Impact Total Psoas Volume on Short- and Long-Term Outcomes in Patients Undergoing Curative Resection for Pancreatic Adenocarcinoma: a New Tool to Assess Sarcopenia

Dynamic Anthropometrics in Pancreatic Cancer: Associations Between Body Composition Changes During Neoadjuvant Therapy and Survival Outcomes After Resection

BACKGROUND

Assessment of individual tumor biology and response to systemic therapy in pancreatic ductal adenocarcinoma (PDAC) remains a clinical challenge. The significance of anthropometric (body composition) changes during chemotherapy as a surrogate for tumor biology in the setting of localized PDAC is unknown.

METHODS

A retrospective, single-institution analysis of patients with PDAC who received neoadjuvant therapy (NAT) and pancreatectomy from 2017 to 2021 was performed. Radiologic anthropometric analysis used artificial intelligence-driven software to segment and compute total and sub-compartment muscle area, adipose tissue area, and attenuation values at the level of the L3 vertebra. Kaplan-Meier survival estimates, log-rank tests, and multivariable Cox regression models were used in survival analyses.

RESULTS

The inclusion criteria were met by 138 patients. Although decreases in muscle and adipose tissue areas during NAT were predominant, a subset of patients experienced an increase in these compartments. Increases in muscle greater than 5% (hazard ratio [HR], 0.352; 95% confidence interval [CI] 0.135-0.918; p = 0.033) and increases in adipose tissue greater than 15% (HR, 0.375; 95% CI 0.144-0.978; p = 0.045), were significantly associated with improved survival, whereas loss of visceral fat greater than 15% was detrimental (HR 1.853; CI 1.099-3.124; p = 0.021). No significant associations with single time-point anthropometrics were observed. Gains in total muscle and adipose mass were associated with improved pathologic response to systemic therapy and less advanced pathologic tumor stage.

CONCLUSIONS

Dynamic anthropometric analysis during NAT for PDAC is a stronger prognostic indicator than measurements taken at a single point in time. Repeated anthropometric analysis during preoperative chemotherapy may serve as a biomarker for individual tumor biology and response to therapy.

Diagnostic and prognostic value of parameters of erector spinae in patients with uremic sarcopenia

AIM

This study aimed to investigate whether computed tomography (CT)-measured erector spinae parameters (ESPs) have diagnostic, severity assessment, and prognostic predictive value in uremic sarcopenia (US).

MATERIALS AND METHODS

A total of 202 uremic patients were enrolled and divided into two groups: a control group and a sarcopenia group. Sarcopenia was classified into two types: severe and nonsevere. The area, volume, and density of the erector spinae (ES) were measured using chest CT images, and the relevant ESP, including the erector spinae index (ESI), total erector spinae volume (TESV), erector spinae density (ESD), and erector spinae gauge (ESG) were calculated. The occurrence of adverse events was followed-up for 36 months. The diagnostic value and severity of US were determined using the receiver operating characteristic (ROC) curve. Survival curves diagnosed using CT were plotted and compared with the curve drawn using the gold standard. Cox regression analysis was used to identify independent risk factors associated with survival in US.

RESULTS

With an area under the curve (AUC) of 0.840 and 0.739, the combined ESP has diagnostic value and the ability to assess the severity of US. There was no significant difference in the survival curve between the combined ESP for the diagnosis of US and the gold standard (P > 0.05). ESI is a standalone predictor of survival in patients with US.

CONCLUSION

ESP measured by CT has diagnostic values for US and its severity, as well as being a predictive value for the prognosis of US.

The ratio of skeletal muscle mass to body mass index combined with inflammatory immune markers to stratify survival of pancreatic cancer after pancreatoduodenectomy

BACKGROUND

We sought to combine skeletal muscle index and inflammatory immune markers to stratify long-term survival in patients with pancreatic cancer after pancreatoduodenectomy (PD).

METHODS

A total of 581 patients with pancreatic cancer underwent PD were included, and divided into the training and validation cohort. Image analysis of computed tomography scans was used to calculate the ratio of skeletal muscle (SM) area to body mass index (BMI). Naples prognostic score (NPS) was calculated from blood-test inflammatory immune markers. Propensity score matching (PSM) analysis was performed to minimize biases of clinicopathological characteristics. To estimate the overall survival (OS), a nomogram was developed using the training cohort. The predictive accuracy of nomogram was estimated by concordance index (C-index), calibration curve, and receiver operating characteristics (ROC) curve.

RESULTS

After PSM analysis, SM/BMI ratio, NPS, lymph node metastasis, TNM stage, surgical margin, tumor grade and adjuvant therapy were independent predictors of OS, which were all assembled into nomogram. The SM/BMI ratio was the best single-predictor for 3- and 5-year OS, with an AUC of 0.805 (95% CI: 0.755-0.855) and 0.812 (95% CI: 0.736-0.888), respectively. Harrell's c-index of the nomogram in the training cohort was 0.786 (95% CI: 0.770-0.802), and the area under ROC curve of 1-year, 3- and 5-year OS prediction were 0.869 (95%CI: 0.837-0.901), 0.846 (95%CI: 0.810-0.882) and 0.849 (95%CI: 0.801-0.896).

CONCLUSIONS

The nomogram based on SM/BMI ratio and NPS had excellent predictive performance, which should be incorporated to conventional risk scores to stratify survival of patients with PDAC after PD.

Association between psoas major muscle mass and CPET performance and long-term survival following major colorectal surgery: A retrospective cohort study

OBJECTIVES

To evaluate whether computed tomography (CT)-derived psoas major muscle measurements could predict preoperative cardiopulmonary exercise testing (CPET) performance and long-term mortality in patients undergoing major colorectal surgery and to compare predictive performance of psoas muscle measurements using 2D approach and 3D approach.

METHODS

A retrospective cohort study compliant with STROCSS standards was conducted. Consecutive patients undergoing major colorectal surgery between January 2011 and January 2017 following CPET as part of their preoperative assessment were included. Regression analyses were modelled to investigate association between the CT-derived psoas major muscle mass variables [total psoas muscle area (TPMA), total psoas muscle volume (TPMV) and psoas muscle index (PMI)] and CPET performance and mortality (1-year and 5-year). Discriminative performances of the variables were evaluated using Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

A total of 457 eligible patients were included. The median TPMA and TPMV were 21 ​cm2 (IQR: 15-27) and 274 ​cm3 (IQR: 201-362), respectively. The median PMI measured via 2D and 3D approaches were 7 ​cm2/m2 (IQR: 6-9) and 99 ​cm3/m2 (IQR: 76-120), respectively. The risks of 1-year and 5-year mortality were 7.4% and 27.1%, respectively. Regression analyses showed TPMA, TPMV, and PMI can predict preoperative CPET performance and long-term mortality. However, ROC curve analyses showed no significant difference in predictive performance amongst TPMA, TPMV, and PMI.

CONCLUSION

Radiologically-measured psoas muscle mass variables may predict preoperative CPET performance and may be helpful with informing more objective selection of patients for preoperative CPET and prehabilitation.

Development and validation of a reliable method for automated measurements of psoas muscle volume in CT scans using deep learning-based segmentation: a cross-sectional study

OBJECTIVES

We aimed to develop an automated method for measuring the volume of the psoas muscle using CT to aid sarcopenia research efficiently.

METHODS

We used a data set comprising the CT scans of 520 participants who underwent health check-ups at a health promotion centre. We developed a psoas muscle segmentation model using deep learning in a three-step process based on the nnU-Net method. The automated segmentation method was evaluated for accuracy, reliability, and time required for the measurement.

RESULTS

The Dice similarity coefficient was used to compare the manual segmentation with automated segmentation; an average Dice score of 0.927 ± 0.019 was obtained, with no critical outliers. Our automated segmentation system had an average measurement time of 2 min 20 s ± 20 s, which was 48 times shorter than that of the manual measurement method (111 min 6 s ± 25 min 25 s).

CONCLUSION

We have successfully developed an automated segmentation method to measure the psoas muscle volume that ensures consistent and unbiased estimates across a wide range of CT images.

Evolving concepts on perioperative nutrition of sarcopenic cancer patients

The recent recognition of the association of sarcopenia with an increased risk of complications after a surgical procedure calls for rethinking the proper approach of the perioperative care in cancer patients. Sarcopenia is broadly considered in literature according to three different definitions: loss of muscle mass, loss of muscle mass plus reduced muscle function and myosteatosis. The aim of this short review on this issue is to define the excess of risk by type of primary and of surgical procedure, depending on the definition of sarcopenia, to speculate on this association (casual versus causal) and to examine the current therapeutical approaches. The analysis of the data shows that sarcopenia, defined as loss of muscle mass plus reduced muscle function, has the higher predictive power for the occurrence of postoperative complications than the two other definitions, and any definition of sarcopenia works better than the usual indexes or scores of surgical risk. Our analysis supports the concept that: a) sarcopenia is frequently associated with inflammation, but inflammation cannot be considered the only or the absolute cause for sarcopenia, b) sarcopenia is not a simple marker of risk but can have a direct role in the increase of risk. Data on perioperative care of sarcopenic cancer patients are scanty but a correct approach cannot rely on nutritional support alone but on a combined approach of optimized nutrition and exercise, hopefully associated with an anti-inflammatory treatment. This strategy should be applied proactively in keeping with the recent recommendations of the American Society of Clinical Oncology for the medical treatment of advanced cancer patients even if a clear demonstration of effectiveness is still lacking.

