Textbook outcome as a predictor of long-term prognosis in ampullary cancer: A retrospective cohort study

doi:10.3748/wjg.122776

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Dec 28, 2026; 32(48): 122776
Published online Dec 28, 2026. doi: 10.3748/wjg.122776

Table 1 Baseline characteristics of patients with or without achieving textbook outcome after pancreaticoduodenectomy, n (%)/median (interquartile range)

Characteristic	Overall (n = 347)	TO (n = 230)	Non-TO (n = 117)	P value
Sex				0.335
Female	189 (54)	130 (57)	59 (50)
Male	158 (46)	100 (43)	58 (50)
Age (years)	58 (51, 64)	58 (51, 64)	58 (51, 64)	0.992
BMI (kg/m²)	21.70 (20.26, 23.64)	21.70 (20.04, 23.54)	21.70 (20.62, 23.64)	0.179
Previous abdominal surgery	113 (33)	75 (33)	38 (32)	> 0.999
Tumor differentiation				0.511
Well	232 (67)	157 (68)	75 (64)
Poor	115 (33)	73 (32)	42 (36)
T-stage				0.117
T1	37 (11)	29 (13)	8 (6.8)
T2	122 (35)	85 (37)	37 (32)
T3a	87 (25)	58 (25)	29 (25)
T3b	90 (26)	53 (23)	37 (32)
T4	11 (3.2)	5 (2.2)	6 (5.1)
N-stage				0.138
N0	209 (60)	147 (64)	62 (53)
N1	106 (31)	63 (27)	43 (37)
N2	32 (9.2)	20 (8.7)	12 (10)
TNM-stage				0.076
IA+IB	124 (36)	93 (40)	31 (26)
IIA	59 (17)	40 (17)	19 (16)
IIB	23 (6.6)	15 (6.5)	8 (6.8)
IIIA	103 (30)	60 (26)	43 (37)
IIIB	38 (11)	22 (9.6)	16 (14)
Perineural invasion	32 (9.2)	19 (8.3)	13 (11)	0.502
Biliary drainage	120 (35)	82 (36)	38 (32)	0.640
CA19-9 > 37 U/mL	209 (60)	134 (58)	75 (64)	0.350
CEA > 5 ng/mL	62 (18)	36 (16)	26 (22)	0.173
Preoperative EUS	49 (14)	31 (13)	18 (15)	0.750
Biliary duct dilatation	263 (76)	173 (75)	90 (77)	0.827
Pancreatic duct dilatation	188 (54)	124 (54)	64 (55)	0.980
Operation method				0.141
OPD	178 (51)	111 (48)	67 (57)
LPD	169 (49)	119 (52)	50 (43)
Operative time (minutes)	320 (260, 390)	290 (260, 370)	330 (270, 390)	0.032^a
EIBL (mL)	150 (60, 350)	150 (80, 350)	150 (50, 350)	0.963
Tumor size (cm)	2.00 (1.50, 3.00)	2.00 (1.50, 3.00)	2.00 (1.50, 3.00)	0.445
Pancreas hardness				0.523
Hard	71 (20)	50 (22)	21 (18)
Intermediate	62 (18)	43 (19)	19 (16)
Soft	214 (62)	137 (60)	77 (66)
Pancreatic anastomosis				0.040^a
End-to-end (invaginated)	34 (9.8)	27 (12)	7 (6.0)
Modified end-to-side (imbedding)	136 (39)	96 (42)	40 (34)
Duct-to-mucosa	177 (51)	107 (47)	70 (60)
Positive resection margin	21 (6.1)	9 (3.9)	12 (10)	0.035^a
Additional organ resection	11 (3.2)	5 (2.2)	6 (5.1)	0.246
Postoperative nasogastric tube removal (days)	4.0 (2.0, 6.0)	4.0 (2.0, 5.0)	4.0 (2.0, 6.0)	< 0.001^a
First oral food intake (days)	6.0 (4.0, 8.0)	5.0 (4.0, 7.0)	7.0 (4.0, 11.0)	0.002^a
First off-bed activity (days)	3.0 (3.0, 5.0)	3.0 (2.0, 5.0)	3.0 (3.0, 5.0)	0.007^a

^aP < 0.05.

TO: Textbook outcome; BMI: Body mass index; TNM: Tumor-node-metastasis; CA19-9: Carbohydrate antigen 19-9; CEA: Carcinoembryonic antigen; EUS: Endoscopic ultrasonography; OPD: Open pancreaticoduodenectomy; LPD: Laparoscopic pancreaticoduodenectomy; EIBL: Estimated intraoperative blood loss.

