Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study

Clinical Impact of Sarcopenia in the Decision-Making Process for Patients with Acute Diverticulitis

Background: Acute diverticulitis (AD), an inflammatory complication of diverticulosis, affects around 4% of individuals with diverticulosis, with increased incidence in older populations. This study aims to assess the impact of sarcopenia, the age-related loss of muscle mass, on the clinical decision-making and outcomes of patients with AD. Materials and Methods: A retrospective study was conducted on 237 patients admitted to the Emergency Department (ED) between January 2014 and February 2022. Patients diagnosed with AD Hinchey ≥ 2 via contrasted tomography (CT) were included. Sarcopenia was assessed using CT scans at the third lumbar vertebra (L3), with skeletal muscle area (SMA) normalized by height to calculate the skeletal muscle index (SMI). Patients were divided into two groups based on sarcopenia status and analysed for surgical outcomes, non-operative management (NOM) success, and complications. Results: The prevalence of sarcopenia was 46%. Sarcopenic patients were significantly older and had lower BMI and higher frailty scores. A higher proportion of sarcopenic patients underwent Hartmann, while non-sarcopenic patients more often had anastomosis. Sarcopenia did not significantly affect overall morbidity, mortality, or the failure rate of NOM. However, sarcopenic patients with a BMI > 25 had a higher likelihood of requiring redo surgeries. Conclusions: Sarcopenia plays a critical role in the surgical management of AD but does not predict worse clinical outcomes. The decision to perform surgery, particularly Hartmann's procedure, is influenced by sarcopenia, yet morbidity and mortality rates are comparable between sarcopenic and non-sarcopenic patients. These findings highlight the need for sarcopenia to be considered in preoperative assessments.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Combining sarcopenia and ASA status to inform emergency laparotomy outcomes: could it be that simple?

BACKGROUND

Risk assessment for emergency laparotomy (EL) is important for guiding decision-making and anticipating the level of perioperative care in acute clinical settings. While established tools such as the American College of Surgeons National Surgical Quality Improvement Program calculator (ACS-NSQIP), the National Emergency Laparotomy Audit Risk Prediction Calculator (NELA) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity calculation (P-POSSUM) are accurate predictors for mortality, there has been increasing recognition of the benefits from including measurements for frailty in a simple and quantifiable manner. Psoas muscle to 3rd lumbar vertebra area ratio (PM:L3) measured on CT scans was proven to have a significant inverse association with 30-, 90- and 365-day mortality in EL patients.

METHODS

A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016-2017, and had contemporaneous abdomino-pelvic CT scans. Radiological sarcopenia was measured as PM:L3 ratios. ASC-NSQIP, NELA and P-POSSUM were retrospectively calculated. Univariate and multivariate logistic regression modelling was used to assess these ratios and scores, as well as American Society of Anaesthesiologists (ASA) classification separated into ASA I-III and IV/V (simplified ASA), as potential predictors of 30-, 90- and 365-day mortality.

RESULTS

PM:L3, simplified ASA, ACS-NSQIP, NELA and P-POSSUM were each statistically significant predictors of 30-day, 90-day and 365-day mortality (P < 0.001). Logistic regression models of 30-, 90- and 365-day mortality combining PM:L3 (P = 0.001) and simplified ASA (P < 0.001) exhibited AUCs of 0.838 (0.780, 0.896), 0.805 (0.751, 0.860) and 0.775 (0.729, 0.822), respectively, which were comparable to that of ACS-NSQIP and NELA.

CONCLUSION

Combining the semi-physiological parameter ASA classification with PM:L3 provides a quick and simple alternative to the more complex established risk assessment scores and is superior to PM:L3 alone.

Poorer outcomes associated with sarcopenia following emergency laparotomy: a systematic review and meta-analysis

BACKGROUND

Despite the negative effect of sarcopenia on postoperative outcomes being well recognized in the elective setting, there remains a paucity of studies describing this phenomenon in the emergency laparotomy (EL) setting. This systematic review and meta-analysis aimed to compare short- and long-term postoperative outcomes following EL in patients with and without sarcopenia.

METHODS

A systematic review using PRISMA guidelines was used to identify studies comparing perioperative outcomes following EL for patients with and without sarcopenia. A subsequent meta-analysis was conducted. The following data were extracted from the included studies: patient demographics, pathology or type of operation performed for EL, post-operative mortality at inpatient, 30-day, 90-day and 1-year, and functional outcomes. A quality assessment of included studies was undertaken.

RESULTS

Twelve studies reporting the outcomes of sarcopenia following EL were identified. Sarcopenia was significantly associated with higher 30-day and 1-year mortality rates following EL (OR 3.50, P < 0.01; OR 3.49, P < 0.01, respectively). Additionally, sarcopenia was significantly associated with unfavourable functional outcomes at discharge following emergency laparotomy (OR 2.44, p < 0.01).

