Impact of Sarcopenic Obesity on Surgical Site Infection after Laparoscopic Total Gastrectomy

The role of sarcopenic obesity for the prediction of prognosis of patients with gastrointestinal cancer

BACKGROUND

Sarcopenic obesity (SO) in patients with gastrointestinal cancer is associated with a poor prognosis. We aimed to investigate the prognostic impact of SO in patients with gastrointestinal cancer, as well as the diagnostic cut-off value of SO in patients with gastrointestinal cancer among Chinese population.

METHODS

We conducted a consecutive cohort study. Between January 2017 and January 2019, 289 patients diagnosed with gastrointestinal cancer were included in our study. Skeletal muscle area, total fat area, and subcutaneous fat area were measured by CT scan. All patients were followed up for 5 years. Receiver operating characteristic curves (ROC) were adopted to determine the cut-off values of visceral fat obesity for the prediction of sarcopenia. Based on the cut-off values, patients with sarcopenia combined with visceral fat obesity were divided into the SO group, and the others were divided into the non-sarcopenic obesity (NSO) group. Kaplan-Meier curves and univariate and multivariate Cox proportional hazard models were employed to explore the associations of body composition profiles with 5-year overall survival and disease-specific survival.

RESULTS

Obtained from Youden's Index for ROC for the prediction of 5-year survival, skeletal muscle mass index (SMI) ≤40.02 cm2/m2 with VFA ≥ 126.30 cm2 in men and SMI ≤32.05 cm2/m2 with VFA ≥72.42 cm2 in women indicate a risk of poor prognosis in patients diagnosed with gastrointestinal cancer. Patients with SO had poorer 5-year overall survival (OS) than patients with NSO (6.74% vs. 82.84%, p < 0.001), and poorer 5-year DFS (6.74% vs. 81.82%, p < 0.001). In multivariate analysis, we found that the long-term mortality risk was approximately 13-fold higher among patients in the SO group compared to those with no conditions.

CONCLUSIONS

Preoperative assessment of SO is useful not only for monitoring nutritional status but also for predicting 5-year OS in gastrointestinal cancer patients.

Sarcopenic obesity predicts short- and long-term outcomes after neoadjuvant chemotherapy and surgery for gastric cancer

BACKGROUND

Sarcopenic obesity (SO) affects outcomes in various malignancies. However, its clinical significance in patients undergoing neoadjuvant chemotherapy (NAC) for locally advanced gastric cancer (LAGC) remains unclear. This study investigated the impact of pre- and post-NAC SO on postoperative morbidity and survival.

METHODS

Data from 207 patients with LAGC, who underwent NAC followed by radical gastrectomy between January 2010 and October 2019, were reviewed. Skeletal muscle mass and visceral fat area were measured pre- and post-NAC using computed tomography to define sarcopenia and obesity, the coexistence of which was defined as SO.

RESULTS

Among the patients, 52 (25.1%) and 38 (18.4%) developed SO before and after NAC, respectively. Both pre- (34.6%) and post- (47.4%) NAC SO were associated with the highest postoperative morbidity rates; however, only post-NAC SO was an independent risk factor for postoperative morbidity [hazard ratio (HR) = 9.550, 95% confidence interval (CI) = 2.818-32.369; P < .001]. Pre-NAC SO was independently associated with poorer 3-year overall [46.2% vs. 61.3%; HR = 1.258 (95% CI = 1.023-1.547); P = .049] and recurrence-free [39.3% vs. 55.4%; HR 1.285 (95% CI 1.045-1.579); P = .017] survival.

CONCLUSIONS

Pre-NAC SO was an independent prognostic factor in patients with LAGC undergoing NAC; post-NAC SO independently predicted postoperative morbidity.

Body composition assessment by artificial intelligence can be a predictive tool for short-term postoperative complications in Hartmann's reversals

BACKGROUND

Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It demands careful planning and patient optimisation to help reduce postoperative complications. Preoperative evaluation of body composition has been useful in identifying patients at high risk of short-term postoperative outcomes following colorectal cancer surgery. We sought to explore the use of our in-house derived Artificial Intelligence (AI) algorithm to measure body composition within patients undergoing Hartmann's reversal procedure in the prediction of short-term postoperative complications.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal within a single tertiary referral centre (Western) in Melbourne, Australia and who had a preoperative Computerised Tomography (CT) scan performed. Body composition was measured using our previously validated AI algorithm for body segmentation developed by the Department of Surgery, Western Precinct, University of Melbourne. Sarcopenia in our study was defined as a skeletal muscle index (SMI), calculated as Skeletal Muscle Area (SMA) /height2 < 38.5 cm2/m2 in women and < 52.4 cm2/m2 in men.

RESULTS

Between 2010 and 2020, 47 patients (mean age 63.1 ± 12.3 years; male, n = 28 (59.6%) underwent body composition analysis. Twenty-one patients (44.7%) were sarcopenic, and 12 (25.5%) had evidence of sarcopenic obesity. The most common postoperative complication was surgical site infection (SSI) (n = 8, 17%). Sarcopenia (n = 7, 87.5%, p = 0.02) and sarcopenic obesity (n = 5, 62.5%, p = 0.02) were significantly associated with SSIs. The risks of developing an SSI were 8.7 times greater when sarcopenia was present.

CONCLUSION

Sarcopenia and sarcopenic obesity were related to postoperative complications following Hartmann's reversal. Body composition measured by a validated AI algorithm may be a beneficial tool for predicting short-term surgical outcomes for these patients.

Predictors for different types of surgical site infection in patients with gastric cancer: A systematic review and meta-analysis

Various factors contribute to different types of surgical site infections (SSI) in gastric cancer patients undergoing surgery, and the risk factors remain uncertain. This meta-analysis aims to clarify the relationship between various factors and SSI, resolving existing controversies. Thirty-four eligible articles with 66 066 patients were included in the meta-analysis. Significant risk factors for SSI included age ≥65 years, male gender, BMI ≥25 kg/m2, diabetes, hypertension, advanced TNM stage ≥III, pathologic T stage ≥T3, pathologic N stage ≥N1, ASA ≥3, open surgery, blood transfusion, extensive resection, combined resection, splenectomy, D2 or more lymph node dissection, and operative time ≥240 min. Operative time showed a nonlinear relationship with SSI risk. Subgroup analysis revealed significant differences in the effects of risk factors among different infection types. These findings inform the development of targeted preventive measures to reduce SSI rates.

Sarcopenic obesity in cancer

BACKGROUND

Sarcopenic obesity is a relatively new term. It is a clinical condition characterized by sarcopenia (loss of muscle mass and function) and obesity (increase in fat mass) that mainly affects older adults. As the incidence of sarcopenia and obesity increases worldwide, sarcopenic obesity is becoming a greater problem also in cancer patients. In fact, sarcopenic obesity is associated with poorer treatment outcomes, longer hospital stays, physical disability, and shorter survival in several cancers. Oxidative stress, lipotoxicity, and systemic inflammation, as well as altered expression of skeletal muscle anti-inflammatory myokines in sarcopenic obesity, are also associated with carcinogenesis.

CONCLUSIONS

Reported prevalence of sarcopenic obesity in cancer varies because of heterogeneity in definitions and variability in diagnostic criteria used to estimate the prevalence of sarcopenia and obesity. Therefore, the aim of this review is to describe the definitions, prevalence, and diagnostic criteria as well as the mechanisms that cancer has in common with sarcopenic obesity.

Prognostic significance of MRI-defined sarcopenia in patients with nasopharyngeal carcinoma: A propensity score matched analysis of real-world data

BACKGROUND AND PURPOSE

Image-defined sarcopenia is linked to increased mortality among patients with cancer. Nevertheless, its effect on patients with nasopharyngeal carcinoma (NPC) is incompletely established. This study's aim was to investigate the prognostic significance of MRI-defined sarcopenia on the survival of patients undergoing concurrent chemoradiotherapy (CCRT) ± inducing chemotherapy (IC) for NPC treatment.

