Sarcopenia is a prognostic factor in living donor liver transplantation

Skeletal muscle mass assessed by computed tomography correlates to muscle strength and physical performance at a liver-related hospital experience

AIM

We aimed to evaluate whether skeletal muscle mass measured by computed tomography (CT) or bioelectrical impedance analysis (BIA) correlated to muscle strength and physical performance in liver-related hospital cases.

METHODS

We prospectively conducted this study in 120 liver-related hospital cases. Skeletal muscle mass was measured by CT scan and BIA. Muscle strength was determined by hand grip strength and physical performance by usual gait speed.

RESULTS

Skeletal muscle mass measured using CT significantly correlated to usual gait speed (r(2)  = 0.17, P < 0.0001) and hand grip strength (r(2)  = 0.66, P < 0.0001), but the correlations were lower using BIA (r(2)  = 0.1, P = 0.0005; r(2)  = 0.54, P < 0.0001). With regard to liver function, the relationship between skeletal muscle mass measured by CT and BIA and two muscle function parameters in the Child-Pugh A group were significant. In contrast, skeletal muscle mass measured by BIA in the Child-Pugh B or C group was not significantly related to usual gait speed.

CONCLUSION

Skeletal muscle mass measured by CT was significantly correlated to hand grip strength and usual gait speed, with higher correlations compared with BIA. Moreover, skeletal muscle mass measured by CT significantly correlated with two muscle functions, even in patients with Child-Pugh B or C.

Sarcopenia as a predictor of pulmonary complications after esophagectomy for thoracic esophageal cancer

BACKGROUND AND OBJECTIVES

Sarcopenia or loss of skeletal muscle mass has been identified as a poor prognostic factor for a wide variety of diseases and conditions. We investigated whether preoperative sarcopenia is associated with postoperative complications in patients undergoing esophagectomy for thoracic esophageal cancer.

METHODS

We retrospectively reviewed the medical records of consecutive patients with thoracic esophageal cancer who underwent esophagectomy between September 2005 and July 2014 at Kyoto University Hospital. Skeletal muscle mass was assessed using preoperative computed tomographic scans by measuring the cross-sectional muscle area at the third lumbar vertebral level.

RESULTS

Among the 199 eligible patients, 149 (75%) were classified as having sarcopenia. There was no difference in the incidence of overall complications between the groups (risk ratio [RR]: 1.10, 95% confidence interval [CI]: 0.80-1.53, P = 0.54). However, pulmonary complications were significantly more frequent in the sarcopenia group than in the nonsarcopenia group (RR: 2.63, 95% CI: 1.20-5.77, P = 0.007). Multivariate analyses demonstrated that sarcopenia was associated with a high adjusted risk of one or more pulmonary complications (odds ratio: 2.96, 95% CI: 1.14-7.69, P = 0.026).

CONCLUSIONS

Sarcopenia independently predicts pulmonary complications after esophagectomy for thoracic esophageal cancer. J. Surg. Oncol. 2016;113:678-684. © 2016 Wiley Periodicals, Inc.

Nonalcoholic steatohepatitis is strongly associated with sarcopenic obesity in patients with cirrhosis undergoing liver transplant evaluation

BACKGROUND

Sarcopenia is the most common complication of cirrhosis and adversely affects quality of life and outcomes before, during, and after liver transplantation. We studied predictors of sarcopenia and sarcopenic obesity in patients with cirrhosis undergoing liver transplant (LT) evaluation.

METHODS

A retrospective analysis of 207 adult cirrhotic patients that underwent LT from January 2008 to December 2013 was performed at our institution.

RESULTS

Two hundred seven patients were evaluated, 68% were male with a mean age of 54 ± 8 years. The most common etiology of cirrhosis was alcoholic liver disease (38.6%), followed by chronic hepatitis C (38.2%), nonalcoholic steatohepatitis (NASH) (21.7%), and hepatocellular carcinoma (HCC) (24.6%). The mean body mass index of the cohort was of 30.1 ± 5.7 kg/m(2) . Forty-eight percent of these patients were obese. Of the 207 patients, 88% had computed tomographic (CT) scans within 90 days before transplant; of these, 59% had sarcopenia found during LT evaluation. Of the patients with pretransplant sarcopenia, 59 had CT scan at 6 months posttransplant and 56 (95%) remained sarcopenic. Of the 56 patients who had sarcopenia at 6 months, 31 had available CT scans at 1 year, and 100% persisted with sarcopenia. These 31 subjects had a mean skeletal muscle index of 35 at 6 months and 36 at 1 year. SO was found in 41.7% of our patients. On multivariable regression analysis, obesity and age were found to be independently associated with pretransplant sarcopenia after controlling for gender and alcohol liver disease diagnosis (P = 0.00001, odds ratio [OR] 0.22, and P = 0.008, OR 2.0, respectively). A multivariable logistic regression analysis found that NASH as cause of cirrhosis and model of end-stage liver disease score are independent predictors of sarcopenic obesity after controlling for age, gender, alcoholic liver disease diagnosis, and HCC (P = 0.014 and 0.038, respectively; 95% confidence interval, 1.44-25.26 and 1.00-1.15, respectively; OR 6.03, 1.08, respectively).

