Low muscularity increases the risk for post-operative pneumonia and delays recovery from complications after oesophago-gastric cancer resection

Predictive value of the prognostic nutritional index combined with serum chloride levels for the prognosis of patients with acute decompensated heart failure

BACKGROUND

The prognostic nutritional index (PNI) and serum chloride level are related to adverse outcomes in patients with heart failure. However, little is known about the relationship between the PNI and serum chloride level in predicting the poor prognosis of patients with acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We reviewed 1221 consecutive patients with ADHF admitted to the First Affiliated Hospital of Kunming Medical University from January 2017 to October 2021. After excluding patients with in hospital death, missing follow-up data, missing chloride data, missing lymphocyte (LYM) count data, or missing serum albumin data, 805 patients were included. PNI was calculated using the formula: serum albumin (ALB) (g/L) + 5 × LYM count (10^9/L). Patients were divided into 4 groups according to the quartiles of the PNI, and the highest PNI quartile (PNI Q4: PNI ≥ 47.3) was set as the reference group. The patients in the lowest PNI quartile (PNI Q1: PNI < 40.8) had the lowest cumulative survival rate, and mortality risk decreased progressively through the quartiles (log-rank χ2 142.283, P < 0.0001). Patients with ADHF were divided into 8 groups by quartiles of PNI and median levels of serum chloride. After adjustment, the hazard ratio (HR) for all-cause mortality in ADHF patients in Group 1 was 8.7 times higher than that in the reference Group 8. Furthermore, the addition of serum chloride level and PNI quartile to the Cox model increased the area under the Receiver operating characteristic (ROC) curve by 0.05, and the area under the ROC curve of the new model was higher than that of the original model with traditional risk factors.

CONCLUSIONS

Both the lowest PNI quartiles and low chloride level indicate a higher risk of all-cause death in patients with ADHF.

Sarcopenia impacts perioperative and survival outcomes after esophagectomy for cancer: a multicenter study

BACKGROUND

The impact of sarcopenia on outcomes after esophagectomy is controversial. Most data are currently derived from Asian populations. This study aimed to correlate sarcopenia to short-term perioperative complication rates and long-term survival and recurrence outcomes.

METHODS

A retrospective analysis was performed of patients undergoing esophagectomy for cancer from 3 tertiary referral centers in Australia. Sarcopenia was defined using cutoffs for skeletal muscle index (SMI), assessed on preoperative computed tomography images. Outcomes measured included complications, overall survival (OS), and disease-free survival (DFS).

RESULTS

Of 462 patients (78.4% male; median age, 67 years), sarcopenia was evident in 276 (59.7%). Patients with sarcopenia had a higher rate of major (Clavien-Dindo ≥ 3b) complications (27.9% vs 14.5%; P < .001), including higher rates of postoperative cardiac arrythmia (16.3% vs 9.7%; P = .042), pneumonia requiring antibiotics (14.5% vs 9.1%; P = .008), and 30-day mortality (5.1% vs 0%; P = .002). In the sarcopenic group, the median OS was lower (37 months [95% CI, 27.1-46.9] vs 114 months [95% CI, 75.8-152.2]; P < .001), as was the median DFS (27 months [95% CI, 18.9-35.1] vs 77 months [95% CI, 36.4-117.6]; P < .001). Sarcopenia was an independent risk factor for lower survival on multivariate analysis (hazard ratio, 1.688; 95% CI, 1.223-2.329; P = .001).

CONCLUSION

Patients with preoperative sarcopenia based on analysis of SMI are at a higher risk of major complications and have inferior survival and oncologic outcomes after esophagectomy for esophageal cancer.

Malnutrition defined by GLIM criteria identifies a higher incidence of malnutrition and is associated with pulmonary complications after oesophagogastric cancer surgery, compared to ICD-10-defined malnutrition

BACKGROUND & OBJECTIVES

Low muscle mass, measured using computed tomography (CT), is associated with poor surgical outcomes. We aimed to include CT-muscle mass in malnutrition diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria, compare it to the International Classification of Diseases 10th Revision (ICD-10) criteria, and assess the impact on postoperative outcomes after oesophagogastric (OG) cancer surgery.

METHODS

One hundred and eight patients who underwent radical OG cancer surgery and had preoperative abdominal CT imaging were included. GLIM and ICD-10 malnutrition data were assessed against complication and survival outcomes. Low CT-muscle mass was determined using predefined cut-points.

RESULTS

GLIM-defined malnutrition prevalence was significantly higher than ICD-10-malnutrition (72.2% vs. 40.7%, p < 0.001). Of the 78 patients with GLIM-defined malnutrition, low muscle mass (84.6%) was the predominant phenotypic criterion. GLIM-defined malnutrition was associated with pneumonia (26.9% vs. 6.7%, p = 0.010) and pleural effusions (12.8% vs. 0%, p = 0.029). Postoperative complications did not correlate with ICD-10 malnutrition. Severe GLIM (HR: 2.51, p = 0.014) and ICD-10 (HR: 2.15, p = 0.039) malnutrition were independently associated with poorer 5-year survival.