METHODS

1,307 patients with stage II-IVa NPC were included in this retrospective study. Sarcopenia was defined using skeletal muscle index (SMI) determined through baseline MRI at the C3 level. The association of sarcopenia with overall survival (OS) and progression-free survival (PFS) was assessed by Cox regression models using 1:1 propensity score matching (PSM) analysis. We also conducted a stratification analysis using BMI and treatment strategies.

RESULTS

Sarcopenia was an independent risk factor for both OS and PFS (all P < 0.05). However, BMI was not substantially linked to OS and PFS (all P > 0.05). Sarcopenic patients showed lower rates of OS (HR = 2.00, 95% CI: 1.54-2.60, P < 0.001) and PFS (HR = 1.67, 95% CI: 1.35-2.07, P < 0.001) in contrast with nonsarcopenic patients. According to stratification analysis, being overweight was linked to a protective effect in nonsarcopenic patients only. Sarcopenic patients showed similar OS and PFS regardless of the treatment modality.

CONCLUSIONS

Sarcopenia is underrecognized in NPC patients. Measurement of sarcopenia using routine MRI scans in NPC patients provided significant prognostic information, outperforming BMI. Patients with sarcopenia failed to benefit from an additional IC regimen.

A systematic review of automated segmentation of 3D computed-tomography scans for volumetric body composition analysis

Automated computed tomography (CT) scan segmentation (labelling of pixels according to tissue type) is now possible. This technique is being adapted to achieve three-dimensional (3D) segmentation of CT scans, opposed to single L3-slice alone. This systematic review evaluates feasibility and accuracy of automated segmentation of 3D CT scans for volumetric body composition (BC) analysis, as well as current limitations and pitfalls clinicians and researchers should be aware of. OVID Medline, Embase and grey literature databases up to October 2021 were searched. Original studies investigating automated skeletal muscle, visceral and subcutaneous AT segmentation from CT were included. Seven of the 92 studies met inclusion criteria. Variation existed in expertise and numbers of humans performing ground-truth segmentations used to train algorithms. There was heterogeneity in patient characteristics, pathology and CT phases that segmentation algorithms were developed upon. Reporting of anatomical CT coverage varied, with confusing terminology. Six studies covered volumetric regional slabs rather than the whole body. One study stated the use of whole-body CT, but it was not clear whether this truly meant head-to-fingertip-to-toe. Two studies used conventional computer algorithms. The latter five used deep learning (DL), an artificial intelligence technique where algorithms are similarly organized to brain neuronal pathways. Six of seven reported excellent segmentation performance (Dice similarity coefficients > 0.9 per tissue). Internal testing on unseen scans was performed for only four of seven algorithms, whilst only three were tested externally. Trained DL algorithms achieved full CT segmentation in 12 to 75 s versus 25 min for non-DL techniques. DL enables opportunistic, rapid and automated volumetric BC analysis of CT performed for clinical indications. However, most CT scans do not cover head-to-fingertip-to-toe; further research must validate using common CT regions to estimate true whole-body BC, with direct comparison to single lumbar slice. Due to successes of DL, we expect progressive numbers of algorithms to materialize in addition to the seven discussed in this paper. Researchers and clinicians in the field of BC must therefore be aware of pitfalls. High Dice similarity coefficients do not inform the degree to which BC tissues may be under- or overestimated and nor does it inform on algorithm precision. Consensus is needed to define accuracy and precision standards for ground-truth labelling. Creation of a large international, multicentre common CT dataset with BC ground-truth labels from multiple experts could be a robust solution.

Gastric Cancer with Sarcopenia: an Area Worth Focusing On

OPINION STATEMENT

Gastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer death worldwide, which seriously endangers human health. A number of studies have shown that sarcopenia occurs more frequently in patients with gastric cancer than in the general population and can significantly affect the disease status and survival of patients, which is of great significance in predicting the prognosis of gastric cancer. Patients with gastric cancer may suffer sarcopenia no matter before or after surgery, and the pathogenesis is complex. Abnormal nutrient metabolism and reduced exercise are the leading causes. In addition, surgical treatment and chemotherapy for gastric cancer might participate in the physiological and pathological mechanism of sarcopenia. Generally speaking, exercise and nutritional therapy are the main prevention and treatment methods for sarcopenia. But more prospective evidence is needed to establish reasonable interventions, and other drug treatments are in their infancy. For the diagnostic criteria of sarcopenia, the cut-off values of the skeletal muscle mass index obtained from CT images vary widely and need to be standardized and unified. We also need to explore simple predictors to facilitate sarcopenia risk assessment. More research is needed to formulate more appropriate treatments for gastric cancer patients with sarcopenia.

[Sarcopenia in patients with pancreatic cancer, an independant prognostic factor]

BACKGROUND

Pancreatic cancer is despite modern diagnostic tools and treatment regimen associated with poor outcome. Many patients show cachexia and sarcopenia.

METHODS

In a retrospective analysis the SMI (cm²/m²) was measured by determining the skelettal muscle area in a computed tomography image at lumbar vertebrae 3. Further clinical parameters were measured to determine the outcome.

RESULTS

The mean survival after diagnosis in the population with sarcopenia was significantly lower (14,4 vs 17,7 months, p=0,046). Significantly shorter survival was also seen for higher age (p=0,006), no tumor resection (p=0,004), metastases (p=0,002) and high CA19-9 level (p=0,002) CONCLUSION: Sarcopenia is an indipendant prognostic factor in patients with pancreatic cancer. SMI should be measured clinical practice and further studies are necessary to asses a potential therapeutic strategy.

The effect of sarcopenia and sarcopenic obesity on survival in gastric cancer

BACKGROUND

Sarcopenic obesity arises from increased muscle catabolism triggered by inflammation and inactivity. Its significance lies in its role in contributing to morbidity and mortality in gastric cancer. This study aims to explore the potential correlation between sarcopenia, sarcopenic obesity, and gastric cancer, as well as their effect on survival.

MATERIALS AND METHODS

This retrospective study included 162 patients aged ≥ 18 years who were diagnosed with stomach cancer. Patient age, gender, diagnostic laboratory results, and cancer characteristics were documented. Sarcopenia was assessed using the skeletal muscle index (SMI) (cm2/m2), calculated by measuring muscle mass area from a cross-sectional image at the L3 vertebra level of computed tomography (CT).

RESULTS

Among the 162 patients, 52.5% exhibited sarcopenia (with cut-off limits of 52.4 cm2/m2 for males and 38.5 cm2/m2 for females), and 4.9% showed sarcopenic obesity. Average skeletal muscle area (SMA) was 146.8 cm2; SMI was 50.6 cm2/m2 in men and 96.9 cm2 and 40.6 cm2/m2 in women, respectively. Sarcopenia significantly reduced mean survival (p = 0.033). There was no association between sarcopenic obesity and mortality (p > 0.05), but mortality was higher in sarcopenic obesity patients (p = 0.041). Patient weight acted as a protective factor against mortality, supporting the obesity paradox. Tumor characteristics, metabolic parameters, and concurrent comorbidities did not significantly impact sarcopenia or mortality.

CONCLUSION

Sarcopenia is more prevalent in the elderly population and is linked to increased mortality in gastric cancer patients. Paradoxically, higher body mass index (BMI) was associated with improved survival. Computed tomography offers a practical and reliable method for measuring muscle mass and distinguishing these distinctions.

TRIAL REGISTRATION

This study was approved by Istanbul Training and Research Hospital Clinical Research Ethics Committee of the University of Health Sciences (29.05.2020/2383).

Impact of Sarcopenic Obesity on Severe Postoperative Complications in Patients with Gastric Cancer Undergoing Gastrectomy

INTRODUCTION

Several studies have indicated that sarcopenia affects the short- and long-term outcomes of cancer patients, including those with gastric cancer. In recent years, sarcopenic obesity and its effects have been reported in cancer patients. This study aimed to evaluate the impact of sarcopenic obesity on postoperative complications in patients with gastric cancer undergoing gastrectomy.

