Association of preoperative sarcopenia with postoperative dysphagia in patients with thoracic esophageal cancer

Impact of Presarcopenic Dysphagia on 1-Year Mortality After Videofluoroscopic Swallowing Study in Patients with Cancer

Sarcopenic dysphagia is the term for swallowing difficulty associated with loss of mass, strength, and physical performance, which leads to increased pharyngeal residues. Unlike sarcopenia, presarcopenia is characterized by low muscle mass without decreased muscle strength or physical performance and can develop into dysphagia due to low skeletal muscle mass. This retrospective study investigated the impact of presarcopenic dysphagia (PSD) on 1-year mortality in patients with cancer and dysphagia who underwent a videofluoroscopic swallowing study (VFSS). An operational definition of PSD based on presarcopenia and pharyngeal residues was adopted. The psoas muscle mass index (cm2/height [m2]), calculated by the psoas muscle area at the third lumber vertebra via abdominal computed tomography (CT) and related to height, was used to assess presarcopenia with cutoff values of 4.62 for men and 2.66 for women. Pharyngeal residues were assessed using a VFSS to evaluate dysphagia. Patients' medical charts were analyzed to investigate 1-year mortality after a VFSS. Out of 111 consecutive patients with cancer, 53 (47.7%) were defined as having PSD. In a forward-stepwise Cox proportional regression analysis, PSD (HR 2.599; 95% CI 1.158-5.834; p = 0.021) was significantly associated with 1-year mortality after a VFSS, even after adjusting for the factors of operation, Functional Oral Intake Scale (FOIS) scores at discharge, and modified Barthel Index (BI) scores at discharge. PSD, defined as CT-based presarcopenia and pharyngeal residues observed during a VFSS, is associated with increased 1-year mortality in patients with cancer and dysphagia.

Impact of low pharyngeal/esophageal pressure associated with sarcopenia on postendoscopic submucosal dissection pneumonia in patients with superficial esophageal cancer

OBJECTIVES

The aging population, including patients with superficial esophageal cancer, encounters critical dysphagia- and postoperative pneumonia-related issues. Although endoscopic submucosal dissection (ESD) provides advantages over other modalities, older patients are at higher risk of postoperative pneumonia. Furthermore, the etiologies of pneumonia are complex and include patient- (such as sarcopenia) and treatment- (including ESD) related factors. Therefore, this study evaluated swallowing function in patients with superficial esophageal cancer and identified post-ESD pneumonia-associated factors.

METHODS

Comprehensive swallowing function and sarcopenia were evaluated in patients pre-ESD and 2 months post-ESD using high-resolution manometry and several swallowing studies by multiple experts. The effects of mucosal resection and sarcopenia on swallowing function changes post-ESD, the relationship between preoperative swallowing function and sarcopenia, and the factors influencing postoperative pneumonia were investigated.

RESULTS

Twenty patients were included in the study. Patients with preoperative sarcopenia had significantly lower pharyngeal/upper esophageal sphincter and tongue pressures than those without sarcopenia. However, ESD did not worsen pharyngeal or upper esophageal pressure. Post-ESD pneumonia incidence tended to be higher in patients with sarcopenia than in those without sarcopenia. The lower upper esophageal sphincter-integrated relaxation pressure (UES-IRP) was a significant factor in pneumonia development. Furthermore, the receiver operating characteristic curve for UES-IRP in pneumonia yielded an area under the curve of 0.82.

CONCLUSIONS

Sarcopenia is associated with preoperative dysphagia, which increases post-ESD pneumonia risk. Therefore, postoperative pneumonia incidence is expected to increase with an aging population, making preoperative sarcopenia and swallowing function evaluation crucial.