CONCLUSION

Opportunistically identified on cross-sectional imaging, sarcopenia is a valuable predictor of short- and long-term morbidity and mortality following EL. Further studies are required to identify the most appropriate diagnostic criteria of sarcopenia and better define this physiological phenomenon.

CT psoas calculations on the prognosis prediction of emergency laparotomy: a single-center, retrospective cohort study in eastern Asian population

Background

Emergency laparotomy (EL) has a high mortality rate. Clinically, frail patients have a poor tolerance for EL. In recent years, sarcopenia has been used as an important indicator of frailty and has received much attention. There have been five different calculation methods of psoas for computed tomography (CT) to measure sarcopenia, but lack of assessment of these calculation methods in Eastern Asian EL patients.

Methods

We conducted a 2-year retrospective cohort study of patients over 18 years of age who underwent EL in our institution. Five CT measurement values (PMI: psoas muscle index, PML3: psoas muscle to L3 vertebral body ratio, PMD: psoas muscle density, TPG: total psoas gauge, PBSA: psoas muscle to body face area ratio) were calculated to define sarcopenia. Patients with sarcopenia defined by the sex-specific lowest quartile of each measurement were compared with the rest of the cohort. The primary outcome was "ideal outcome", defined as: (1) No postoperative complications of Clavien-Dindo Grade ≥ 4; (2) No mortality within 30 days; (3) When discharged, no need for fluid resuscitation and assisted ventilation, semi-liquid diet tolerated, and able to mobilize independently. The second outcome was mortality at 30-days. Multivariate logistic regression and receiver operating characteristic (ROC) analysis were used.

Results

Two hundred and twenty-eight patients underwent EL met the inclusion criteria, 192 (84.2%) patients had an ideal outcome after surgery; 32 (14%) patients died within 30 days. Multivariate analysis showed that, except PMD, each calculation method of psoas was independently related to clinical outcome (ideal outcome: PML3, P < 0.001; PMI, P = 0.001; PMD, P = 0.157; TPG, P = 0.006; PBSA, P < 0.001; mortality at 30-days: PML3, P < 0.001; PMI, P = 0.002; PMD, P = 0.088; TPG, P = 0.002; PBSA, P = 0.001). In ROC analysis, the prediction model containing PML3 had the largest area under the curve (AUC) value (AUC value = 0.922 and 0.920, respectively).

Conclusion

The sarcopenia determined by CT psoas measurements is significantly related to the clinical outcome of EL. The calculation of CT psoas measurement is suitable for application in outcome prediction of EL. In the future, it is necessary to develop a scoring tool that includes sarcopenia to evaluate the risk of EL better.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00435-x.

Short and long-term impact of sarcopenia on outcomes from emergency laparotomy

PURPOSE

Emergency laparotomy (EL) carries a high risk of morbidity and mortality, that is greater among older patients. Sarcopenia refers to an age- or pathology-associated muscle loss and has been demonstrated to correlate with poorer outcomes in several surgical conditions. This study assessed the impact of sarcopenia on morbidity and mortality in elderly patients undergoing EL.

METHODS

Patients aged ≥ 65 years-old undergoing EL between May 2012-June 2017 with a pre-operative abdominal computerised tomography (CT) scan at Middlemore Hospital (New Zealand) were included. Psoas and Skeletal Muscle Index (PMI and SMI) were calculated from abdominal CT measurements after standardisation based on height. Validated cut-offs for sarcopenia were used. Frailty was estimated using the 11-point modified frailty index (mFI). The primary outcome was 30-day, 1-year, and 4-year post-operative mortality. Secondary outcomes included correlations between mFI and sarcopenic measures, unplanned readmissions, and post-operative complications.

RESULTS

A total of 167 patients (84 sarcopenic; 83 non-sarcopenic) were included. Sarcopenic and non-sarcopenic patients had similar 30-day (14.2 vs. 12.0%; p = 0.84), 1-year (23.8 vs. 25.3%; p = 0.96), and 4-year (39.3 vs. 47.0%; p = 0.40) mortality rates following an EL. Survivors had a higher mean PMI at 1-year (p = 0.0078) and 4-year (p = 0.013) but not 30-day (p = 0.40) follow-up. Sarcopenia performed poorly in discriminating between 30-day (AUC 0.51) and 1-year (AUC 0.53) mortality. The mFI did not correlate with PMI (p = 0.85) nor SMI (p = 0.18). Rates of readmissions and post-operative complications did not differ between sarcopenic and non-sarcopenic cohorts.

CONCLUSION

Sarcopenia does not provide useful short-term prognostic information in elderly EL patients.