Sarcopenia assessed by the quantity and quality of skeletal muscle is a prognostic factor for patients undergoing cardiac surgery

Sarcopenia and risk of postoperative pneumonia: a systematic review and meta-analysis

BACKGROUND

Identifying patients at risk for postoperative pneumonia and preventing it in advance is crucial for improving the prognoses of patients undergoing surgery. This review aimed to interpret the predictive value of sarcopenia on postoperative pneumonia.

METHODS

Science Citation Index Expanded (SCIE), Embase, Medline, and Cochrane Central Register of Controlled Trials were searched from inception to August 2nd, 2023 to retrieve eligible studies. The risk of bias was assessed by the Newcastle-Ottawa Scale (NOS). For each study, we computed the odds ratio (OR) and 95% confidence interval (CI) for postoperative pneumonia in patients with and without preoperative sarcopenia, and the I-squared (I2) test was employed to estimate heterogeneity.

RESULTS

The search identified 6530 studies, and 32 studies including 114,532 participants were analyzed in this review. In most of the studies included, the risk of bias was moderate. The most reported surgical site was the chest and abdomen, followed by the abdomen, chest, limbs and spine, and head and neck. Overall, patients with preoperative sarcopenia have a 2.62-fold increased risk of developing postoperative pneumonia compared to non-sarcopenic patients [OR 2.62 (I2 = 67.5%, 95%CI 2.04-3.37). Subgroup analysis focusing on different surgical sites revealed that sarcopenia has the strongest predictive effect on postoperative pneumonia following abdominal surgery (OR 4.69, I2 = 0, 95% CI 3.06-7.19). Subgroup analyses targeting different types of research revealed that sarcopenia has a stronger predictive effect on postoperative pneumonia in prospective studies (OR 5.84 vs. 2.22).

CONCLUSIONS

Our research findings indicate that preoperative sarcopenia significantly increases the risk of postoperative pneumonia. Future high-quality prospective studies and intervention studies are needed to validate the relationship between sarcopenia and postoperative pneumonia and improve patient outcomes.

Identifying potential predictors of the risk of surgical site infection following cardiac surgery: a scoping review

OBJECTIVES

This scoping review was undertaken to identify risk prediction models and pre-operative predictors of surgical site infection (SSI) in adult cardiac surgery. A particular focus was on the identification of novel predictors that could underpin the future development of a risk prediction model to identify individuals at high risk of SSI, and therefore guide a national SSI prevention strategy.

METHODS

A scoping review to systematically identify and map out existing research evidence on pre-operative predictors of SSI was conducted in two stages. Stage 1 reviewed prediction modelling studies of SSI in cardiac surgery. Stage 2 identified primary studies and systematic reviews of novel cardiac SSI predictors.

RESULTS

The search identified 7887 unique reports; 7154 were excluded at abstract screening and 733 were selected for full-text assessment. Twenty-nine studies (across 30 reports) were included in Stage 1 and reported the development (N=14), validation (N=13), or both development and validation (N=2) of 52 SSI risk prediction models including 67 different pre-operative predictors. The remaining 703 reports were re-assessed in Stage 2; 49 studies met the inclusion criteria, and 56 novel pre-operative predictors that have not been assessed previously in models were identified.

CONCLUSIONS

This review identified 123 pre-operative predictors of the risk of SSI following cardiac surgery, 56 of which have not been included previously in the development of cardiac SSI risk prediction models. These candidate predictors will be a valuable resource in the future development of risk prediction scores, and may be relevant to prediction of the risk of SSI in other surgical specialities.

Ct-based diagnosis of sarcopenia as a prognostic factor for postoperative mortality after elective open-heart surgery in older patients: a cohort-based systematic review and meta-analysis

Background

Cardiac open-heart surgery, which usually involves thoracotomy and cardiopulmonary bypass, is associated with a high incidence of postoperative mortality and adverse events. In recent years, sarcopenia, as a common condition in older patients, has been associated with an increased incidence of adverse prognosis.

