Computed Tomography-Measured Psoas Density Predicts Outcomes After Enterocutaneous Fistula Repair

Association Between Two Muscle-Related Parameters and Postoperative Complications in Patients Undergoing Colorectal Tumor Resection Surgery

BACKGROUND

This study aimed to investigate the associations of 2 preoperative muscle-related parameters, the third lumbar vertebra skeletal muscle index (L3 SMI) for muscle mass and the Hounsfield unit average calculation (HUAC) for muscle density, with the occurrence of postoperative complications among patients undergoing colorectal tumor resection surgery under general anesthesia. We hypothesized that muscle-related parameters are associated with the occurrence of postoperative complications.

METHODS

This was a single-center, retrospective observational study. Adult patients who underwent colorectal tumor resection surgery under general anesthesia between 2018.09.01 and 2021.09.01 were enrolled. The last abdominal computed tomography (CT) scan images obtained within 3 months before surgery were used to calculate the L3 SMI and HUAC. The primary outcome was defined as the occurrence of any postoperative complications corresponding to Clavien-Dindo classification before discharge. The secondary outcome was defined as the occurrence of any severe postoperative complications (Clavien-Dindo grade ≥3) before discharge. Multivariable logistic regression analyses were used to estimate the association between muscle-related parameters and incidence of postoperative complications. Patients' baseline demographics, past medical history and intraoperative parameters were adjusted in the multivariable logistic regression analysis.

RESULTS

A total of 317 patients with a median age of 66 (58-72) years were included. Sarcopenia (muscle mass reduction) patients in our cohort and myosteatosis (muscle density decline) were present in 254 (80.1 %) and 79 (24.9%) patients, respectively. A total of 135 patients (42.6 %) developed postoperative complications. According to the multivariable logistic regression, myosteatosis (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.0-3.3, P = .039) was significantly associated with postoperative complications.

CONCLUSIONS

A significant association was observed between myosteatosis and postoperative complications (corresponding to Clavien-Dindo classification before discharge), especially severe postoperative complications (Clavien-Dindo grade ≥3) in patients undergoing colorectal tumor resection. Screening for myosteatosis with HUAC using the CT before surgery may help clinicians identify high-risk perioperative patients early.

Association between body composition and mortality in patients requiring extracorporeal membrane oxygenation support

AIM

To ascertain the association between body composition, including muscle mass and adiposity, and patient mortality in those requiring extracorporeal membrane oxygenation (ECMO) for acute respiratory failure.

MATERIALS AND METHODS

A retrospective study was undertaken of all patients with acute respiratory failure requiring veno-venous (VV) ECMO between January 2015 and December 2019. Automated image segmentation software was used to quantify the cross-sectional area and average radiodensity (in Hounsfield units) of different muscle and fat compartments at the L3 level of whole-body computed tomography (CT) images taken within 48 h of initiation of ECMO support. The primary endpoint was 30-day post-ECMO initiation all-cause mortality. Logistic regression was used to analyse the correlation between CT measurements, co-morbidities, and 30-day survival.

RESULTS

The study included 189 patients (age = 43.8 ± 14.6, sex = 42.3% female). There was no significant association between 30-day survival status and cross-sectional area of muscle or fat. Muscle attenuation (psoas, long spine, and abdominal muscles respectively) at the L3 level were significantly lower in those who died within 30 days of ECMO cannulation (p<0.05). On multivariable analysis including age, sex, and pre-existing respiratory comorbidities, psoas muscle attenuation was an independent predictor of survival at 30 days (OR 0.97; 95% CI 0.94 to 1.00; p=0.047).

CONCLUSIONS

Reduced psoas muscle attenuation is associated with poorer survival outcomes at 30 days post-ECMO cannulation in patients who received VV ECMO support for respiratory failure. Cross-sectional areas of muscle and fat compartments did not correlate with survival outcomes at 30 days even when corrected for height and sex.