Nature, severity, and impact of chronic oropharyngeal dysphagia following curative resection for esophageal cancer: a cross-sectional study

Chronic oropharyngeal dysphagia (COD) and aspiration after esophageal cancer surgery may have clinical significance; however, it is a rarely studied topic. In a prospective cross-sectional observational study we comprehensively evaluated the nature, severity, and impact of COD, its predictors, and the impact of the surgical approach and site of anastomosis. Forty participants were recruited via purposive sampling from the (Irish) National Center between November 2021 and August 2022. Swallow evaluations included videofluoroscopy [Dynamic Imaging Grade of Swallowing Toxicity v2 (DIGESTv2), MBS Impairment Profile, Penetration-Aspiration Scale)]. Functional Oral Intake Scale (FOIS) identified oral intake status. The patient reported outcome measures of swallowing, and Quality of Life (QL) included EAT-10 and MD Anderson Dysphagia Inventory (MDADI). Fourteen (35%) participants presented with COD on DIGESTv2 and 10% had uncleared penetration/aspiration. Avoidance or modification of diet on FOIS was observed in 17 (42.5%). FOIS was associated with pharyngeal dysphagia (OR = 4.05, P = 0.046). Median (range) EAT-10 and MDADI Composite results were 3(0-30) and 77.9(60-92.6), respectively. Aspiration rates significantly differed across surgical groups (P = 0.029); only patients undergoing transhiatal surgery aspirated. Survivors of esophageal cancer surgery may have COD that is undiagnosed, potentially impacting swallow-related QL. Given the small number of aspirators, further research is required to determine whether aspiration risk is associated with surgical approach. A FOIS score below 7 may be a clinically useful prompt for the MDT to refer for evaluation of COD following curative intent surgery. These data present findings that may guide preventive and rehabilitative strategies toward optimizing survivorship.

Association Between Body Composition and Survival in Patients With Gastroesophageal Adenocarcinoma: An Automated Deep Learning Approach

PURPOSE

Body composition (BC) may play a role in outcome prognostication in patients with gastroesophageal adenocarcinoma (GEAC). Artificial intelligence provides new possibilities to opportunistically quantify BC from computed tomography (CT) scans. We developed a deep learning (DL) model for fully automatic BC quantification on routine staging CTs and determined its prognostic role in a clinical cohort of patients with GEAC.

MATERIALS AND METHODS

We developed and tested a DL model to quantify BC measures defined as subcutaneous and visceral adipose tissue (VAT) and skeletal muscle on routine CT and investigated their prognostic value in a cohort of patients with GEAC using baseline, 3-6-month, and 6-12-month postoperative CTs. Primary outcome was all-cause mortality, and secondary outcome was disease-free survival (DFS). Cox regression assessed the association between (1) BC at baseline and mortality and (2) the decrease in BC between baseline and follow-up scans and mortality/DFS.

RESULTS

Model performance was high with Dice coefficients ≥0.94 ± 0.06. Among 299 patients with GEAC (age 63.0 ± 10.7 years; 19.4% female), 140 deaths (47%) occurred over a median follow-up of 31.3 months. At baseline, no BC measure was associated with DFS. Only a substantial decrease in VAT >70% after a 6- to 12-month follow-up was associated with mortality (hazard ratio [HR], 1.99 [95% CI, 1.18 to 3.34]; P = .009) and DFS (HR, 1.73 [95% CI, 1.01 to 2.95]; P = .045) independent of age, sex, BMI, Union for International Cancer Control stage, histologic grading, resection status, neoadjuvant therapy, and time between surgery and follow-up CT.

CONCLUSION

DL enables opportunistic estimation of BC from routine staging CT to quantify prognostic information. In patients with GEAC, only a substantial decrease of VAT 6-12 months postsurgery was an independent predictor for DFS beyond traditional risk factors, which may help to identify individuals at high risk who go otherwise unnoticed.

Hand Grip Strength Assessment Based on Sarcopenia Diagnostic Criteria Predicts Swallowing Function

The purpose of this study is to clarify whether swallowing function can be inferred from grip strength. Based on the diagnostic criteria of sarcopenia, patients were divided into two groups according to grip strength, and it was analyzed whether there was a difference in the evaluation index for swallowing function between the two groups. Among the cases requesting evaluation of swallowing function from June 10, 2020 to October 28, 2020, 83 cases (mean age: 71.7 years, 59 males and 24 females) who received assessment tests and swallowing endoscopy were included. According to the diagnostic criteria for grip strength in the Asian working group in Sarcopenia, less than 28 kgf and 18 kgf were defined as the weak group for men and women, respectively. Hyodo scores, repeated salivary swallowing tests (RSST), maximum vocalization time (MPT), and dysphagia severity classification (DSS) were compared between the two groups. Of the 83 patients, 29 and 54 were in the normal group and weak group, respectively. In all indicators, the normal group showed significantly better results than the weak group: Hyodo score (2.4 vs. 4.0, p < 0.01), RSST (4.1 times vs. 2.4 times, p < 0.01), MPT (12.1 s vs. 5.9 s, p < 0.001), DSS (4.5 vs. 5.9, p < 0.001), respectively. In multiple regression analysis with DSS as the dependent variable, grip strength was a significant independent variable of DSS even after adjusting for age, gender, and body mass index. Grip strength assessment based on sarcopenia criteria can be a useful tool for estimating swallowing function.