Methods

We conducted a search of databases including PubMed, Embase, and Cochrane, with the search date up to January 1, 2024, to identify all studies related to elective cardiac open-heart surgery in older patients. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence.

Results

A total of 12 cohort studies were included in this meta-analysis for analysis. This meta-analysis revealed that patients with sarcopenia had a higher risk of postoperative mortality. Furthermore, the total length of hospital stay and ICU stay were longer after surgery. Moreover, there was a higher number of patients requiring further healthcare after discharge. Regarding postoperative complications, sarcopenia patients had an increased risk of developing renal failure and stroke.

Conclusion

Sarcopenia served as a tool to identify high-risk older patients undergoing elective cardiac open-heart surgery. By identifying this risk factor early on, healthcare professionals took targeted steps to improve perioperative function and made informed clinical decisions.Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023426026.

Association between preoperative lumbar skeletal muscle index and postoperative nausea and vomiting in patients undergoing pylorus-preserving pancreatoduodenectomy: a retrospective study

BACKGROUND

Sarcopenia is associated with postoperative complications; however, its impact on the quality of postoperative recovery, such as postoperative nausea and vomiting (PONV) and pain, remains unclear. We investigated the association of preoperative lumbar skeletal muscle mass index (LSMI) with PONV, postoperative pain, and complications.

METHODS

Medical records of 756 patients who underwent pylorus-preserving pancreatoduodenectomy (PPPD) were retrospectively reviewed. The skeletal muscle areas were measured on abdominal computed tomography (CT) images. LSMI was calculated by dividing the skeletal muscle area by the square of the patient's height. We analyzed the correlations between preoperative LSMI calibrated with confounding variables and PONV scores, PONV occurrence, pain scores, rescue analgesic administration, postoperative complications, and length of hospital stay.

RESULTS

The median (1Q, 3Q) LSMI was 47.72 (40.74, 53.41) cm2/m2. The incidence rates of PONV according to time period were as follows: post-anesthesia care unit, 42/756 (5.6%); 0-6 h, 54/756 (7.1%); 6-24 h, 120/756 (15.9%); 24-48 h, 46/756 (6.1%); and overall, 234/756 (31.0%). The incidence of PONV was inversely correlated with LSMI 24-48 h post-surgery and overall. LSMI and PONV scores were negatively associated 6-24 h and 24-48 h post-surgery. There was no association between LSMI and postoperative pain scores, rescue analgesic administration, complications, or length of hospital stay.

CONCLUSIONS

Preoperative LSMI was associated with PONV in patients undergoing PPPD. Therefore, LSMI measured on preoperative abdominal CT can be a predictive indicator of PONV. Appropriate PONV prophylaxis is necessary in patients with low LSMI before PPPD.

Feasibility of Colorectal Endoscopic Submucosal Dissection in Elderly Patients: The Impact of Sarcopenia

INTRODUCTION

Colorectal cancer is a public health concern associated with high incidence rates. Sarcopenia is a known risk factor for postoperative complications, although an association between increased complications after colorectal endoscopic submucosal dissection (ESD) and sarcopenia remains undocumented. Herein, we aimed to explore the feasibility of colorectal ESD in patients with sarcopenia.

METHODS

This retrospective study included 499 patients (69 with and 430 without sarcopenia). We evaluated the short- and long-term outcomes of colorectal ESD.

