Sarcopenia is associated with blood transfusions in head and neck cancer free flap surgery

Sarcopenia predicts postoperative complications in head and neck cancer: a systematic review and meta-analysis

PURPOSE

We performed this systematic review and meta-analysis to explore the impact of preoperative sarcopenia on postoperative complication risks after head and neck cancer (HNC) surgery.

METHODS

We identified eligible studies by searching Ovid-MEDLINE, Ovid-Embase, EBM Reviews-Cochrane Central Register of Controlled Trials, Web of Science Core Collection, and Scopus. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

RESULTS

Twenty-one studies with a total of 3480 patients met our inclusion criteria. The presence of sarcopenia significantly increased the incidence of overall postoperative complications (OR = 1.72, 95% CI 1.23, 2.41; P = 0.002; I2 = 59%). Subgroup analyses showed a higher risk of postoperative complications in the populations in which sarcopenia was diagnosed with low L3-skeletal muscle index (L3-SMI) or low cross-sectional area of the rectus femoris, but not in the group that sarcopenia was diagnosed with low C3-SMI. Preoperative sarcopenia also substantially increased the risk of severe postoperative complications (OR = 2.26), pharyngocutaneous fistulas (OR = 2.15), free flap-related complications (OR = 1.63), and surgical site infections (OR = 1.84). We also found a tendency toward a higher incidence of wound complications and 30-day mortality in patients with sarcopenia.

CONCLUSION

Preoperative sarcopenia is a negative prognostic indicator for postoperative complications in patients with HNC after surgery. To reduce the incidence of postoperative complications and improve poor prognosis, further attention needs to be paid to the evaluation and management of preoperative sarcopenia.

Prevalence and Clinical Impact of Sarcopenia in Patients Undergoing Total Joint Arthroplasty: A Systematic Review and a Meta-Analysis

BACKGROUND

Sarcopenia is a progressive loss of skeletal muscle mass and function. It is associated with adverse outcomes after several orthopaedic procedures. However, its role in total joint arthroplasty (TJA) is not fully explored. Therefore, we wanted to conduct a systematic review and meta-analysis to answer the following questions: (1) What is the prevalence of sarcopenia in patients undergoing TJA?; (2) What factors are associated with the prevalence of sarcopenia in patients undergoing TJA?; What is the impact of sarcopenia on medical outcomes following TJA?; and (4) What is the impact of sarcopenia on surgical outcomes following TJA?

METHODS

Electronic databases PubMed, Scopus, Cochrane, and Google Scholar were searched. The data were pooled using the random-effects model and graphically represented by a forest plot. We included a total of 13 studies, evaluating 399,097 patients.

RESULTS

The pooled prevalence of sarcopenia was 20.1% (95% confidence interval [CI] 13.6 to 28.8%; P < .00001; I2 = 94.7%) in total knee arthroplasty (TKA) and 5.2% (95% CI 0.1 to 69.7%; P = .128; I2 = 99.6%) in total hip arthroplasty (THA). Meta-regression found no links between age, sex, body mass index, diabetes, obesity, arthroplasty type, and sarcopenia prevalence in TJA. Sarcopenia increased risk of blood transfusion (odds ratio [OR] 4.68 [95% CI 3.51 to 6.25]; P < .00001), pneumonia (OR 1.94 [95% CI 1.14 to 3.30]; P = .01), urinary tract infection (UTI) (OR 1.64 [95% CI 1.31 to 2.05]; P < .001), prosthetic fracture (OR 2.12 [95% CI 1.51 to 2.98]; P < .0001), prosthetic dislocation (OR 1.99 [95% CI 1.62 to 2.44]; P < .00001), and mechanical loosening (OR 1.78 [95% CI 1.43 to 2.22]; P < .00001) in TKA. Sarcopenic patients were at an increased risk of UTI (OR 1.79 [95% CI 1.32 to 2.43]; P = .0002) and prosthetic loosening (OR 1.97 [95% CI 1.10 to 3.53]; P = .02) post-THA.