METHODS

This single-center, retrospective study included 155 patients who underwent curative gastrectomy for gastric cancer from January 2015 to July 2021. Sarcopenia was defined by the psoas muscle index (<6.36 cm2/m2 in men and <3.92 cm2/m2 in women), which measures the iliopsoas muscle area at the lumbar L3 level using computed tomography. Obesity was defined by body mass index (≥25). Patients with both sarcopenia and obesity were defined as the sarcopenic obesity group and others as the non-sarcopenic obesity group. Severe postoperative complications were defined as Clavien-Dindo classification grade IIIa or higher.

RESULTS

Of the 155 patients, 26 (16.8%) had sarcopenic obesity. The incidence of severe postoperative complications was significantly higher in the sarcopenic obesity group (30.8% vs. 10.9%; p = 0.014). Multivariate analysis indicated that sarcopenic obesity was an independent risk factor for severe postoperative complications (odds ratio, 3.950; 95% confidence interval, 1.390-11.200; p = 0.010).

CONCLUSION

Sarcopenic obesity is an independent risk factor for severe postoperative complications.

Colonization of the gastric juice by Candida spp. promotes surgical site infection after hepatectomy

PURPOSE

Candida spp. cause opportunistic infections in conditions of immunodeficiency. Here, we investigated the relationship between colonization of the gastric juice by Candida spp. and surgical site infection (SSI) in hepatectomy.

METHODS

Consecutive hepatectomy cases between November 2019 and April 2021 were enrolled. Gastric juice samples (collected intraoperatively through a nasogastric tube) were cultured. We compared factors related to patient background, blood test findings, surgical findings, and postoperative complications between the Candida + group (positive for colonization of the gastric juice by Candida spp.) and the Candida - group (negative). In addition, we identified the factors that contribute to SSI.

RESULTS

There were 29 and 71 patients in the Candida + and Candida - groups, respectively. The Candida + group was significantly older (average age: Candida + 74 years vs. Candida - 69 years; p = 0.02) and contained more patients negative for the hepatitis B and C virus (Candida + 93% vs. Candida - 69%; p = 0.02). SSI was significantly more common in the Candida + group (Candida + 31% vs. Candida - 9%; p = 0.01). Postoperative bile leakage and colonization of the gastric juice by Candida spp. were independent predictors of SSI.

CONCLUSION

Colonization of the gastric juice by Candida spp. is a risk factor for SSI after hepatectomy.

Sarcopenia assessed with DXA and CT increases the risk of perioperative complications in patients with gastrectomy

OBJECTIVES

We investigated sarcopenia prevalence using various diagnostic criteria based on dual-energy X-ray absorptiometry (DXA) and computed tomography (CT) in gastric cancer patients who underwent gastrectomy, and evaluated the association between sarcopenia and perioperative complications.

METHODS

This retrospective study included consecutive patients with gastric cancer who underwent gastrectomy, and preoperative DXA and CT from January 2013 to November 2020. Body composition was measured using DXA and CT. Height-adjusted DXA-based Appendicular Skeletal Muscle Mass Index (ASMI) and CT-based skeletal muscle cross-sectional area at the L3 level (SMI) were measured. Sarcopenia and sarcopenic obesity were defined using reported cutoff values. The chi-square test and univariate analysis were performed to determine risk factors for significant and severe perioperative complications (Clavien-Dindo Grades ≥ 2 and ≥ 3, respectively).

RESULTS

In total, 77 males and 43 females aged 61.4 ± 11.0 years were included. ASMI and SMI were correlated (r = 0.819), but sarcopenia prevalence varied (20.0-63.3%), depending on the criteria applied. Univariate analysis revealed sarcopenia defined using the Asian Working Group on Sarcopenia (AWGS) criteria and sarcopenic obesity as risk factors for significant (odds ratio [OR] 2.76, p = 0.030 vs. OR 4.31, p = 0.002) and severe perioperative complications (OR 3.77, p = 0.036 vs. OR 4.78, p = 0.010). In subgroup analyses, sarcopenia and sarcopenic obesity were significantly associated with perioperative complications only in males.

CONCLUSION

Perioperative complication risk can be predicted from sarcopenia defined using the AWGS criteria and sarcopenic obesity measured using DXA and CT, particularly in males.

KEY POINTS

• The prevalence of sarcopenia varies due to definition differences. • Sarcopenia and sarcopenic obesity are risk factors for significant and severe perioperative complications, particularly in males. • Our results suggest that physicians need to pay attention to perioperative complications after surgical treatment of male patients with sarcopenia and sarcopenic obesity.

Impact of Sarcopenic Obesity on Long-Term Cancer Outcomes and Postoperative Complications After Gastrectomy for Gastric Cancer

BACKGROUND

The prevalence of sarcopenia in gastric cancer (GC), although varying among the reported studies, is around 60%. In the last few years, it has been recognised that sarcopenia can also occur not only in patients with weight loss and low body weight, but also in patients with normal or increased body mass index. Therefore, the term sarcopenic obesity (SO) is a new definition that further expands the implications of altered body composition. The aim of this study was to assess the impact of SO on the perioperative morbidity and the survival of GC patients undergoing gastrectomy by evaluating body composition on CT images.

METHODS

Preoperative CT scans were obtained from all patients with a diagnosis of GC undergoing gastrectomy with curative intent between January 2012 and December 2019. Skeletal muscle mass index (SMMI) and visceral adipose tissue (VAT) cross-sectional area at the level of the transverse processes of the third lumbar vertebra (L3) were measured. Sarcopenia and obesity were defined according to sex-specific cut-off points.

RESULTS

After analysing 190 patients, the prevalence of SO was 21.1% (40 patients) and sarcopenia was 14.7% (28 patients). Multivariate analysis showed that corporal composition was an independent factor of overall survival (p = 0.049). Logistic regression was performed to identify risk factors associated with postoperative complications. SO was identified as a risk factor for serious Clavien-Dindo complications > IIIb/IV [OR 2.82 (1.1-7.1); p = 0.028].

CONCLUSION

SO was a risk factor for severe postoperative complications as well as worse long-term oncological after a gastrectomy for GC.

Association of visceral adipose tissue with postoperative outcome in upper gastrointestinal cancer: a systematic review and meta-analysis

BACKGROUND

There is no consensus on the relation between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer.

OBJECTIVES

The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the WHO International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through 20 July 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using the Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. HRs and 95% CIs for OS were pooled.

RESULTS

Ninety-one studies (n = 20,583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relation between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (HR: 0.69; 95% CI: 0.55, 0.87; I2 = 65%; n = 3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias, and publication bias.

CONCLUSIONS

High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

Prevalence of Sarcopenic Obesity in Various Comorbidities, Diagnostic Markers, and Therapeutic Approaches: A Review

The coexistence of sarcopenia and obesity characterizes sarcopenic obesity. In this condition, there is an imbalance between lean and fat mass amounts. It is a prevalent issue that is gaining prevalence among the elderly population. To evaluate the condition, allied health professionals may employ non-invasive diagnostic techniques, such as gait speed, skeletal muscle mass, and muscle strength. Nevertheless, early diagnosis and treatment of pathology are essential for preventing debilitating effects and providing the highest quality of care. This article reviews the prevalence of sarcopenic obesity in numerous medical conditions, such as cancer, arthritis, postoperative cases, diabetes mellitus, obesity, and metabolic syndrome. In addition, this paper aims to examine the available evidence regarding the prevalence of sarcopenic obesity in other conditions along with their diagnostic markers and therapeutic approaches.

Sarcopenic obesity and therapeutic outcomes in gastrointestinal surgical oncology: A meta-analysis

Background

Sarcopenic obesity (SO) has been indicated as a scientific and clinical priority in oncology. This meta-analysis aimed to investigate the impacts of preoperative SO on therapeutic outcomes in gastrointestinal surgical oncology.