RESULTS

There were no significant differences between the two groups regarding en bloc, R0, or curative resection rates. However, poor bowel preparation was significantly more common in the sarcopenia group. Moreover, patients with sarcopenia exhibited a significant increase in complications (37.7% vs. 10.5%). Multivariate analysis revealed that sarcopenia (odds ratio [OR]: 3.78, 95% confidence interval [Cl]: 1.85-7.73, p < 0.001), anticoagulation therapy (OR: 3.59, 95% Cl: 1.86-6.92, p < 0.001), procedure time (OR: 1.28, 95% Cl: 1.11-1.47, p < 0.001), and resection size (OR: 1.25, 95% Cl: 1.03-1.52, p = 0.02) were significantly correlated with the Common Terminology Criteria for Adverse Events (CTCAE) ≥ grade 2. The correlation between sarcopenia and CTCAE ≥ grade 2 was maintained after matching, resulting in more extended hospital stays in patients with sarcopenia. However, we detected no association between sarcopenia and overall survival and ESD-related death.

CONCLUSION

Sarcopenia is a risk factor for complications in colorectal ESD, suggesting that colorectal ESD could be performed for patients with sarcopenia, although much caution should be taken.

The cross-sectional area of erector spinae muscle and the liver-to-spleen ratio are associated with frailty in older patients with diabetes: a cross-sectional study

BACKGROUND

Older patients with diabetes mellitus are more susceptible to frailty. Although some imaging markers of appendicular skeletal muscle mass obtained using dual-energy X-ray absorptiometry or computed tomography (CT) imaging can reflect frailty status, the association between imaging indices obtained by abdominal CT scans and frailty in older inpatients has not been reported.

METHODS

A total of 151 older inpatients with diabetes mellitus (median age, 79 years; men, 42%) who underwent abdominal CT scans close to the admission date were studied to examine the associations between abdominal CT indices and frailty. Two frailty definitions were used: the modified Cardiovascular Health Study (mCHS) criteria and Kihon Checklist (KCL) criteria. Using the imaging analysis software SYNAPSE VINCENT®, we compared the cross-sectional areas (CSA) of four truncal muscles (erector spinae, iliopsoas, rectus abdominis, and abdominal oblique muscles) and the liver-to-spleen ratio (L/S), the ratio of the CT values of the liver and spleen between frail and non-frail patients. The muscle areas that showed the strongest associations with frailty were also investigated in relation to grip strength and walking speed. Finally, multivariate binominal logistic regression analyses were performed to assess the independent associations of CSA of muscle and L/S with the prevalence of frailty.

RESULTS

The prevalence of frailty defined by the mCHS and KCL criteria was 55% and 52%, respectively. The CSA of the erector spinae muscle was most significantly associated with frailty, and was significantly smaller in both sexes of mCHS-defined frail patients and in men with KCL-defined frailty. The CSA of erector spinae muscle was also positively correlated with grip strength and walking speed. In contrast, the L/S was higher in men with KCL-defined frailty. Multivariate logistic regression analyses revealed that the CSA of the erector spinae muscle was independently associated with mCHS-defined frailty in women, and the L/S was associated with KCL-defined frailty in men.

CONCLUSIONS

The CSA of erector spinae muscle and low liver fat content could be indices of frailty in older patients with diabetes.

Impact of sarcopenia on early and mid-term outcomes of surgery for acute type A aortic dissection in octogenarians

OBJECTIVE

To determine the association between sarcopenia and surgical outcomes in octogenarians with acute type A aortic dissection.

METHODS

We enrolled 72 octogenarians who had undergone type A aortic dissection surgery between April 2013 and March 2019. The psoas muscle index, an indexed area of the psoas muscle at the L3 level on preoperative computed tomography, was obtained as an indicator of sarcopenia. The study participants were divided into sarcopenia and non-sarcopenia groups based on the mean psoas muscle index. The postoperative outcomes were compared between the groups.

RESULTS

The median age was 84 years (interquartile range 82-87 years), and 13 patients were male. The mean psoas muscle index was 3.53 ± 0.97 cm2/m2. Except for sex, no significant differences were observed in patients' baseline characteristics and operative data between the two groups. The 30-day mortality rates in the sarcopenia and non-sarcopenia groups were 14% and 8%, respectively (P = 0.71), and postoperative morbidity was similar in both groups. Postoperative all-cause mortality was significantly higher in the sarcopenia group (log-rank P = 0.038), especially in patients aged 85 years or older (log-rank P < 0.01). The sarcopenia group had a lower home discharge rate than the non-sarcopenia group (21% vs. 54%, P < 0.01), and home discharge was associated with longer survival (log-rank P = 0.015).