Current fistula management

PURPOSE OF REVIEW

Enterocutaneous fistulas (ECFs) pose a significant impact in the healthcare system, both financially and in resource utilization. Delivery of optimal care is complex and involves intensive wound care, complex nutritional delivery and multidisciplinary care teams for optimization. Recently, there have been pushes to modernize the traditional approach to ECF care to a new paradigm of protocol-based individualized delivery of care.

RECENT FINDINGS

There is an increased trend towards pushing enteral nutrition for the management of ECF patients. Adjuncts, including improved fistuloclysis devices, supplements and absorptive aides have challenged the conventional dogma of ECF treatment. There has also been increased focus on surgical prehabilitation and the ability to improve patient outcomes.

SUMMARY

ECF care is complex and requires a multidisciplinary approach focused on source control, nutritional optimization with focus on enteral nutrition, wound care and prehabilitation.

Effectiveness of Fistuloclysis in Nutritional Management of Enteroatmospheric Fistulas: A Retrospective Study at Santo Tomás Hospital, Panama

Introduction Enteroatmospheric fistulas (EAF) present significant challenges in surgical management due to their complex nature and high mortality rate. Traditional approaches often rely on prolonged parenteral nutrition, but emerging evidence suggests the potential benefits of enteral nutrition via fistuloclysis, an underappreciated enteral nutrition route. This study aims to evaluate the effectiveness of nutritional therapy, specifically fistuloclysis, in patients with EAF managed at the Trauma Unit of Santo Tomás Hospital, Panama. Methods A retrospective analysis was conducted on nine male patients diagnosed with EAF between January 2016 and December 2020. Data on demographics, fistula characteristics, and nutritional management were collected through chart review. Descriptive statistics were used for analysis. Results We analyzed nine patients, all of whom received enteral nutrition (EN) via fistuloclysis in a median of 5.5 days from the diagnosis of EAF. Seven patients required parenteral nutrition (PN) at the beginning. The use of specialized enteral formulas, supplemented with hydrolyzed proteins and medium-chain triglycerides, facilitated discontinuation of PN once 80% of nutritional requirements were met via the enteral route, and EN was continued until definitive surgery. The median duration of PN was 34 days. No adverse effects related to EN were observed, whereas complications such as central venous catheter infections were reported in all cases requiring PN. Conclusion Fistuloclysis is a viable and effective alternative to traditional PN in patients with EAF. Specialized nutritional strategies, including the use of semi-elemental formulas, contribute to improved outcomes and reduced complications. Early initiation and gradual increase in enteral nutrition via fistuloclysis demonstrate safety and efficacy, underscoring the importance of tailored nutritional approaches in optimizing patient care for complex surgical conditions.

Muscle-related parameters-based machine learning model for predicting postinduction hypotension in patients undergoing colorectal tumor resection surgery

Objectives

This study used machine learning algorithms to identify important variables and predict postinduction hypotension (PIH) in patients undergoing colorectal tumor resection surgery.

Methods

Data from 318 patients who underwent colorectal tumor resection under general anesthesia were analyzed. The training and test sets are divided based on the timeline. The Boruta algorithm was used to screen relevant basic characteristic variables and establish a model for the training set. Four models, regression tree, K-nearest neighbor, neural network, and random forest (RF), were built using repeated cross-validation and hyperparameter optimization. The best model was selected, and a sorting chart of the feature variables, a univariate partial dependency profile, and a breakdown profile were drawn. R2, mean absolute error (MAE), mean squared error (MSE), and root MSE (RMSE) were used to plot regression fitting curves for the training and test sets.

Results

The basic feature variables associated with the Boruta screening were age, sex, body mass index, L3 skeletal muscle index, and HUAC. In the optimal RF model, R2 was 0.7708 and 0.7591, MAE was 0.0483 and 0.0408, MSE was 0.0038 and 0.0028, and RMSE was 0.0623 and 0.0534 for the training and test sets, respectively.

Conclusion

A high-performance algorithm was established and validated to demonstrate the degree of change in blood pressure after induction to control important characteristic variables and reduce PIH occurrence.

Total Psoas Area is a Measure for Deconditioning in Colorectal Surgery Patients

INTRODUCTION

Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes.

