval]) (2.11 [1.29\u0026ndash;3.47]; \u003cem\u003eP\u003c/em\u003e = 0.003), lymph node metastasis (1.84 [1.10\u0026ndash;3.09]; \u003cem\u003eP\u003c/em\u003e = 0.002), a large decrease in PNI (\u0026ge;11.0%; 2.14 [1.27\u0026ndash;3.54]; \u003cem\u003eP\u003c/em\u003e = 0.005), and a large decrease in PMI (\u0026ge; 6.6%; 2.00 [1.18\u0026ndash;3.50]; \u003cem\u003eP\u003c/em\u003e = 0.009) were independent predictors of OS in multivariate analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Clinicopathological predictors of overall survival after BTC resection\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eClinicopathological characteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eUnivariate analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eMultivariate analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHR\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 75\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 21\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarcinoembryonic antigen (ng/mL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarbohydrate antigen 19-9 (U/mL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 50\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.16\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.69\u0026ndash;1.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.556\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative cholangitis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative PMI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Low PMI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;High PMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.55\u0026nbsp;(0.97\u0026ndash;2.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative\u0026nbsp;PNI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 42\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0.91\u0026ndash;2.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGlasgow Prognostic Score\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeutrophil-to-lymphocyte ratio\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt;\u0026nbsp;2.20\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge;\u0026nbsp;2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlatelet-to-lymphocyte ratio\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 106\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOperative time (min)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 420\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 300\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026lt; 300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative complications (Clavien\u0026ndash;Dindo Grade \u0026ge; IIIa)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT\u0026nbsp;classification\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.11\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.29\u0026ndash;3.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLymph node metastasis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.84\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.10\u0026ndash;3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative adjuvant chemotherapy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePercentage decrease in PNI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Large decrease (decrease percentage \u0026ge; 11.0%)\u003c/p\u003e\n \u003cp\u003eSmall decrease or increase (decrease percentage \u0026lt; 11.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.14\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.27\u0026ndash;3.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePercentage decrease in PMI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Large decrease (decrease percentage \u0026ge; 6.6%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Small decrease or increase (decrease percentage \u0026lt; 6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.18\u0026ndash;3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHR, hazard ratio; CI, confidence interval\u003c/p\u003e\n\u003cp\u003ePNI, Prognostic Nutritional Index; PMI, Psoas Muscle Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnivariate and multivariate analyses of clinicopathological factors associated with recurrence-free survival in patients with resected BTC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;4\u0026nbsp;shows the relationship between clinicopathological variables and\u0026nbsp;RFS\u0026nbsp;in patients\u0026nbsp;with resected BTC. Univariate analysis showed that\u0026nbsp;BMI\u0026nbsp;\u0026ge;\u0026nbsp;21 kg/m\u003csup\u003e2\u003c/sup\u003e, carbohydrate antigen 19-9 \u0026ge; 50, preoperative cholangitis, a low PMI, a low PNI (\u0026lt; 42), blood loss \u0026ge; 300 ml, T classification \u0026ge; 3, lymph node metastasis, postoperative adjuvant chemotherapy, a large PNI decrease (\u0026ge; 11.0%), and a large PMI decrease (\u0026ge; 6.6%) were associated with poor RFS. T classification \u0026ge; 3 (hazard ratio [95% confidence interval]) (1.72 [1.02\u0026ndash;2.91]; \u003cem\u003eP\u003c/em\u003e = 0.038), lymph node metastasis (1.77 [1.03\u0026ndash;3.05]; \u003cem\u003eP\u003c/em\u003e = 0.039), a large PNI decrease (\u0026ge; 11.0%; 1.80 [1.01\u0026ndash;3.20]; \u003cem\u003eP\u003c/em\u003e = 0.048), and a large PMI decrease (\u0026ge; 6.6%; 1.90 [1.08\u0026ndash;3.47]; \u003cem\u003eP\u003c/em\u003e = 0.009) were independent predictors of RFS in the multivariate analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4.