CONCLUSIONS

All-cause mortality after emergency surgery for acute type A aortic dissection was significantly higher in octogenarians with sarcopenia than in those without, especially in patients aged 85 years or older.

Impact of sarcopenia on long-term survival after cardiac surgery for end-stage renal disease patients

BACKGROUND

The long-term mortality of end-stage renal disease (ESRD) patients is still unsatisfactory. Therefore, long-term risk assessments in ESRD patients undergoing cardiac surgery are needed. Recently, sarcopenia is major concern in cardiac surgery because of its association with poor long-term survival. However, the impact of sarcopenia on the long-term survival of ESRD patients undergoing cardiac surgery is not well understood.

METHODS

Eighty-two ESRD patients who underwent elective cardiac surgery were enrolled. Sarcopenia was identified based on noncontrast abdominal computed tomography. The impact of preoperative and intraoperative factors on long-term survival was investigated.

RESULTS

Forty-three patients (52%) were diagnosed with sarcopenia. The in-hospital mortality rate was 4.9%. The 5-year overall survival rate was 48%. The multivariate analyses revealed that STS score ≥ 4 (odds ratio, 6.0; confidence interval, 2.5-14.7; p < 0.01) and presence of sarcopenia (odds ratio, 2.4; confidence interval, 1.3-4.5; p  =  0.03) were independent risk factors for overall survival. The 5-year survival rates of low-risk (Society of Thoracic Surgeons score of < 4) patients without sarcopenia, low-risk with sarcopenia, more than intermediate-risk (Society of Thoracic Surgeons score of ≥ 4) without sarcopenia, and more than intermediate-risk with sarcopenia groups were 80%, 51%, 50%, and 26%, respectively.

CONCLUSIONS

Among the ESRD patients, the low risk without sarcopenia group showed an excellent long-term survival, in contrast to more than intermediate-risk patients with sarcopenia, who can expect poor long-term survival. Preoperative assessment of sarcopenia in addition to the surgical risk score can be useful in developing a therapeutic strategy.

Sarcopenia Adversely Affects Outcomes following Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Sarcopenia is a degenerative condition characterised by the loss of skeletal muscle mass and strength. Its impact on cardiac surgery outcomes remains poorly investigated. This meta-analysis aims to provide a comprehensive synthesis of the available evidence to determine the effect of sarcopenia on cardiac surgery outcomes.

METHODS

A systematic review and meta-analysis followed PRISMA guidelines from inception to April 2023 in EMBASE, MEDLINE, Cochrane database, and Google Scholar. Twelve studies involving 2717 patients undergoing cardiac surgery were included. Primary outcomes were early and late mortality; secondary outcomes included surgical time, infection rates, and functional outcomes. Statistical analyses were performed using appropriate methods.

RESULTS

Sarcopenic patients (906 patients) had a significantly higher risk of early mortality (OR: 2.40, 95% CI: 1.44 to 3.99, p = 0.0007) and late mortality (OR: 2.65, 95% CI: 1.57 to 4.48, p = 0.0003) compared to non-sarcopenic patients (1811 patients). There were no significant differences in overall surgical time or infection rates. However, sarcopenic patients had longer ICU stays, higher rates of renal dialysis, care home discharge, and longer intubation times.

CONCLUSION

Sarcopenia significantly increases the risk of early and late mortality following cardiac surgery, and sarcopenic patients also experience poorer functional outcomes.

