Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data

Pharmaconutrition: Which substrates?

With the term "pharmaconutrition" or "immunonutrition" is intended the use of specific nutritional substrates having the ability of modulating specific mechanisms involved in several immune and inflammatory pathways. To achieve these goals, these substrates have to be administered with over physiologic dose. Glutamine and omega-3 polyunsaturated fatty acids, used as single substrate, did not show clear clinical advantages on solid endpoints such as postoperative complications. Despite several multiple substrate enteral feeds are available on the market, very few of them have been tested in randomized clinical trial to prove efficacy. The most extensive investigated formulation is a combination of arginine, omega-3 fatty acids, ribonucleic acid with or without glutamine. Several meta-analyses of randomized clinical trials have been conducted to compare the effects of enteral immunonutrition with control diets on post-surgical morbidity. The results consistently showed that the use of enteral multiple substrate formulas significantly reduced infectious complications and duration of hospitalization. In a more contemporary view, pharmaconutrition should be tested more accurately in the contest of enhanced recovery programs, during neoadjuvant chemotherapy, and in the prehabilitation setting.

Multimodal prerehabilitation for elderly patients with sarcopenia in colorectal surgery

Sarcopenia, which is characterized by progressive and generalized loss of skeletal muscle mass and strength, has been well described to be associated with numerous poor postoperative outcomes, such as increased perioperative mortality, postoperative sepsis, prolonged length of stay, increased cost of care, decreased functional outcome, and poorer oncological outcomes in cancer surgery. Multimodal prehabilitation, as a concept that involves boosting and optimizing the preoperative condition of a patient prior to the upcoming stressors of a surgical procedure, has the purported benefits of reversing the effects of sarcopenia, shortening hospitalization, improving the rate of return to bowel activity, reducing the costs of hospitalization, and improving quality of life. This review aims to present the current literature surrounding the concept of sarcopenia, its implications pertaining to colorectal cancer and surgery, a summary of studied multimodal prehabilitation interventions, and potential future advances in the management of sarcopenia.

Impact of CT-measured sarcopenic obesity on postoperative outcomes following colon cancer surgery

OBJECTIVE

This study aimed to investigate the influence of sarcopenic obesity on anastomotic leak following elective colon resection for non-metastatic colon cancer. Secondary outcomes included overall morbidity, mortality and length of hospital stay.

METHODS

This retrospective observational study, conducted at a colorectal surgery referral centre, spanned from January 1, 2015, to January 1, 2020. A total of 544 consecutive patients who underwent elective colon resection were included in the analysis, excluding patients with rectal cancer, urgent surgery, absence of anastomosis, lack of imaging, multivisceral resections and synchronic tumours.

RESULTS

Postoperative complications were observed in 177 (32.3%) patients, with 51 (9.31%) classified as severe (Clavien-Dindo > II). Sarcopenic obesity was identified in 9.39% of the sample and emerged as an independent predictor of increased overall morbidity [OR 2.15 (1.14-3.69); p = 0.016] and 30-day mortality [OR 5.07 (1.22-20.93); p = 0.03] and was significantly associated with the development of anastomotic leak [OR 2.95 (1.41-6.18); p = 0.007]. Furthermore, it increased the risk of reoperation and was linked to a prolonged length of hospital stay.

CONCLUSIONS

CT-measured sarcopenic obesity demonstrates a discernible correlation with an elevated risk of postoperative morbidity and mortality in the context of colon cancer surgery.

Muscle quality, not quantity, is associated with outcome after colorectal cancer surgery

INTRODUCTION

Emerging evidence suggests that deconditioned patients benefit most from prehabilitation before colorectal cancer surgery. So far, selecting patients with poor muscle status and high perioperative risk remains challenging. Therefore, this study evaluates the potential of the CT-derived Skeletal Muscle Index (SMI), representing muscle mass, and of the Muscle Radiation Attenuation (MRA), a measure of muscle quality, for risk stratification in colorectal cancer patients.

METHODS

In this retrospective, single-center observational study, 207 patients with resection of colorectal adenocarcinoma between January 2016 and December 2020 were included. The Charlson comorbidity index (CCI), postoperative complications, length of hospital stay, and survival were recorded. Data were analyzed using multivariable linear, logistic, and Cox proportional hazards regression models adjusted for age, sex, BMI, CCI, neoadjuvant therapy, tumor stage, and surgery type.