\u003c/strong\u003e Clinicopathological predictors of recurrence-free survival after BTC resection\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eClinicopathological characteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eUnivariate analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eMultivariate\u003c/p\u003e\n \u003cp\u003eanalysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 75\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 21\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003cp\u003e(0.93\u0026ndash;2.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarcinoembryonic antigen (ng/mL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCarbohydrate antigen 19-9 (U/mL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 50\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.25\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.73\u0026ndash;2.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.401\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative cholangitis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.17\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.71\u0026ndash;1.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative\u0026nbsp;PMI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Low PMI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;High PMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.12\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.66\u0026ndash;1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.672\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative PNI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 42\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.60\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.94\u0026ndash;2.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGlasgow Prognostic Score\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeutrophil-to-lymphocyte ratio\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt;\u0026nbsp;2.20\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge;\u0026nbsp;2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlatelet-to-lymphocyte ratio\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 106\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOperative time (min)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 420\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 300\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026lt; 300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.06\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.64\u0026ndash;1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.802\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative complications (Clavien\u0026ndash;Dindo Grade \u0026ge; IIIa)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eT\u0026nbsp;classification\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt; 3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.72\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.02\u0026ndash;2.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLymph node metastasis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.77\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.03\u0026ndash;3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative adjuvant chemotherapy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.45\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.81\u0026ndash;2.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePercentage decrease in PNI\u003c/p\u003e\n \u003cp\u003eLarge decrease (decrease percentage \u0026ge; 11.0%)\u003c/p\u003e\n \u003cp\u003eSmall decrease or increase (decrease percentage \u0026lt; 11.0%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.80\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.01\u0026ndash;3.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.048*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePercentage decrease in PMI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Large decrease (decrease percentage \u0026ge; 6.6%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Small decrease or increase (decrease percentage \u0026lt; 6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.90\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.08\u0026ndash;3.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHR, hazard ratio; CI, confidence interval; PNI, Prognostic Nutritional Index; PMI, Psoas Muscle Index\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe significance of skeletal muscle mass in the prognosis and outcome of various diseases has been increasingly recognized. The present study investigated how the pre- to postoperative changes in skeletal muscle mass, assessed using the PMI, as well as using the PNI in nutritional and inflammation assessment, influence survival outcomes after curative resection in patients with BTC. We found that a greater degree of reduction in PMI and PNI was significantly associated with worse survival in patients with BTC who underwent surgical curative resection. To our knowledge, no previous study has investigated the prognostic value and postoperative changes in the PNI and PMI in patients with BTC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the present study, postoperative skeletal muscle loss was an independent factor associated with a poor prognosis. Moreover, the large PMI-decrease group had a poor prognosis, irrespective of whether they had preoperative sarcopenia. Preoperative assessment of sarcopenia is important; however, we show that postoperative evaluation of skeletal muscle loss is equally important. Preoperative sarcopenia, defined by a low PMI, was not a predictive factor for postoperative muscle depletion. Rather, postoperative complications and chemotherapy induction were more strongly associated with a large decrease in the PMI. These findings suggest the importance of controlling comorbidities and paying attention to early postoperative management. Furthermore, this study demonstrated a relationship between a marked decrease in PMI and postoperative BTC recurrence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMaeda et al. analyzed the timing of cancer recurrence and its correlation with skeletal muscle mass reduction. The findings indicated that skeletal muscle decline was most evident within the first postoperative year in patients who experienced recurrence of gastrointestinal cancer [27]. Skeletal muscle dynamics may serve as a promising early indicator of cancer recurrence. In our study, a large decrease in PMI influenced RFS. Further studies are required to validate whether skeletal muscle loss can reliably predict recurrence timing and patterns in patients with BTC.