Sarcopenia and Cardiovascular Diseases

Sarcopenia is the loss of muscle strength, mass, and function, which is often exacerbated by chronic comorbidities including cardiovascular diseases, chronic kidney disease, and cancer. Sarcopenia is associated with faster progression of cardiovascular diseases and higher risk of mortality, falls, and reduced quality of life, particularly among older adults. Although the pathophysiologic mechanisms are complex, the broad underlying cause of sarcopenia includes an imbalance between anabolic and catabolic muscle homeostasis with or without neuronal degeneration. The intrinsic molecular mechanisms of aging, chronic illness, malnutrition, and immobility are associated with the development of sarcopenia. Screening and testing for sarcopenia may be particularly important among those with chronic disease states. Early recognition of sarcopenia is important because it can provide an opportunity for interventions to reverse or delay the progression of muscle disorder, which may ultimately impact cardiovascular outcomes. Relying on body mass index is not useful for screening because many patients will have sarcopenic obesity, a particularly important phenotype among older cardiac patients. In this review, we aimed to: (1) provide a definition of sarcopenia within the context of muscle wasting disorders; (2) summarize the associations between sarcopenia and different cardiovascular diseases; (3) highlight an approach for a diagnostic evaluation; (4) discuss management strategies for sarcopenia; and (5) outline key gaps in knowledge with implications for the future of the field.

Impact of Sarcopenia on Outcomes of Minimally Invasive Cardiac Surgery

Sarcopenia is an objective marker of poor outcome following cardiac surgery through median sternotomy. However, the clinical impact of sarcopenia after minimally invasive cardiac surgery (MICS) has not been well established. This study aimed to analyze the influence of sarcopenia on the early and late outcomes following MICS. We retrospectively examined 1248 patients who underwent MICS via right mini-thoracotomy or upper sternotomy between February 2009 and April 2020. Patients older than 65 years who underwent preoperative computed tomography were enrolled. Sarcopenia was defined as the lowest sex-specific quartile of the body surface area adjusted psoas muscle area. The early operative and late survival outcomes were compared, and the predictor of late composite outcome was analyzed using Cox proportional regression model. Early and late composite outcomes in both groups were also compared. A total of 367 patients were classified into the sarcopenia (n = 92) or non-sarcopenia (n = 275) group. Patients in the sarcopenia group were older, and had lower preoperative hemoglobin and albumin levels. They had higher estimated surgical mortality, but similar early mortality and major morbidity. The survival and late composite outcome were comparable between the two groups. Sarcopenia was neither an independent predictor of late death nor a composite outcome in the multivariable model. After MICS, patients with sarcopenia displayed comparable perioperative outcomes and survival. The clinical impact of sarcopenia on postoperative outcomes might be alleviated by MICS and early recovery protocol after MICS. MICS could be a reasonable approach for elderly patients with sarcopenia.

Muscle Quality Predicts Outcomes after Surgery for Early-Stage Non-Small-Cell Lung Cancer

Purpose: This study investigated the impact of skeletal muscle quality on the outcomes of patients undergoing surgery for early-stage non–small-cell lung cancer (NSCLC).

Methods: A total of 98 patients with pathological stage I–II NSCLC who underwent lobectomy or segmentectomy were retrospectively analyzed. Along with skeletal muscle quantity, muscle quality was evaluated by intramuscular adipose tissue content (IMAC) at the first lumbar vertebral level; a higher IMAC indicates lower skeletal muscle quality. Patients were divided into two groups according to the gender-specific quartiles of IMAC, and the prognostic impact of IMAC was investigated.

Results: No significant differences in the body and skeletal mass indices, which indicate skeletal muscle quantity, were observed between patients with high and those with normal IMAC. Patients with high IMAC (n = 23) showed a significantly poorer prognosis in overall and disease-specific survivals than those with normal IMAC (n = 75; P <0.001 and P = 0.048, respectively). In a bivariate analysis that included other clinicopathological factors, a high IMAC was independently associated with worse overall survival.