CONCLUSIONS

Sarcopenia and sarcopenic obesity is seen in a significant number of patients with cirrhosis undergoing LT evaluation. Sarcopenia progresses after LT initially and does not recover at least within the first year after surgery. Obesity is an independent predictor of pretransplant sarcopenia and NASH was associated with 6-fold increased risk of having sarcopenic obesity in cirrhotic patients in our cohort.

Impact of sarcopenia on long-term mortality following endovascular aneurysm repair

Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence ( n=25) or absence ( n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3–11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.

Nutrition therapy: Integral part of liver transplant care

Managing malnutrition before liver transplantation (LTx) while on the waiting list and, excessive weight gain/metabolic disturbances in post-surgery are still a challenge in LTx care. The aim of this review is to support an interdisciplinary nutrition approach of these patients. Cirrhotic patients are frequently malnourished before LTx and this is associated with a poor prognosis. Although the relation between nutritional status versus survival, successful operation and recovery after LTx is well established, prevalence of malnutrition before the operation is still very high. Emerging research has also demonstrated that sarcopenia pre and post-transplant is highly prevalent, despite the weight gain in the postoperative period. The diagnosis of the nutritional status is the first step to address the adequate nutritional therapy. Nutritional recommendations and therapy to manage the nutritional status of LTx patients are discussed in this review, regarding counseling on adequate diets and findings of the latest research on using certain immunonutrients in these patients (branched chain amino-acids, pre and probiotics). Nutrition associated complications observed after transplantation is also described. They are commonly related to the adverse effects of immunosuppressive drugs, leading to hyperkalemia, hyperglycemia and weight gain. Excessive weight gain and post-transplant metabolic disorders have long been described in post-LTx and should be addressed in order to reduce associated morbidity and mortality.

Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery

According to the United States census bureau 20% of Americans will be older than 65 years in 2030 and half of them will need an operation - equating to about 36 million older surgical patients. Older adults are prone to complications during gastrointestinal cancer treatment and therefore may need to undergo special pretreatment assessments that incorporate frailty and sarcopenia assessments. A focused, structured literature review on PubMed and Google Scholar was performed to identify primary research articles, review articles, as well as practice guidelines on frailty and sarcopenia among patients undergoing gastrointestinal surgery. The initial search identified 450 articles; after eliminating duplicates, reports that did not include surgical patients, case series, as well as case reports, 42 publications on the impact of frailty and/or sarcopenia on outcome of patients undergoing gastrointestinal surgery were included. Frailty is defined as a clinically recognizable state of increased vulnerability to physiologic stressors resulting from aging. Frailty is associated with a decline in physiologic reserve and function across multiple physiologic systems. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Unlike cachexia, which is typically associated with weight loss due to chemotherapy or a general malignancy-related cachexia syndrome, sarcopenia relates to muscle mass rather than simply weight. As such, while weight reflects nutritional status, sarcopenia - the loss of muscle mass - is a more accurate and quantitative global marker of frailty. While chronologic age is an important element in assessing a patient's peri-operative risk, physiologic age is a more important determinant of outcomes. Geriatric assessment tools are important components of the pre-operative work-up and can help identify patients who suffer from frailty. Such data are important, as frailty and sarcopenia have repeatedly been demonstrated among the strongest predictors of both short- and long-term outcome following complicated surgical procedures such as esophageal, gastric, colorectal, and hepato-pancreatico-biliary resections.

Impact of postoperative changes in sarcopenic factors on outcomes after hepatectomy for hepatocellular carcinoma

BACKGROUND

We have reported that preoperative low skeletal muscle quality was an independent risk factor for poor outcomes after hepatectomy for hepatocellular carcinoma (HCC). However, postoperative changes of quality as well as quantity of skeletal muscle after hepatectomy for HCC and their impact on postoperative outcomes have not been fully investigated.

