Hildebrand ND; Department of Surgery, Maastricht University,
Maastricht, the Netherlands;
Alhulaili ZM; Driessens H; Hoeijmakers LSM; Bongers BC; et al

European Journal of Surgical Oncology. 52(8):111913, 2026 Aug.

INTRODUCTION: Major complication rates after pancreatoduodenectomy (PD)
are high. Cardiorespiratory fitness and body composition are considered
important determinants of postoperative outcomes. This study evaluated the
association between a multimodal preoperative assessment of
cardiorespiratory fitness and body composition as core patient phenotypes
and the occurrence of major complications following PD.

METHODS: In this two-center retrospective cohort study (2022-2024),
patients undergoing PD were included. Preoperative cardiorespiratory
fitness was assessed using cardiopulmonary exercise testing (CPET) or the
modified steep ramp test (mSRT). Poor cardiorespiratory fitness was
defined as an oxygen uptake (VO2) at the ventilatory anaerobic threshold
(AT) < 11.0 mL/kg/min or VO2 at peak exercise (VO2peak) < 18.0 mL/kg/min
during CPET, or a work rate at peak exercise <2.1W/kg at the mSRT.
Preoperative body composition parameters were derived from abdominal
computed tomography scans. Low muscle mass based on skeletal muscle index
(SMI) and myosteatosis (defined as low skeletal muscle radiation
attenuation, SM-RA) were assessed. The primary outcome was 30-day major
complications (Clavien-Dindo >= III). Logistic regression analyses
identified predictors.

RESULTS: Among 175 eligible patients (mean +/- SD age 69.1 +/- 8.2 years,
44.6% female), 34.9% were unfit; 54.9% had low muscle mass and 35.4% had
myosteatosis. Major complications occurred in 37.7% and 8.0% required
unplanned intensive care unit (ICU) admission. Preoperative
cardiorespiratory fitness correlated moderately with SM-RA (rho =
0.36-0.47; all p < 0.001). Poor cardiorespiratory fitness was associated
with major complications in multivariable analysis (adjusted odds ratio
[aOR] 2.54, 95% CI 1.17-5.54, p=0.02). Combined myosteatosis and poor
cardiorespiratory fitness (n = 28, 16.0%) was associated with both major
complications (aOR 3.40, 95% CI 1.25-9.28, p = 0.02) and unplanned ICU
admission (aOR 4.62, 95% CI 1.06-20.16, p = 0.04).

CONCLUSION: Myosteatosis correlates with lower cardiorespiratory fitness.
The combination of preoperative myosteatosis and poor cardiorespiratory
fitness is associated with major complications and postoperative ICU
admission. In future preoperative assessment, these patient phenotypes may
help to refine personalized risk assessment and guide inclusions for
trials on targeted preventive interventions.