\u003c/p\u003e\n\u003cp\u003eThe PNI is based on serum albumin levels and total lymphocyte counts, both of which can be easily obtained from routine blood tests [5]. The PNI is\u0026nbsp;a marker of nutritional status and systemic inflammation. The prognostic significance of preoperative PNI in patients with resected BTC, including proposed mechanistic explanations, has been previously described\u0026nbsp;[28].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study demonstrated that a large decrease in PNI after surgery is an independent prognostic factor for patients with BTC in terms of both OS and RFS. The results of this study also indicated that the degree of change in the PNI after surgery could be a valuable predictive marker. In various cancers, perioperative changes in PNI have been reported to be a significant prognostic factor [29-31]. A decreased PNI, although not a low preoperative PNI, was identified as an independent risk factor for OS and RFS in patients with small hepatocellular carcinomas who underwent liver resection [31]. Patients with pStage II/III colorectal cancer with lower postoperative PNI values also had worse OS and RFS [30]. Perioperative PNI changes have the potential to induce significant alterations in the tumor immune response following curative surgery for BTC. The presence of inflammatory cytokines derived from cancer cells can result in the proliferation of neutrophils, suppression of lymphocytes, and increased breakdown of proteins, including albumin [32]. Therefore, in the small-PNI-decrease group, tumor-mediated immune suppression may resolve more promptly following surgery, contributing to the more favorable outcomes observed in this group. To ascertain the clinical significance of perioperative PNI changes as a clinically relevant biomarker, future studies are necessary to validate our results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn association has been demonstrated between skeletal muscle loss and a decrease in local tumor immunity [33]. The infiltrative behavior of tumor and immune cells has been shown to be pivotal in the progression of extrahepatic cholangiocarcinoma \u0026nbsp;[34]. Skeletal muscle mass appears to have increasing relevance as a prognostic factor for BTC; however, further investigation is necessary to elucidate the underlying mechanisms. Some reports have described a relationship between the mechanisms of distant metastasis and sarcopenia. During the process of micrometastasis, the tumor tissue produces a variety of pro-inflammatory cytokines that activate systemic inflammation and metabolic disorders that suppress host immunity [35]. Moreover, this may lead to sarcopenia [36]. In addition, skeletal muscle loss may promote an inflammatory microenvironment that is conducive to micrometastasis formation, in part through facilitation of epithelial–mesenchymal transition. The tumor micrometastasis environment can induce microinfiltration [37]. Therefore, tumor microinfiltration, inflammation, and skeletal muscle loss may mutually enhance each other. In this study, the decrease in PNI was significantly greater in the large-PMI-decrease group than in the small-PMI-decrease group. However, it remains unclear whether skeletal muscle loss leads to an increased recurrence rate due to impaired immune function. Further studies are needed to clarify the association between postoperative muscle loss and cancer recurrence.\u003c/p\u003e\n\u003cp\u003eThe administration of supportive therapy, with a focus on nutrition and rehabilitation, has been demonstrated to improve outcomes following resection of BTC in patients with poor nutritional status. Kaido et al. [38] demonstrated the impact of nutritional therapy on the prognosis of sarcopenia patients who had undergone liver transplantation. Other studies have shown that preoperative rehabilitation can reduce complications after surgery for different types of cancer [39, 40]. Preoperative physical conditioning, also known as prehabilitation, is the process of improving an individual’s functional and physiological capacity and ability to tolerate surgical stress and assist in postoperative recovery [41]. In our study, the factors that contributed to postoperative skeletal muscle loss were postoperative complications and the use of chemotherapy. Thus, since postoperative skeletal muscle loss occurs in patients regardless of the presence of preoperative sarcopenia, postoperative factors such as complications and chemotherapy may be useful in identifying patients more likely to have a poor prognosis. Patients with postoperative factors need more aggressive nutritional intervention and rehabilitation. Further studies are warranted to clarify the benefits of prehabilitation and nutritional intervention in improving surgical outcomes.