Full Size Table

Table 2 Factors associated with overall survival and disease-free survival identified by univariable and multivariable Cox regression, median (interquartile range)

Characteristic	OS¹		DFS¹		OS²		DFS²
Characteristic	HR	P value	HR	P value	HR	P value	HR	P value
TO achievement
No	Reference		Reference
Yes	0.50 (0.36, 0.68)	< 0.001^a	0.61 (0.46, 0.81)	< 0.001^a	0.61 (0.44, 0.84)	0.002^a	0.75 (0.56, 0.99)	0.044^a
Sex
Female	Reference		Reference
Male	0.91 (0.67, 1.24)	0.606	0.87 (0.65, 1.17)	0.355
Age (years)	1.02 (1.00, 1.03)	0.064	1.01 (1.00, 1.03)	0.157
Tumor differentiation
Well	Reference		Reference
Poor	2.89 (2.12, 3.94)	< 0.001^a	2.19 (1.65, 2.89)	< 0.001^a	1.56 (1.11, 2.19)	0.011^a	1.24 (0.91, 1.70)	0.249
T-stage
T1	Reference		Reference
T2	1.97 (0.88, 4.42)	0.102	1.81 (0.99, 3.30)	0.054^a	1.73 (0.76, 3.90)	0.202	1.66 (0.90, 3.04)	0.106
T3a	4.00 (1.79, 8.94)	< 0.001^a	2.78 (1.50, 5.14)	< 0.001^a	3.11 (1.38, 7.04)	0.006^a	2.37 (1.27, 4.43)	0.007^a
T3b	11.0 (4.97, 24.1)	< 0.001^a	6.81 (3.72, 12.5)	< 0.001^a	5.79 (2.53, 13.2)	< 0.001^a	4.00 (2.11, 7.57)	< 0.001^a
T4	18.7 (6.83, 51.3)	< 0.001^a	11.3 (4.85, 26.2)	< 0.001^a	6.35 (2.20, 18.4)	< 0.001^a	4.29 (1.75, 10.5)	0.001^a
N-stage
N0	Reference		Reference
N1	2.71 (1.92, 3.81)	< 0.001^a	2.37 (1.75, 3.22)	< 0.001^a	1.94 (1.33, 2.82)	< 0.001^a	1.88 (1.34, 2.66)	< 0.001^a
N2	6.73 (4.22, 10.7)	< 0.001^a	6.81 (4.35, 10.7)	< 0.001^a	2.86 (1.67, 4.91)	< 0.001^a	3.31 (1.96, 5.58)	< 0.001^a
Perineural invasion	2.34 (1.46, 3.73)	< 0.001^a	2.11 (1.35, 3.32)	< 0.001^a	1.74 (1.06, 2.86)	0.028^a	1.63 (1.02, 2.60)	0.042^a
Preoperative raised serum CA19-9 (> 37 U/mL)	1.79 (1.28, 2.51)	< 0.001^a	1.84 (1.36, 2.48)	< 0.001^a	1.47 (1.04, 2.08)	0.028^a	1.63 (1.20, 2.21)	0.002^a
Preoperative raised serum CEA (> 5 ng/mL)	0.95 (0.63, 1.41)	0.753	0.82 (0.57, 1.20)	0.279
Operation method
OPD	Reference		Reference
LPD	1.05 (0.77, 1.43)	0.848	1.09 (0.82, 1.43)	0.538
Tumor size (cm)	1.10 (0.99, 1.22)	0.078	1.05 (0.95, 1.16)	0.429
Positive resection margin	3.74 (2.21, 6.32)	< 0.001^a	3.17 (1.89, 5.32)	< 0.001^a	2.26 (1.28, 3.98)	0.005^a	1.78 (1.00, 3.14)	0.048^a
Additional organ resection	1.10 (0.45, 2.68)	0.831	0.89 (0.37, 2.17)	0.802

¹Univariable analysis.

²Multivariable analysis.

^aP <0.05.

OS: Overall survival; DFS: Disease-free survival; TO: Textbook outcome; CA19-9: Carbohydrate antigen 19-9; CEA: Carcinoembryonic antigen; OPD: Open pancreaticoduodenectomy; LPD: Laparoscopic pancreaticoduodenectomy.

Full Size Table

Table 3 Characteristics of patients before and after propensity score matching, n (%)/median (interquartile range)