CONCLUSIONS

Baseline sarcopenia was prevalent in patients undergoing TJA. It was associated with an increased risk of UTI and prosthetic loosening following TKA and THA. Increased risk of blood transfusion, pneumonia, prosthetic fractures, and mechanical loosening following TKA.

Masseter muscle thickness is predictive of cancer cachexia in patients with head and neck cancer

BACKGROUND

Cancer cachexia is prevalent in head and neck cancer patients. The L3 skeletal muscle index (SMI) is often used to assess sarcopenia and cachexia but is infrequently able to be measured in this population. Masseter muscle thickness (MT) may serve as an alternative predictor of cachexia.

METHODS

SMI and MT were calculated from 20 trauma (CTRL) and 40 cachectic (CA-CX) and non-cachectic (CA-NCX) head and neck cancer patients. Area Under the Curve of the Receiver Operating Characteristics (AUC-ROC) analysis was performed for SMI and MT.

RESULTS

Both SMI and MT were significantly decreased in CA-CX patients (vs. CA-NCX mean difference -19.5 cm2/m2 and -2.06 mm, respectively) and significant predictors of CA-CX (AUC = 0.985 and 0.805, respectively). When analyzed by sex, the same findings were observed for MT in males and trended toward significance in females.

CONCLUSIONS

Compared with SMI, MT is a good alternative prognostic biomarker to determine CA-CX status in HNC patients.

MRI-based central sarcopenia negatively impacts the therapeutic effectiveness of single-segment lumbar fusion surgery in the elderly

Central sarcopenia is associated with the prognosis of various orthopedic surgeries in the elderly. This study aims to investigate its impact on the outcomes of single-segment lumbar fusion surgery in elderly patients. Retrospective analysis was conducted on 314 patients aged 60 to 80 who underwent single-segment posterior lumbar fusion surgery due to degenerative lumbar diseases. Patients were categorized into high psoas and L4 vertebral index (PLVI) and low PLVI groups according to the MRI-measured PLVI for central sarcopenia. Basic patient data, surgery-related parameters, functional assessments at preoperative and postoperative 3, 6, and 12 months, and X-ray-based fusion status were compared. The basic data of the two groups showed no significant differences. Parameters including the operative segment, preoperative hemoglobin levels, surgical duration, and intraoperative blood loss exhibited no significant variances. However, notable differences were observed in postoperative initial hemoglobin levels, transfusion requirements, and length of hospital stay between the two groups. During the postoperative follow-ups at 3, 6, and 12 months, the VAS scores for lower back pain and ODI scores in the lower PLVI group were significantly higher compared to the high PLVI group. Additionally, the EuroQoL 5D scores were notably lower in the low PLVI group. There were no significant differences between the groups in terms of leg pain VAS scores at each time point and the fusion status at 12 months postoperatively. MRI-based central sarcopenia has a negative impact on the therapeutic effectiveness following single-segment lumbar fusion surgery in elderly patients.

Effect of Perioperative Antithrombotics on Postoperative Transfusion and Hematoma in Head and Neck Free Flaps

Objective

To explore if antiplatelet or anticoagulant therapy increases the risk of transfusion requirement or postoperative hematoma formation in patients undergoing microvascular reconstruction for head and neck defects.

Study Design

Retrospective cohort study.

Setting

Departments of Otolaryngology-Head and Neck Surgery at the University of Alabama at Birmingham, the University of Colorado, and the University of California Irvine.

Methods

A multi-institutional, retrospective review on microvascular reconstruction of the head and neck between August 2013 to July 2021. Perioperative antithrombotic data were collected to examine predictors of postoperative transfusion and hematoma.

Results

A total of 843 free flaps were performed. Preoperative hemoglobin, hematocrit, operative time, and flap type were positive predictors of postoperative transfusion in both bivariate (P < .0001) and multivariate analyses (P < .0001). However, neither anticoagulation nor antiplatelet therapy were predictive of postoperative transfusion rates and hematoma formation.