METHODS

We retrospectively analyzed 241 patients undergoing primary hepatectomy for HCC between January 2007 and September 2012. The quality and quantity of skeletal muscle were evaluated by intramuscular adipose tissue content (IMAC) and the psoas muscle mass index (PMI) using computed tomography imaging at the umbilical level, respectively. We evaluated postoperative changes in IMAC and PMI in patients according to preoperative sarcopenia, sex, and surgical procedure. We also investigated the impact of ΔIMAC and ΔPMI on HCC recurrence in patients with preoperative normal IMAC.

RESULTS

On multivariate analysis, indocyanine green retention test at 15 min ≥ 15% (odds ratio [OR] = 3.156; P = 0.041) and high ΔIMAC at 6 months after hepatectomy (OR = 3.713; P = 0.024) were the risk factors for HCC recurrence in patients with preoperative normal IMAC.

CONCLUSION

Postoperative depletion of skeletal muscle quality is closely involved with HCC recurrence after hepatectomy for HCC.

Profile of plasma amino acids values as a predictor of sepsis in patients following living donor liver transplantation: Special reference to sarcopenia and postoperative early nutrition

AIM

Sarcopenia is an independent predictor of mortality and sepsis after living donor liver transplantation (LDLT). However, the exact mechanisms by which sarcopenia affects poor prognosis or worse immunity against postoperative sepsis are unclear, particularly regarding muscular amino acid metabolism, and the authors aimed to identify the role of plasma amino acids in sarcopenia by retrospective study.

METHODS

The area of the psoas muscle in 228 recipients of LDLT was retrospectively measured by dynamic computed tomography. Additionally, plasma amino acid levels were measured both pre- and postoperatively. The impact of plasma amino acids for postoperative sepsis and the relationship between sarcopenia and early nutrition after LDLT were analyzed.

RESULTS

Among the plasma amino acids, only leucine, isoleucine and glutamine in patients with sarcopenia were significantly lower than those without sarcopenia (each, P < 0.05). Multivariate analysis identified the lower plasma glutamine levels as a risk factor of postoperative sepsis after LDLT (odds ratio 5.371, P = 0.002). In sarcopenia patients, plasma glutamine levels after LDLT were significantly decreased compared with before LDLT in patients both with and without postoperative early nutrition. However, in non-sarcopenia patients with early nutrition, plasma glutamine levels after LDLT were comparable with those before LDLT.

CONCLUSION

This is the first report to study the profile of plasma amino acid change before and after LDLT. Low preoperative glutamine values were an independent risk factor for predicting postoperative sepsis. The efficacy of postoperative early nutrition may prevent postoperative sepsis by improving glutamine levels.

Muscle atrophy as pre-sarcopenia in Japanese patients with chronic liver disease: computed tomography is useful for evaluation

BACKGROUND/AIM

The definition of muscle atrophy (pre-sarcopenia) and its diagnostic criteria have not been well reported. To elucidate the frequency of pre-sarcopenia in chronic liver disease (CLD), we examined clinical features of Japanese CLD patients using abdominal computed tomography (CT) findings.

METHODS

We enrolled 988 CLD (736 with naïve hepatocellular carcinoma) and 372 normal control subjects (NCs). The psoas muscle area index [PI, psoas muscle area at the mid-L3 level in CT (cm(2))/height (m)(2)] was calculated using personal computer software. The cut-off level for pre-sarcopenia was defined as less than two standard deviations (SDs) below the mean PI value in the NCs under 55 years old [males, 45.6 ± 5.7 years (n = 61), 4.24 cm(2)/m(2); females, 47.0 ± 6.1 years (n = 49), 2.50 cm(2)/m(2)]. Elderly was defined as 65 years or older. Clinical features were retrospectively evaluated.

RESULTS

In the CLD group (HCV:HBV:HBV and HCV:alcohol:non-HBV and HCV = 652:88:7:82:159), pre-sarcopenia was observed in 15.3% of patients with chronic hepatitis (CH), 24.4% of those with liver cirrhosis (LC) Child-Pugh A, 37.7% of those with LC Child-Pugh B, and 37.1% of those with LC Child-Pugh C. A comparison between NC and CH by age (<55, 55-64, 65-74, ≥75 years) showed that the frequency of pre-sarcopenia was higher in CH regardless of age (1.8 vs. 3.6%, 3.2 vs. 15.9%, 4.9 vs. 13.4%, 14.3 vs. 20.2%, respectively). PI values showed correlations with BMI (r = 0.361), age (r = -0.167), albumin (r = 0.115), and branched-chain amino acids (r = 0.199) (P < 0.01).

