Pre-operative psoas major measurement compared to P-POSSUM as a prognostic indicator in over-80s undergoing emergency laparotomy

Pre-injury sarcopenia and the association with discharge destination in critical care trauma patients

Background

Sarcopenia is a key physical component in the aetiology of frailty, representing progressive and CT-quantifiable muscle mass loss. In older trauma patients admitted to critical care, sarcopenic defined-frailty is associated with adverse outcomes, including poor function at discharge. This may complicate discharge to the usual place of residence, an important outcome for patients. This study aimed to identify pre-injury sarcopenia in all trauma patients admitted to critical care and investigate factors associated with discharge destination.

Methods

We performed a retrospective analysis of adult trauma patients admitted to a Major Trauma Centre (Level 1 equivalent) over 18 months. Psoas muscle density (PMD) was measured at the level of L4 vertebra from admission computerised tomography (CT) abdomen/pelvis. Sarcopenia was defined as the PMD calculated using Hounsfield unit average calculation within the lowest quartile for sex. Discharge destination was dichotomised into independent and dependent discharge. Multivariable logistic regression was used to determine factors associated with discharge destination.

Results

Overall, 197 patients were included. Patients were predominantly male (73%) with a median age of 52 (32–72) and the majority were severely injured (72%). Sarcopenia was identified in a quarter of the cohort on admission to critical care ( n = 49). Only a third of sarcopenic patients were discharged to home, compared to a half of non-sarcopenic patients ( p = 0.03). Sarcopenia (OR 0.30; 95% CI 0.17–0.81, p = 0.01), blunt injury (OR 0.22; 95% CI 0.06–0.87, p = 0.03), age (OR 0.97; 95% CI 0.95–0.99, p = 0.01) and Multiple Organ Dysfunction Syndrome (OR 0.24; 95% CI 0.12–0.57, p = 0.01) were associated with a decreased rate of independent discharge.

Conclusion

For trauma critical care patients, sarcopenia on admission CT was associated with dependent discharge destination and therefore is unfavourable. Defining sarcopenia early in an trauma patients critical care admission may help to identify those at risk of poor outcomes.

Combining sarcopenia and ASA status to inform emergency laparotomy outcomes: could it be that simple?

BACKGROUND

Risk assessment for emergency laparotomy (EL) is important for guiding decision-making and anticipating the level of perioperative care in acute clinical settings. While established tools such as the American College of Surgeons National Surgical Quality Improvement Program calculator (ACS-NSQIP), the National Emergency Laparotomy Audit Risk Prediction Calculator (NELA) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity calculation (P-POSSUM) are accurate predictors for mortality, there has been increasing recognition of the benefits from including measurements for frailty in a simple and quantifiable manner. Psoas muscle to 3rd lumbar vertebra area ratio (PM:L3) measured on CT scans was proven to have a significant inverse association with 30-, 90- and 365-day mortality in EL patients.

METHODS

A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016-2017, and had contemporaneous abdomino-pelvic CT scans. Radiological sarcopenia was measured as PM:L3 ratios. ASC-NSQIP, NELA and P-POSSUM were retrospectively calculated. Univariate and multivariate logistic regression modelling was used to assess these ratios and scores, as well as American Society of Anaesthesiologists (ASA) classification separated into ASA I-III and IV/V (simplified ASA), as potential predictors of 30-, 90- and 365-day mortality.

RESULTS

PM:L3, simplified ASA, ACS-NSQIP, NELA and P-POSSUM were each statistically significant predictors of 30-day, 90-day and 365-day mortality (P < 0.001). Logistic regression models of 30-, 90- and 365-day mortality combining PM:L3 (P = 0.001) and simplified ASA (P < 0.001) exhibited AUCs of 0.838 (0.780, 0.896), 0.805 (0.751, 0.860) and 0.775 (0.729, 0.822), respectively, which were comparable to that of ACS-NSQIP and NELA.

CONCLUSION

Combining the semi-physiological parameter ASA classification with PM:L3 provides a quick and simple alternative to the more complex established risk assessment scores and is superior to PM:L3 alone.

Markers of sarcopenia increase 30-day mortality following emergency laparotomy: A systematic review

BACKGROUND AND OBJECTIVE

Decreased skeletal muscle mass and quality are one of the several markers used for sarcopenia diagnosis and are generally associated with increased rates of post-operative infections, poorer recovery and increased mortality. The aim of this review was to evaluate methods applied to detect markers of sarcopenia and the associated outcomes for patients undergoing emergency laparotomy.

METHODS

This review was conducted with reference to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase and Google Scholar databases were searched. Studies detecting patients with sarcopenia or skeletal muscle decline markers and the associated outcomes after emergency laparotomy surgery were considered. The Newcastle-Ottawa Scale was used to evaluate publication quality.

RESULTS

Out of 103 studies, which were screened, 19 full-text records were reviewed and 7 studies were ultimately analyzed. The study cohort sizes ranged from n = 46 to n = 967. The age range was 36-95 years. There were 1107 females (53%) and 973 males (47%) across all 7 studies. All studies measured psoas muscle mass and three studies assessed psoas muscle quality using computerized tomography (CT) imaging. No study assessed muscle strength or function, while five studies showed an association between low muscle mass and increased mortality rates after emergency laparotomy. Among the three studies, which assessed muscle quality, two of three studies showed poorer 30-day survival rates.