Postoperative long‑term outcomes of acute normovolemic hemodilution in pancreatic cancer: A propensity score matching analysis

Acute normovolemic hemodilution (ANH) is a useful intraoperative blood conservation technique. However, the impact on long-term outcomes in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study investigated the impact of ANH on long-term outcomes in patients with PDAC undergoing radical surgery. Data from 155 resectable PDAC cases were collected. Patients were categorized according to whether or not they had received intraoperative allogeneic blood transfusion (ABT) or ANH. Postoperative complications, recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ANH. A total of 44 patients (28.4%) were included in the ANH group and 30 patients (19.4%) were included in the ABT group; 81 (52.3%) patients, comprising the standard management (STD) group, received neither ANH nor ABT. The ABT group had the worst prognosis among them. Before PSM, ANH was significantly associated with decreased RFS (P=0.043) and DSS (P=0.029) compared with the STD group before applying Bonferroni correction; however, no significant difference was observed after applying Bonferroni correction. Cox regression analysis identified ANH as an independent prognostic factor for RFS [relative risk (RR), 1.696; P=0.019] and DSS (RR, 1.876; P=0.009). After PSM, the ANH group exhibited less favorable RFS [median survival time (MST), 12.1 vs. 18.1 months; P=0.097] and DSS (MST, 32.1 vs. 50.5 months; P=0.097) compared with the STD group; however, these differences were not statistically significant. In conclusion, while ANH was not as harmful as ABT, it exhibited potentially more negative effects on long-term postoperative outcomes in PDAC than STD.

Sarcopenia, a Risk Predictor of Postoperative Acute Kidney Injury in Elderly Patients after Hip Fracture Surgery: A Retrospective Analysis

Background and Objectives: Hip fracture surgery, which affects quality of life, can be a major challenge in geriatric populations. Although sarcopenia is known to be associated with postoperative outcomes, there are few studies on the association between sarcopenia and postoperative acute kidney injury (AKI) in this population. We investigated the association between sarcopenia and postoperative AKI in elderly patients following hip fracture surgery. Materials and Methods: We retrospectively reviewed the records of patients who underwent hip fracture surgery at our institution from March 2019 to December 2021. Patients under the age of 65, patients with no preoperative computed tomography (CT) scans and patients with inappropriate cross-sectional images for measurement were excluded. The psoas-lumbar vertebral index (PLVI), which is the ratio of the average area of both psoas muscles to the area of the fourth lumbar vertebral body, was measured from preoperative CT scans. Sarcopenia was defined as a PLVI within the lowest 25% for each sex, and patients were categorized into sarcopenic and nonsarcopenic groups. The occurrence of AKI was determined based on the serum creatinine level within postoperative day 7 using the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Univariate and multivariate logistic regression analyses were performed to evaluate the associations between clinical variables and the occurrence of AKI. Results: Among the 348 enrolled patients, 92 patients were excluded, and 256 patients were analyzed. The PLVI cutoff values for defining sarcopenia lower than 25% for male and female patients were 0.57 and 0.43, respectively. The overall incidence of AKI was 18.4% (47 patients), and AKI occurred more frequently in sarcopenic patients than in nonsarcopenic patients (29.7% vs. 14.6%, p = 0.007). According to the multivariate logistic regression, which included all variables with a p value < 0.05 in the univariate analysis and adjusted for age, body mass index (BMI) and American Society of Anesthesiologists (ASA) physical status, sarcopenia was revealed to be an independent predictor of postoperative AKI (odds ratio = 5.10, 95% confidence interval = 1.77-14.77; p = 0.003). Conclusions: Preoperative sarcopenia, which corresponds to the lowest quartile of PLVI values, is associated with postoperative AKI among elderly patients who underwent hip fracture surgery.

Standard Nutritional Assessment Tools Are Unable to Predict Loss of Muscle Mass in Patients Due to Undergo Pancreatico-Duodenectomy: Highlighting the Need for Detailed Nutritional Assessment

BACKGROUND AND METHODS

Pancreatico-duodenectomy (PD) carries significant morbidity and mortality, with very few modifiable risk factors. Radiological evidence of sarcopenia is associated with poor outcomes. This retrospective study aimed to analyse the relationship between easy-to-use bedside nutritional assessment techniques and radiological markers of muscle loss to identify those patients most likely to benefit from prehabilitation.

RESULTS

Data were available in 184 consecutive patients undergoing PD. Malnutrition was present in 33-71%, and 48% had a high visceral fat-to-skeletal muscle ratio, suggestive of sarcopenic obesity (SO). Surgical risk was higher in patients with obesity (OR 1.07, 95%CI 1.01-1.14, p = 0.031), and length of stay was 5 days longer in those with SO (p = 0.006). There was no correlation between skeletal muscle and malnutrition using percentage weight loss or the malnutrition universal screening tool (MUST), but a weak correlation between the highest hand grip strength (HGS; 0.468, p < 0.001) and the Global Leadership in Malnutrition (GLIM) criteria (-0.379, p < 0.001).

CONCLUSIONS

Nutritional assessment tools give widely variable results. Further research is needed to identify patients at significant nutritional risk prior to PD. In the meantime, those with malnutrition (according to the GLIM criteria), obesity or low HGS should be referred to prehabilitation.

Lean body mass in living kidney donors impacts postoperative renal function

PURPOSE

A living donor kidney transplant is the optimal treatment for chronic renal impairment. Our objective is to assess if lean skeletal muscle mass and donor factors such as body mass index, hypertension, and age impact on renal function following donor nephrectomy.

METHODS

Potential donors undergo CT angiography as part of their work-up in our institution. Using dedicated software (Horos®), standardized skeletal muscle area measured at the L3 vertebrae was calculated. When corrected for height, skeletal muscle index can be derived. Skeletal muscle mass index below predefined levels was classified as sarcopenic. The correlation of CT-derived skeletal muscle index and postoperative renal function at 12 months was assessed. Co-variables including donor gender, age, body mass index (BMI), and presence of pre-op hypertension were also assessed for their impact on postoperative renal function.

RESULTS

275 patients who underwent living donor nephrectomy over 10 years were included. Baseline pre-donation glomerular filtration rate (GFR) and renal function at one year post-op were similar between genders. 29% (n = 82) of patients met the criteria for CT-derived sarcopenia. Sarcopenic patients were more likely to have a higher GFR at one year post-op (69.3 vs 63.9 mL/min/1.73 m2, p < 0.001). The main factors impacting better renal function at one year were the presence of sarcopenia and younger age at donation.

CONCLUSION

When selecting donors, this study highlights that patients with low skeletal mass are unlikely to underperform in terms of recovery of their renal function postoperatively at one year when compared to patients with normal muscle mass and should not be a barrier to kidney donation.

Association between preoperative sarcopenia and prognosis of pancreatic cancer after curative-intent surgery: a updated systematic review and meta-analysis

BACKGROUND

Sarcopenia is associated with poor outcomes in many malignancies. However, the relationship between sarcopenia and the prognosis of pancreatic cancer has not been well understood. The aim of this meta-analysis was to identify the prognostic value of preoperative sarcopenia in patients with pancreatic cancer after curative-intent surgery.

METHODS

Database from PubMed, Embase, and Web of Science were searched from its inception to July 2023. The primary outcomes were overall survival (OS), progression-free survival (PFS), and the incidence of major complications. The hazard ratio (HR), odds ratio (OR), and 95% confidence intervals (CIs) were used to assess the relationship between preoperative sarcopenia and the prognosis of patients with pancreatic cancer. All statistical analyses were conducted by Review Manager 5.3 and STATA 17.0 software.

RESULTS

A total of 23 retrospective studies involving 5888 patients were included in this meta-analysis. The pooled results demonstrated that sarcopenia was significantly associated with worse OS (HR = 1.53, P < 0.00001) and PFS (HR = 1.55, P < 0.00001). However, this association was not obvious in regard to the incidence of major complications (OR = 1.33, P = 0.11).

CONCLUSION

Preoperative sarcopenia was preliminarily proved to be associated with the terrible prognosis of pancreatic cancer after surgery. However, this relationship needs to be further validated in more prospective studies.

Automated evaluation of masseter muscle volume: deep learning prognostic approach in oral cancer

BACKGROUND

Sarcopenia has been identified as a potential negative prognostic factor in cancer patients. In this study, our objective was to investigate the relationship between the assessment method for sarcopenia using the masseter muscle volume measured on computed tomography (CT) images and the life expectancy of patients with oral cancer. We also developed a learning model using deep learning to automatically extract the masseter muscle volume and investigated its association with the life expectancy of oral cancer patients.

METHODS

To develop the learning model for masseter muscle volume, we used manually extracted data from CT images of 277 patients. We established the association between manually extracted masseter muscle volume and the life expectancy of oral cancer patients. Additionally, we compared the correlation between the groups of manual and automatic extraction in the masseter muscle volume learning model.

RESULTS

Our findings revealed a significant association between manually extracted masseter muscle volume on CT images and the life expectancy of patients with oral cancer. Notably, the manual and automatic extraction groups in the masseter muscle volume learning model showed a high correlation. Furthermore, the masseter muscle volume automatically extracted using the developed learning model exhibited a strong association with life expectancy.