Methods

We searched the PubMed, EMBASE, and Cochrane Library databases through March 4th 2022 to identify cohort studies. Endpoints included postoperative complications and survival outcomes. Newcastle Ottawa Scale was used for quality assessment. Heterogeneity and publication bias were assessed. Subgroup analyses and sensitivity analyses were performed.

Results

Twenty-six studies (8,729 participants) with moderate to good quality were included. The pooled average age was 65.6 [95% confidence interval (CI) 63.7–67.6] years. The significant heterogeneity in SO definition and diagnosis among studies was observed. Patients with SO showed increased incidences of total complications (odds ratio 1.30, 95% CI: 1.03–1.64, P = 0.030) and major complications (Clavien-Dindo grade ≥ IIIa, odds ratio 2.15, 95% CI: 1.39–3.32, P = 0.001). SO was particularly associated with the incidence of cardiac complications, leak complications, and organ/space infection. SO was also predictive of poor overall survival (hazard ratio 1.73, 95% CI: 1.46–2.06, P &lt; 0.001) and disease-free survival (hazard ratio 1.41, 95% CI: 1.20–1.66, P &lt; 0.001). SO defined as sarcopenia in combination with obesity showed greater association with adverse outcomes than that defined as an increased ratio of fat mass to muscle mass. A low prevalence rate of SO (&lt; 10%) was associated with increased significance for adverse outcomes compared to the high prevalence rate of SO (&gt; 20%).

Conclusion

The SO was associated with increased complications and poor survival in gastrointestinal surgical oncology. Interventions aiming at SO have potentials to promote surgery benefits for patients with gastrointestinal cancers. The heterogeneity in SO definition and diagnosis among studies should be considered when interpreting these findings.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255286], identifier [CRD42021255286].

Identification of sarcopenic obesity in adults undergoing orthopaedic surgery: Relationship between “a body shape index” (ABSI) and fat-free mass. A cross -sectional study

Background

Sarcopenic obesity is a condition characterised by the coexistence of low muscle mass and function (sarcopenia) and excessive fat mass (obesity). The aim of this study was to determine the prevalence of this condition in patients undergoing orthopaedic surgery by gender and type of orthopaedic surgery. In addition, this study investigated the suitability of a waist circumference-based anthropometric measure, body shape index (ABSI), for predicting sarcopenic obesity and the predictive power of ABSI for fat-free mass index (FFMI), a surrogate marker of lean body mass.

Methods and findings

A cross-sectional study of overweight and obese orthopaedic patients undergoing knee or hip and spine surgery was conducted between October 2019 and March 2020 in Orthopaedic Hospital Valdoltra, Slovenia. General anthropometric parameters body mass index (BMI) and ABSI = (WC/(BMI^2/3x height^½) as well as body composition data (fat mass FM, fat-free mass FFM, FFMI, and the ratio FM/FFM as an index of sarcopenic obesity) were determined in 120 women (aged 66.5 ± 9.6 years) and 89 men (aged 65.5 ± 7.8 years) with overweight (25 kg/m² ≤ BMI < 30 kg/m²) and obesity (BMI ≥ 30 kg/m²) by bioelectrical impedance analysis (BIA). Sarcopenic obesity phenotypes based on FM/FFM ratio > 0.80 was present in 15.3% of patients, mainly in female patients undergoing knee surgery. ABSI was significantly associated with age in all women and obese men and with waist circumference (WC) in all patients. ABSI did not correlate with BMI in women and men; however, multiple linear regression analysis showed that BMI independently predicted FFMI (R = 0.83 and 0.70, respectively, p < 0.001) in women and men (β-coefficients: 0.801 and 0.686, respectively) and ABSI in women only (β-coefficient: -0.104). Women with a lower ABSI had a significantly higher FFMI than the group with a higher ABSI.

Conclusions

Sarcopenic obesity was most prevalent in obese women scheduled for knee surgery. In addition, ABSI, independently predicted FFMI in women and represents a significant predictor of sarcopenic obesity.

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.

Risk factors and clinical outcomes of postgastrectomy sarcopenia newly developed after curative resection for gastric cancer

This study aimed to investigate the risk factors and clinical impact of newly developed sarcopenia after surgical resection on the prognosis of patients undergoing curative gastrectomy for gastric cancer (GC).The clinicopathological data of 573 consecutive patients with GC who underwent curative gastrectomy were reviewed. Their skeletal muscle mass and abdominal fat volume were measured using abdominal computed tomography.Forty six of them (8.0%) were diagnosed with preoperative sarcopenia. Among the 527 patients without sarcopenia, 57 (10.8%) were diagnosed with postgastrectomy sarcopenia newly developed 1 year after curative gastrectomy. Female sex, weight loss, proximal location of the tumor and differentiated tumor were significant risk factors of postgastectomy sarcopenia newly developed after curative gastrectomy. There was a significant difference in the 5-year overall survival among the preoperative sarcopenic, nonsarcopenic, and postgastrectomy sarcopenic groups (P = .017). Especially, there was a significant difference between nonsarcopenic and postgastrectomy sarcopenic groups (P = .009). However, there was no significant difference in the 5-year disease-free survival among the groups (P = .49).Since newly developed sarcopenia after surgical resection had an influence on the overall survival, patients with high sarcopenia risks after curative gastrectomy may require early nutritional support.

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study

Gastric cancer (GC) accounts for 4% of all cancers in Europe. Sarcopenia is a complex syndrome characterized by a loss of muscle mass and function associated with age, often present in neoplastic patients. Recently, several studies have shown a significant association between sarcopenia and poor prognosis in various pathological conditions. The current observational retrospective study investigates the association between sarcopenia and overall survival (OS) and recurrence-free survival (RFS) in patients with GC undergoing up-front surgery with curative intent. Resected GC patients' clinical records and CT images were retrospectively assessed. The preoperative CT calculation of the skeletal muscle index (SMI) at L3 level allowed us to categorize patients as sarcopenic or not. Kaplan-Meyer and univariate and multivariate Cox regression analyses were performed to determine the difference in survival and presence of independent prognostic factors. Fifty-five patients, 28 male and 27 female, out of 298 studied for gastric cancer were enrolled in the current study from two cancer referral centers in Italy. The preoperative CT calculation of the SMI at L3 level allowed us to identify 39 patients with and 16 without sarcopenia. A statistically significant difference between the sarcopenic and non-sarcopenic groups was observed in both OS and RFS (p < 0.023; p < 0.006). Moreover, sarcopenia was strongly correlated to a higher risk of recurrence in univariate and multivariate analysis (p < 0.02). Sarcopenia can be considered a critical risk factor for survival in patients with resectable GC treated with up-front surgery. Identifying sarcopenic patients at the time of diagnosis would direct selection of patients who could benefit from early nutritional and/or physical treatments able to increase their muscle mass and possibly improve the prognosis. More extensive multicenter studies are needed to address this issue.

Clinical Implications of Malnutrition in the Management of Patients with Pancreatic Cancer: Introducing the Concept of the Nutritional Oncology Board

Pancreatic cancer represents a very challenging disease, with an increasing incidence and an extremely poor prognosis. Peculiar features of this tumor entity are represented by pancreatic exocrine insufficiency and an early and intense nutritional imbalance, leading to the highly prevalent and multifactorial syndrome known as cancer cachexia. Recently, also the concept of sarcopenic obesity has emerged, making the concept of pancreatic cancer malnutrition even more multifaceted and complex. Overall, these nutritional derangements play a pivotal role in contributing to the dismal course of this malignancy. However, their relevance is often underrated and their assessment is rarely applied in clinical daily practice with relevant negative impact for patients' outcome in neoadjuvant, surgical, and metastatic settings. The proper detection and management of pancreatic cancer-related malnutrition syndromes are of primary importance and deserve a specific and multidisciplinary (clinical nutrition, oncology, etc.) approach to improve survival, but also the quality of life. In this context, the introduction of a "Nutritional Oncology Board" in routine daily practice, aimed at assessing an early systematic screening of patients and at implementing nutritional support from the time of disease diagnosis onward seems to be the right path to take.