CONCLUSION

Retrospective evaluate for pre-sarcopenia was easy to perform with CT findings. Nutrition and exercise instruction should be considered for early stage and even non-elderly CLD as well as LC.

Newly Developed Sarcopenia as a Prognostic Factor for Survival in Patients who Underwent Liver Transplantation

Introduction

The relationship between a perioperative change in sarcopenic status and clinical outcome of liver transplantation (LT) is unknown. We investigated whether post-LT sarcopenia and changes in sarcopenic status were associated with the survival of patients.

Method

This retrospective study was based on a cohort of 145 patients from a single transplant center who during a mean of 1 year after LT underwent computed tomography imaging evaluation. The cross-sectional area of the psoas muscle of LT patients was compared with that of age- and sex-matched healthy individuals. The Cox proportional hazards regression model was used to determine whether post-LT sarcopenia and changes in sarcopenic status affect post-LT survival.

Results

The mean age at LT of the 116 male and 29 female patients was 50.2 ± 7.9 years; the mean follow-up duration was 51.6 ± 32.9 months. All pre-LT patients with sarcopenia still had sarcopenia 1 year after LT; 14 (15%) patients had newly developed sarcopenia. The mean survival duration was 91.8 ± 4.2 months for non-sarcopenic patients and 80.0 ± 5.2 months for sarcopenic patients (log-rank test, p = 0.069). In subgroup analysis, newly developed sarcopenia was an independent negative predictor for post-LT survival (hazard ratio: 10.53, 95% confidence interval: 1.37–80.93, p = 0.024).

Conclusion

Sarcopenia in LT recipients did not improve in any of the previously sarcopenic patients and newly developed within 1 year in others. Newly developed sarcopenia was associated with increased mortality. Newly developed sarcopenia can be used to stratify patients with regard to the risk of post-LT mortality.

Impact of the preoperative quantity and quality of skeletal muscle on outcomes after resection of extrahepatic biliary malignancies

BACKGROUND

Skeletal muscle depletion, referred to as sarcopenia, predicts mortality after major surgery. This study investigated the impact of preoperative skeletal muscle quantity and quality on outcomes in patients undergoing resection of extrahepatic biliary cancer.

METHODS

We performed a retrospective analysis of 207 patients undergoing resection for biliary cancer between 2004 and 2013. The quantity and quality of skeletal muscle, indicated by the psoas muscle mass index (PMI) and intramuscular adipose tissue content (IMAC), were measured on preoperative images of computed tomography. Overall survival (OS) and recurrence-free survival (RFS) rates were compared by PMI and IMAC, and prognostic factors after operation were assessed.

RESULTS

The OS and RFS rates were less in patients with low PMI (low muscle quantity) than in those with normal PMI (P < .001 and P < .001; 5-year OS, 15.7 vs 53.5%). The OS and RFS rates were also less in patients with high IMAC (low muscle quality) than in those with normal IMAC (P < .001 and P < .001; 5-year OS, 23.8 vs 55.9%). Low PMI and high IMAC were independent factors predictive of poor OS (hazard ratio [HR], 2.921 [95% CI, 1.920-4.470; P < .001] and HR, 1.725 [95% CI, 1.159-2.590; P = .007]) and RFS (HR, 2.141 [95% CI, 1.464-3.129, P < .001] and HR, 1.492 [95% CI, 1.032-2.166, P = .034]).

CONCLUSION

Preoperative sarcopenia, indicating a low quantity and quality of skeletal muscle, is related closely to mortality after resection of biliary cancer.

Sarcopenia and liver transplant: The relevance of too little muscle mass

Loss of muscle mass and function is a common occurrence in both patients with decompensated cirrhosis and those undergoing liver transplantation. Sarcopenia is associated with morbidity and mortality before and after liver transplantation. The ability of skeletal muscle mass to recover after transplant is questionable, and long term adverse events associated with persistent sarcopenia have not been well studied. Limited data is available examining mechanisms by which decreased muscle mass might develop. It is not clear which interventions might reduce the prevalence of sarcopenia and associated health burdens. However, measures to either decrease portal hypertension or improve nutrition appear to have benefit. Research on sarcopenia in the liver transplant setting is hampered by differing methodology to quantify muscle mass and varied thresholds determining the presence of sarcopenia. One area highlighted in this review is the heterogeneity used when defining sarcopenia. The health consequences, clinical course and potential pathophysiologic mechanisms of sarcopenia in the setting of cirrhosis and liver transplantation are further discussed.

