Sarcopenia, as Assessed by Psoas Cross-Sectional Area, Is Predictive of Adverse Postoperative Outcomes in Patients Undergoing Colorectal Cancer Surgery

Abstract

BACKGROUND: Frailty and sarcopenia are important concepts in surgical practice because of their association with adverse postoperative outcomes. Radiologically assessed psoas muscle mass has been proposed as a surrogate for sarcopenia and may be predictive of poor postoperative outcomes. OBJECTIVE: This study aimed to determine the association between sarcopenia, as assessed by psoas cross-sectional area, and postoperative outcomes in patients undergoing colorectal cancer surgery. DESIGN: This was a retrospective review of patient records from 2014 to 2016. SETTINGS: This study was conducted at a single tertiary center. PATIENTS: Patients undergoing elective resection of colorectal cancer were included. MAIN OUTCOME MEASURES: Sarcopenia was assessed using the total psoas index, calculated by measuring the cross-sectional area of the psoas muscle at the third lumbar vertebra and normalized for patient height. Preoperative and intraoperative variables, including the presence of preoperative sarcopenia, were evaluated as potential risk factors for adverse postoperative outcomes. RESULTS: Of 350 patients, 115 (32.9%) were identified as sarcopenic. Sarcopenia was associated with a significantly increased length of stay (13 days vs 7 days; OR, 1.31; 95% CI, 1.23–1.42; p < 0.01) and 1-year mortality (13.9% vs 0.9%; OR, 16.2; 95% CI, 4.34–83.4; p < 0.01). Sarcopenia was also associated with a significant increased risk of any complication (85.2% vs 34.5%; OR, 15.4; 95% CI, 8.39–29.7; p < 0.01) and of major complications (30.4% vs 8.9%; OR, 15.1; 95% CI, 7.16–33.2; p < 0.01). LIMITATIONS: This study was limited by its retrospective design and by being conducted in a single institution. Although reduced muscle mass is suggestive of sarcopenia, it does not assess a patient’s physical function or other components of the frailty phenotype. CONCLUSION: Radiological sarcopenia is an important predictive risk factor for adverse postoperative outcomes in surgical patients. Computed tomography scans, which are routinely performed as part of staging, provide an opportunity to assess for sarcopenia preoperatively. See Video Abstract at http://links.lww.com/DCR/B201. LA SARCOPENIA, EVALUADA POR EL ÁREA TRANSVERSAL DE PSOAS, PREDICE RESULTADOS POSTOPERATORIOS ADVERSOS EN PACIENTES SOMETIDOS A CIRUGÍA DE CÁNCER COLORECTAL ANTECEDENTES: La fragilidad y la sarcopenia son conceptos importantes en la práctica quirúrgica debido a su asociación con los resultados postoperatorios adversos. La masa muscular del psoas evaluada radiológicamente se ha propuesto como un sustituto de la sarcopenia y puede predecir resultados postoperatorios deficientes. OBJETIVO: Determinar la asociación entre la sarcopenia, según lo evaluado por el área transversal del psoas, y los resultados postoperatorios en pacientes sometidos a cirugía de cáncer colorrectal. DISEÑO: Esta fue una revisión retrospectiva de los registros de pacientes de 2014 a 2016. AJUSTES: Este estudio se llevo a cabo en un solo centro terciario. PACIENTES: Se incluyeron pacientes sometidos a resección electiva de cáncer colorrectal. PRINCIPALES MEDIDAS DE RESULTADO: La sarcopenia se evaluó utilizando el índice de psoas total (TPI), calculado midiendo el área de la sección transversal del músculo psoas en la tercera vértebra lumbar y normalizado para la altura del paciente.Se evaluaron las variables preoperatorias e intraoperatorias, incluida la presencia de sarcopenia preoperatoria, como posibles factores de riesgo de resultados postoperatorios adversos. RESULTADOS: De 350 pacientes, 115 (32,9%) fueron identificados como sarcopénicos. La sarcopenia se asoció con un aumento significativo de la duración de la estancia (13 días frente a 7 días, OR 1.31, IC 95% 1.23–1.42, p < 0.01) y de la mortalidad al año (13.9% vs 0.9%, OR 16.2, IC 95% 4.34–83.4, p < 0.01). La sarcopenia también se asoció con un aumento significativo del riesgo de cualquier complicación (85.2% vs 34.5%, OR 15.4, IC 95% 8.39–29.7, p < 0.01) y de complicaciones mayores (30.4% vs 8.9%, OR 15.1 IC 95% 7.16–33,2, p < 0,01). LIMITACIONES: Este estudio estuvo limitado por su diseño retrospectivo y por el hecho de que se realizó en una sola institución. Aunque la reducción de la masa muscular es un indicio de sarcopenia, no evalúa la función física del paciente ni otros componentes del fenotipo de fragilidad. CONCLUSIÓN: La sarcopenia radiológica es un importante factor de riesgo predictivo para resultados postoperatorios adversos en pacientes quirúrgicos. Las tomografías computarizadas, que se realizan rutinariamente como parte de la estadificación, brindan la oportunidad de evaluar la sarcopenia antes de la operación. Consulte Video Resumen en http://links.lww.com/DCR/B201. (Traducción—Dr. Gonzalo Hagerman)

Influence of Postoperative Changes in Sarcopenia on Long-Term Survival in Non-Metastatic Colorectal Cancer Patients

“…In non-metastatic colorectal cancer, sarcopenia was reported to increase postoperative complications and mortality [ 6 , 21 , 22 , 23 ], as well as oncologic outcomes [ 17 , 18 , 19 ]. A routinely performed preoperative CT scan provides information to quantify sarcopenia and stratify risk groups and give a chance for active nutritional support and risk-stratified postoperative management.…”

Preoperative Sarcopenia is Associated with Poorer Compliance Rate of Adjuvant Chemotherapy and Worse Disease-free Survival of Patients with Stage Ⅲ Colon Cancer

“…Sarcopenia was diagnosed in 19.6% to 32.9% of colorectal cancer patients in early studies. [8,11] There were 45.9% of patients being classi ed as sarcopenia in our study. This may because we only included patients with stage colon cancer, which was more likely to cause frailty.…”

“…The association between TPI and surgical outcomes has been explored in recent years, and the results indicated it was a poor prognostic predictor in colorectal cancer [11] . However, whether low TPI (sarcopenia) affected the compliance of patients to receive the recommended standard adjuvant chemotherapy (AC) has not been well explored.…”

“…[4,5,9,10] However, this method is often timeconsuming and complicated, and is not suitable for clinical application. Some studies tried to use the total psoas index (TPI), which measured the total area at the level of L3 vertebral body and normalized according to patients' height, to assess sarcopenia and satisfactory results were obtained [8,11,12] . The TPI is easy to measure and reproduced in clinical practice.…”

The Impact of Surgical Delays on Short- and Long-Term Survival Among Colon Cancer Patients

“…Physicians should appropriately assess these conditions preoperatively since sarcopenia, frailty, and comorbidities such as diabetes can negatively impact colon cancer surgery outcomes. [18][19][20] Medical providers should be aware of how a patient's economic status or medical complexity can lead to delays in care, and work to address these issues in a multidisciplinary manner.…”