Conclusion

Antithrombotic regimens do not increase the risk of postoperative transfusion or hematoma in head and neck microvascular reconstruction. Based on this limited data, perioperative antithrombotic regimens can be considered in patients who may otherwise be at risk for these postoperative complications.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Preoperative CT-Based Skeletal Muscle Mass Depletion and Outcomes after Total Laryngectomy

PURPOSE

To assess the role of preoperative CT-based skeletal muscle mass depletion on postoperative clinical outcomes and survival in patients who underwent total laryngectomy for cancer.

METHODS

Patients operated on between January 2011 and March 2020 were retrospectively included. Skeletal muscle area and intra- and inter-muscular fat accumulation were measured at the third lumbar vertebral level on preoperative CT scans. Skeletal muscle mass depletion was defined based on pre-established cut-off values. Their association with postoperative morbidity, length of stay (LOS), costs, and survival was assessed.

RESULTS

A total of 84 patients were included, of which 37 (44%) had preoperative skeletal muscle mass depletion. The rate of postoperative fistula (23% vs. 35%, p = 0.348), cutaneous cervical dehiscence (17% vs. 11%, p = 0.629), superficial incisional surgical site infections (SSI) (12% vs. 10%, p = 1.000), and unplanned reoperation (38% vs. 37%, p = 1.000) were comparable between the two patient groups. No difference in median LOS was observed (41 vs. 33 days, p = 0.295), nor in treatment costs (119,976 vs. 109,402 CHF, p = 0.585). The median overall survival was comparable between the two groups (3.43 vs. 4.95 years, p = 0.09).

CONCLUSIONS

Skeletal muscle mass depletion alone had no significant impact on postoperative clinical outcomes or survival.

Role of sarcopenia on survival and treatment-related toxicity in head and neck cancer: a narrative review of current evidence and future perspectives

PURPOSE

The purpose of this article is to provide an up-to-date summary of sarcopenia and its clinical implications for patients with head and neck cancer (HNC).

METHODS

We conducted a literature review of recent studies investigating the prevalence of sarcopenia in HNC patients, its detection using MRI or CT scans, and its association with clinical outcomes such as disease-free and overall survival time, radiotherapy-related side effects, cisplatin toxicity, and surgical complications.

RESULTS

Sarcopenia, characterized by low skeletal muscle mass (SMM), is a prevalent condition in HNC patients and can be effectively detected using routine MRI or CT scans. Low SMM in HNC patients is associated with increased risks of shorter disease-free and overall survival times, as well as radiotherapy-related side effects such as mucositis, dysphagia, and xerostomia. In addition, cisplatin toxicity is more severe in HNC patients with low SMM, leading to higher dose-limiting toxicity and treatment interruptions. Low SMM may also predict higher risks of surgical complications in head and neck surgery. Identifying sarcopenic patients can aid physicians in better riskstratifying HNC patients for therapeutic or nutritional interventions to improve clinical outcomes.

CONCLUSIONS

Sarcopenia is a significant concern for HNC patients and can impact their clinical outcomes. Routine MRI or CT scans can effectively detect low SMM in HNC patients. Identifying sarcopenic patients can aid physicians in better risk-stratifying HNC patients for therapeutic or nutritional interventions to improve clinical outcomes. Further research is needed to explore the potential of interventions to mitigate the negative effects of sarcopenia in HNC patients.

Deep Learning-Based Muscle Segmentation and Quantification of Full-Leg Plain Radiograph for Sarcopenia Screening in Patients Undergoing Total Knee Arthroplasty

Sarcopenia, an age-related loss of skeletal muscle mass and function, is correlated with adverse outcomes after some surgeries. Here, we present a deep-learning-based model for automatic muscle segmentation and quantification of full-leg plain radiographs. We illustrated the potential of the model to predict sarcopenia in patients undergoing total knee arthroplasty (TKA). A U-Net-based deep learning model for automatic muscle segmentation was developed, trained and validated on the plain radiographs of 227 healthy volunteers. The radiographs of 403 patients scheduled for primary TKA were reviewed to test the developed model and explore its potential to predict sarcopenia. The proposed deep learning model achieved mean IoU values of 0.959 (95% CI 0.959–0.960) and 0.926 (95% CI 0.920–0.931) in the training set and test set, respectively. The fivefold AUC value of the sarcopenia classification model was 0.988 (95% CI 0.986–0.989). Of seven key predictors included in the model, the predicted muscle volume (PMV) was the most important of these features in the decision process. In the preoperative clinical setting, wherein laboratory tests and radiographic imaging are available, the proposed deep-learning-based model can be used to screen for sarcopenia in patients with knee osteoarthritis undergoing TKA with high sarcopenia screening performance.