Low, rather than high, body mass index confers increased risk for post-liver transplant death and graft loss: Risk modulated by model for end-stage liver disease

With increasing attention being paid to optimizing patient outcomes, it has been proposed that liver transplantation (LT) for individuals with elevated body mass index (BMI) values and high Model for End-Stage Liver Disease (MELD) scores may adversely affect post-LT outcomes. We investigated the impact of BMI on post-LT outcomes in the context of MELD at LT. Using United Network for Organ Sharing data, we identified all adult (≥ 18 years) primary LT recipients from March 1, 2002 to September 30, 2011. BMI categories included the following: underweight, normal, overweight, class I obese, class II obese, and class III obese (<18.5; 18.5-24.9; 25-29.9; 30-34.9; 35-39.9; ≥ 40 kg/m(2), respectively). One-year post-LT death and graft loss were modeled using Cox regression, including interactions between BMI and MELD. A total of 45,551 adult recipients were identified: 68% male; median (interquartile range [IQR]) age 55 years (IQR, 49-60 years); MELD, 19 (IQR, 13-26); and donor risk index, 1.39 (IQR, 1.12-1.69). Representations in the BMI categories were underweight (n = 863, 2%), normal (n = 13,262, 29%), overweight (n = 16,329, 36%), class I obese (n = 9639, 21%), class II obese (n = 4062, 9%), and class III obese (n = 1396, 3%). In adjusted analyses, elevated BMI was not associated with increased risk for death or graft loss. Among the underweight, there were significant interactions between BMI and MELD with respect to death (P = 0.02) and graft loss (P = 0.01), with significantly increased risks for death (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.38-2.09; P = 0.006) and graft loss (HR, 1.45; 95% CI, 1.21-1.74; P = 0.02) among those with low MELD (≤ 26), compared to normal BMI recipients with low MELD. In conclusion, overweight and obese LT recipients do not have increased risk of death or graft loss regardless of MELD. Underweight patients are at increased risk for poor outcomes post-LT, specifically underweight recipients with low MELD have increased risk for death and graft loss. Mechanisms underlying this phenomenon warrant further investigation.

Liver Cirrhosis: Evaluation, Nutritional Status, and Prognosis

The liver is the major organ for the metabolism of three major nutrients: protein, fat, and carbohydrate. Chronic hepatitis C virus infection is the major cause of chronic liver disease. Liver cirrhosis (LC) results from different mechanisms of liver injury that lead to necroinflammation and fibrosis. LC has been seen to be not a single disease entity but one that can be graded into distinct clinical stages related to clinical outcome. Several noninvasive methods have been developed for assessing liver fibrosis and these methods have been used for predicting prognosis in patients with LC. On the other hand, subjects with LC often have protein-energy malnutrition (PEM) and poor physical activity. These conditions often result in sarcopenia, which is the loss of skeletal muscle volume and increased muscle weakness. Recent studies have demonstrated that PEM and sarcopenia are predictive factors for poorer survival in patients with LC. Based on these backgrounds, several methods for evaluating nutritional status in patients with chronic liver disease have been developed and they have been preferably used in the clinical field practice. In this review, we will summarize the current knowledge in the field of LC from the viewpoints of diagnostic method, nutritional status, and clinical outcomes.

Nutrition in liver transplantation: too little or too much?

PURPOSE OF REVIEW

The purpose of this study was to review the most recent findings on approaches to managing the obesity and muscle wasting that are found in patients before and after liver transplantation.

RECENT FINDINGS

A number of articles have contributed to the accumulating evidence that morbid obesity is not an absolute contraindication to liver transplantation with survival outcomes similar across BMI groups. Obesity is, however, a risk factor for early post-transplant complications and obesity-related comorbidities markedly increase this risk. Very limited data are as yet available, dietary, or otherwise, related to amelioration of these comorbidities and evidence that weight loss leads to improved outcomes in obese patients is lacking. Abdominal computed tomography imaging is increasingly being used to identify muscle wasting, and poorer post-transplant survival is seen in patients with significant muscle wasting. This modality has confirmed the persistence of depleted muscle stores after transplant extending well beyond 1 year. Coupled with this is a high incidence of weight gain and metabolic syndrome and the associated risks. Although dietary intervention and exercise are considered possible approaches to address these issues, work in these areas so far is sparse.