Detection of sarcopenic obesity and prediction of long-term survival in patients with gastric cancer using preoperative computed tomography and machine learning

Background

Previous studies evaluating the prognostic value of computed tomography (CT)‐derived body composition data have included few patients. Thus, we assessed the prevalence and prognostic value of sarcopenic obesity in a large population of gastric cancer patients using preoperative CT, as nutritional status is a predictor of long‐term survival after gastric cancer surgery.

Methods

Preoperative CT images were analyzed for 840 gastric cancer patients who underwent gastrectomy between March 2009 and June 2018. Machine learning algorithms were used to automatically detect the third lumbar (L3) vertebral level and segment the body composition. Visceral fat area and skeletal muscle index at L3 were determined and used to classify patients into obesity, sarcopenia, or sarcopenic obesity groups.

Results

Out of 840 patients (mean age = 60.4 years; 526 [62.6%] men), 534 (63.5%) had visceral obesity, 119 (14.2%) had sarcopenia, and 48 (5.7%) patients had sarcopenic obesity. Patients with sarcopenic obesity had a poorer prognosis than those without sarcopenia (hazard ratio [HR] = 3.325; 95% confidence interval [CI] = 1.698–6.508). Multivariate analysis identified sarcopenic obesity as an independent risk factor for increased mortality (HR = 2.608; 95% CI = 1.313–5.179). Other risk factors were greater extent of gastrectomy (HR = 1.928; 95% CI = 1.260–2.950), lower prognostic nutritional index (HR = 0.934; 95% CI = 0.901–0.969), higher neutrophil count (HR = 1.101; 95% CI = 1.031–1.176), lymph node metastasis (HR = 6.291; 95% CI = 3.498–11.314), and R1/2 resection (HR = 4.817; 95% CI = 1.518–9.179).

Conclusion

Body composition analysis automated by machine learning predicted long‐term survival in patients with gastric cancer.

Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review

Patients undergoing complex gastrointestinal surgery are at high risk of major postoperative complications (e.g., anastomotic leakage, sepsis), classified as Clavien-Dindo (CD) ≥ IIIa. Identification of preoperative risk factors can lead to the identification of high-risk patients. These risk factors can also be used to design personalized perioperative care. This systematic review focuses on the identification of these factors. The Medline and Embase databases were searched for prospective, retrospective cohort studies and randomized controlled trials investigating the effect of risk factors on the occurrence of major postoperative complications and/or mortality after complex gastrointestinal cancer surgery. Risk of bias was assessed using the Quality in Prognostic Studies tool. The level of evidence was graded based on the number of studies reporting a significant association between risk factors and major complications. A total of 207 eligible studies were retrieved, identifying 33 risk factors for major postoperative complications and 13 preoperative laboratory results associated with postoperative complications. The present systematic review provides a comprehensive overview of preoperative risk factors associated with major postoperative complications. A wide range of risk factors are amenable to actions in perioperative care and prehabilitation programs, which may lead to improved outcomes for high-risk patients. Additionally, the knowledge of this study is important for benchmarking surgical outcomes.

Is Sarcopenic Obesity an Indicator of Poor Prognosis in Gastric Cancer Surgery? A Cohort Study in a Western Population

BACKGROUND

The prognostic value of sarcopenic obesity in gastric cancer surgery remains debated. We aimed to evaluate the impact on outcomes of body composition and sarcopenic obesity after gastrectomy for gastric cancer.

METHODS

A retrospective review of prospectively maintained database of patients undergoing gastrectomy for gastric cancer from 2010 to 2017 was performed. Skeletal muscle mass and visceral adipose tissue were evaluated by preoperative computed tomography to define sarcopenia and obesity. Patients were classified in body composition groups according to the presence or absence of sarcopenia and obesity. Prognostic factors for survival were assessed by multivariate Cox analysis.

RESULTS

Of the 198 patients undergoing gastrectomy for gastric cancer, 90 (45.4%) patients were sarcopenic, 130 (67.7%) obese, and in the subclassification for body composition categories: 33 (17%) nonsarcopenic nonobesity, 75 (38%) non sarcopenic obesity, 35 (17%) sarcopenic nonobesity, and 55 (28%) sarcopenic obesity. No category of body composition was a predictor of postoperative complications and worse overall and disease-free survival outcomes. Multivariable analysis identified ASA III classification, preoperative weight loss > 10%, postoperative surgical re-intervention, and advanced tumor stage as independent prognostic factors for overall survival, and patients aged 75 years or older, preoperative weight loss > 10%, elevated netrophil-lymphocyte ratio, and advanced tumor stage as independent prognostic factors for disease-free survival.

CONCLUSIONS

Sarcopenia, obesity, and sarcopenic obesity were not associated with worse outcomes after gastric cancer surgery.

Risk factors for surgical-site infections after radical gastrectomy for gastric cancer: a study in China

Background

About 10% of patients get a surgical-site infection (SSI) after radical gastrectomy for gastric cancer, but SSI remains controversial among surgeons. The aim of this study was to explore the risk factors for SSIs after radical gastrectomy in patients with gastric cancer to guide clinical therapies and reduce the incidence of SSI.

Methods

The study was a retrospective cohort study in patients who underwent radical gastrectomy for gastric cancer. SSI was defined in accordance with the National Nosocomial Infection Surveillance System. We evaluated patient-related and peri-operative variables that could be risk factors for SSIs. The Chi-squared test and logistic regression analysis were used to assess the association between these risk factors and SSI.

Results

Among the 590 patients, 386 were men and 204 were women. The mean age was 56.6 (28–82) years and 14.2% (84/590) of these patients had an SSI. Among them, incisional SSI was observed in 23 patients (3.9%) and organ/space SSI in 61 patients (10.3%). Multivariate logistic regression analysis identified sex (odds ratios [ORs] = 2.548, and 95% confidence interval [CI]: 1.268–5.122, P = 0.009), total gastrectomy (OR = 2.327, 95% CI: 1.352–4.004, P = 0.002), albumin level (day 3 after surgery) <30 g/L (OR = 1.868, 95% CI: 1.066–3.274, P = 0.029), and post-operative total parenteral nutrition (OR = 2.318, 95% CI: 1.026–5.237, P = 0.043) as independent risk factors for SSI.

Conclusions

SSI was common among patients after radical gastrectomy for gastric cancer. The method supporting post-operative nutrition and the duration of prophylactic antibiotics may be important modifiable influencing factors for SSI.

The Role of Visceral Obesity, Sarcopenia and Sarcopenic Obesity on Surgical Outcomes After Liver Resections for Colorectal Metastases

Background

The impact of body compositions on surgical results is controversially discussed. This study examined whether visceral obesity, sarcopenia or sarcopenic obesity influence the outcome after hepatic resections of synchronous colorectal liver metastases.

Methods

Ninety-four consecutive patients with primary hepatic resections of synchronous colorectal metastases were identified from a single center database between January 2013 and August 2018. Patient characteristics and 30-day morbidity were retrospectively analyzed. Body fat and skeletal muscle were calculated by planimetry from single-slice CT images at the level of L3.

Results

Fifty-nine patients (62.8%) underwent minor hepatectomies, and 35 patients underwent major resections (37.2%). Postoperative complications occurred in 60 patients (62.8%) including 35 patients with major complications (Clavien–Dindo grade III–V). The mortality was nil at 30 days and 2.1% at 90 days. The body mass index showed no influence on postoperative outcomes (p = 1.0). Visceral obesity was found in 66 patients (70.2%) and was significantly associated with overall and major complication rates (p = .002, p = .012, respectively). Sarcopenia was observed in 34 patients (36.2%) without a significant impact on morbidity (p = .461), however, with longer hospital stay. Sarcopenic obesity was found in 18 patients (19.1%) and was significantly associated with postoperative complications (p = .014). Visceral obesity, sarcopenia and sarcopenic obesity were all identified as significant risk factors for overall postoperative complications.