\u003c/p\u003e\n\u003cp\u003eThe present study had some limitations. First, the relationship between postoperative PMI changes and the underlying biological mechanisms remains to be elucidated. Second, this was of a retrospective nature and encompassed a population of patients exhibiting a wide range of baseline characteristics. Third, the study’s sample size was comparatively limited, and the duration of the follow-up period was short. The number of patients required for the study was not statistically predetermined. Fourth, the cut-off values for PMI and PNI percentage change were derived by maximizing the Youden index within the same dataset used for prognostic analysis; this data-driven approach may introduce overfitting and inflate apparent discriminatory performance. Prospective validation using predefined thresholds is needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, postoperative skeletal muscle loss, based on a large decrease in the PMI and a large decrease in the PNI, was identified as an independent predictor of a poor prognosis in patients with resectable BTC. We propose that skeletal muscle loss and a decrease in the PNI between pre- and postoperative time points could provide useful information regarding the prognosis of patients after curative resection for BTC. Our results suggest that early interventions, such as providing nutritional support and implementing physical exercise programs, may optimize treatment strategies and improve patient outcomes after resection of BTC; this should be verified in future studies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBTC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Biliary tract cancer\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed tomography\u003c/p\u003e\n\u003cp\u003eOS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Overall survival\u003c/p\u003e\n\u003cp\u003ePMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Psoas Muscle Index\u003c/p\u003e\n\u003cp\u003ePNI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Prognostic Nutritional Index\u003c/p\u003e\n\u003cp\u003eRFS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Recurrence-free survival\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study design was approved by the Ethical Review Board of the National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan (approval numbers: ERBP2025042, ERBP2025040). Clinical trial number: not applicable.\u0026nbsp;The requirement for obtaining written informed patient consent was waived because of the retrospective nature of the study\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: MU, KK, NT, RT, NO, KO, HO, RH, HM, FT, YT, SO, and MI\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcquisition of data: MI, MU, KK, and NT.\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data: MU, KK, and NT\u003c/p\u003e\n\u003cp\u003eDrafting of manuscript: MU\u003c/p\u003e\n\u003cp\u003eCritical revision of manuscript: MI\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.com) for English language editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003cstrong\u003e\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69:7\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasegawa S, Ikai I, Fujii H, Hatano E, Shimahara Y. Surgical resection of hilar cholangiocarcinoma: analysis of survival and postoperative complications. World J Surg. 2007;31:1256\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Li J, Xia Y, Gong R, Wang K, Yan Z, et al. Prognostic nomogram for intrahepatic cholangiocarcinoma after partial hepatectomy. J Clin Oncol. 2013;31:1188\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuettner S, van Vugt JLA, Gaspersz MP, Coelen RJS, Roos E, Labeur TA, et al. Survival after resection of perihilar cholangiocarcinoma in patients with lymph node metastases. HPB (Oxford). 2017;19:735\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnodera T, Goseki N, Kosaki G. [Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients]. Nihon Geka Gakkai Zasshi. 1984;85:1001\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Bo X, Li M, Nan L, Wang C, Gao Z, et al. Prediction efficacy for clinical outcome of prognostic nutritional index in patients with resectable biliary tract cancer depends on sex and obstructive jaundice status. Ann Surg Oncol. 2021;28:430\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo YJ, Kang CM, Choi M, Rho SY, Hwang HK, Lee WJ, et al. Preoperative prognostic nutritional index as an independent prognostic factor for resected ampulla of Vater cancer. PLoS ONE. 2020;15:e0229597.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamura Y, Ashida R, Ito T, Sugiura T, Mori K, Uesaka K. Preoperative neutrophil to lymphocyte ratio and prognostic nutritional index predict overall survival after hepatectomy for hepatocellular carcinoma. World J Surg. 2015;39:1501\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUtsumi M, Kitada K, Tokunaga N, Yoshida Y, Narusaka T, Hamano R, et al. Comparison of inflammation-based prognostic scores in patients with biliary tract cancer after surgical resection. Anticancer Res. 2021;41:2147\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9:629\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European working group on sarcopenia in older people. Age Ageing. 2010;39:412\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUtsumi M, Inagaki M, Kitada K, Tokunaga N, Yonoki K, Sakurai Y, et al. Prognostic significance of sarcopenia and systemic inflammatory markers in biliary tract cancer: A retrospective cohort study. J Gastrointest Cancer. 2024;55:888\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura R, Yoneyama S, Tobita R, Kurihara S, Hatori T, Numata T, et al. Effect of postoperative muscle loss after resection of non-small cell lung cancer on surgical outcomes. Anticancer Res. 2022;42:3159\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyake M, Morizawa Y, Hori S, Marugami N, Shimada K, Gotoh D, et al. Clinical impact of postoperative loss in psoas major muscle and nutrition index after radical cystectomy for patients with urothelial carcinoma of the bladder. BMC Cancer. 