METHODS

After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18 years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm2/m2.

RESULTS

1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population.

CONCLUSIONS

Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

Relationship Between Preoperative Psoas Major Muscle Quality and Forgotten Joint Score-12 in Patients After Total Hip Arthroplasty

Background

There are limited reports on the factors affecting the Forgotten Joint Score-12 (FJS-12) in patients after total hip arthroplasty (THA). Therefore, this study aimed to determine whether the quantity and quality of the preoperative psoas muscle are related to the FJS-12 in post-THA patients.

Methods

This retrospective cohort study used mailed questionnaires and medical records. Questionnaires containing the FJS-12 were mailed to 752 patients who underwent THA at our hospital between April 2015 and August 2020. The quantity and quality of the psoas major muscle were measured by computed tomography. The association between FJS-12 and the quantity and quality of the psoas major muscle was assessed by logistic regression analysis adjusted for potentially relevant factors.

Results

In total, 484 patients were included in the analysis. The FJS-12 score of the analyzed subjects was 75 points. Poor psoas major muscle quality was associated with a poor group of patients scoring <50 on the FJS-12. This association was independent of the adjustment factors. However, the quantity of psoas muscle was not associated.

Conclusions

The quality of the psoas major muscle is associated with FJS-12. In the rehabilitation of patients undergoing THA, focusing on the quality of the psoas major muscle may help achieve the ultimate goal.

Computed tomography measured epicardial adipose tissue and psoas muscle attenuation: new biomarkers to predict major adverse cardiac events and mortality in patients with heart disease and critically ill patients. Part II: Psoas muscle area and density

Sarcopenia is a syndrome characterised by loss of skeletal muscle mass, loss of muscle quality, and reduced muscle strength, resulting in low performance. Sarcopenia has been associated with increased mortality and complications after medical interventions. In daily clinical practice, sarcopenia is assessed by clinical assessment of muscle strength and performance tests and muscle mass quantification by dual-energy X-ray absorptio-metry (DXA) or bioelectrical impedance analysis (BIA). Assessment of the skeletal muscle quantity and quality obtained by abdominal computed tomography (CT) has gained interest in the medical community, as abdominal CT is performed for various medical reasons, and quantification of the psoas and skeletal muscle can be performed without additional radiation load and dye administration. The definitions of CT-derived skeletal muscle mass quantification are briefly reviewed: psoas muscle area (PMA), skeletal muscle area (SMA), and transverse psoas muscle thickness (TPMT). We explain how CT attenuation coefficient filters are used to determine PMA and SMA, resulting in the psoas muscle index (PMI) and skeletal muscle index (SMI), respectively, after indexation to body habitus. Psoas muscle density (PMD), a biomarker for skeletal muscle quality, can be assessed by measuring the psoas muscle CT attenuation coefficient, expressed in Hounsfield units. The concept of low-density muscle (LDM) is explained. Finally, we review the medical literature on PMI and PMD as predictors of adverse outcomes in patients undergoing trauma or elective major surgery, transplantation, and in patients with cardiovascular and internal disease. PMI and PMD are promising new biomarkers predicting adverse outcomes after medical interventions.

The psoas muscle density as a predictor of postoperative complications and 30-day mortality for acute mesenteric ischemia patients

OBJECTIVE

Low muscle mass and quality is associated with poor surgical outcomes. Psoas muscle density (PMD)is a validated surrogate for muscle quality that can be easily measured from a clinical computed tomography (CT) scan. The objective of this study was to investigate the association between PMD and short-term postoperative outcomes in patients with acute mesenteric ischemia (AMI).

METHODS

From April 2006 and September 2019, the clinical data of all patients who underwent surgical intervention with a preoperative diagnosis of AMI and had preoperative non-contrast CT images available were retrospectively reviewed. PMD was measured by CT at the third lumbar vertebra. The lowest quartile of PMD for men and women in all patients was used as sex-specific cut-off values for low PMD. Univariate and multivariate analyses evaluating risk factors of postoperative complications and 30-day mortality were performed.