CONCLUSIONS

The sarcopenia assessment method is useful for predicting the life expectancy of patients with oral cancer. In the future, it is crucial to validate and analyze various factors within the oral surgery field, extending beyond cancer patients.

Association between reduced muscle mass and poor prognosis of biliary sepsis

Sepsis is a life-threatening disease, contributing to significant morbidity and mortality. This study aimed to investigate the association between low muscle mass and the prognosis of patients with biliary sepsis, focusing on outcomes such as length of hospital stay (LOS), intensive care unit (ICU) admission, and in-hospital mortality. This retrospective, single-center, observational study included adult patients with biliary sepsis who visited the emergency department between January 2016 and December 2021. Low muscle mass was assessed using the psoas muscle index (PMI). Using computed tomography imaging, the area of both sides of the psoas muscle at the L3 level was measured, and the PMI, corrected by the patient's height was calculated. The primary outcome was in-hospital mortality, and the secondary outcomes were intensive care unit (ICU) admission, LOS, and 14-day mortality. A total of 745 patients were included in this study. Low muscle mass was defined as a PMI < 421 mm2/m2 for males and < 268 mm2/m2 for females with the lower quartile of PMI according to sex. The cohort was classified into sarcopenic (n = 189) and non-sarcopenic (n = 556) groups. There was a significant association between low muscle mass and in-hospital mortality (odds ratio, 3.81; 95% confidence interval, 1.08-13.47; p < 0.001), while there was no significant association between low muscle mass and ICU admission. In addition, the median LOS in the sarcopenic group (10 [7-14] days) was significantly longer than the median (8 [6-11] days) in the non-sarcopenic group. Low muscle mass was significantly associated with clinical outcomes, particularly in-hospital mortality and LOS, in patients with biliary sepsis.

Applicability of the CT Radiomics of Skeletal Muscle and Machine Learning for the Detection of Sarcopenia and Prognostic Assessment of Disease Progression in Patients with Gastric and Esophageal Tumors

PURPOSE

Sarcopenia is considered a negative prognostic factor in patients with malignant tumors. Among other diagnostic options, computed tomography (CT), which is repeatedly performed on tumor patients, can be of further benefit. The present study aims to establish a framework for classifying the impact of sarcopenia on the prognosis of patients diagnosed with esophageal or gastric cancer. Additionally, it explores the significance of CT radiomics in both diagnostic and prognostic methodologies.

MATERIALS AND METHODS

CT scans of 83 patients with esophageal or gastric cancer taken at the time of diagnosis and during a follow-up period of one year were evaluated retrospectively. A total of 330 CT scans were analyzed. Seventy three of these patients received operative tumor resection after neoadjuvant chemotherapy, and 74% of the patients were male. The mean age was 64 years (31-83 years). Three time points (t) were defined as a basis for the statistical analysis in order to structure the course of the disease: t1 = initial diagnosis, t2 = following (neoadjuvant) chemotherapy and t3 = end of the first year after surgery in the "surgery" group or end of the first year after chemotherapy. Sarcopenia was determined using the psoas muscle index (PMI). The additional analysis included the analysis of selected radiomic features of the psoas major, quadratus lumborum, and erector spinae muscles at the L3 level. Disease progression was monitored according to the response evaluation criteria in solid tumors (RECIST 1.1). CT scans and radiomics were used to assess the likelihood of tumor progression and their correlation to sarcopenia. For machine learning, the established algorithms decision tree (DT), K-nearest neighbor (KNN), and random forest (RF) were applied. To evaluate the performance of each model, a 10-fold cross-validation as well as a calculation of Accuracy and Area Under the Curve (AUC) was used.

RESULTS

During the observation period of the study, there was a significant decrease in PMI. This was most evident in patients with surgical therapy in the comparison between diagnosis and after both neoadjuvant therapy and surgery (each p < 0.001). Tumor progression (PD) was not observed significantly more often in the patients with sarcopenia compared to those without sarcopenia at any time point (p = 0.277 to p = 0.465). On average, PD occurred after 271.69 ± 104.20 days. The time from initial diagnosis to PD in patients "with sarcopenia" was not significantly shorter than in patients "without sarcopenia" at any of the time points (p = 0.521 to p = 0.817). The CT radiomics of skeletal muscle could predict both sarcopenia and tumor progression, with the best results for the psoas major muscle using the RF algorithm. For the detection of sarcopenia, the Accuracy was 0.90 ± 0.03 and AUC was 0.96 ± 0.02. For the prediction of PD, the Accuracy was 0.88 ± 0.04 and the AUC was 0.93 ± 0.04.

CONCLUSIONS

In the present study, the CT radiomics of skeletal muscle together with machine learning correlated with the presence of sarcopenia, and this can additionally assist in predicting disease progression. These features can be classified as promising alternatives to conventional methods, with great potential for further research and future clinical application. However, when sarcopenia was diagnosed with PMI, no significant correlation between sarcopenia and PD could be observed.

Effect of sarcopenia on survival in patients after pancreatic surgery: a systematic review and meta-analysis

Background

Numerous studies have reported sarcopenia to be associated with unfavorable outcomes in patients who have undergone pancreatectomy. Therefore, in this meta-analysis, we examined the relationship between sarcopenia and survival after pancreatic surgery.

Methods

PubMed, Embase, and Cochrane Library were searched for studies that examined the association between sarcopenia and survival after pancreatic surgery from the inception of the database until June 1, 2023. Hazard ratio (HR) for overall survival (OS) and/or progression-free survival (PFS) of sarcopenia and pancreatic surgery were extracted from the selected studies and random or fixed-effect models were used to summarize the data according to the heterogeneity. Publication bias was assessed using Egger's linear regression test and a funnel plot.

Results

Sixteen studies met the inclusion criteria. For 13 aggregated univariate and 16 multivariate estimates, sarcopenia was associated with decreased OS (univariate analysis: HR 1.69, 95% CI 1.48-1.93; multivariate analysis: HR 1.69; 95% CI 1.39-2.05, I2 = 77.4%). Furthermore, sarcopenia was significantly associated with poor PFS of pancreatic resection (Change to univariate analysis: HR 1.74, 95% CI 1.47-2.05; multivariate analysis: HR 1.54; 95% CI 1.23-1.93, I2 = 63%).

Conclusion

Sarcopenia may be a significant prognostic factor for a shortened survival following pancreatectomy since it is linked to an elevated risk of mortality. Further studies are required to understand how sarcopenia affects long-term results after pancreatic resection.Systematic review registrationRegistration ID: CRD42023438208 https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

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.

Impact of Frailty and Sarcopenia on Short- and Long-Term Outcomes in Elderly Patients Undergoing Radical Gastrectomy for Gastric Cancer

BACKGROUND

The impact of frailty and sarcopenia in patients with gastric cancer is unclear. This study aimed to comprehensively examine the impact of frailty and sarcopenia on the short- and long-term outcomes in elderly patients undergoing radical gastrectomy for gastric cancer.

METHODS

We retrospectively assessed 246 patients aged ≥ 65 years who underwent radical gastrectomy. Frailty and sarcopenia were assessed using the modified frailty index (mFI) and psoas muscle mass index (PMI), respectively.

RESULTS

There were 30 (12.2%) and 60 (24.4%) patients with High-mFI and Low-PMI, respectively. As the age increased, both sexes showed significant correlations with PMI and mFI (r = - 0.238, 0.322, P = 0.003 and 0.002, respectively). High-mFI and Low-PMI did not affect the short-term outcomes. However, High-mFI was an independent risk factor for non-home discharge (P = 0.004) and was a significant predictor of 3- and 5-year overall survival (OS) (HR = 2.76 and 2.26; P = 0.002 and 0.005, respectively) and 1-, 3- and 5-year non-cancer-specific survival (non-CSS) (HR = 4.88, 8.05, and 4.01; P = 0.017, < 0.001, < 0.001, respectively). Low-PMI was a significant predictor of only 5-year OS (HR = 2.03, P = 0.003) and non-CSS (HR = 2.10, P = 0.020).

CONCLUSIONS

Frailty is significant predictor of non-home discharge and 1-, 3-, 5-year OS and 3- and 5-year non-CSS. Sarcopenia is a significant predictor of 5-year OS and non-CSS. Preoperative assessment of both frailty and sarcopenia can help surgeons to select adequate treatment strategies for the elderly population.

Can sarcopenia predict poor prognosis of sepsis due to acute cholecystitis?

AIM OF THE STUDY

As sepsis is a life-threatening disease, it is important to predict the prognosis in the early stages to establish treatment plans. This study aimed to investigate the association between sarcopenia, determined by the psoas muscle area, and the prognosis of sepsis due to acute cholecystitis.

METHODS

This retrospective single-center observational study included adult patients with sepsis due to acute cholecystitis who visited the emergency department between January 2016 and December 2021. The area of both sides of the psoas muscle at the L3 level was measured, and the psoas muscle index (PMI) corrected by the patient's height was calculated. Sarcopenia was determined based on PMI. The primary outcome was in-hospital mortality, and secondary outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and 14-day mortality.