2017;17:237.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKudou K, Saeki H, Nakashima Y, Kimura K, Ando K, Oki E, et al. Postoperative skeletal muscle loss predicts poor prognosis of adenocarcinoma of upper stomach and esophagogastric junction. World J Surg. 2019;43:1068\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamaguchi Y, Kaido T, Okumura S, Kobayashi A, Hammad A, Tamai Y, et al. Proposal for new diagnostic criteria for low skeletal muscle mass based on computed tomography imaging in Asian adults. Nutrition. 2016;32:1200\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoussens LM, Werb Z. Inflammation and cancer. Nature. 2002;420:860\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBano G, Trevisan C, Carraro S, Solmi M, Luchini C, Stubbs B, et al. Inflammation and sarcopenia: A systematic review and meta-analysis. Maturitas. 2017;96:10\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H, Choi HZ, Choi JM, Kang BM, Lee JW, Hwang JW. Sarcopenia with systemic inflammation can predict survival in patients with hepatocellular carcinoma undergoing curative resection. J Gastrointest Oncol. 2022;13:744\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng H, Tan X. The prognostic significance of sarcopenia and the neutrophil-to-lymphocyte ratio in elderly patients with esophageal squamous cell carcinoma. Cancer Manag Res. 2021;13:3209\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeliciano EMC, Kroenke CH, Meyerhardt JA, Prado CM, Bradshaw PT, Kwan ML, et al. Association of systemic inflammation and sarcopenia with survival in nonmetastatic colorectal cancer: Results from the C SCANS study. JAMA Oncol. 2017;3:e172319.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor MJ, Talwar D, Balmar SM, O'Reilly DS, Foulis AK, Horgan PG, et al. The relationship between the presence and site of cancer, an inflammation-based prognostic score and biochemical parameters. Initial results of the Glasgow Inflammation Outcome Study. Br J Cancer. 2010;103:870\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol. 2005;91:181\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith RA, Bosonnet L, Raraty M, Sutton R, Neoptolemos JP, Campbell F, et al. Preoperative platelet-lymphocyte ratio is an independent significant prognostic marker in resected pancreatic ductal adenocarcinoma. Am J Surg. 2009;197:466\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkumura S, Kaido T, Hamaguchi Y, Fujimoto Y, Masui T, Mizumoto M, et al. Impact of preoperative quality as well as quantity of skeletal muscle on survival after resection of pancreatic cancer. Surgery. 2015;157:1088\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaeda Y, Miyamoto Y, Ohuchi M, Ogawa K, Hiyoshi Y, Yoshida N, et al. Impact of preoperative skeletal muscle mass on prognosis and postoperative change in patients with gastrointestinal cancer. World J Surg. 2025;49:1600\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUtsumi M, Kitada K, Tokunaga N, Kato T, Narusaka T, Hamano R, et al. A combined prediction model for biliary tract cancer using the prognostic nutritional index and pathological findings: a single-center retrospective study. BMC Gastroenterol. 2021;21:375.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayasaka K, Notsuda H, Onodera K, Watanabe T, Watanabe Y, Suzuki T, et al. Prognostic value of perioperative changes in the prognostic nutritional index in patients with surgically resected non-small cell lung cancer. Surg Today. 2024;54:1031\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTatsuta K, Sakata M, Kojima T, Akai T, Shimizu M, Morita Y, et al. Impact of perioperative prognostic nutritional index changes on the survival of patients with stage II/III colorectal cancer. Ann Gastroenterol Surg. 2024;8:817\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng W, Li C, Wen TF, Yan LN, Li B, Wang WT, et al. Postoperative prognostic nutritional index change is an independent predictor of survival in patients with small hepatocellular carcinoma. Am J Surg. 2016;212:122\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoffelt SB, Wellenstein MD, de Visser KE. Neutrophils in cancer: neutral no more. Nat Rev Cancer. 2016;16:431\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaitoku N, Miyamoto Y, Hiyoshi Y, Tokunaga R, Sakamoto Y, Sawayama H, et al. Preoperative skeletal muscle status is associated with tumor-infiltrating lymphocytes and prognosis in patients with colorectal cancer. Ann Gastroenterol Surg. 2022;6:658\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitano Y, Okabe H, Yamashita YI, Nakagawa S, Saito Y, Umezaki N, et al. Tumour-infiltrating inflammatory and immune cells in patients with extrahepatic cholangiocarcinoma. Br J Cancer. 2018;118:171\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyamoto Y, Hanna DL, Zhang W, Baba H, Lenz HJ. Molecular pathways: Cachexia signaling-a targeted approach to cancer treatment. Clin Cancer Res. 2016;22:3999\u0026ndash;4004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuscaritoli M, Anker SD, Argiles J, Aversa Z, Bauer JM, Biolo G, et al. Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) cachexia-anorexia in chronic wasting diseases and nutrition in geriatrics. Clin Nutr. 2010;29:154\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrado CM, Baracos VE, McCargar LJ, Reiman T, Mourtzakis M, Tonkin K, et al. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009;15:2920\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaido T, Ogawa K, Fujimoto Y, Ogura Y, Hata K, Ito T, et al. Impact of sarcopenia on survival in patients undergoing living donor liver transplantation. Am J Transpl. 