Development of predictive score for postoperative dysphagia after emergency abdominal surgery in patients of advanced age

Aim

Postoperative dysphagia after emergency abdominal surgery (EAS) in patients of advanced age has become problematic, and appropriate dysphagia management is needed. This study was performed to identify predictive factors of dysphagia after EAS and to explore the usefulness of swallowing screening tools (SSTs).

Methods

This retrospective study included 267 patients of advanced age who underwent EAS from 2012 to 2022. They were assigned to a dysphagia group and non-dysphagia group using the Food Intake Level Scale (FILS) (dysphagia was defined as a FILS level of <7 on postoperative day 10). From 2018, original SSTs including a modified water swallowing test were performed by nurses.

Results

The incidence of postoperative dysphagia was 22.8% (61/267). Patients were significantly older in the dysphagia than non-dysphagia group. The proportions of patients who had poor nutrition, cerebrovascular disorder, Parkinson's disease, dementia, nursing-care service, high intramuscular adipose tissue content (IMAC), and postoperative ventilator management were much higher in the dysphagia than non-dysphagia group. Using logistic regression analysis, high IMAC, postoperative ventilator management, cerebrovascular disorder, and dementia were correlated with postoperative dysphagia and were assigned 10, 4, 3, and 3 points, respectively, according to each odds ratio. The optimal cut-off value was 7 according to a receiver operating characteristics curve. Using 1:1 propensity score matching for high-risk patients, the incidence of postoperative dysphagia was reduced by SSTs.

Conclusions

The new prediction score obtained from this study can identify older patients at high risk for dysphagia after EAS, and SSTs may improve these patients' short-term outcomes.

The impact of sarcopenia on esophagectomy for cancer: a systematic review and meta-analysis

BACKGROUND

Esophagectomy is the gold-standard treatment for locally advanced esophageal cancer but has high morbimortality rates. Sarcopenia is a common comorbidity in cancer patients. The exact burden of sarcopenia in esophagectomy outcomes remains unclear. Therefore, this systematic review and meta-analysis were performed to establish the impact of sarcopenia on postoperative outcomes of esophagectomy for cancer.

METHODS

We performed a systematic review and meta-analysis comparing sarcopenic with non-sarcopenic patients before esophagectomy for cancer (Registration number: CRD42021270332). An electronic search was conducted on Embase, PubMed, Cochrane, and LILACS, alongside a manual search of the references. The inclusion criteria were cohorts, case series, and clinical trials; adult patients; studies evaluating patients with sarcopenia undergoing esophagectomy or gastroesophagectomy for cancer; and studies that analyze relevant outcomes. The exclusion criteria were letters, editorials, congress abstracts, case reports, reviews, cross-sectional studies, patients undergoing surgery for benign conditions, and animal studies. The meta-analysis was synthesized with forest plots.

RESULTS

The meta-analysis included 40 studies. Sarcopenia was significantly associated with increased postoperative complications (RD: 0.08; 95% CI: 0.02 to 0.14), severe complications (RD: 0.11; 95% CI: 0.04 to 0.19), and pneumonia (RD: 0.13; 95% CI: 0.09 to 0.18). Patients with sarcopenia had a lower probability of survival at a 3-year follow-up (RD: -0.16; 95% CI: -0.23 to -0.10).

CONCLUSION

Preoperative sarcopenia imposes a higher risk for overall complications and severe complications. Besides, patients with sarcopenia had a lower chance of long-term survival.

Negative impact of computed tomography-based low skeletal muscle mass on swallowing recovery in patients with post-stroke dysphagia

OBJECTIVES

Dysphagia due to stroke has a high prevalence, and evaluating the swallowing function of dysphagia and promoting oral intake is essential in patients with stroke. The psoas muscle mass index（cm2/height2（m2））, calculated by the psoas muscle area at the L3 level via abdominal computed tomography （CT）, can predict the development of dysphagia. However, knowledge about the impact of CT-based skeletal muscle mass on swallowing recovery, remains unknown. Therefore, we investigated whether CT-based low skeletal muscle mass impacted swallowing recovery.