RESULTS

A total of 374 patients were included in this study. In this cohort, the lower quartile of PMI according to gender was set as the cut-off value to define sarcopenia. Sarcopenia was defined as PMI < 423 mm2/m2 for males and < 269 mm2/m2 for females. There were 94 patients in the sarcopenic group and 280 in the non-sarcopenic group. There was a significant association between sarcopenia and ICU admission (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.05-3.76), and there was also a significant association between sarcopenia and in-hospital mortality (OR, 6.40; 95%CI, 1.13-36.09). Additionally, the median LOS in the sarcopenic group (11.5 (Cruz-Jentoft et al., 2010; Kawaguchi et al., 2019; Kim et al., 2017; Ritz et al., 2021; Cox et al., 2021; Lee et al., 2018; Okada et al., 2021; Prashanthi et al., n.d.; Amini et al., 2015; Fearon et al., 2011) days) was significantly longer than the median (8 (Rosenberg, 1989, 1997; Cruz-Jentoft et al., 2010; Kawaguchi et al., 2019; Kim et al., 2017; Ritz et al., 2021) days) in the non-sarcopenic group.

CONCLUSIONS

In patients with sepsis due to acute cholecystitis, sarcopenia was significantly associated with ICU admission, LOS, and in-hospital mortality.

Total Psoas Area is a Measure for Deconditioning in Colorectal Surgery Patients

INTRODUCTION

Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes.

METHODS

After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18 years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm2/m2.

RESULTS

1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population.

CONCLUSIONS

Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

The impact of sarcopenia on prognosis of patients with pancreatic cancer: A systematic review and meta-analysis

OBJECTIVE

To summarize recent findings on the association of low skeletal muscle mass and muscle quality with overall survival and recurrence-free survival in patients with pancreatic cancer.

METHODS

A systematic search was conducted using Medline (via PubMed), Embase and Scopus databases for observational studies reporting on the overall survival and recurrence-free survival. Pooled effect sizes were reported as hazards ratio along with 95% confidence intervals.

RESULTS

A total of 34 studies were included. Low skeletal muscle index (indicating muscle mass) was associated with poor overall survival (hazards ratio: 1.50; 95% confidence interval: 1.34, 1.67) and lower recurrence-free survival (hazards ratio: 1.28, 95% confidence interval: 1.15, 1.43). Low skeletal muscle attenuation (indicating muscle quality) was associated with poor overall survival (hazards ratio: 1.32; 95% confidence interval: 1.05, 1.66). Recurrence-free survival was similar in patients with low and normal/high skeletal muscle attenuation (hazards ratio: 1.12, 95% confidence interval: 0.89, 1.40).

CONCLUSION

Both low skeletal muscle mass and poor muscle quality are associated with poor long-term survival. Low skeletal muscle index, but not low skeletal muscle attenuation, are associated with poor recurrence-free survival.

Clinical implication of thoracic skeletal muscle volume as a predictor of ventilation-weaning failure in brain-injured patients: A retrospective observational study

Sarcopenia, a generalized loss of skeletal muscle mass that is primarily evident in the respiratory musculature, is associated with adverse outcomes in critically ill patients. However, the relationship between sarcopenia and ventilation-weaning outcomes has not yet been fully studied in patients with brain injuries. In this study, we examined the effect of reduced respiratory muscle mass on ventilation weaning in patients with brain injury. This observational study retrospectively reviewed the medical records of 73 patients with brain injury between January 2017 and December 2019. Thoracic skeletal muscle volumes were measured from thoracic CT images using the institute's three-dimensional modeling software program of our institute. The thoracic skeletal muscle volumes index (TSMVI) was normalized by dividing muscle volume by the square of patient height. Sarcopenia was defined as a TSMVI of less than the 50th sex-specific percentile. Among 73 patients with brain injury, 12 (16.5%) failed to wean from mechanical ventilation. The patients in the weaning-failure group had significantly higher sequential organ failure assessment scores [7.8 ± 2.7 vs 6.1 ± 2.2, P = .022] and lower thoracic skeletal muscle volume indexes [652.5 ± 252.4 vs 1000.4 ± 347.3, P = .002] compared with those in the weaning-success group. In multivariate analysis, sarcopenia was significantly associated with an increased risk of weaning failure (odds ratio 12.72, 95% confidence interval 2.87-70.48, P = .001). Our study showed a significant association between the TSMVI and ventilation weaning outcomes in patients with brain injury.

Psoas muscle quantified muscle status and long-term mortality after cardiovascular interventions

RESULTS

In the meta-analysis, psoas muscle measurements were significantly associated with mortality among men (p < 0.05), with high heterogeneity in the associations across all cohorts. There was very little difference in the association between PMA and PMD and mortality (HR 0.83, 95% CI 0.69-0.99, p = 0.002; HR 0.85, 95% CI 0.77-0.94, p = 0.041 for one SD increase in PMA and PMD in the random effects model). Combining PMA and PMD into one composite variable by multiplying their values together showed the most robust association in terms of the magnitude of the effect size in men (HR, 0.77; 95% CI 0.73-0.87, p < 0.001). Indexing PMA to body size did not result in any significant differences in this association. Among women, psoas muscle measurements were not associated with long-term mortality in this meta-analysis.

CONCLUSIONS

Different psoas muscle measurements were significantly and very similarly associated with mortality among men but not among women. No single measurement stands out, although combining PMA and PMD seems to be a slightly stronger estimate in terms of effect size and should be considered in further studies.

Association of Sarcopenia with a Poor Prognosis and Decreased Tumor-Infiltrating CD8-Positive T Cells in Pancreatic Ductal Adenocarcinoma: A Retrospective Analysis

BACKGROUND

Sarcopenia, defined as a loss of skeletal muscle mass and quality, is found in 30-65% of patients with pancreatic ductal adenocarcinoma (PDAC) at diagnosis, and is a poor prognostic factor. However, it is yet to be evaluated why sarcopenia is associated with poor prognosis. Therefore, this study elucidated the tumor characteristics of PDAC with sarcopenia, including driver gene alterations and tumor microenvironment.

PATIENTS AND METHODS

We retrospectively analyzed 162 patients with PDAC who underwent pancreatic surgery between 2008 and 2017. We defined sarcopenia by measuring the skeletal muscle mass at the L3 level using preoperative computed tomography images and evaluated driver gene alteration (KRAS, TP53, CDKN2A/p16, and SMAD4) and tumor immune (CD4+, CD8+, and FOXP3+) and fibrosis status (stromal collagen).

RESULTS

In localized-stage PDAC (stage ≤ IIa), overall survival (OS) and recurrence-free survival were significantly shorter in the sarcopenia group than in the non-sarcopenia group (2-year OS 89.7% versus 59.1%, P = 0.03; 2-year RFS 74.9% versus 50.0%, P = 0.02). Multivariate analysis revealed that sarcopenia was an independent poor prognostic factor in localized-stage PDAC. Additionally, tumor-infiltrating CD8+ T cells in the sarcopenia group were significantly less than in the non-sarcopenia group (P = 0.02). However, no difference was observed in driver gene alteration and fib.rotic status. These findings were not observed in advanced-stage PDAC (stage ≥ IIb).

CONCLUSIONS

Sarcopenia was associated with a worse prognosis and decreased tumor-infiltrating CD8+ T cells in localized-stage PDAC. Sarcopenia may worsen a patient's prognosis by suppressing local tumor immunity.

Nutrition support in pancreatic cancer: An expert statement on practical implementation of French guidelines

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines, shortened in 2021, are widely used for providing the most suitable nutrition support to patients with cancer. However, there is a lack of specialized guidelines for different cancer types. In 2020, members of the French medical and surgical societies involved in digestive oncology, nutrition and supportive care developed the Thésaurus National de Cancérologie Digestive (TNCD) practice guidelines which are specific nutritional and physical activity guidelines for patients with digestive cancers. These guidelines were recently updated in 2022. This review discusses the French intergroup guidelines, specifically in the context of pancreatic cancer at different stages of the disease. Pancreatic cancer is highly prevalent in Europe, with an increasing worldwide incidence over the last three decades. In France alone, about 14,000 new cases of pancreatic cancer are reported annually. More than 60% of patients with pancreatic cancer reportedly experience malnutrition and other nutritional issues which are known to have a negative impact on quality of life, treatment tolerability, general morbidity, and mortality. Given that the recommendations of TNCD guidelines correlate to other guidelines like the International Study Group on Pancreatic Surgery (ISGPS; for the perioperative setting), ESPEN and Spanish Society of Medical Oncology (SEOM) guidelines, their use can be suitably applied in other European countries. This review discusses the recommendations issued by nutrition guidelines, the challenges with effective integration of nutrition support in oncologic treatment, and the proposed algorithms on patient care pathways for pancreatic cancer management in the clinical setting.

Comparative analysis of the sarcopenia and HALP score on postoperative outcomes in pancreatic cancer patients after pancreatoduodenectomy

BACKGROUND

Sarcopenia and HALP (Hemoglobin, Albumin, Lymphocyte, and Platelet) scores are factors commonly associated with postoperative outcomes used in cancer patients. This study aims to evaluate the effect of these two prognostic factors on postoperative outcomes in operated pancreatic cancer patients and their correlation with each other.

METHODS

The study is a single-center, retrospective study conducted with 179 patients diagnosed with pancreatic adenocarcinoma after pancreatoduodenectomy (PD) between January 2012 and January 2022. The Psoas muscular index (PMI) and HALP scores of the patients were calculated. Cut-off values were determined in order to determine the nutritional status of the patients and to group them. The cut-off value of the HALP score was determined according to survival status. In addition, the clinical data and pathological findings of tumors were collected. These two parameters were evaluated in terms of length of hospital stay, postoperative complication rates, fistula development, and overall survival, and their correlations with each other were examined.