Conclusion: The skeletal muscle quality evaluated by IMAC could be used to predict survival risk after surgery for early-stage NSCLC.

Use of computed tomography for the diagnosis of surgical sarcopenia: Review of recent research advances

Sarcopenia, also known as muscle decay, is associated with high morbidity among surgical patients. It is highly correlated with adverse clinical outcomes, such as increased postoperative complications, prolonged hospital stay, and increased mortality. Computed tomography (CT) is one of the main methods for diagnosing sarcopenia, which has the advantages of intuitiveness, rapidity, and accuracy. Clinical studies have shown that CT-defined sarcopenia can help predict the clinical outcomes and prognosis of surgical patients and provide an important reference for the formulation of antitumor treatment protocols. In recent years, some scholars have tried to construct an intelligent CT-based diagnostic model, which is expected to improve the diagnostic efficiency and establish standardized diagnostic criteria for CT-defined sarcopenia. In this review, we summarize the recent progress in the understanding of the diagnosis of sarcopenia and its potential prognostic value in surgery.

Reversal of deficits in aged skeletal muscle during disuse and recovery in response to treatment with a secrotome product derived from partially differentiated human pluripotent stem cells

Aged individuals are at risk to experience slow and incomplete muscle recovery following periods of disuse atrophy. While several therapies have been employed to mitigate muscle mass loss during disuse and improve recovery, few have proven effective at both. Therefore, the purpose of this study was to examine the effectiveness of a uniquely developed secretome product (STEM) on aged skeletal muscle mass and function during disuse and recovery. Aged (22 months) male C57BL/6 were divided into PBS or STEM treatment (n = 30). Mice within each treatment were assigned to either ambulatory control (CON; 14 days of normal cage ambulation), 14 days of hindlimb unloading (HU), or 14 days of hindlimb unloading followed by 7 days of recovery (recovery). Mice were given an intramuscular delivery into the hindlimb muscle of either PBS or STEM every other day for the duration of their respective treatment group. We found that STEM-treated mice compared to PBS had greater soleus muscle mass, fiber cross-sectional area (CSA), and grip strength during CON and recovery experimental conditions and less muscle atrophy and weakness during HU. Muscle CD68 +, CD11b + and CD163 + macrophages were more abundant in STEM-treated CON mice compared to PBS, while only CD68 + and CD11b + macrophages were more abundant during HU and recovery conditions with STEM treatment. Moreover, STEM-treated mice had lower collagen IV and higher Pax7 + cell content compared to PBS across all experimental conditions. As a follow-up to examine the cell autonomous role of STEM on muscle, C2C12 myotubes were given STEM or horse serum media to examine myotube fusion/size and effects on muscle transcriptional networks. STEM-treated C2C12 myotubes were larger and had a higher fusion index and were related to elevated expression of transcripts associated with extracellular matrix remodeling. Our results demonstrate that STEM is a unique cocktail that possesses potent immunomodulatory and cytoskeletal remodeling properties that may have translational potential to improve skeletal muscle across a variety of conditions that adversely effect aging muscle.

The Psoas Muscle Index Is Associated with Prognosis in Elderly Patients Undergoing Cardiovascular Surgery

Background

Sarcopenia is associated with poor outcomes in elderly patients. However, current surgical risk assessment tools for cardiovascular surgery do not include the impact of sarcopenia.

Objectives

This study aimed to assess whether the psoas muscle index, a numerical score used to assess sarcopenia, is associated with outcomes in elderly patients undergoing cardiovascular surgery.

Methods

This nested case-control study evaluated patients aged ≥ 75 years who underwent elective cardiovascular surgery and were admitted to the intensive care unit at Jichi Medical University, Saitama Medical Center between January 1, 2016 and March 31, 2017. The case group (poor outcomes) included patients who either died or were transferred to a rehabilitation facility postoperatively. The control group (good outcomes) included patients who were discharged postoperatively. Clinical factors likely to affect patient outcomes were assessed, and the characteristics of the two outcome groups were compared using logistic regression analysis.