Conclusion

Visceral obesity, sarcopenic obesity and sarcopenia are independent risk factors for overall complications after resections of CRLM. Early recognition of extremes in body compositions could prompt to perioperative interventions and thus improve postoperative outcomes.

CT assessment of preoperative nutritional status in gastric cancer: severe low skeletal muscle mass and obesity-related low skeletal muscle mass are unfavorable factors of postoperative complications

BACKGROUND

Computed tomography (CT) has become an important technique for assessing skeletal muscle mass. Low skeletal muscle mass (LSMM) is considered an unfavorable factor for postoperative complications in patients with gastric cancer (GC).

METHODS

Patients who underwent laparoscopic gastrectomy for GC were included. Skeletal muscle mass at the third lumbar vertebra (L3) level was measured by preoperatively using CT. The patients were divided into an LSMM group and a non-LSMM group and the intergroup differences were analyzed. Furthermore, we divided the LSMM group into mild and severe LSMM subgroups. The study also analyzed the influence of obesity-related LSMM on postoperative complications.

RESULTS

A total of 409 patients were enrolled; of them, 265 had LSMM and 41 had severe LSMM. LSMM was associated with age, body mass index, and Nutritional Risk Screening 2002 score. In the multivariate analysis, LSMM was not related to postoperative complications. Further analysis revealed that severe LSMM was a risk factor for postoperative complications. The study also found that the risk of postoperative complications was significantly increased in patients with obesity-related LSMM.

CONCLUSIONS

LSMM was not significantly correlated with postoperative complications. Severe LSMM and obesity-related LSMM are unfavorable factors for postoperative complications with GC after gastrectomy.

Is sarcopenia really a risk factor in the development of postoperative complications?

PURPOSE

This study was aimed to evaluate the impact of sarcopenia, which was defined by total psoas area (TPA) and total psoas volume (TPV) measurements, on the development of major postoperative complications.

MATERIAL-METHODS

Sarcopenia was assessed in 225 patients with gastrointestinal cancer who underwent surgery between October 2015 and March 2020. The impact of sarcopenia defined by TPA and TPV on major postoperative complications was assessed using multivariate analysis.

RESULTS

Both the median TPA and TPV were higher in men than that in women (p < 0.001). The cut-off value of TPA to define sarcopenia was 526.5 mm²/m² and 495.68 mm²/m² for men and women, respectively, and the cut-off value of TPV was 79.6 cm³/m² for men and 83.1 cm³/m² for women, While 102 patients (45.3%) had sarcopenia defined by TPA, 54 (24%) had sarcopenia defined by TPV. Seventy-eight patients had at least one complication; 36 (46%) had major complications, and 15 patients died during the study. In logistic regression analysis, only sex was found as a risk factor for the development of sarcopenia (OR = 13.403, p = 0.014). There was a positive correlation between TPA and TPV in male and female patients separately (r = 0.841 and r = 0.883, respectively, p < 0.001). Only sarcopenia defined by TPV was found as a risk factor for the development of major postoperative complication (OR: 35.349, p = 0.028).

CONCLUSION

Sarcopenia defined by TPV is an independent risk factor in predicting major postoperative complications, not TPA. We believe that volume measurement instead of area is a more accurate method for evaluating sarcopenia in gastrointestinal cancer surgery.

Preoperative CT anthropometric measurements and pancreatic pathology increase risk for postoperative pancreatic fistula in patients following pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD). However, risk factors for this complication remain controversial. We conducted a retrospective analysis of 107 patients who underwent PD. POPF was diagnosed in strict accordance with the definition of the 2016 update of pancreatic fistula from the International Study Group on Pancreatic Fistula (ISGPF). Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for POPF. A total of 19 (17.8%) subjects of pancreatic fistula occurred after PD, including 15 (14.1%) with grade B POPF and 4 (3.7%) with grade C POPF. There were 33 (30.8%) patients with biochemical leak. Risk factors for POPF (grade B and C) were larger area of visceral fat (odds ratio [OR], 1.40; p = 0.040) and pathology other than pancreatic adenocarcinoma or pancreatitis (OR, 12.45; p = 0.017) in the multivariate regression analysis. This result could assist the surgeon to identify patients at a high risk of developing POPF.

Relation between Sarcopenia and Surgical Site Infection in Patients Undergoing Gastric Cancer Surgery

Background: Sarcopenia is a syndrome that can have negative consequences after gastric cancer (GC) surgery. This study aims to determine the effect of sarcopenia on surgical site infection (SSI) that develops after open GC surgery. Patients and Methods: In this retrospective design study, data were collected for patients who underwent GC surgery between January 2013 and August 2019. The diagnosis of sarcopenia was made according to the skeletal muscle index (SMI) calculated from pre-operative computed tomography images. Patients with sarcopenia and those without sarcopenia were compared in terms of SSIs; the risk factors for SSI were also analyzed. Results: One hundred forty-nine patients were included in the study and had a mean age of 59.3 years. Post-operative complications developed in 59 patients (39.6%) and SSIs in 28 patients (18.7%). Sarcopenia was detected in 57 (38.3%) patients; the mean age was 59.9 years in the sarcopenic group (SG) and 58.9 years in the non-sarcopenic group (NSG; p = 0.55). The mean SMI was 382.5 mm²/m² and 646.2 mm²/m² in the SG and NSG, respectively (p < 0.001). A relation between SSIs and sarcopenia was detected; 17 patients in the SG (29.8%) versus 11 patients in the NSG (11.9%; p = 0.007). Surgical site infection was not found to be statistically significantly related to obesity, hypoalbuminemia, intra-operative blood loss, or duration of operation, although the sarcopenic obesity patients were found to have the highest SSI rate (40%). Conclusion: The present study identified a relation between sarcopenia and SSIs occurring after GC surgery. The authors believe that studies seeking to reduce the incidence of SSIs, which are a leading cause of morbidity after GC surgery, should be supported.

Prognostic Impact of Sarcopenic Obesity after Neoadjuvant Chemotherapy Followed by Surgery in Elderly Patients with Esophageal Squamous Cell Carcinoma

We evaluated the impact of body composition on clinical outcomes after neoadjuvant chemotherapy (NAC) followed by surgery for elderly cStage II/III esophageal squamous cell carcinoma (ESCC). Ninety-one patients ≥70 years old and 116 patients <70 years old with ECSS who underwent NAC between January 2013 and June 2018 at the Aichi Cancer Center were included. Body composition as assessed from computed tomography (CT), American Society of Anesthesiologists physical status (ASA-PS), and subjective global assessment (SGA) was assessed before initiation of NAC. Although elderly patients showed significantly poorer ASA-PS (p < 0.01) and SGA (p < 0.01), and significantly more frequent history of malignancy (p < 0.05), no significant differences were identified in the frequencies of adverse events, postoperative complications, or in cancer-specific survival (p = 0.65, hazard ratio 1.15), or overall survival (p = 0.42, hazard ratio 1.26). However, multivariate analysis identified sarcopenic obesity as the only independent predictor of prognosis in elderly patients. Sarcopenic obesity was associated with higher body mass index (p = 0.04), better SGA (p < 0.01), and lower pre-treatment weight loss (p = 0.03). NAC was as effective and safe for elderly patients without sarcopenic obesity as for young patients. However, diagnosing sarcopenic obesity based on clinical findings is difficult, so the preoperative CT assessment of sarcopenic obesity is important.

Metabolic syndrome predicts postoperative complications after gastrectomy in gastric cancer patients: Development of an individualized usable nomogram and rating model

Background

Metabolic syndrome (MetS), a public health problem, is reportedly related to an increased risk of postoperative complications after surgery. However, whether MetS have an effect on complications after gastric cancer (GC) surgery are unknown. This study aimed to investigate the effects of preoperative MetS on complications after gastrectomy.