RESULTS

An increase of the MRA was associated with fewer postoperative complications (anastomotic leakage and pneumonia) and lesser severity according to the Clavien-Dindo classification, shorter hospital stays, and prolonged survival (Hazard ratio: 0.63 [95%CI: 0.49-0.81], p < 0.001). No relevant associations were found between the SMI and postoperative complications, length of hospital stay, or survival.

CONCLUSION

The easy-to-raise MRA serves as a more reliable tool than the SMI for identifying high-risk patients with poor muscle status before colorectal surgery. Those patients may benefit most from prehabilitation, which has to be proven in future interventional trials.

Physical frailty recovery is slower than mental frailty recovery after non-cardiac surgery in older adult patients

PURPOSE

Frailty is characterized by fragility and decline in physical, mental, and social activities; it is commonly observed in older adults. No studies have reported frailty status changes between the preoperative and postoperative periods, including mental and cognitive factors. Therefore, this study investigated frailty factors, including mental and cognitive functions, that change after non-cardiac surgery in older adults.

METHODS

Patients aged ≥ 75 years who underwent non-cardiac surgery were surveyed using five tools (Eastern Cooperative Oncology Group-Performance Status (PS); handgrip strengths; Japan-Cardiovascular Health Study index (J-CHS index); Mini-Mental State Examination (MMSE); and Geriatric Depression Scale) for comprehensive evaluation of perioperative functions. The results before surgery, at discharge, and during follow-up at the outpatient clinic were compared.

RESULTS

Fifty-three patients with a median age of 80 (IQR, 77-84) years were evaluated. MMSE scores did not change during the perioperative period. The PS and J-CHS index worsened significantly at discharge and did not improve at the outpatient clinic follow-up. The dominant handgrip strength decreased after surgery (p < 0.001) but improved during follow-up. Additionally, nondominant handgrip strength decreased after surgery (p < 0.001) but did not recover as much as the dominant handgrip strength during follow-up (p = 0.015).

CONCLUSION

Changes in physical frailty and mental and cognitive functions were not identical perioperatively in older adult patients undergoing non-cardiac surgery. Physical frailty did not improve 1 month after surgery, mental function recovered early, and cognitive function did not decline. This study may be important for frailty prevention in older adult patients.

Acute Changes in Body Muscle Mass and Fat Depletion in Hospitalized Young Trauma Patients: A Descriptive Retrospective Study

Background: Loss of muscle mass, and its strength, is associated with adverse outcomes in many medical and surgical conditions. Trauma patients may get malnourished during their hospital course due to many interrelated contributing factors. However, there is insufficient knowledge on the acute muscle and fat changes in young trauma patients in the early days post-admission. Objective: to explore the diagnosis, feeding status, and outcome of muscle mass loss among young abdominal polytrauma patients. Methods: It was a retrospective study including hospitalized abdominal trauma patients who underwent an abdominal computerized tomographic (CT) examination initially and a follow-up one week later. CT scan-based automatic and manual analysis of the muscles and fat of the abdominal region was calculated and compared. Also, we evaluated the feeding and nutritional values to explore the adequacy of the provided calories and proteins and the potential influence of enteral feeding on the CT-based parameters for muscle loss and fat depletion. Results: There were 138 eligible subjects with a mean age of 32.8 ± 13.5 years; of them, 92% were males. Operative interventions were performed on two-thirds of the patients, including abdominal surgery (43%), orthopedic surgeries (34%), and neurosurgical procedures (8.1%). On admission, 56% received oral feeding, and this rate slightly increased to 58.4% after the first week. Enteral feed was prescribed for the remaining, except for two patients. The percentage of change in the total psoas muscle area was significantly reduced after one week of admission in patients on enteral feed as compared to those in the oral feeding group (p = 0.001). There were no statistically significant differences in the percentages of changes in the CT scan findings except for the total psoas muscle area (p = 0.001) and para-spinal muscle area (p = 0.02), which reduced significantly in the those who underwent laparotomy as compared to those who did not need laparotomy. Trauma patients who underwent emergency abdominal surgery lost muscle and fat over time. Conclusions: Loss of muscle mass and body fat is not uncommon among young trauma patients. Patients who underwent laparotomy are more likely to be affected. Further larger studies are needed to assess the specific features in the younger trauma population and how far this can be influenced by the nutrition status and its impact on the clinical outcomes. It could be early or impending stages of sarcopenia linked to trauma patients, or just acute changes in the muscle and fat, that need further investigation and follow-up after hospital discharge.