METHODS

A retrospective cohort study was conducted on patients with post-stroke dysphagia who underwent acute treatments along with a videofluoroscopic swallowing study（VFSS）. Swallowing recovery was identified as the improvement of the Functional Oral Intake Scale （FOIS） from the time of VFSS to discharge（observational period: ObPd）. The psoas muscle mass index's cut-off values for low skeletal muscle mass were 3.74 cm2/m2 and 2.29 cm2/m2 for men and women respectively.

RESULTS

There were 53 subjects （36 male, median age 73.9）. The median during the ObPd was 26 days, and the median days from onset to admission and admission to VFSS were 0 and 18, respectively. Sixteen patients had low skeletal muscle mass. The median improvement of FOIS during the ObPd was 2, and the median length of hospital stay was 51 days. In the stepwise multiple linear regression analysis for the improvement of FOIS during the ObPd, low skeletal muscle mass （β - 0.245; 95% confidence interval - 2.248 to - 0.127; p = 0.029） was a significant factor, even adjusted for serum albumin at admission, disturbance of consciousness at VFSS, FOIS at VFSS, and aspiration during VFSS.

CONCLUSION

CT-based low skeletal muscle mass negatively impacted swallowing recovery during the ObPd in patients with post-stroke dysphagia.

Oropharyngeal dysphagia and cachexia: Intertwined in head and neck cancer

BACKGROUND

This study aims to investigate the relationship between cancer cachexia and oropharyngeal dysphagia (OD) in patients with head and neck cancer (HNC) prior to chemoradiotherapy or bioradiotherapy (CRT/BRT).

METHODS

A prospective cohort study with patients with HNC undergoing CRT/BRT (2018-2021) was conducted. Body composition and skeletal muscle function were evaluated using bioelectrical impedance analysis, handgrip strength, and the short physical performance battery (SPPB). The M. D. Anderson Dysphagia Inventory (MDADI), Eating Assessment Tool (EAT)-10 questionnaire, and patient characteristics were collected. A standardized videofluoroscopic swallowing study was offered to patients.

RESULTS

Sixty-six patients were included. Twenty-six patients scored EAT-10 ≥ 3 and seventeen were cachectic. ACE-27 score >1, cachexia, abnormal SPPB-derived repeated chair-stand test, lower MDADI scores, and higher overall stage grouping showed potential predictive value (p ≤ 0.10) for EAT-10 ≥ 3. Using multivariable regression analysis, only cachexia remained a significant predictor of EAT-10 ≥ 3 (HR 9.000 [95%CI 2.483-32.619], p = 0.001).

CONCLUSION

Cachexia independently predicted the presence of patient-reported OD.

Nutritional Status and the Outcomes of Endoscopic Stenting in Benign and Malignant Diseases of Esophagus

BACKGROUND

Endoscopic stenting (ES) is a widely known method for palliative dysphagia treatment in esophageal strictures. Esophageal cancer is often associated with advanced malnutrition, which may increase the risk of complications of the procedure. The aim of this study was to evaluate complication rates and the impact of nutritional status on the outcomes of ES.

PATIENTS AND METHODS

A single-center retrospective study was conducted at Copernicus Hospital in Gdańsk, Poland. Adult patients who underwent endoscopic stenting between February 2014 and December 2018 were included. The influence of patient characteristics (age, sex, indications for esophageal stenting, and location of stenosis) and nutritional status (BMI, NRS 2002, GLIM, and dysphagia score) on complication rates and survival were analyzed.