RESULTS

Of the patients, 74 (41.3%) were female, and 105 (58.7%) were male. According to PMI cut-off values, 83 (46.4%) patients were in the sarcopenia group. According to the HALP score cut-off values, 77 (43.1%) patients were in the low HALP group. Sarcopenia and Low HALP group had a higher risk of death (respectively Hazard ratio:5.67, CI:3.58-8.98, Hazard ratio:5.95, CI: 3.72-9.52) (p < 0.001). There was a moderate correlation between PMI and HALP score (rs = 0.34, p = 0.01). The correlation in these values was higher in the female gender.

CONCLUSIONS

In line with the data obtained from our study, HALP score and sarcopenia are among the important parameters used to evaluate postoperative complications and provide information about survival. Patients with a low HALP score and sarcopenic have an increased likelihood of developing postoperative complications and a lower survival.

Evaluation of Nutritional Status and the Impact of Nutritional Treatment in Patients with Pancreatic Cancer

Patients with pancreatic cancer who develop irreversible cancer cachexia have a life expectancy of less than 3 months. Therefore, it is extremely important to evaluate the patient's nutritional status as early as possible and to implement an appropriate nutritional intervention in order to reduce the risk of further weight loss and/or muscle loss, which affect the outcomes of cancer treatment and the correct nutritional treatment in patients with pancreatic cancer. A literature review was performed by using the PubMed and Cochrane quick search methodology. The main purpose of this review was to present the current approach to nutritional treatment in pancreatic cancer. The review included publications, most of which concerned clinical nutrition as part of the phase of treatment of patients with pancreatic cancer, nutritional and metabolic disorders in pancreatic cancer, and the period after pancreatic resection. Some of the publications concerned various nutritional interventions in patients with pancreatic cancer undergoing chemotherapy or surgical treatment (nutritional support before surgery, after surgery, or during palliative treatment). There is an unmet need for integrated nutritional therapy as a key part of the comprehensive care process for PC patients. Nutritional counseling is the first line of nutritional treatment for malnourished cancer patients, but pancreatic enzyme replacement therapy also constitutes the cornerstone of nutritional treatment for relieving symptoms of indigestion and maintaining or improving nutritional status.

Evaluating Metabolite-Based Biomarkers for Early Diagnosis of Pancreatic Cancer: A Systematic Review

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers, with five-year survival rates around 10%. The only curative option remains complete surgical resection, but due to the delay in diagnosis, less than 20% of patients are eligible for surgery. Therefore, discovering diagnostic biomarkers for early detection is crucial for improving clinical outcomes. Metabolomics has become a powerful technology for biomarker discovery, and several metabolomic-based panels have been proposed for PDAC diagnosis, but these advances have not yet been translated into the clinic. Therefore, this review focused on summarizing metabolites identified for the early diagnosis of PDAC in the last five years. Bibliographic searches were performed in the PubMed, Scopus and WOS databases, using the terms "Biomarkers, Tumor", "Pancreatic Neoplasms", "Early Diagnosis", "Metabolomics" and "Lipidome" (January 2018-March 2023), and resulted in the selection of fourteen original studies that compared PDAC patients with subjects with other pancreatic diseases. These investigations showed amino acid and lipid metabolic pathways as the most commonly altered, reflecting their potential for biomarker research. Furthermore, other relevant metabolites such as glucose and lactate were detected in the pancreas tissue and body fluids from PDAC patients. Our results suggest that the use of metabolomics remains a robust approach to improve the early diagnosis of PDAC. However, these studies showed heterogeneity with respect to the metabolomics techniques used and further studies will be needed to validate the clinical utility of these biomarkers.

Sarcopenia assessed by total psoas index - is it correlated with post-operative complications in all digestive cancers?

Background and aims

In cancer patients sarcopenia may be a predictor for postoperative complications of curative or palliative surgery. Several indices including the total psoas area index (TPAI) are proposed for the diagnosis of this condition, but there is no validated cut-off point.Our study aimed to assess the role of TPAI as a marker for sarcopenia and to compare the utility of previously proposed cut-off values for predicting post-operative complications in patients with digestive cancers undergoing surgery.

Methods

We retrospectively included all adult patients with digestive cancers admitted to a tertiary center for elective surgery between January and December 2019. Sarcopenia was considered based on TPAI evaluated on abdominal computed tomography (CT) and for analysis we used different cut-off points published by various authors. The primary endpoint was the occurrence of any complications as defined by the Clavien-Dindo classification. The secondary endpoints were fistula development, low- versus high-grade Clavien-Dindo post-operative complications, moderate or severe anemia at discharge, major bleeding, hypoalbuminemia at discharge, and decrease in albumin levels by at least 1g/dL.

Results

We included 155 patients with a mean age of 64.78 ± 11.40 years, of which 59.35% were males; 58.06% developed postoperative complications. TPAI evaluated as a continuous variable was not a predictor for the development of post-operative complications neither in the general study sample, nor in the gender subgroups of patients. Sarcopenia defined by previously proposed cut-off values was not a predictor of the secondary end-points either.

Conclusion

TPAI as a sole parameter for defining sarcopenia was not a predictor for postoperative complications in patients undergoing surgery for digestive neoplasia.

Association between Computed Tomography-Determined Loss of Muscle Mass and Impaired Three-Month Survival in Frail Older Adults with Cancer

As patients with solid (non-hematological) cancers and a life expectancy of <3 months rarely benefit from oncological treatment, we examined whether the CT-determined loss of muscle mass is associated with an impaired 3-month overall survival (OS) in frail ≥75-year-old patients with cancer. Frailty was assessed with G8-screening and comprehensive geriatric assessment in older adults at risk of frailty. The L3-level skeletal (SMI) and psoas (PMI) muscle indexes were determined from routine CT scans. Established and optimized SMI and PMI cut-offs were used. In the non-curative treatment group (n = 58), 3-month OS rates for normal and low SMI were 95% and 64% (HR 9.28; 95% CI 1.2-71) and for PMI 88%, and 60%, respectively (HR 4.10; 1.3-13). A Cox multivariable 3-month OS model showed an HR of 10.7 (1.0-110) for low SMI, 2.34 (0.6-9.8) for ECOG performance status 3-4, 2.11 (0.5-8.6) for clinical frailty scale 5-9, and 0.57 (0.1-2.8) for males. The 24-month OS rates in the curative intent group (n = 21) were 91% and 38% for the normal and low SMI groups, respectively. In conclusion, CT-determined low muscle mass is independently associated with an impaired 3-month OS and, alongside geriatric assessment, could aid in oncological versus best supportive care decision-making in frail patients with non-curable cancers.

Predictive value of total psoas muscle index for postoperative physical functional decline in older patients undergoing emergency abdominal surgery

BACKGROUND

Older individuals increasingly require emergency abdominal surgeries. They are susceptible to surgical stress and loss of independence in performing daily activities. We hypothesized that the psoas muscle volume would be significantly associated with postoperative functional decline (FD) in older patients undergoing emergency abdominal surgery and aimed to evaluate the use of the psoas muscle volume on computed tomography (CT) scans.

METHODS

A retrospective, single-center study of patients aged ≥ 65 years who had undergone emergency abdominal surgery between January 2019 and June 2021 was performed. We assessed patients' activities of daily living using the Barthel Index. FD was defined as a ≥ 5-point decrease between preoperative and 28-day postoperative values. The psoas muscle volume was measured by CT, which was used for diagnosis, and normalized by height to calculate total psoas muscle index (TPI). We evaluated associations between FD and TPI using receiver operating characteristics (ROC) analysis and multiple logistic regression analysis.

RESULTS

Of 238 eligible patients, 71 (29.8%) had clinical postoperative FD. Compared to the non-FD group, the FD group was significantly older and had a higher proportion of females, higher Charlson Comorbidity Index, lower body mass index, higher American Society of Anesthesiology score, lower serum albumin level, and lower TPI. ROC analyses revealed that TPI had the highest area under the curve (0.802; 95% confidence interval [CI], 0.75-0.86). A multivariable logistic regression model revealed that low TPI was an independent predictor of postoperative FD (odds ratio, 0.14; 95% CI, 0.06-0.32).

CONCLUSIONS

TPI can predict postoperative FD due to emergency abdominal surgery. Identification of patients who are at high risk of FD before surgery may be useful for enhancing the regionalized system of care for emergency general surgery.

Impact of Sarcopenia on Percutaneous Epidural Balloon Neuroplasty in Patients with Lumbar Spinal Stenosis: A Retrospective Analysis

Background and Objectives: With the aging population, the incidence of degenerative lumbar spinal stenosis (LSS) is increasing. Sarcopenia is an age-related muscular decrease. Although epidural balloon neuroplasty is effective in patients with LSS refractory to conventional treatments, its effect has not been assessed in patients with sarcopenia. Therefore, this study evaluated the effect of epidural balloon neuroplasty in patients with LSS and sarcopenia. Materials and Methods: This retrospective study reviewed the following details from the electronic medical records: patient characteristics, including sex, age, body mass index, diabetes, hypertension, stenosis grading, pain duration, location, pain intensity, and medications. Back and leg pain intensity was evaluated before and after the procedure at one, three, and six months during the follow-up period. A generalized estimating equations model was used at six months follow-up. Patients were divided into sarcopenia and non-sarcopenia groups using the cross-sectional area of the psoas muscle at the level of L3 on magnetic resonance imaging. Results: A total of 477 patients were included (sarcopenia group: 314 patients, 65.8%; non-sarcopenia group: 163 patients, 34.2%). Age, sex, body mass index, and medication quantification scale III were statistically different between both groups. The generalized estimating equations analyses-with unadjusted and adjusted estimation-revealed a significantly reduced pain intensity after the procedure compared to the baseline in both groups. The difference in pain intensity between both groups was not statistically different. Conclusions: Percutaneous epidural balloon neuroplasty may be considered for patients with chronic lumbar LSS regardless of accompanying sarcopenia.