Results

In total, 183 patients were evaluated; among them, 137 and 46 patients were categorized to the good and poor outcome groups, respectively. The psoas muscle index was significantly associated with outcome (odds ratio: 0.25; 95% confidence interval: 0.14 – 0.43; P < 0.001). A psoas muscle index cut-off of 3.24 had a specificity, sensitivity, positive predictive value, and negative predictive value of 0.86, 0.63, 0.58, and 0.87, respectively, for predicting worse outcome at discharge.

Conclusions

The psoas muscle index was strongly associated with discharge to home in patients aged ≥ 75 years who underwent elective cardiovascular surgery. This finding suggests that the psoas muscle index might be useful in identifying the eligibility of older patients for cardiovascular surgery.

Association of phase angle with hospital-acquired functional decline in older patients undergoing cardiovascular surgery

OBJECTIVE

The aim of this study was to examine whether preoperative phase angle (PhA) measured by bioelectrical impedance analysis was associated with a hospital-acquired functional decline in older patients undergoing cardiovascular surgery.

METHODS

This was an observational study of prospectively collected data of 114 patients (>65 y of age) with cardiovascular disease who underwent elective cardiovascular surgery between September 2019 and August 2020. Patients were classified into tertiles based on PhA levels. Factors associated with the occurrence of hospital-acquired functional decline (postoperative recovery to preoperative physical function was not possible) were analyzed using univariate and multivariate analyses.

RESULTS

Patients in the low PhA group were significantly older than those in the middle and high PhA groups; were predominantly women; had higher New York Heart Association cardiovascular and EuroSCORE severity scores; and had significantly lower levels of body mass index, Geriatric Nutritional Risk Index, hemoglobin, and albumin. There was a significant correlation between PhA and nutrition and physical function. The incidence of hospital-acquired functional decline occurred in 26.3% of all patients, with a significantly higher incidence in patients in the low PhA group. Multivariate analysis showed that PhA was extracted as a factor for the hospital-acquired functional decline in all the models.

CONCLUSIONS

PhA was associated with hospital-acquired functional decline in older patients undergoing cardiovascular surgery. PhA is likely to be a comprehensive indicator of physical health that indicates nutritional status, physical function, and geriatric syndrome (frailty/sarcopenia), and is an important predictor of hospital-acquired functional decline in this group of older patients.

Preoperative Serum GDF-15, Endothelin-1 Levels, and Intraoperative Factors as Short-Term Operative Risks for Patients Undergoing Cardiovascular Surgery

Objectives: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. We investigated the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: In total, 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by ELISA. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. In multivariable logistic regression analysis, the preoperative ET-1 level and CPB time were the independent determinants of AKI, even adjusted by age, sex, and BMI. The preoperative GDF-15 level, CPB time, and RCC transfusion were independent determinants of 30-day mortality plus morbidity. Conclusion: Preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risks for patients undergoing cardiovascular surgery.

The prognostic impact of sarcopenia on elderly patients undergoing pulmonary resection for non-small cell lung cancer

PURPOSE

The number of elderly patients who undergo surgery is increasing, even though they are at a high risk due to a decreased physical strength. Furthermore, sarcopenia is generally associated with a poor prognosis in patients with non-small cell lung cancer (NSCLC).

METHODS

This study included NSCLC patients  ≥ 65 years old who underwent pulmonary resection in our hospital between 2012 and 2015. Sarcopenia was assessed using the psoas muscle mass index based on computed tomography at the level of the third lumbar vertebra. We elucidated the impact of sarcopenia on short- and long-term outcomes after surgery.