CONCLUSIONS

GLIM criteria appear to identify more malnourished patients and more closely relate to surgical risk than ICD-10 malnutrition, likely due to incorporating objective muscle mass assessment.

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.

Automated machine learning (AutoML) can predict 90-day mortality after gastrectomy for cancer

Early postoperative mortality risk prediction is crucial for clinical management of gastric cancer. This study aims to predict 90-day mortality in gastric cancer patients undergoing gastrectomy using automated machine learning (AutoML), optimize models for preoperative prediction, and identify factors influential in prediction. National Cancer Database was used to identify stage I-III gastric cancer patients undergoing gastrectomy between 2004 and 2016. 26 features were used to train predictive models using H2O.ai AutoML. Performance on validation cohort was measured. In 39,108 patients, 90-day mortality rate was 8.8%. The highest performing model was an ensemble (AUC = 0.77); older age, nodal ratio, and length of inpatient stay (LOS) following surgery were most influential for prediction. Removing the latter two parameters decreased model performance (AUC 0.71). For optimizing models for preoperative use, models were developed to first predict node ratio or LOS, and these predicted values were inputted for 90-day mortality prediction (AUC of 0.73-0.74). AutoML performed well in predicting 90-day mortality in a larger cohort of gastric cancer patients that underwent gastrectomy. These models can be implemented preoperatively to inform prognostication and patient selection for surgery. Our study supports broader evaluation and application of AutoML to guide surgical oncologic care.

Low Muscle Mass and Radiodensity Associate with Impaired Pulmonary Function and Respiratory Complications in Patients with Esophageal Cancer

BACKGROUND

Sixty percent of patients with esophageal cancer display signs of cachexia at diagnosis. Changes in body composition are common, and muscle mass and quality are measurable through imaging studies. Cachexia leads to functional impairments that complicate treatments, including surgery. We hypothesize that low muscle mass and quality associate with pulmonary function testing parameters, highlighting ventilatory deficits, and postoperative complications in patients receiving esophagectomy.

STUDY DESIGN

We performed a retrospective review of patients receiving esophagectomy between 2012 and 2021 at our facility. PET/CT scans were used to quantify skeletal muscle at the L3 and T4 levels. Patient characteristics were recorded, including pulmonary function testing parameters. Regression models were created to characterize predictive associations.

RESULTS

One hundred eight patients were identified. All were included in the final analysis. In linear regression adjusted for sex, age, and COPD status, low L3 muscle mass independently associated with low forced vital capacity (p < 0.005, β 0.354) and forced expiratory volume in 1 second (p < 0.001, β 0.392). Similarly, T4 muscle mass independently predicted forced vital capacity (p < 0.005, β 0.524) and forced expiratory volume in 1 second (p < 0.01, β 0.480). L3 muscle quality correlated with total lung capacity ( R 0.2463, p < 0.05). Twenty-six patients had pleural effusions postoperatively, associated with low muscle quality on L3 images (p < 0.05). Similarly, patients with hospitalization more than 2 weeks presented with lower muscle quality (p < 0.005).

CONCLUSIONS

Cachexia and low muscle mass are common. Reduced muscle mass and quality independently associate with impaired forced vital capacity, forced expiratory volume in 1 second, and total lung capacity. We propose that respiratory muscle atrophy occurs with weight loss. Body composition analyses may aid in stratifying patients. Pulmonary function testing may also serve as a functional endpoint for clinical trials. These findings highlight the need to study mechanisms that lead to respiratory muscle pathology and dysfunction in tumor-bearing hosts.

Association Between Prognostic Nutritional Index and Prognosis in Patients With Heart Failure: A Meta-Analysis

Background

The prognostic nutritional index (PNI) has been proposed as a marker of malnutrition and associated with the prognosis of cardiovascular disease. However, whether PNI can serve as a potential biomarker for the prognosis of heart failure (HF) upon those established risk factors were still controversial. This meta-analysis aimed to generate comprehensive evidence on the prognostic value of PNI in patients with HF.

Methods

Multiple databases (PubMed, Embase, the Cochrane Library, and Google Scholar) were searched for related studies up to January 31, 2022. Observational studies accessed associations between PNI levels and the prognosis in patients with HF were included for meta-analysis. The hazard ratios (HRs) and 95% confidence intervals (CI) were calculated.

Results

Fourteen studies, comprising 19,605 patients with HF were included for meta-analysis. The median follow-up duration was 18.5 months. Compared with those with higher PNI (normal nutritional status), patients with HF with lower PNI (malnourished) were associated with a higher risk of all-cause mortality (HR 1.53, 95% CI 1.27–1.85) and composite major adverse cardiac outcomes (MACEs; HR 2.26, 95% CI 1.54–3.31) in the multivariable-adjusted model. Furthermore, when PNI was defined as per 1 increment as a continuous metric, higher PNI was associated with a decrease in all-cause mortality (per 1 increment of PNI: HR 0.94, 95% CI 0.88–0.96) and MACEs (per 1 increment of PNI: HR 0.97, 95% CI 0.95–0.98).

Conclusions

The PNI can serve as an easily calculated bedside “malnutrition-inflammation” biomarker in HF. Lower PNI was associated with a worse prognosis in patients with HF.