Characteristics	Before PSM (n = 347)				After PSM (n = 222)
Characteristics	Open (n = 178)	Laparoscopic (n = 169)	P value	SMD	Open (n = 111)	Laparoscopic (n = 111)	P value	SMD
Sex			0.068	0.21			0.494	0.10
Female	88 (49)	101 (60)			57 (51)	63 (57)
Male	90 (51)	68 (40)			54 (49)	48 (43)
Age (years)	58 (51, 64)	59 (51, 65)	0.686	0.03	56 (49, 63)	57 (51, 64)	0.714	0.05
BMI (kg/m²)	21.70 (20.38, 23.11)	21.71 (19.51, 23.28)	0.469	0.10	21.70 (20.26, 22.80)	21.15 (19.31, 23.16)	0.667	0.08
Previous abdominal surgery			0.997	0.00			0.783	0.06
No	120 (67)	114 (67)			76 (68)	73 (66)
Yes	58 (33)	55 (33)			35 (32)	38 (34)
Tumor differentiation			0.592	0.07			0.970	0.00
Well	116 (65)	116 (69)			74 (67)	78 (70)
Poor	62 (35)	53 (31)			37 (33)	33 (30)
T-stage			0.241	0.26			1.000	0.00
T1	15 (8.4)	22 (13)			14 (13)	14 (13)
T2	71 (40)	51 (30)			48 (43)	48 (43)
T3a	39 (22)	48 (28)			24 (22)	24 (22)
T3b	48 (27)	42 (25)			22 (20)	22 (20)
T4	5 (2.8)	6 (3.6)			3 (2.7)	3 (2.7)
N-stage			< 0.001^a	0.55			0.917	0.07
N0	87 (49)	122 (72)			72 (65)	72 (65)
N1	75 (42)	31 (18)			31 (28)	29 (26)
N2	16 (9.0)	16 (9.5)			8 (7.2)	10 (9.0)
TNM-stage			< 0.001^a	0.72			0.978	0.05
IA+IB	65 (37)	59 (35)			48 (43)	49 (44)
IIA	20 (11)	39 (23)			20 (18)	20 (18)
IIB	2 (1.1)	21 (12)			2 (1.8)	2 (1.8)
IIIA	73 (41)	30 (18)			30 (27)	28 (25)
IIIB	18 (10)	20 (12)			11 (9.9)	12 (11)
Preoperative raised serum CA19-9			0.656	0.05			0.990	0.02
≤ 37 U/mL	73 (41)	65 (38)			43 (39)	44 (40)
> 37 U/mL	105 (59)	104 (62)			68 (61)	67 (60)
Preoperative raised serum CEA			0.532	0.08			0.771	0.07
≤ 5 ng/mL	149 (84)	136 (80)			90 (81)	87 (78)
> 5 ng/mL	29 (16)	33 (20)			21 (19)	24 (22)
Preoperative biliary drainage			0.239	0.16			0.381	0.13
No	123 (69)	104 (62)			76 (68)	69 (62)
Yes	55 (31)	65 (38)			35 (32)	42 (38)

^aP < 0.05.

PSM: Propensity score matching; SMD: Standardized mean difference; BMI: Body mass index; TNM: Tumor-node-metastasis stage; CA19-9: Carbohydrate antigen 19-9; CEA: Carcinoembryonic antigen.

Full Size Table

Table 4 Comparison of textbook outcome between laparoscopic and open pancreaticoduodenectomy, n (%)/median (interquartile range)

Characteristics	OPD (n = 111)	LPD (n = 111)	P value
TO achievement			0.400
No	38 (34)	31 (28)
Yes	73 (66)	80 (72)
Clavien-Dindo ≥ III			0.916
No	93 (84)	95 (86)
Yes	18 (16)	16 (14)
POPF (ISGPS grade B/C)			0.721
No	96 (86)	99 (89)
Yes	15 (14)	12 (11)
PPH (ISGPS grade B/C)			> 0.9
No	105 (95)	106 (95)
Yes	6 (5.4)	5 (4.5)
BL (ISGLS grade B/C)			0.610
No	108 (97)	110 (99)
Yes	3 (2.7)	1 (0.9)
Readmission within 30 days after discharge			> 0.9
No	106 (95)	106 (95)
Yes	5 (4.5)	5 (4.5)
In-hospital or 30-day mortality			> 0.9
No	108 (97)	109 (98)
Yes	3 (2.7)	2 (1.8)
Operative time (minutes)	310 (250, 380)	330 (280, 410)	0.033^a
EIBL (mL)	250 (50, 450)	100 (60, 300)	0.018^a
Tumor size (cm)	2.00 (1.50, 3.00)	2.00 (1.50, 3.00)	0.511
First off-bed activity (days)	4.0 (3.0, 6.0)	3.0 (2.0, 3.0)	< 0.001^a
Postoperative nasogastric tube removal (days)	4.0 (3.0, 6.0)	3.0 (2.0, 5.0)	0.008^a
First oral food intake (days)	6.0 (5.0, 9.0)	5.0 (4.0, 8.0)	0.020^a

^aP < 0.05.

OPD: Open pancreaticoduodenectomy; LPD: Laparoscopic pancreaticoduodenectomy; POPF: Postoperative pancreatic fistula; PPH: Postoperative hemorrhage; BL: Bile leakage; EIBL: Estimated intraoperative blood loss; TO: Textbook outcome; ISGPS: International Study Group of Pancreatic Surgery; ISGLS: International Study Group of Liver Surgery.

Full Size Table

Citation: Guo XY, Zhang JZ, Guo T, Huang XR, Zhu DS, Zhang Z, Zheng H, Yu YH, Zhang ZW. Textbook outcome as a predictor of long-term prognosis in ampullary cancer: A retrospective cohort study. World J Gastroenterol 2026; 32(48): 122776
URL: https://www.wjgnet.com/1007-9327/full/v32/i48/122776.htm
DOI: https://dx.doi.org/10.3748/wjg.122776

Guo XY, Zhang JZ, Guo T, Huang XR, Zhu DS, Zhang Z, Zheng H, Yu YH, Zhang ZW. Textbook outcome as a predictor of long-term prognosis in ampullary cancer: A retrospective cohort study. World J Gastroenterol 2026; 32(48): 122776 [DOI: 10.3748/wjg.122776]

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