2013;13:1549\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenzo R, Wigle D, Novotny P, Wetzstein M, Nichols F, Shen RK, et al. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer. 2011;74:441\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayo NE, Feldman L, Scott S, Zavorsky G, Kim DJ, Charlebois P, et al. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery. 2011;150:505\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePouwels S, Hageman D, Gommans LN, Willigendael EM, Nienhuijs SW, Scheltinga MR, et al. Preoperative exercise therapy in surgical care: a scoping review. J Clin Anesth. 2016;33:476\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Psoas Muscle Index, Survival outcomes, Sarcopenia, Overall survival, Lymph node metastasis","lastPublishedDoi":"10.21203/rs.3.rs-9303435/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9303435/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLow preoperative Psoas Muscle Index (PMI) and Prognostic Nutritional Index (PNI) values in patients with biliary tract cancer (BTC) indicate unfavorable prognoses. However, the impact of changes in PMI and PNI from pre- to postoperative on survival outcomes remains unclear. We sought to clarify whether changes in skeletal muscle mass and PNI could affect the long-term postoperative prognosis of patients with BTC who underwent curative surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed 168 patients who underwent BTC resection. The PMI was assessed within 1 month before surgery, and the PNI was calculated from blood samples collected within 2 weeks before surgery; postoperative assessments were performed at 4\u0026ndash;6 months (PMI) and 6 months (PNI) after surgery. We classified patients into a large decrease and a small decrease/increase group, according to the percentage change in PMI and PNI, using the optimal cut-off point. Associations between clinicopathological characteristics, including changes in the PMI and PNI, and survival outcomes were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePreoperative PMI values were similar in both groups. The decrease in PNI was significantly greater in the large- than in the small-PMI-decrease group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). T classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (hazard ratio [95% confidence interval]) (2.11 [1.29\u0026ndash;3.47]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), lymph node metastasis (1.84 [1.10\u0026ndash;3.09]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), and a large PNI (\u0026ge;\u0026thinsp;11.0%; 2.14 [1.27\u0026ndash;3.54]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005), and PMI (\u0026ge;\u0026thinsp;6.6%; 2.00 [1.18\u0026ndash;3.50]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009) decrease independently predicted overall survival in multivariate analysis. T classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (1.72 [1.02\u0026ndash;2.91]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038), lymph node metastasis (1.77 [1.03\u0026ndash;3.05]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039), and a large PMI decrease (\u0026ge;\u0026thinsp;6.6%; 1.90 [1.08\u0026ndash;3.47]; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026) were independent predictors of RFS in the multivariate analysis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLarge postoperative reductions in the PMI and PNI were independent predictors of poor survival, regardless of the preoperative sarcopenia status of patients with resectable BTC.\u003c/p\u003e","manuscriptTitle":"Clinical impact of postoperative changes in the psoas muscle mass and Prognostic Nutritional Index for patients with biliary tract cancer: A retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 17:47:09","doi":"10.21203/rs.3.rs-9303435/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-17T18:59:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325609569822671579254011707622156392806","date":"2026-05-15T21:20:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26299837820044268124572803558405139027","date":"2026-05-08T08:59:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T14:29:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99273728022452493383372328029101970276","date":"2026-05-07T14:24:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-06T08:49:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-14T11:19:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-09T03:06:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-09T03:06:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-04-02T12:49:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"33904980-c4eb-4d40-ac85-416ea6831478","owner":[],"postedDate":"May 15th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-17T18:59:24+00:00","index":64,"fulltext":""},{"type":"reviewerAgreed","content":"325609569822671579254011707622156392806","date":"2026-05-15T21:20:39+00:00","index":61,"fulltext":""},{"type":"reviewerAgreed","content":"26299837820044268124572803558405139027","date":"2026-05-08T08:59:24+00:00","index":42,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T14:29:47+00:00","index":41,"fulltext":""},{"type":"reviewerAgreed","content":"99273728022452493383372328029101970276","date":"2026-05-07T14:24:49+00:00","index":40,"fulltext":""},{"type":"reviewersInvited","content":"30","date":"2026-05-06T08:49:58+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T17:47:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-15 17:47:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9303435","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9303435","identity":"rs-9303435","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}