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

In head and neck cancer (HNC) there is a need for more personalized treatment based on risk assessment for treatment related adverse events (i.e. toxicities and complications), expected survival and quality of life. Sarcopenia, defined as a condition characterized by loss of skeletal muscle mass and function, can predict adverse outcomes in HNC patients. A review of the literature on the measurement of sarcopenia in head and neck cancer patients and its association with frailty was performed. Skeletal muscle mass (SMM) measurement only is often used to determine if sarcopenia is present or not. SMM is most often assessed by measuring skeletal muscle cross-sectional area on CT or MRI at the level of the third lumbar vertebra. As abdominal scans are not always available in HNC patients, measurement of SMM at the third cervical vertebra has been developed and is frequently used. Frailty is often defined as an age-related cumulative decline across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to withstand stress, leading to increased risk of adverse health outcomes. There is no international standard measure of frailty and there are multiple measures of frailty. Both sarcopenia and frailty can predict adverse outcomes and can be used to identify vulnerable patients, select treatment options, adjust treatments, improve patient counselling, improve preoperative nutritional status and anticipate early on complications, length of hospital stay and discharge. Depending on the definitions used for sarcopenia and frailty, there is more or less overlap between both conditions. However, it has yet to be determined if sarcopenia and frailty can be used interchangeably or that they have additional value and should be used in combination to optimize individualized treatment in HNC patients.

Low muscle mass is an independent risk factor for postoperative blood transfusion in total knee arthroplasty: a retrospective, propensity score-matched cohort study

Background

Sarcopenia, an age-related loss of skeletal muscle mass and function, is correlated with adverse outcomes after some surgeries. This study examined the characteristics of sarcopenic patients undergoing primary total knee arthroplasty (TKA), and identified low muscle mass as an independent risk factor for postoperative TKA complications.

Methods

A retrospective cohort study examined 452 patients who underwent TKA. The skeletal muscle index (SMI) was obtained via bioelectrical impedance analysis (BIA), along with demographics, the Charlson Comorbidity Index, and medication, laboratory and operative data for 2018–2021. Patients were categorized into normal (n = 417) and sarcopenic (n = 35) groups using the SMI cut-off suggested by the Asian Working Group for Sarcopenia 2019 (males, < 7.0 kg/m²; females, < 5.7 kg/m²). Three postoperative complications were analysed: blood transfusion, delirium, and acute kidney injury (AKI). Baseline characteristics were propensity score-matched to address potential bias and confounding factors.

Results

The proportion of sarcopenic patients in primary TKA was 7.7% (35/452). The sarcopenic group had a lower preoperative haemoglobin (12.18 ± 1.20 vs. 13.04 ± 1.73 g/dL, p = 0.004) and total protein (6.73 ± 0.42 vs. 7.06 ± 0.44 mg/dL, p = 0.001). Propensity scoring matching and logistic regression showed that more patients in the sarcopenic group received postoperative blood transfusions (OR = 6.60, 95% CI: 1.57–45.5, p = 0.021); there was no significant difference in AKI or delirium. Univariate receiver operating characteristic curve analysis of the propensity-matched group, to determine the predictive value of SMI for postoperative transfusion, gave an AUC of 0.797 (0.633–0.96) and SMI cut-off of 5.6 kg/m².

Conclusions

Low muscle mass determined by BIA was an independent risk factor for postoperative transfusion in TKA. Multifrequency BIA can serve as a screening tool for sarcopenia that may influence the orthopaedic decision-making process or treatment planning in patients with sarcopenia undergoing primary TKA.

Level of evidence

III, retrospective cohort study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02903-0.