SUMMARY

An urgent need exists for interventional studies on the basis of nutrition and/or exercise to address the challenges presented by both obesity and muscle wasting, which likely coexist in many patients in both the pretransplant and the post-transplant periods.

The Role of Sarcopenia and Frailty in Hepatic Encephalopathy Management

Normal regulation of total body and circulating ammonia requires a delicate interplay in ammonia formation and breakdown between several organ systems. In the setting of cirrhosis and portal hypertension, the decreased hepatic clearance of ammonia leads to significant dependence on skeletal muscle for ammonia detoxification; however, cirrhosis is also associated with muscle depletion and decreased functional muscle mass. Thus, patients with diminished muscle mass and sarcopenia may have a decreased ability to compensate for hepatic insufficiency and a higher likelihood of developing physiologically significant hyperammonemia and hepatic encephalopathy.

Sarcopenia in the prognosis of cirrhosis: Going beyond the MELD score

Estimating the prognosis of patients with cirrhosis remains challenging, because the natural history of cirrhosis varies according to the cause, presence of portal hypertension, liver synthetic function, and the reversibility of underlying disease. Conventional prognostic scoring systems, including the Child-Turcotte-Pugh score or model for end-stage liver diseases are widely used; however, revised models have been introduced to improve prognostic performance. Although sarcopenia is one of the most common complications related to survival of patients with cirrhosis, the newly proposed prognostic models lack a nutritional status evaluation of patients. This is reflected by the lack of an optimal index for sarcopenia in terms of objectivity, reproducibility, practicality, and prognostic performance, and of a consensus definition for sarcopenia in patients with cirrhosis in whom ascites and edema may interfere with body composition analysis. Quantifying skeletal muscle mass using cross-sectional abdominal imaging is a promising tool for assessing sarcopenia. As radiological imaging provides direct visualization of body composition, it is useful to evaluate sarcopenia in patients with cirrhosis whose body mass index, anthropometric measurements, or biochemical markers are inaccurate on a nutritional assessment. Sarcopenia defined by cross-sectional imaging-based muscular assessment is prevalent and predicts mortality in patients with cirrhosis. Sarcopenia alone or in combination with conventional prognostic systems shows promise for a cirrhosis prognosis. Including an objective assessment of sarcopenia with conventional scores to optimize the outcome prediction for patients with cirrhosis needs further research.

Preoperative computed tomography assessment of skeletal muscle mass is valuable in predicting outcomes following hepatectomy for perihilar cholangiocarcinoma

BACKGROUND

Liver surgery for perihilar cholangiocarcinoma (PHC) is associated with high rates of morbidity and mortality.

OBJECTIVES

This study investigated the impact of low skeletal muscle mass on short- and longterm outcomes following hepatectomy for PHC.

METHODS

Patients included underwent liver surgery for PHC between 1998 and 2013. Total skeletal muscle mass was measured at the level of the third lumbar vertebra using available preoperative computed tomography images. Sex-specific cut-offs for low skeletal muscle mass were determined by optimal stratification.

RESULTS

In 100 patients, low skeletal muscle mass was present in 42 (42.0%) subjects. The rate of postoperative complications (Clavien-Dindo Grade III and higher) was greater in patients with low skeletal muscle mass (66.7% versus 48.3%; multivariable adjusted P = 0.070). Incidences of sepsis (28.6% versus 5.2%) and liver failure (35.7% versus 15.5%) were increased in patients with low skeletal muscle mass. In addition, 90-day mortality was associated with low skeletal muscle mass in univariate analysis (28.6% versus 8.6%; P = 0.009). Median overall survival was shorter in patients with low muscle mass (22.8 months versus 47.5 months; P = 0.014). On multivariable analysis, low skeletal muscle mass remained a significant prognostic factor (hazard ratio 2.02; P = 0.020).

CONCLUSIONS

Low skeletal muscle mass has a negative impact on postoperative mortality and overall survival following resection of PHC and should therefore be considered in preoperative risk assessment.

Update on the management of the liver transplant patient

PURPOSE OF REVIEW

To review and highlight recent literature regarding the medical management of adult patients undergoing liver transplantation.