Usefulness of the Measurement of Psoas Muscle Volume for Sarcopenia Diagnosis in Patients with Liver Disease

Computed tomography (CT) is often used in the diagnosis of sarcopenia. In this study, we validated the assessment of sarcopenia by the psoas muscle volume using versatile software. The study involved a retrospective analysis of data from 190 patients with liver disease who underwent grip-strength testing and abdominal pelvic computed tomography. To assess sarcopenia, SYNAPSE 3D was used to obtain the skeletal muscle index, the psoas muscle index (PMI), and the simple method. We also used the recently proposed PMI cutoff values, for which the usefulness has been evaluated (O-PMI). The cutoff value of the psoas muscle volume index (PMVI) was determined using one of the diagnostic methods as the gold standard. All diagnostic methods showed that patients with sarcopenia had shorter survival, with O-PMI having the highest hazard ratio (HR) (HR, 6.12; 95% confidence interval [CI], 2.6–14.41; p < 0.001). Even when sarcopenia could not be diagnosed by O-PMI, low PMVI was associated with shorter survival (HR, 3.53; 95% CI, 1.34–9.32; p = 0.01). PMVI may be useful in the evaluation of sarcopenia, including the identification of poor overall survival in cases that cannot be diagnosed by O-PMI, which is considered more useful than PMI.

Pre-Therapeutic Sarcopenia among Cancer Patients: An Up-to-Date Meta-Analysis of Prevalence and Predictive Value during Cancer Treatment

This study will address the prevalence of pre-therapeutic sarcopenia (PS) and its clinical impact during cancer treatment among adult cancer patients ≥ 18 years of age. A meta-analysis (MA) with random-effect models was performed via a MEDLINE systematic review, according to the PRISMA statement, focusing on articles published before February 2022 that reported observational studies and clinical trials on the prevalence of PS and the following outcomes: overall survival (OS), progression-free survival (PFS), post-operative complications (POC), toxicities (TOX), and nosocomial infections (NI). A total of 65,936 patients (mean age: 45.7-85 y) with various cancer sites and extensions and various treatment modes were included. Mainly defined by CT scan-based loss of muscle mass only, the pooled prevalence of PS was 38.0%. The pooled relative risks were 1.97, 1.76, 2.70, 1.47, and 1.76 for OS, PFS, POC, TOX, and NI, respectively (moderate-to-high heterogeneity, I²: 58-85%). Consensus-based algorithm definitions of sarcopenia, integrating low muscle mass and low levels of muscular strength and/or physical performance, lowered the prevalence (22%) and heterogeneity (I² < 50%). They also increased the predictive values with RRs ranging from 2.31 (OS) to 3.52 (POC). PS among cancer patients is prevalent and strongly associated with poor outcomes during cancer treatment, especially when considering a consensus-based algorithm approach.

Sarcopenia of kidney transplant recipients as a predictive marker for reduced graft function and graft survival after kidney transplantation

PURPOSE

The association between sarcopenia of kidney transplant recipients and outcome after kidney transplantation (KT) has not yet been fully understood and is still considered controversial. The aim of our study was to analyze the impact of pre-transplant sarcopenia on graft function, postoperative complication rates, and survival of the patients after renal transplantation.

METHODS

In this retrospective single-center study, all patients who underwent KT (01/2013-12/2017) were included. Demographic data, rejection rates, delayed graft function, and graft and patient survival rates were analyzed. Sarcopenia was measured in computed tomography images by the sex-adjusted Hounsfield unit average calculation (HUAC).

RESULTS

During the study period, 111 single KTs (38 women and 73 men) were performed. Living donor kidney transplants were performed in 48.6%. In total, 32.4% patients had sarcopenia. Sarcopenic patients were significantly older (59.6 years vs. 49.8 years; p < 0.001), had a higher body mass index (BMI = 27.6 kg/m2 vs. 25.0 kg/m2; p = 0.002), and were more likely to receive deceased donor kidneys (72.2% vs. 41.3%; p = 0.002). Interestingly, 3 years after KT, the creatinine serum levels were significantly higher (2.0 mg/dl vs. 1.5 mg/dl; p = 0.001), whereas eGFR (39.9 ml/min vs. 53.4 ml/min; p = 0.001) and graft survival were significantly lower (p = 0.004) in sarcopenic transplant recipients. Sarcopenic patients stayed in hospital significantly longer postoperatively than those who were non-sarcopenic.

CONCLUSIONS

At the time of kidney transplantation, sarcopenia was found to predict reduced long-term graft function and diminished graft survival after KT. The early identification of sarcopenic patients can not only enable an optimized selection of recipients, but also the initiation of pre-habilitation programs during the waiting period.

The TPA score (total psoas muscle area) is the best marker for preoperative measurement of pre-sarcopenia in pancreatic surgery

INTRODUCTION

Pre-sarcopenia, defined by the loss of muscle mass, is significantly associated with an increased risk of postoperative complications in digestive surgery, particularly pancreatic resection. The five predominant markers of sarcopenia are: psoas muscle area (TPA), intramuscular adipose tissue content (IMAC), Average Hounsfield Unit Calculation (HUAC), Skeletal Muscle Mass Index (MMI), and the ratio between visceral adipose tissue area and muscle surface area (VFA/TAMA). No standard reference marker has been determined.

MATERIAL AND METHODS

This retrospective cohort included patients who underwent pancreatic resection at the University Hospital of Angers between January 2008 and June 2017. The goal was to determine the marker that was most significantly associated with morbidity and mortality in pancreatic surgery. The secondary objective was to determine the characteristics of pre-sarcopenic patients.

RESULTS

The TPA score is the most sensitive marker for identifying patients at highest risk for immediate complications (P=0.008), proving far more sensitive than MMI (P=0.02), HUAC (P=0.34), IMAC (P=1), or VFA/TAMA (P=0.42). Postoperative mortality was 3.3% (n=5), morbidity was 63.8% (n=97). Pre-sarcopenic patients, as identified by the TPA index had significantly more immediate complications (71.2% versus 49.5%, P=0.008), in particular, more gastroparesis (P=0.02) and pancreatic fistula (P=0.03).

CONCLUSION

In patients requiring pancreatic surgery, the prevalence of pre-sarcopenia is high and seems to be associated with a greater risk of immediate postoperative complications. The TPA score seems to be the most sensitive marker for detecting pre-sarcopenia. Evaluation of TPA preoperatively would make it possible to identify priority patients a priori who might benefit from pre-habilitation programs.

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.

Sarcopenia is associated with worse surgical complications but not relapse-free survival and overall survival in patients with retroperitoneal liposarcoma

OBJECTIVE

This investigation aimed to explore the relationship between sarcopenia and severe postoperative complications, relapse-free survival (RFS), and overall survival (OS) in patients with retroperitoneal liposarcoma (RLPS).

MATERIAL AND METHODS

This retrospective study included 72 RLPS patients (47 men, 25 women; mean age, 57.49 years, SD 10.92) who had abdominal CT exams. Clinical information was recorded, including RLPS characteristics (histologic subtypes, grade, size), laboratory assessment (ALB, PALB, A/G, Hb, SCr), relapse-free survival, overall survival, and postoperative complications. The relationships between those variables and RFS and OS were analyzed using Cox proportional hazard models.

RESULTS

There were 8 severe postoperative complications (Clavien-Dindo grade > 2). The chi-square test showed sarcopenia was associated with severe postoperative complications (P = 0.011). In multivariate analysis, sarcopenia was not associated with relapse-free survival (P = 0.574) and overall survival (P = 0.578).

CONCLUSIONS

Sarcopenia predicts worse surgical complications but does not affect relapse-free survival and overall survival.

Sarcopenia in pancreatic cancer: Effect on patient outcomes

Pancreatic cancer is a challenging disease with an increasing incidence and extremely poor prognosis. The clinical outcomes of pancreatic cancer depend on tumor biology, responses to treatments, and malnutrition or cachexia. Sarcopenia represents a severe catabolic condition defined by the age-related loss of muscle mass and strength and affects as much as 70% of malnourished pancreatic cancer patients. The lumbar skeletal muscle index, defined as the total abdominal muscle area at the L3 vertebral level adjusted by the square of the height, is widely used for assessing sarcopenia in patients with pancreatic cancer. Several studies have suggested that sarcopenia may be a risk factor for perioperative complications and decreased recurrence-free or overall survival in patients with pancreatic cancer undergoing surgery. Sarcopenia could also intensify chemotherapy-induced toxicities and worsen the quality of life and survival in the neoadjuvant or palliative chemotherapy setting. Sarcopenia, not only at the time of diagnosis but also during treatment, decreases survival in patients with pancreatic cancer. Theoretically, multimodal interventions may improve sarcopenia and clinical outcomes; however, no study has reported positive results. Further prospective studies are needed to confirm the prognostic role of sarcopenia and the effects of multimodal interventions in patients with pancreatic cancer.