RESULTS

We enrolled 259 patients, including 179 with sarcopenia. Patients with sarcopenia before surgery tended to have postoperative complications (p = 0.0521), although they did not show a poor prognosis. In patients with sarcopenia, a multivariate analysis revealed that postoperative complications and the progression of sarcopenia 1 year after surgery were significant risk factors for a poor prognosis (p = 0.0169 and 0.00370, respectively).

CONCLUSIONS

The progression of sarcopenia after surgery is associated with a poor prognosis in elderly NSCLC patients with sarcopenia. A strategy to prevent postoperative progressive sarcopenia may be necessary for improving the clinical outcome of this population.

Low-Intensity Resistance Training with Moderate Blood Flow Restriction Appears Safe and Increases Skeletal Muscle Strength and Size in Cardiovascular Surgery Patients: A Pilot Study

We examined the safety and the effects of low-intensity resistance training (RT) with moderate blood flow restriction (KAATSU RT) on muscle strength and size in patients early after cardiac surgery. Cardiac patients (age 69.6 ± 12.6 years, n = 21, M = 18) were randomly assigned to the control (n = 10) and the KAATSU RT group (n = 11). All patients had received a standard aerobic cardiac rehabilitation program. The KAATSU RT group additionally executed low-intensity leg extension and leg press exercises with moderate blood flow restriction twice a week for 3 months. RT-intensity and volume were increased gradually. We evaluated the anterior mid-thigh thickness (MTH), skeletal muscle mass index (SMI), handgrip strength, knee extensor strength, and walking speed at baseline, 5-7 days after cardiac surgery, and after 3 months. A physician monitored the electrocardiogram, rate of perceived exertion, and the color of the lower limbs during KAATSU RT. Creatine phosphokinase (CPK) and D-dimer were measured at baseline and after 3 months. There were no side effects during KAATSU RT. CPK and D-dimer were normal after 3 months. MTH, SMI, walking speed, and knee extensor strength increased after 3 months with KAATSU RT compared with baseline. Relatively low vs. high physical functioning patients tended to increase physical function more after 3 months with KAATSU RT. Low-intensity KAATSU RT as an adjuvant to standard cardiac rehabilitation can safely increase skeletal muscle strength and size in cardiovascular surgery patients.

Sarcopenia is poor risk for unfavorable short- and long-term outcomes in stage I non-small cell lung cancer

Background

Sarcopenia characterized by skeletal muscle loss may influence postoperative outcomes through physical decline and weakened immunity. We aimed to investigate clinical significance of sarcopenia in resected early-stage non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 315 consecutive patients with pathologic stage I NSCLC who had undergone lobectomy with systematic nodal dissection. Sarcopenia was defined as the lowest quartile of psoas muscle area on the 3rd vertebra on the high-resolution computed tomography (HRCT) image. Clinicopathological variables were used to investigate the correlation to postoperative complications as well as overall and recurrence-free survival.

Results

Upon multivariable analysis, male sex [odds ratio (OR) =5.780, 95% confidence interval (CI): 2.681–12.500, P<0.001], and sarcopenia (OR =21.00, 95% CI: 10.30–42.80, P<0.001) were independently associated with postoperative complications. The sarcopenia group showed significantly lower 5-over all survival (84.4% vs. 69.1%, P<0.001) and recurrence-free survival (77.2% vs. 62.0%, P<0.001) comparing with the non-sarcopenia group. In a multivariable analysis, sarcopenia was an independent prognostic factor [hazard ratio (HR) =1.978, 95% CI: 1.177–3.326, P=0.010] together with age ≥70 years (HR =1.956, 95% CI: 1.141–3.351, P=0.015) and non-adenocarcinoma histology (HR =1.958, 95% CI: 1.159–3.301, P=0.016).

Conclusions

This is the first study which demonstrates that preoperative sarcopenia is significantly associated with unfavorable postoperative complications as well as long-term survival in pathologic stage I NSCLC. This readily available factor on HRCT may provide valuable information to consider possible choice of surgical procedure and perioperative management.