Methods

Altogether, 718 gastric cancer patients who planned to receive radical gastrectomy between June 2014 and December 2016 were enrolled, demographic and clinicopathological characteristics were analyzed. Univariate and multivariate analyses were performed to identify potential risk factors for postoperative complications. A predictive model for postoperative complications was constructed in the form of a nomogram, and its clinical usefulness was assessed.

Results

Of the 628 patients ultimately included in the study (mean age 62.92 years, 450 men and 178 women), 84 were diagnosed with MetS preoperatively. Severe postoperative complications (Clavien‐Dindo grade ≥II) were significantly more common in patients with MetS (41.7% versus 23.7%, P < .001). Predictors of postoperative complications included MetS (odds ratio [OR] = 1.800, P = .023), age (OR = 1.418, P = .050), Charlson score (OR = 1.787, P = .004 for 1‐2 points) and anastomosis type (OR = 1.746, P = .007 for Billroth II reconstruction). The high‐risk rating had a high AUC (ROC I = 0.503, ROC Ib = 0.544, ROC IIa = 0.601, ROC IIb = 0.612, ROC IIc = 0.638, ROC III = 0.735), indicating that the risk‐rating model has good discriminative capacity and clinical usefulness.

Conclusions

MetS was an independent risk factor for complications after gastrectomy. The nomogram and rating model incorporating MetS, Billroth II anastomosis, age, and Charlson score was useful for individualized prediction of postoperative complications.

Assessment of body composition and impact of sarcopenia and sarcopenic obesity in patients with gastric cancer

Malnutrition is a critical problem in patients with gastric cancer (GC); however, no universally accepted marker that is convenient for clinical use has been defined. Recently, body composition has attracted considerable attention as a means to assess nutrition status in patients with cancer. The clinical role of skeletal muscle mass has also been increasingly recognized. In patients with GC, sarcopenia, which is the loss of skeletal muscle mass, was found to be significantly associated with increased post-surgical complications including hospital stay, healthcare costs, and poor survival. In addition, sarcopenic obesity, which combines the health risks of obesity and sarcopenia, is recognized as a strong risk factor for poor short- and long-term outcomes following gastrectomy. The mechanism linking sarcopenia to worse postoperative outcomes remains unclear; however, skeletal muscle has been found to act as an endocrine organ that produces substances affecting the immune system. In addition, sarcopenia was reported to be associated with toxicity and termination of chemotherapy. Patients with sarcopenia may be unable to react appropriately to the stress of gastrectomy and perioperative chemotherapy. To improve the short- and long-term outcomes of patients with GC and sarcopenia, adequate energy and protein intake are necessary during resistance training. In the present study, we performed a literature review and presented a method to evaluate body composition, the relationship between skeletal muscle mass and GC, and perioperative nutrition and exercise therapy for patients with sarcopenia.

Reference Values for Skeletal Muscle Mass - Current Concepts and Methodological Considerations

Assessment of a low skeletal muscle mass (SM) is important for diagnosis of ageing and disease-associated sarcopenia and is hindered by heterogeneous methods and terminologies that lead to differences in diagnostic criteria among studies and even among consensus definitions. The aim of this review was to analyze and summarize previously published cut-offs for SM applied in clinical and research settings and to facilitate comparison of results between studies. Multiple published reference values for discrepant parameters of SM were identified from 64 studies and the underlying methodological assumptions and limitations are compared including different concepts for normalization of SM for body size and fat mass (FM). Single computed tomography or magnetic resonance imaging images and appendicular lean soft tissue by dual X-ray absorptiometry (DXA) or bioelectrical impedance analysis (BIA) are taken as a valid substitute of total SM because they show a high correlation with results from whole body imaging in cross-sectional and longitudinal analyses. However, the random error of these methods limits the applicability of these substitutes in the assessment of individual cases and together with the systematic error limits the accurate detection of changes in SM. Adverse effects of obesity on muscle quality and function may lead to an underestimation of sarcopenia in obesity and may justify normalization of SM for FM. In conclusion, results for SM can only be compared with reference values using the same method, BIA- or DXA-device and an appropriate reference population. Limitations of proxies for total SM as well as normalization of SM for FM are important content-related issues that need to be considered in longitudinal studies, populations with obesity or older subjects.

The Predictive Value of Low Muscle Mass as Measured on CT Scans for Postoperative Complications and Mortality in Gastric Cancer Patients: A Systematic Review and Meta-Analysis

Risk assessment is relevant to predict outcomes in patients with gastric cancer. This systematic review aimed to investigate the predictive value of low muscle mass for postoperative complications in gastric cancer patients. A systematic literature search was performed to identify all articles reporting on muscle mass as measured on computed tomography (CT) scans in patients with gastric cancer. After full text screening, 15 articles reporting on 4887 patients were included. Meta-analysis demonstrated that patients with low muscle mass had significantly higher odds of postoperative complications (odds ratio (OR): 2.09, 95% confidence interval (CI): 1.55–2.83) and severe postoperative complications (Clavien–Dindo grade ≥III, OR: 1.73, 95% CI: 1.14–2.63). Moreover, patients with low muscle mass had a significantly higher overall mortality (hazard ratio (HR): 1.81, 95% CI: 1.52–2.14) and disease-specific mortality (HR: 1.58, 95% CI: 1.36–1.84). In conclusion, assessment of muscle mass on CT scans is a potential relevant clinical tool for risk prediction in gastric cancer patients. Considering the heterogeneity in definitions applied for low muscle mass on CT scans in the included studies, a universal cutoff value of CT-based low muscle mass is required for more reliable conclusions.

The Incidence of Postoperative Complications after Gastrectomy Increases in Proportion to the Amount of Preoperative Visceral Fat

Background

Visceral obesity is a risk factor for complications after gastrectomy in patients with gastric cancer. However, it is unclear whether postoperative complications decrease with preoperative reduction of visceral fat without the achievement of a nonobese state. This is because previous studies have performed categorical comparisons of obesity and nonobesity. The current study was performed to estimate the impact of the preoperative visceral fat area (VFA) as a continuous variable on postoperative complications after gastrectomy.

Methods

Consecutive patients with gastric cancer who underwent curative gastrectomy between June 2006 and August 2017 at the Kyoto University Hospital were included in this retrospective study. The VFA at the level of the umbilicus was measured using preoperative computed tomography. The relationship between postoperative complications and VFA was investigated with univariate and multivariate analyses.

Results

total of 566 patients were included in the study. Their mean VFA was 110 ± 58 cm², and postoperative complications occurred in 121 patients (21.4%). The larger the VFA (<50, 50–99, 100–149, and ≥150 cm²), the higher the incidence of postoperative complications (11%, 14%, 21%, and 38%, respectively, P < 0.001). Multivariate logistic regression analyses showed that the VFA was associated with postoperative complications (odds ratio: 1.009, 95% confidence interval (CI): 1.004–1.013, P < 0.001), with an incidence of postoperative complications that was 9% (95% CI: 4%–12%) higher for every 10 cm² increase in the VFA.

Conclusion

The incidence of postoperative complications after gastrectomy increases in proportion to an increase in the preoperative VFA.

Prevalence of sarcopenic obesity in adults with end-stage knee osteoarthritis

OBJECTIVE

To identify the prevalence of sarcopenic obesity, a phenotype of low muscle mass and high adiposity, in adults with end-stage knee osteoarthritis (OA). Various diagnostic criteria, including assessment of muscle/fat mass, muscle strength and physical function, were used to identify patients with and without sarcopenic obesity, and to compare outcomes of pain, function and quality of life.

DESIGN

Cross-sectional clinical study including adults with a body mass index (BMI) ≥30 kg/m² and knee OA. Body composition was measured by dual-energy X-ray absorptiometry (DXA). Assessments included gait speed, handgrip strength, six minute walk test, and self-reported pain, physical function, and health-related quality of life using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol Foundation (EQ-5D).