RESULTS

The cohort consisted of 88 patients with a mean age of 58.8 ± 16.2 years, of whom 21 (23.9%) patients had low PMD based on the diagnostic cut-off values (40.5 HU for men and 28.4 HU for women), 35 (39.8%) patients developed complications within 30 days of the operation, and 10 (11.3%) patients died within 30 days of surgery. Low PMD patients had a higher risk of postoperative complications and 30-day mortality than patients without low PMD patients. In a multivariate analysis, low PMD and low psoas muscle area (PMA) were independent predictors of postoperative complications. However, only low PMD remained an independent risk factor for 30-day mortality.

CONCLUSIONS

Preoperative assessment of the PMD on CT can be a practical method for identifying AMI patients at risk for postoperative complications and 30-day mortality.

Pectoralis Muscle Mass on Chest CT at Admission Predicts Prognosis in Patients with Pneumonia

Methods

A retrospective cohort study was performed in patients aged 18 years or older with pneumonia who underwent chest CT within 24 hours of admission between April 2014 and March 2019. We measured the thickness, area, and volume of the pectoralis major and minor muscles at the level of the aortic arch. Factors associated with mortality were examined using logistic regression analysis.

Results

A total of 483 patients (mean age 77 ± 14 years, 300 men (62%)) were included, and fifty-one patients (11%) died during admission. In univariate analysis, decreased thickness, area, and volume of the pectoralis major and minor muscles were associated with higher in-hospital mortality. Multivariate analysis with adjustment for age, gender, serum albumin, and A-DROP revealed that thinner pectoralis major and minor muscles were independent factors of poor prognosis (odds ratio: 0.878, 95% confidence interval (CI): 0.783-0.985, P=0.026 and odds ratio: 0.842, 95% CI: 0.733-0.968, P=0.016, respectively). Approximately 25% of the patients died when the pectoralis minor muscle thickness was 5 mm or less, and no patients died when it was 15 mm or more.

Conclusion

The pectoralis muscle mass may be an independent prognostic factor in hospitalized patients with pneumonia.

Psoas Muscle Index Defined by Computer Tomography Predicts the Presence of Postoperative Complications in Colorectal Cancer Surgery

Background and Objectives: Sarcopenia is a recognized prognostic factor for both complications and survival in cancer patients. This study aims to analyze the relationship between sarcopenia measured by psoas muscle index on computer tomography scans and the presence of postoperative complications in colorectal cancer surgery. Materials and Methods: In a prospective study we recorded data from 51 patients who underwent colorectal cancer surgery in the Mures County Clinical Hospital, Romania. Total psoas muscle area and psoas density were measured at the level of the third lumbal vertebra (L3) for further index calculation. We also evaluated the general characteristics and laboratory analyses to obtain more information about status of the patients. Short-term postoperative complications were scored according to the Clavien-Dindo classification. Results: The majority of the 51 patients were male (61%) and the median age was 65 years. More than half of the cancer was located in the rectum (56.9%), a quarter in the right colon (25.5%), the rest in the sigmoid (11.8%), and the left colon (5.9%). Twenty-one patients (41.2%) developed a complication, five (9.8%) of these were Clavien-Dindo grade 3, 4 or 5 (high grade) and sixteen (31.3%) grade 1 or 2 (low grade). The low- and high-grade groups showed a significantly lower right psoas muscle area, left psoas muscle area, total psoas muscle area, and psoas muscle index (p < 0.001 in all cases). Among laboratory analyses, a significantly lower perioperative hematocrit, hemoglobin, and albumin level were found in patients who developed complications. Furthermore we observed that an elevated serum C-reactive protein level was associated with a higher grade of complication (p < 0.043). Conclusions: The psoas muscle index (PMI) influence on the postoperative outcome is an important factor in our single center prospective study and it appears to be a good overall predictor in colorectal surgery. A lower PMI is directly associated with a low or high grade complication by Clavien-Dindo classification. Perioperative inflammatory and nutritional status evidenced by serum C-reactive protein (CRP) and albumin level influences the presence of postoperative complications.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.