The methods of prophylaxis of the pancreatic fistula occurrence after pancreato–duodenectomy

Objective. To elaborate the measures system, which permit to reduce the occurrence of pancreatic fistula and other severe complications after performance of pancreato–duodenectomy. Materials and methods. There were analyzed the results of treatment of 327 patients, in whom pancreato–duodenectomy was performed. In accordance to the scheme proposed, using the elaborated scale of risk for the postoperative pancreatic fistula occurrence with estimation of sarcopenia presence and application of certain prophylactic measures 98 patients were operated in period from November 2018 to December 2020 yr. (the main group). Into the control group 229 patients were included, operated on in the clinic from January 2015 to October 2018 yr. without estimation of risk for the pancreatic fistula occurrence and presence of sarcopenia. The method of pancreato–jejunoanastomosis formation was selected by operating surgeon. Results. Postoperative complications have occurred in 94 (41.0%) patients of the control group and in 28 (28.6%) patients of the main group (c 2 = 4.56, p=0.03). Clinically significant postoperative pancreatic fistula of B Degree have occurred in 9 (9.2%) patients of the main group, what was statistically significantly lower, than in the control group, in which postoperative pancreatic fistula of B or C Degree have occurred in 64 (27.9%) patients (c 2 = 11.6, p=0.0007). Lethality was 2.2% in the control group and 1.02% – in the main one. Conclusion. Introduction of the measures system elaborated have permitted to lower the postoperative pancreatic fistula rate statistically significantly from 27.9 to 9.2%, and of other postoperative complications – from 41.0 to 28.6% and lethality from 2.2 to 1.02%.

Effects of changes in skeletal muscle mass on the prognosis of pediatric malignant solid tumors

PURPOSE

This study aims to clarify the relationship between changes in skeletal muscle mass during treatment and prognosis of pediatric malignant solid tumors.

METHODS

Patients with pediatric malignant solid tumors who were treated at Kyushu University Hospital from 2007 to 2017 were divided into two groups: the progression-free survival (PFS) group and the relapse/death (R/D) group; the psoas major muscle volume (PMV) was then compared. We also measured the PMV and psoas muscle area (PMA) of pediatric patients with no complications who underwent surgery for acute appendicitis (control) and compared the values with those of patients with malignant tumors.

RESULTS

No significant differences were observed in the PMV and PMA between patients with appendicitis and those with malignant tumors. Significant differences were found in the rate of change in PMV between the PFS (1.424) and R/D groups (1.071) (P = 0.0024). When the cut-off value of the rate of change in the PMV was 1.20, patients whose rate of change in PMV was ≥ 1.20 had longer PFS (P = 0.0231) and overall survival (P = 0.0229) than those whose rate of change was < 1.20.

CONCLUSION

Pediatric patients with malignant solid tumors and increased skeletal muscle mass during treatment have a good prognosis.

Multi-omics profiling reveals Chitinase-3-like protein 1 as a key mediator in the crosstalk between sarcopenia and liver cancer

Sarcopenia is prevalent in patients with hepatocellular carcinoma (HCC), and can adversely affect their outcomes. This study aims to explore the key mechanisms in the crosstalk between sarcopenia and HCC based on multi-omics profiling. A total of 136 male patients with HCC were enrolled. Sarcopenia was an independent risk factor for poor outcomes after liver transplantation (p < 0.05). Inflammatory cytokine and metabolomic profiling on these patients identified elevated plasma sTNF-R1/CHI3L1 and dysregulated lipid metabolism as related to sarcopenia and tumor recurrence risk concurrently (p < 0.05). Integrated analysis revealed close relationship between CHI3L1 and fatty acid metabolism. In mouse cachectic models by intraperitoneal injection of H22 cells, CHI3L1 was significantly elevated in the atrophic muscle tissue, as well as in circulation. In-vitro, CHI3L1 was up-regulated in muscle cells to protect itself from inflammatory damage through TNF-α/TNF-R1 signaling. CHI3L1 secreted by the muscle cells promoted the invasion of co-cultured HCC cells. Tumor tissue transcriptome data for 73 out of the 136 patients revealed that CHI3L1 may regulate fatty acid metabolism and oxidative stress. In vitro, CHI3L1 caused ROS and lipid accumulation. Targeted lipid profiling further proved that CHI3L1 was able to activate arachidonic acid metabolism, leading to lipid peroxide (LPO) accumulation. Meanwhile, LPO inhibition could compromise the remarkable pro-cancerous effects of CHI3L1. In conclusion, sarcopenia adversely affects the outcomes of liver transplantation for HCC. In sarcopenic patients, CHI3L1 was up-regulated and secreted by the skeletal muscle to protect itself through TNF-α/TNF-R1 signaling, which, in turn, can promote HCC tumor progression by inducing LPO accumulation.

Preoperative Rapid Weight Loss as a Prognostic Predictor After Surgical Resection for Pancreatic Cancer

OBJECTIVE

The aim of the study is to evaluate the influence of cachexia at the time of diagnosis of pancreatic ductal adenocarcinoma (PDAC) on prognosis in patients undergoing surgical resection.

METHODS

Patients with data on preoperative body weight (BW) change followed by surgical resection during 2008-2017 were selected. Large BW loss was defined as weight loss >5% or >2% in individuals with body mass index less than 20 kg/m2 within 1 year preoperatively. Influence of large BW loss, ΔBW defined as preoperative BW change (%) per month, prognostic nutrition index, and indices of sarcopenia.

RESULTS

We evaluated 165 patients with PDAC. Preoperatively, 78 patients were categorized as having large BW loss. ΔBW was ≤ -1.34% per month (rapid) and > -1.34% per month (slow) in 95 and 70 patients, respectively. The median postoperative overall survival of rapid and slow ΔBW groups was 1.4 and 4.4 years, respectively (P < 0.001). In multivariate analyses rapid ΔBW (hazard ratio [HR], 3.88); intraoperative blood loss ≥430 mL (HR, 1.89); tumor size ≥2.9 cm (HR, 1.74); and R1/2 resection (HR, 1.77) were independent predictors of worse survival.

CONCLUSIONS

Preoperative rapid BW loss ≥1.34% per month was an independent predictor of worse survival of patients with PDAC.

Sarcopenia Is Associated With Increased Mortality in Patients With Necrotizing Soft Tissue Infections

INTRODUCTION

Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI.

METHODS

This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality.

RESULTS

There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8).

CONCLUSIONS

Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families.

Validation of automated body composition analysis using diagnostic computed tomography imaging in patients with pancreatic cancer

BACKGROUND

Sarcopenia is associated with complications and inferior oncologic outcomes in solid tumors. Axial computed tomography (CT) scans can be used to evaluate sarcopenia, however manual quantification is laborious. We sought to validate an automated method of quantifying muscle cross-sectional area (CSA) in patients with pancreatic adenocarcinoma (PDAC).

METHODS

Mid-L3 CT images from patients with PDAC were analyzed: CSAs of skeletal muscle (SM) were measured using manual segmentation and the software AutoMATiCA, and then compared with linear regression.

RESULTS

Five-hundred-twenty-five unique scans were analyzed. There was robust correlation between manual and automated segmentation for L3 CSA (R2 0.94, P < 0.001). Bland-Altman analysis demonstrated a consistent overestimation of muscle CSA by AutoMATiCA with a mean difference of 5.7%. A correction factor of 1.06 was validated using a unique test dataset of 36 patients with non-PDAC peripancreatic malignancies.

CONCLUSIONS

Automated muscle CSA measurement with AutoMATiCA is highly efficient and yields results highly correlated with manual measurement. These findings support the potential use of high-throughput sarcopenia analysis with abdominal CT scans for both clinical and research purposes.

Acute post-traumatic muscle atrophy on CT scan predicts prolonged mechanical ventilation and a worse outcome in severe trauma patients

BACKGROUND

The aim of present study was to assess the association between acute post-traumatic atrophy (APTMA) determined on psoas computed tomography [CT] scan and the duration of mechanical ventilation and outcomes in severe trauma patients.

METHODS

A retrospective analysis of severe trauma patients (Injury Severity Score [ISS], >15) hospitalized in the intensive care unit (ICU) for more than 7 days between January 2010 and December 2015 was performed. The psoas muscle index (PMI) was measured on admission and at delayed CT scan. ΔPMI was calculated as the percentage PMI loss between these two scans. Three groups were defined and compared a posteriori using the quartiles of the ΔPMI values: low (lower quartile), moderate, and severe (higher quartile) APTMA groups. Linear regression analysis was performed to predict the duration of mechanical ventilation, of catecholamines, length of stay (LOS) in the ICU and hospital, and complications were assessed.