RESULTS

Eighty-one patients (69% men) were enrolled in the study. In 69%, the indication for ES was malignancy (mainly esophageal cancer). The median dysphagia score significantly decreased from 2.8 to 0.6 after the procedure (p < 0.001). Complications were observed in 27% (n = 22) of the patients. Early complications were bleeding (2.5%), stent unexpansion (2.5%), and stent migration during the procedure (3.7%). There were no early fatal complications of the procedure. Late complications included: stent migration (6.2%), tissue overgrowth (6.2%), food impaction (2.2%), fistula formation (3.7%), bleeding (3.7%), and stent malposition (1.2%). A total of 76% of the participants scored ≥ 3 points in nutritional screening (NRS2002) and 70% were diagnosed with severe malnutrition (GLIM -stage 2). A stent diameter of < 2.2 cm compared with ≥ 2.2 was associated with a higher rate of migrations (15.5% vs. 2.5%). The median survival time in the malignant group was 90 days. Histopathological diagnosis and patients' nutritional status (BMI, NRS 2002, GLIM, and dysphagia score) had no significant effect on complication rates and survival after esophageal stent insertion.

CONCLUSIONS

Endoscopic stenting is a relatively safe procedure for the palliative treatment of esophageal strictures. Severe malnutrition, although common, does not affect the outcomes of the procedure.

Usefulness of the skeletal muscle index in postoperative ileus of colorectal cancer patients: a retrospective cohort study

BACKGROUND

Postoperative complications of colorectal cancer mainly include infections (surgical site infection, remote infection, etc.), post-operative ileus (POI), and anastomosis leakage. POI reportedly prolongs the hospital stay and increases medical costs. Therefore, predicting POI is very important. There have been some reports on the relationships between sarcopenia and postoperative complications in colorectal cancer patients, but none have been limited to POI. We therefore conducted a retrospective clinical study with a logistic regression analysis to confirm the risk factors for ileus after colorectal cancer surgery.

METHODS

We retrospectively analyzed 213 patients who underwent elective oncological colorectal surgery for colorectal cancer from November 2017 to July 2021. The skeletal muscle mass (SMM, kg) was estimated using a whole-body bioelectrical impedance analysis (BIA), and the skeletal muscle index (SMI) was calculated as the SMM/height². We divided all patients into 2 groups based on a low SMI (male < 8.958 kg/m², female < 8.443 kg/m²) or normal SMI. Preoperative and intraoperative factors as well as, postoperative outcomes were then compared between the two groups.

RESULTS

The median (range) age of the 213 included patients was 72.0 (33-91) years old. Complications were noted in 96 patients (45.1%), including 21 (9.9%) with POI. There were 68 (31.9%) low SMI patients. POI occurred significantly more frequently in low SMI patients (19.1%) than in normal SMI patients (5.5%) (p = 0.005). In the multivariate analysis, bleeding (p = 0.039) and a low SMI (p = 0.031) were significantly associated with POI. In addition, a propensity score matching analysis was performed to further reduce the selection bias. As a result, a low SMI was the only independent POI predictor among the 78 matched cases.

CONCLUSION

A preoperative low SMI in colorectal cancer patients was considered a risk factor for POI.

Pylorus-preserving versus Pylorus-resecting: Impact on dynamic changes of nutrition and body composition in pancreatic cancer patients before and after pancreatoduodenectomy

OBJECTIVES

To investigate if different methods of pancreatoduodenectomy (with or without pyloric preservation) would have different impacts on postoperative nutrition and body composition changes among pancreatic cancer patients.

METHODS

Demographic and clinicopathological data, perioperative data were collected, body composition (e.g. skeletal muscle cross-sectional area [CSA], visceral fat area [VFA]) were evaluated with abdominal CT before and after surgery. Sarcopenia patients' proportion changes were also recorded.

RESULTS

The hospital stay in the PRPD group was significantly less than that in the PPPD group (p < 0.05). A significant difference was found in CSA, skeletal muscle index (SMI), VFA, VFA/CSA and albumin (ALB) in both groups between preoperative, 3, and 12 months after surgery. The loss of visceral fat in the PRPD group was more prominent than that in the PPPD group at 3 months and 12 months after surgery (p < 0.05). VFA/CSA was higher in the PPPD group than in the PRPD group (3 months: p < 0.05, 12 months: p < 0.001). The proportion of sarcopenic patients increased significantly over time in the PPPD and PRPD groups (p < 0.001).

CONCLUSIONS

Postoperative CSA and VFA continued to significantly decrease in both PPPD and PRPD groups, while the incidence of sarcopenia continued to increase. Compared with PRPD, PPPD has a protective effect on visceral fat. PPPD may contribute to better maintaining visceral fat mass and blood ALB levels. CT quantification can be an objective and effective method to evaluate the nutritional status of pancreatic cancer patients during the pre- and postoperative period and can provide a useful objective basis for guiding clinical treatment.