Consensus-defined sarcopenia predicts adverse outcomes after elective abdominal surgery: meta-analysis

BACKGROUND

Sarcopenia refers to the progressive age- or pathology-associated loss of skeletal muscle. When measured radiologically as reduced muscle mass, sarcopenia has been shown to independently predict morbidity and mortality after elective abdominal surgery. However, the European Working Group on Sarcopenia in Older People (EWGSOP) recently updated their sarcopenia definition, emphasizing both low muscle 'strength' and 'mass'. The aim of this systematic review and meta-analysis was to determine the prognostic impact of this updated consensus definition of sarcopenia after elective abdominal surgery.

METHODS

MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for studies comparing prognostic outcomes between sarcopenic versus non-sarcopenic adults after elective abdominal surgery from inception to 15 June 2022. The primary outcomes were postoperative morbidity and mortality. Sensitivity analyses adjusting for confounding patient factors were also performed. Methodological quality assessment of studies was performed independently by two authors using the QUality in Prognosis Studies (QUIPS) tool.

RESULTS

Twenty articles with 5421 patients (1059 sarcopenic and 4362 non-sarcopenic) were included. Sarcopenic patients were at significantly greater risk of incurring postoperative complications, despite adjusted multivariate analysis (adjusted OR 1.56, 95 per cent c.i. 1.39 to 1.76). Sarcopenic patients also had significantly higher rates of in-hospital (OR 7.62, 95 per cent c.i. 2.86 to 20.34), 30-day (OR 3.84, 95 per cent c.i. 1.27 to 11.64), and 90-day (OR 3.73, 95 per cent c.i. 1.19 to 11.70) mortality. Sarcopenia was an independent risk factor for poorer overall survival in multivariate Cox regression analysis (adjusted HR 1.28, 95 per cent c.i. 1.13 to 1.44).

CONCLUSION

Consensus-defined sarcopenia provides important prognostic information after elective abdominal surgery and can be appropriately measured in the preoperative setting. Development of targeted exercise-based interventions that minimize sarcopenia may improve outcomes for patients who are undergoing elective abdominal surgery.

Immunonutrition and prehabilitation in pancreatic cancer surgery: A new concept in the era of ERAS® and neoadjuvant treatment

Pancreatic cancer (PC) is an aggressive disease, with a growing incidence, and a poor prognosis. Neoadjuvant treatments in PC are highly recommended in borderline resectable and recently in upfront resectable PC. PC is characterized by exocrine insufficiency and nutritional imbalance, leading to malnutrition/sarcopenia. The concept of malnutrition in PC is multifaceted, as the cancer-related alterations create an interplay with adverse effects of anticancer treatments. All these critical factors have a negative impact on the postoperative and oncological outcomes. A series of actions and programs can be implemented to improve resectable and borderline resectable PC in terms of postoperative complications, oncological outcomes and patients' quality of life. A timely nutritional evaluation and the implementation of appropriate evidence-based nutritional interventions in onco-surgical patients should be considered of importance to improve preoperative physical fitness. Unfortunately, nutritional care and its optimization are often neglected in real-world clinical practice. Currently available studies and ERAS® guidelines mostly support the use of pre- or perioperative medical nutrition, including immunonutrition, in order to decrease the rate of postoperative infections and length of hospital stay. Further data also suggest that medical nutrition should be considered proactively in PC patients, to possibly prevent severe malnutrition and its consequences on disease and treatment outcomes. This narrative review summarizes the most recent data related to the role of prehabilitation, ERAS® program, medical nutrition, and the timing of intervention on clinical outcomes of upfront resectable and borderline PC, and their potential implementation within the timeframe of neoadjuvant treatments.