RESULTS

A total of 114 trauma patients were included (median age, 40 years; [IQR, 25-54 years]; ISS, 33 [IQR, 25-41]). Based on the ΔPMI determination, 29 patients were allocated in the low APTMA group (range ∆PMI, 0%-6%), 56 in the moderate APTMA group (range ∆PMI, 6%-18%), and 29 in the APTMA group (range ∆PMI, ≥19%). Severity of APTMA was significantly associated with the duration of mechanical ventilation and catecholamines, ICU and hospital LOS (P<0.001). Delayed pneumonia (P=0.006) and other delayed infections (P=0.014), as well as thromboembolic events (P=0.04) were statistically associated with the severity of APTMA, whereas mortality did not differ between the three groups (P=0.20). Using linear regression analysis, each ∆PMI increase of 1% was significantly associated with 0.90 supplementary days of mechanical ventilation (P<0.001), 0.29 supplementary days of catecholamines (P<0.001) and 0.82 supplementary days of hospitalization (P<0.001). All these statistical associations were confirmed in multivariate analysis (P<0.001).

CONCLUSION

Acute muscle atrophy diagnosed on CT scan by psoas area measurement (ΔPMI) was strongly associated with poor outcomes in severe trauma patients.

Psoas muscle measurement as a predictor of recurrent lumbar disc herniation: A retrospective blind study

AbstractParaspinal (erector spinae and multifidus) and psoas muscles contribute to spinal stability, but no study has yet examined the relationship between muscle mass and recurrent lumbar disc herniation (rLDH). The purpose of this study was to investigate the effect of psoas and paraspinal muscle mass on recurrent Lumbar disc herniation (LDH). This retrospective study included 49 patients with LDH (22 men, 27 women; mean age: 59.9 years; range 32-80) who underwent discectomy and partial laminectomy without fusion and underwent both pre- and postoperative magnetic resonance imaging. The presence of rLDH was determined using medical records and postoperative magnetic resonance imagings. Patients were divided into an rLDH group (26 patients) and a without-rLDH group (23 patients). Clinical characteristics, segmental motion, and paraspinal and psoas muscle mass were compared between the groups. Using ImageJ software, the cross-sectional area (CSA), lean muscle mass (LMM), and skeletal muscle index (SMI) were measured on T2 axial preoperative magnetic resonance images at L2-L3, L3-L4, and L4-L5 disc levels to represent muscle mass. Univariate and multivariate logistic regression analyses were performed. In the rLDH group, patients were younger (52.6 years vs 68.2 years; P = .001), segmental instability was more common (50.0% vs 4.3%; P = .001), and the CSA, LMM, CSASMI, and LMMSMI of psoas muscles were larger (5851.59 mm2 vs 4264.93 mm2, 5456.59 mm2 vs 4044.77 mm2, 18.77 cm2/m2 vs 13.86 cm2/m2, and 17.52 cm2/m2 vs 12.98 cm2/m2; P < .01 for all 4 variables). On multivariate logistic regression, age and segmental instability were independent risk factors for rLDH (odds ratio 0.886 and 18.527; P = .01 and P = .02, respectively). In middle-aged and elderly patients with lumbar disc herniation, relatively younger age, segmental instability, and greater psoas muscle mass may be risk factors for recurrence.

Effect of sarcopenia in predicting postoperative mortality in emergency laparotomy: a systematic review and meta-analysis

Background

While emergency laparotomy has been associated with high rates of postoperative mortality and adverse events, preoperative systematic evaluation of patients may improve perioperative outcomes. However, due to the critical condition of the patient and the limited operation time, it is challenging to conduct a comprehensive evaluation. In recent years, sarcopenia is considered a health problem associated with an increased incidence of poor prognosis. This study aimed to investigate the effect of sarcopenia on 30-day mortality and postoperative adverse events in patients undergoing emergency laparotomy.

Methods

We systematically searched databases including PubMed, Embase, and Cochrane for all studies comparing emergency laparotomy in patients with and without sarcopenia up to March 1, 2022. The primary outcome was of 30-day postoperative mortality. Secondary outcomes were the length of hospital stay, the incidence of adverse events, number of postoperative intensive care unit (ICU) admissions, and ICU length of stay. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) tool. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Result

A total of 11 eligible studies were included in this study. The results showed that patients with sarcopenia had a higher risk of death 30 days after surgery (OR = 2.42, 95% CI = 1.93–3.05, P < 0.00001). More patients were admitted to ICU after surgery (OR = 1.58, 95% CI = 1.11–2.25, P = 0.01). Both the ICU length of stay (MD = 0.55, 95% CI = 0.05–1.06, P = 0.03) and hospital length of stay (MD = 2.33, 95% CI = 1.33–3.32, P < 0.00001) were longer in the sarcopenia group. The incidence of postoperative complications was also significantly higher in patients with sarcopenia (OR = 1.78, 95% CI = 1.41–2.26, P < 0.00001).

Conclusion

In emergency laparotomy, sarcopenia was associated with increased 30-day postoperative mortality. Both the lengths of stay in the ICU and the total length of hospital stay were significantly higher than those in non-sarcopenic patients. Therefore, we concluded that sarcopenia can be used as a tool to identify preoperative high-risk patients, which can be considered to develop new postoperative risk prediction models.

Registration number Registered on Prospero with the registration number of CRD42022300132.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00440-0.

Preoperative sarcopenia is a negative predictor for enhanced postoperative recovery after pancreaticoduodenectomy

PURPOSE

Sarcopenia is common in pancreatic cancer patients. Considering the growing adoption of standardized protocols for enhanced recovery after surgery (ERAS), we examined the clinical impact of sarcopenia in pancreaticoduodenectomy (PD) patients in a 5-day accelerated ERAS program, termed the Whipple Accelerated Recovery Pathway.

METHODS

A retrospective review was conducted of patients undergoing PD from 2017 through 2020 on the ERAS pathway. Preoperative computerized tomographic scans taken within 45 days before surgery were analyzed to determine psoas muscle cross-sectional area (PMA) at the third lumbar vertebral body. Sarcopenia was defined as the lowest quartile of PMA respective to gender. Outcome measures were compared between patients with or without sarcopenia.

RESULTS

In this 333-patient cohort, 252 (75.7%) patients had final pathology revealing pancreatic or periampullary cancer. The median age was 66.7 years (16.4-88.4 years) with a 161:172 male to female ratio. Sarcopenia correlated with delayed tolerance of oral intake (OR 2.2; 95%CI 1.1-4.3, P = 0.03), increased complication rates (OR 4.3; 95%CI 2.2-8.5, P < 0.01), and longer hospital length of stay (LOS) (P < 0.05). Preoperative albumin levels, BMI, and history of pancreatitis were also found to correlate with LOS (P < 0.05). Multivariate regression analysis found low PMA, BMI, and male gender to be independent predictors of increased LOS (P < 0.05).

CONCLUSION

Sarcopenia correlated with increased LOS and postoperative complications in ERAS patients after PD. Sarcopenia can be used to predict poor candidates for ERAS protocols who may require an alternative recovery protocol, promoting a clinical tier-based approach to ERAS for pancreatic surgery.

Low skeletal muscle mass and post-operative complications after surgery for liver malignancies: a meta-analysis

Purpose

To assess the influence of low skeletal muscle mass (LSMM) on post-operative complications in patients with hepatic malignancies grade (Clavien Dindo ≥ 3) undergoing resection.

Methods

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between sarcopenia and major post-operative complications (≥ grade 3 according to Clavien-Dindo classification) after resection of different malignant liver tumors. RevMan 5.3 software was used to perform the meta-analysis. The methodological quality of the included studies was assessed according to the QUIPS instrument.

Results

The analysis included 17 studies comprising 3157 patients. Subgroup analyses were performed for cholangiocarcinoma (CCC), colorectal cancer (CRC) liver metastases, and hepatocellular carcinoma (HCC). LSMM as identified on CT was present in 1260 patients (39.9%). Analysis of the overall sample showed that LSMM was associated with higher post-operative complications grade Clavien Dindo ≥ 3 (OR 1.56, 95% CI 1.25–1.95, p < 0.001). In the subgroup analysis, LSMM was associated with post-operative complications in CRC metastases (OR 1.60, 95% CI 1.11–2.32, p = 0.01). In HCC and CCC sub-analyses, LSMM was not associated with post-operative complications in simple regression analysis.

Conclusion

LSMM is associated with major post-operative complications in patients undergoing surgery for hepatic metastases and it does not influence major post-operative complications in patients with HCC and CCC.

Gastrointestinal Cancer Patient Nutritional Management: From Specific Needs to Novel Epigenetic Dietary Approaches

Nutritional habits impinge on the health of the gastrointestinal (GI) tract, contributing to GI disorder progression. GI cancer is a widespread and aggressive tumor sensitive to nutritional changes. Indeed, specific nutritional expedients can be adopted to prevent GI cancer onset and to slow down disease activity. Moreover, the patient’s nutritional status impacts prognosis, quality of life, and chemotherapy tolerance. These patients encounter the highest frequency of malnourishment risk, a condition that can progressively evolve into cachexia. Clinical studies dealing with this topic stressed the importance of nutritional counseling and put under the spotlight nutrient delivery, the type of nutrient supplementation, and timing for the start of nutritional management. A medical practitioner well-prepared on the topic of nutrition and cancer should operate in the clinical team dedicated to these oncological patients. This specific expertise needs to be implemented as soon as possible to adopt nutritional interventions and establish a proper patient-tailored dietary regimen. The nutritional gap closure should be prompt during anticancer treatment to stabilize weight loss, improve treatment tolerability, and ameliorate survival rate. Recently, novel nutritional approaches were investigated to target the bidirectional link between epigenetics and metabolism, whose alteration supports the onset, progression, and therapeutic response of GI cancer patients.