RECENT FINDINGS

The addition of serum sodium concentration to the model for end-stage liver disease (MELD) score more accurately predicts 90-day waitlist mortality. Predictors of waitlist mortality and posttransplant survival include lower albumin and the presence of ascites, varices, and encephalopathy, as well as more nontraditional predictors such as older age, obesity, frailty, and sarcopenia. Indications for liver transplantation are evolving with the advent of effective therapy for hepatitis C and the increased prevalence of nonalcoholic steatohepatitis. Disparities persist in the current allocation system, including geographic variation and MELD inflation for hepatocellular carcinoma. Share 35 allows for broader regional sharing of organs for patients with the highest need, without detrimental effects on waitlist mortality or survival. Everolimus is a recently approved option for posttransplant immunosuppression that spares renal function.

SUMMARY

The MELD score has enabled the liver transplant community to equitably allocate organs. Recent literature has focused on the limitations of the MELD score and the disparities inherent in the current system. The next steps for liver transplantation will be to develop strategies to further optimize waitlist prioritization and organ allocation.

Sarcopenia is a Predictor of Postoperative Respiratory Complications in Patients with Esophageal Cancer

BACKGROUND

Depletion of skeletal muscle mass (sarcopenia) indicates a poor prognosis for patients with several kinds of cancer, but it remains unclear whether esophageal squamous cell carcinoma (ESCC) is among these cancers. The aim of this study was to clarify the relationship between sarcopenia and postoperative outcome in patients with ESCC treated by esophagectomy.

METHODS

Skeletal muscle mass was assessed in 138 patients who underwent esophagectomy from August 2009 to May 2014. A multifrequency bioelectrical impedance analysis (InBody 720; Biospace, Tokyo, Japan) was used to assess skeletal muscle mass just before surgery. Postoperative complications were graded according to the Clavien-Dindo classification, and univariate and multivariate analyses were performed for postoperative respiratory complications.

RESULTS

Sarcopenia was determined in 61 patients (44.2 %). Preoperative pulmonary function was significantly lower and the rate of respiratory complications significantly higher in the sarcopenia group than in the non-sarcopenia group (p < 0.01). For other complications, the differences were not significant. Multivariate analysis showed that sarcopenia [odds ratio (OR) 5.82; p = 0.0001] and longer operation time (OR 3.09; p = 0.04) were risk factors for the occurrence of respiratory complications.

CONCLUSIONS

Sarcopenia may be a predictor of pulmonary complications after esophagectomy. Further analysis is needed to clarify whether nutritional intervention improves skeletal muscle mass and thus contributes to reducing postoperative respiratory complications in sarcopenic patients.

Impact of preoperative quality as well as quantity of skeletal muscle on survival after resection of pancreatic cancer

BACKGROUND

Skeletal muscle depletion, referred to as sarcopenia, is predictive of mortality in patients undergoing digestive operations. The impact of muscle quality on outcomes, however, is unclear. This retrospective study investigated the impact of preoperative skeletal muscle quantity and quality on survival in patients undergoing resection of pancreatic cancer.

METHODS

We investigated 230 patients who underwent resection of pancreatic cancer between 2004 and 2013. The quantity and quality of skeletal muscle, indicated by psoas muscle mass index (PMI) and intramuscular adipose tissue content (IMAC), were measured in preoperative computed tomography images. Overall survival (OS) and recurrence-free survival (RFS) rates were compared according to PMI and IMAC, and prognostic factors after pancreatic resection were assessed.

RESULTS

The OS and RFS rates in patients with low PMI were lesser than in those with normal/high PMI (P < .001, P < .001), with a mean survival time of 17.7 and 33.2 months, respectively. The OS and RFS rates in patients with high IMAC also were less than in those with normal/low IMAC (P < .001, P = .003) (mean survival time = 21.5 and 56.5 months, respectively). Low PMI (low muscle mass) and high IMAC (low muscle quality) were independent prognostic factors of poor OS (hazard ratio [HR] = 1.999, P < .001; HR = 2.527, P < .001) and RFS (HR = 1.607, P = .007; HR = 1.640, P = .004), respectively.

CONCLUSION

Preoperative sarcopenia, indicating low quality and quantity of skeletal muscle, is closely related to mortality after resection of pancreatic cancer.