Clinical significance of sarcopenic dysphagia for patients with esophageal cancer undergoing esophagectomy: A review

The relationships among esophagectomy for esophageal cancer, dysphagia, and sarcopenia are still unclear. We considered appropriate interventions for patients with resectable esophageal cancer for the purpose of reducing postoperative dysphagia and aspiration pneumonia. Dysphagia in patients with esophageal cancer is caused by patient characteristics, such as pathophysiology and age, or complications after esophagectomy. Recently, sarcopenic dysphagia, defined as dysphagia associated with whole‐body sarcopenia, has attracted attention in various fields, and a large proportion of patients with esophageal cancer are expected to have sarcopenic dysphagia. Our systematic review and meta‐analysis suggested that preoperative sarcopenia in patients with esophageal cancer is related to pulmonary complications after esophagectomy, and some reports also suggested that sarcopenia in swallowing‐related muscles, such as the geniohyoid muscle and tongue, might be associated with postoperative pneumonia or dysphagia after esophagectomy. However, clinical studies on sarcopenic dysphagia in patients with esophageal cancer have been limited. To prevent sarcopenic dysphagia after esophagectomy, perioperative interventions involving not only swallowing rehabilitation, but also physical exercise and nutritional support are important. Moreover, several reports have suggested that the chin‐down maneuver might be effective for preventing aspiration after an esophagectomy. To inhibit the progression of sarcopenic dysphagia after esophagectomy, evaluations and interventions by multidisciplinary staff are likely to be necessary.

Sarcopenia predicts an adverse prognosis in patients with combined hepatocellular carcinoma and cholangiocarcinoma after surgery

Background

The prognostic value of sarcopenia in combined hepatocellular carcinoma and cholangiocarcinoma (cHCC‐CC) patients after surgery has not been evaluated, while the efficacy of the available tumor stage for cHCC‐CC remains controversial.

Methods

All consecutive cHCC‐CC patients after surgery were retrieved. The patients were stratified by the sex‐specific medians of the psoas muscle index into groups with or without sarcopenia. Prognosis was analyzed using the Kaplan–Meier (K–M) method, and the K–M curves were adjusted by inverse probability weighting (IPW). A nomogram based on Cox regression analysis was established and further compared with primary liver cancer (PLC) stages by internal validation based on bootstrap resampling and k‐fold cross‐validation.

Results

A total of 153 patients were stratified into sarcopenia and non‐sarcopenia groups. The sarcopenia group revealed statistically worse overall survival (OS) and disease‐free survival (DFS) using the K–M method and K–M curves adjusted by IPW. Multivariate Cox regression analyses suggested sarcopenia as an independent risk factor for OS (HR = 1.55; p = 0.040) and DFS (HR = 1.55; p = 0.019). Subgroup analysis based on baseline variables showed sarcopenia as a stable risk factor for the prognosis. Our nomogram outperformed PLC stages in prognostic prediction, as evidenced by the best c‐index, area under the curve, and positive improvement of the net reclassification index and integrated discrimination improvement. A fivefold cross‐validation revealed consistent results. Decision curve analysis revealed higher net benefits of the nomogram than PLC stages.

Conclusions

Sarcopenia is an independent and stable risk factor for the prognosis of cHCC‐CC patients after surgery. Our nomogram might aid high‐risk patient identification and clinical decisions.

Safety, Precautions, and Modalities in Cancer Rehabilitation: an Updated Review

PURPOSE OF REVIEW

Providing rehabilitation to patients with cancer can be challenging due to the medical complexity associated with the illness and its treatments. This article provides the reader with a summary of frequently encountered medical conditions in the cancer population and associated safety considerations and precautions. An update on treatment modalities commonly used for symptom management is also presented.

RECENT FINDINGS

Cancer and cancer treatments can cause changes in multiple organ systems. Special considerations and precautions are necessary to provide safe and effective rehabilitation. Physical modalities can be used as monotherapy or adjunct to treatment for common cancer-related side effects with recent studies noting benefit with a variety of modalities.

SUMMARY

Detailed assessment of the cancer patient is necessary before implementing a rehabilitation program. Understanding cancer and side effects of treatments, including newer options, are necessary to provide safe care.