Gastric adenocarcinoma with high‑level microsatellite instability: A case report

Gastric cancer (GC) ranks fifth on the list of the most common malignancies worldwide. In Peru, gastric neoplasms are considered the second leading cause of mortality among males. Among the molecular subgroups of GC, microsatellite instability presents a favorable prognosis due to its hypermutated phenotype, which activates immunosurveillance. The present study describes the case of a 75-year-old patient, who was admitted in the hospital with a history of upper gastrointestinal bleeding and recurrent hospital admission, due to severe anemia. The patient presented with pale skin, normal vital functions, slight swelling of the lower extremities, and abdominal distention and bloating upon a physical examination. An endoscopic examination revealed an infiltrating circular ulcerated lesion. The histopathological analysis identified a moderately differentiated intestinal-type adenocarcinoma with pathological stage T3N0M0. Tumor genomic profiling demonstrated alterations in 15 different genes with a tumor mutational burden of 28 mutations/Mb. Finally, the patient underwent a partial gastrectomy without pre-operative chemotherapy. After 4 days, the patient presented with post-operative complications for which he was re-operated on. The patient did not survive. To the best of our knowledge, in the present case, pernicious anemia was an early sign of GC and a gastroscopy had to be performed. Furthermore, MutS homolog 3 alterations probably conditioned the presence of multiple frame-shift mutations.

Extending the benefit of nutrition intervention beyond the operative setting

PURPOSE OF REVIEW

To provide an update of the recent evidence on the potential of perioperative nutritional interventions to benefit adult patients undergoing head and neck and digestive procedures.

RECENT FINDINGS

Perioperative nutrition within multimodal prehabilitation programs improve postoperative outcomes. Perioperative fasting time can be reduced with beverages containing carbohydrate alone or blended with a nitrogenous source such as whey protein; this approach seems to be safe and improve outcome. The choice of protein-containing formula, as well as diet composition to be recommended early during the postoperative refeeding, can be optimized to reduce complications. Sarcopenia is an important risk factor for surgical patients, as such, prehabilitation along with preoperative nutrition is strongly advised. Perioperative supplementation with β-hydroxy β-methylbutyrate to mitigate sarcopenia requires further investigation. Although perioperative nutritional interventions reduce healthcare costs, recent data suggest it has been scarcely prescribed.

SUMMARY

Nutritional intervention is key in multimodal programs of enhanced recovery after surgery to ensure better outcomes. Perioperative fasting should be shortened, and include clear fluids containing carbohydrates and protein, especially in the early postoperative period. Multimodal prehabilitation is key to mitigate sarcopenia. Action to improve knowledge on the cost-effectiveness of nutritional interventions in the perioperative setting are needed.

Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer

BACKGROUND

Sarcopenia is prevalent among older patients with cancer and is associated with poor outcomes.

OBJECTIVE

To explore the relationship between muscle mass, quality, and patient age with overall survival after surgery for advanced ovarian cancer.

METHODS

Patients with advanced stage (IIIC/IV) ovarian cancer who underwent primary cytoreductive surgery between January 2006 and July 2016 were included. Body composition measures were calculated from pre-operative CT imaging: skeletal muscle index (skeletal muscle index=skeletal muscle area normalized for height), skeletal muscle density, and skeletal muscle gauge (product of skeletal muscle index and skeletal muscle density). Each measure was transformed to a z-score and evaluated for association with risk of death using Cox proportional hazards models. Recursive partitioning was used to classify patients into homogeneous subgroups considering age and skeletal muscle gauge as predictors of overall survival.

RESULTS

The study included 429 patients (mean age 64.2 years). Increased age moderately correlated with decreased skeletal muscle gauge (r=-0.45). Decreasing skeletal muscle density and skeletal muscle gauge were significantly associated with increased risk of death; HR (95% CI) per 1-unit decrease in z-score of 1.24 (1.10 to 1.39) for skeletal muscle density and 1.27 (1.12 to 1.44) for skeletal muscle gauge. Associations were diluted after adjusting for age (1.13 (1.00 to 1.29) skeletal muscle density and 1.14 (0.99 to 1.30) skeletal muscle gauge). Recursive partitioning identified three subgroups: <60 years old, ≥60 years old with skeletal muscle gauge ≥937.3, and ≥60 years old with skeletal muscle gauge <937.3; median overall survival was 5.8, 3.3, and 2.3 years, respectively (p<0.001).

CONCLUSIONS

Skeletal muscle gauge, a novel sarcopenia measure incorporating quantity and quality, was associated with poorer survival in patients with advanced ovarian cancer, particularly among patients older than 60. Expanding our knowledge of how sarcopenia relates to solid tumor outcomes among high-risk patients can modify our treatment approach.