RESULTS

151 adults (59% female) aged 65.1 ± 7.9 years, mean BMI 37.1 ± 5.5 kg/m², were included. Prevalence of sarcopenic obesity using diagnostic cut-offs of appendicular skeletal muscle mass (ASM) relevant to height², weight and BMI varied from 1.3% (95% confidence interval (CI): 0.2-4.7%) to 14.6% (9.4-21.2%) and 27.2% (20.2-35%), respectively. A combined diagnostic approach including low ASM with either low strength or low function yielded a prevalence of 8.6% (4.7-14.3%). Sarcopenic obesity influenced walking speed, endurance, strength, and patient-reported difficulty with self-care activities, regardless of diagnostic approach.

CONCLUSION

Prevalence of sarcopenic obesity varied depending on diagnostic criteria. Given the impact of this condition and OA on physical function, we suggest a combined diagnostic approach be used to clarify expected prevalence and enable early clinical identification and management of sarcopenic obesity in patients with knee OA.

Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival

It has frequently been shown that patients with cancer are one of the largest hospital patient groups with a prevalence for malnutrition. Weight loss is a frequent manifestation of malnutrition in patients with cancer. Several large-scale studies over the past 35 y have reported that involuntary weight loss affects 50% to 80% of these patients with the degree of weight loss dependent on tumor site and type and stage of disease. The aim of this review was to determine the consequences of malnutrition, weight loss, and muscle wasting in relation to chemotherapy tolerance, postoperative complications, quality of life, and survival in patients with cancer. The prognostic impact of weight loss on overall survival has long been recognised with recent data suggesting losses as little as 2.4% predicts survival independent of disease, site, stage or performance score. Recently the use of gold-standard methods of body composition assessment, including computed tomography, have led to an increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation, as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities are highly prevalent (ranging from 10-90%, depending on cancer site and the diagnostic criteria used). Both low muscle mass and low muscle attenuation have been associated with poorer tolerance to chemotherapy; increased risk of postoperative complications; significant deterioration in a patients' performance status, and poorer psychological well-being, overall quality of life, and survival.

Prognostic and predictive implications of sarcopenia in Western patients undergoing gastric resections for carcinoma of the stomach

INTRODUCTION

Sarcopenia is highly prevalent in patients with gastrointestinal malignancies, including gastric cancer, but there is a lack of adequate data from Western populations.

METHODS

Computed tomography scans of 138 Caucasian patients subject to stomach resections due to gastric adenocarcinoma between 2012 and 2015 were reviewed to evaluate the impact of sarcopenia. The definition of sarcopenia was based on the lumbar skeletal muscle index (SMI) using cut-off values formulated by the international consensus definitions of sarcopenia (SMI <52.4 cm² /m² for men and <38.5 cm² /m² for women).

RESULTS

Sixty (43%) of 138 patients were sarcopenic. Sarcopenia was associated with postoperative morbidity (43% vs 23%; P = .011), major postoperative complications (Clavien-Dindo ≥3a; 36% vs 21%; P = .035), and reoperations (23% vs 9%; P = .020). Patients with sarcopenia also had prolonged postoperative hospital stay (8.0 vs 6.5 days; P = .010). The overall median survival of patients with sarcopenia was significantly lower than those with normal skeletal muscles (11.0 vs 36.7 months; P = .005) and sarcopenia remained an independent prognostic factor with an odds ratio of 1.94 (95% confidence interval, 1.08 to 3.48; P = .026).

CONCLUSION

Sarcopenia, defined by SMI, is associated with an increased risk of postoperative morbidity and impaired long-term survival.

Frailty Predicts Severe Postoperative Complication after Elective Hepatic Resection

Background

Frail patients are likely to suffer from postoperative complication, but this assumption has not been well confirmed.

Objectives

This study aims to clarify the importance of frailty in patients undergoing hepatectomy for predicting severe postoperative complications.

Method

One hundred and forty-three patients aged >65 years undergoing hepatectomy between 2011 and 2016 were enrolled in this study. The relevance of frailty versus sarcopenia for postoperative outcome was assessed. We defined clinical frailty (CF) as a CF scale >4. Sarcopenia was defined by the total muscle area at the level of the third lumbar vertebra measured on computed tomography.

Results

There were 16 patients (11%) with CF and 80 patients (56%) with sarcopenia. CF was associated with high age (p < 0.0001), severe postoperative complications (Clavien-Dindo classification ≥3) (p = 0.0059), and postoperative in-hospital stay (p = 0.0013). On the other hand, sarcopenia was not associated with postoperative outcome. Logistic regression analysis revealed that only CF was an independent predictor of severe postoperative complication (risk ratio of 4.2; p = 0.017). The occurrence of organ/space surgical site infection was significantly higher in the frailty group than in the non-frailty group.

Conclusion

CF, but not sarcopenia, is a robust predictor of severe postoperative complications for patients undergoing hepatectomy.

A High Visceral-To-Subcutaneous Fat Ratio is an Independent Predictor of Surgical Site Infection after Gastrectomy

Recent studies have shown that body composition is an important factor that affects surgical site infection (SSI). However, each study has utilized different body composition criteria. Therefore, in this study, we aim to determine the most predictable body composition criteria for the prediction of SSI after gastrectomy. The visceral fat area (VFA), subcutaneous fat area (SFA), and muscle area were assessed by a preoperative-stage computed tomographic (CT) scan. To compare the predictive performance of body composition for SSI, logistic regression models were used, and the models were compared using the receiver operation characteristic (ROC) curve and the area under the curve (AUC) value. Of the 1038 eligible patients, 58 patients (5.6%) developed SSI. The VFA-to-SFA ratio showed the best predictive performance (mean AUC 75.11). The cutoff value for the SSI of the VFA-to-SFA ratio was 0.94, and the sensitivity and specificity were 67.86% and 77.65%, respectively. A multivariate logistic analysis indicated that a total gastrectomy (OR, 2.13; p = 0.017), stage III or IV cancer (OR, 2.66; p = 0.003), and a high VFA-to-SFA ratio (OR, 8.09; p < 0.001) were independent risk factors for SSI after gastrectomy. The VFA-to-SFA ratio is the most predictable body composition model for use in predicting the incidence of SSI after gastrectomy.

Prognostic value of sarcopenic obesity estimated by computed tomography in patients with cardiovascular disease and undergoing surgery

BACKGROUND

Sarcopenic obesity is a health condition involving a combination of excess adipose tissue and loss of muscle mass. Although sarcopenic obesity is known to contribute to the morbidity and mortality of chronic diseases, limited data are available in patients with cardiovascular disease. The present study was performed to examine whether sarcopenic obesity determined by preoperative computed tomography (CT) is a useful predictor of postoperative mortality in patients undergoing cardiovascular surgery.

METHODS

We reviewed the findings in 664 consecutive cardiovascular surgery patients (mean age, 65.8±12.7 years; male, 66.6%) who underwent preoperative CT including the level of the third lumbar vertebra for clinical purposes. Psoas muscle attenuation (MA) and visceral adipose tissue (VAT) were measured as metrics of sarcopenia and obesity, respectively. Sarcopenia was defined as low MA (below median), while obesity was defined as high VAT (≥103cm² for males and ≥69cm² for females). The endpoint was all-cause mortality and secondary outcomes were muscle function.

RESULTS

After adjusting for age and sex, sarcopenic obesity showed significant associations with lower grip strength and quadriceps strength, slower gait speed, and shorter 6-min walking distance compared to the normal group (p<0.05). On multivariate Cox regression analysis, sarcopenic obesity was associated with increased risk of mortality after adjusting for EuroSCORE (hazard ratio, 3.04; 95% confidence interval, 1.25-7.40).

CONCLUSIONS

Sarcopenic obesity is associated with poor muscle function and all-cause mortality in patients undergoing cardiovascular surgery.