Sarcopenia as a useful predictor for long-term mortality in cirrhotic patients with ascites

This study aimed to assess and compare sarcopenia with other prognostic factors for predicting long-term mortality in cirrhotic patients with ascites. Clinical data of 65 among 89 patients with measurement of all parameters were consecutively collected. Sarcopenia was evaluated as right psoas muscle thickness measurement divided by height (PMTH) (mm/m). During a mean follow-up of 20 (range: 1-49) months, 19 (29.2%) of 65 patients died. The values of the area under the receiver operating characteristics curve (AUROC) of Child-Pugh score, Model for End-Stage Liver Disease (MELD) score, MELD-Na, and PMTH for predicting 1-yr mortality were 0.777 (95% CI, 0.635-0.883), 0.769 (95% CI, 0.627-0.877), 0.800 (95% CI, 0.661-0.900), and 0.833 (95% CI, 0.699-0.924), whereas hepatic venous pressure gradient was not significant (AUROC, 0.695; 95% CI. 0.547-0.818, P=0.053). The differences between PMTH and other prognostic variables were not significant (all P>0.05). The best cut-off value of PMTH to predict long-term mortality was 14 mm/m. The mortality rates at 1-yr and 2-yr with PMTH>14 mm/m vs. PMTH≤14 mm/m were 2.6% and 15.2% vs. 41.6% and 66.8%, respectively (P<0.001). The mortality in cirrhotic patients with PMTH≤14 mm/m was higher than those with PMTH>14 mm/m (HR, 5.398; 95% CI, 2.111-13.800, P<0.001). In conclusion, sarcopenia, evaluated by PMTH, is an independent useful predictor for long-term mortality in cirrhotic patients with ascites.

Sarcopenia as a useful predictor for long-term mortality in cirrhotic patients with ascites

This study aimed to assess and compare sarcopenia with other prognostic factors for predicting long-term mortality in cirrhotic patients with ascites. Clinical data of 65 among 89 patients with measurement of all parameters were consecutively collected. Sarcopenia was evaluated as right psoas muscle thickness measurement divided by height (PMTH) (mm/m). During a mean follow-up of 20 (range: 1-49) months, 19 (29.2%) of 65 patients died. The values of the area under the receiver operating characteristics curve (AUROC) of Child-Pugh score, Model for End-Stage Liver Disease (MELD) score, MELD-Na, and PMTH for predicting 1-yr mortality were 0.777 (95% CI, 0.635-0.883), 0.769 (95% CI, 0.627-0.877), 0.800 (95% CI, 0.661-0.900), and 0.833 (95% CI, 0.699-0.924), whereas hepatic venous pressure gradient was not significant (AUROC, 0.695; 95% CI. 0.547-0.818, P=0.053). The differences between PMTH and other prognostic variables were not significant (all P>0.05). The best cut-off value of PMTH to predict long-term mortality was 14 mm/m. The mortality rates at 1-yr and 2-yr with PMTH>14 mm/m vs. PMTH≤14 mm/m were 2.6% and 15.2% vs. 41.6% and 66.8%, respectively (P<0.001). The mortality in cirrhotic patients with PMTH≤14 mm/m was higher than those with PMTH>14 mm/m (HR, 5.398; 95% CI, 2.111-13.800, P<0.001). In conclusion, sarcopenia, evaluated by PMTH, is an independent useful predictor for long-term mortality in cirrhotic patients with ascites.

Dorsal muscle group area and surgical outcomes in liver transplantation

INTRODUCTION

Better measures of liver transplant risk stratification are needed. Our previous work noted a strong relationship between psoas muscle area and survival following liver transplantation. The dorsal muscle group is easier to measure, but it is unclear if they are also correlated with surgical outcomes.

METHODS

Our study population included liver transplant recipients with a preoperative CT scan. Cross-sectional areas of the dorsal muscle group at the T12 vertebral level were measured. The primary outcomes for this study were one- and five-yr mortality and one-yr complications. The relationship between dorsal muscle group area and post-transplantation outcome was assessed using univariate and multivariate techniques.

RESULTS

Dorsal muscle group area measurements were strongly associated with psoas area (r = 0.72; p < 0.001). Postoperative outcome was observed from 325 patients. Multivariate logistic regression revealed dorsal muscle group area to be a significant predictor of one-yr mortality (odds ratio [OR] = 0.53, p = 0.001), five-yr mortality (OR = 0.53, p < 0.001), and one-yr complications (OR = 0.67, p = 0.007).

CONCLUSION

Larger dorsal muscle group muscle size is associated with improved post-transplantation outcomes. The muscle is easier to measure and may represent a clinically relevant postoperative risk factor.