CONCLUSIONS

The existing literature is limited, however it indicates that low psoas muscle mass and quality markers are associated with increased 30-day mortality rates after emergency laparotomy. Therefore, muscle markers can be used as a new feasible tool to identify most at risk patients requiring further interventions.

Poorer outcomes associated with sarcopenia following emergency laparotomy: a systematic review and meta-analysis

BACKGROUND

Despite the negative effect of sarcopenia on postoperative outcomes being well recognized in the elective setting, there remains a paucity of studies describing this phenomenon in the emergency laparotomy (EL) setting. This systematic review and meta-analysis aimed to compare short- and long-term postoperative outcomes following EL in patients with and without sarcopenia.

METHODS

A systematic review using PRISMA guidelines was used to identify studies comparing perioperative outcomes following EL for patients with and without sarcopenia. A subsequent meta-analysis was conducted. The following data were extracted from the included studies: patient demographics, pathology or type of operation performed for EL, post-operative mortality at inpatient, 30-day, 90-day and 1-year, and functional outcomes. A quality assessment of included studies was undertaken.

RESULTS

Twelve studies reporting the outcomes of sarcopenia following EL were identified. Sarcopenia was significantly associated with higher 30-day and 1-year mortality rates following EL (OR 3.50, P < 0.01; OR 3.49, P < 0.01, respectively). Additionally, sarcopenia was significantly associated with unfavourable functional outcomes at discharge following emergency laparotomy (OR 2.44, p < 0.01).

CONCLUSION

Opportunistically identified on cross-sectional imaging, sarcopenia is a valuable predictor of short- and long-term morbidity and mortality following EL. Further studies are required to identify the most appropriate diagnostic criteria of sarcopenia and better define this physiological phenomenon.

Sarcopenia 'made simple' and outcomes from emergency laparotomy

BACKGROUND

Emergency Laparotomy (EL) is recognized as high-risk surgery with high mortality. Established surgical risk assessment tools (NELA Risk Prediction Calculator, P-POSSUM, ACS-NSQIP) are accurate predictors of morbidity and mortality. However, their multicomponent complexity limits their use in practice. Sarcopenia is associated with poorer surgical outcomes. This study tests for an association between a simple measure of radiological sarcopenia and mortality in EL patients in an Australian cohort.

METHODS

A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016-2017. All patients had a contemporaneous abdomino-pelvic CT scan. Radiological sarcopenia was measured as the ratio of total psoas muscle area (PM) to L3 vertebral body cross sectional area (PM:L3). Patients were followed up to 12 months. Primary outcomes were 30-, 90- and 365-day mortality.

RESULTS

The mean 30-day mortality predictions for NELA, P-POSSUM and ACS-NSQIP were 11.36%, 17.28% and 11.30% respectively. PM:L3 ratio was associated with 30-, 90- and 365-day mortality (P < 0.001) and sex (P < 0.001) and negatively correlated with age (r = -0.4612; P < 0.001). Radiological sarcopenia had a weak negative correlation with NELA (r = -0.2737; P < 0.001), P-POSSUM (r = -0.1880; P < 0.001) and ACS-NSQIP (r = -0.2351; P < 0.001). The latter three metrics were significantly correlated (r > 0.5696; P < 0.001).

CONCLUSION

Radiological sarcopenia (CT-assessed PM:L3) is a significant predictor of mortality in EL patients in Australia. The results of this study suggest that radiological sarcopenia is equivalent to established risk assessment tools. The more timely and easily accessible CT-assessed PM:L3 metric is potentially automatable and may have significant utility in clinical practice.

Radiological Features for Frailty Assessment in Patients Requiring Emergency Laparotomy

Introduction: As the number of elderly patients requiring surgical intervention rises, it is believed that frailty syndrome has a greater impact on perioperative course than on chronological age. The aim of this study was to evaluate the efficacy of various imaging features for frailty assessment in patients undergoing emergency laparotomy. Methods: The study included all patients that qualified for emergency surgery with preoperative CT scans between 2016 and 2020 in the Second Department of General Surgery. Multiple trauma patients were excluded from the analysis. The modified frailty index and brief geriatric assessment were used in the analysis. CT images were reviewed for the assessment of osteopenia, sarcopenia, sarcopenic obesity, renal volume and abdominal aorta calcification rate. Results: A total of 261 patients were included in the analysis. Multivariate logistic regression identified every next ASA class (OR: 4.161, 95%CI: 1.672–10.355, p = 0.002), intraoperative adverse events (OR: 12.397, 95%CI: 2.166–70.969, p = 0.005) and osteopenia (OR: 4.213, 95%CI: 1.235–14.367, p = 0.022) as a risk factor for 30-day mortality. Our study showed that every next ASA class (OR: 1.952, 95%Cl: 1.171–3.256, p = 0.010) and every point of the BGA score (OR: 1.496, 95%Cl: 1.110–2.016, p = 0.008) are risk factors for major complications. Conclusions: Osteopenia was the best parameter for perioperative mortality risk stratification in patients undergoing emergency surgical intervention. Sarcopenia (measured as psoas muscle area), sarcopenic obesity, aortic calcifications and mean kidney volume do not predict poor outcomes in those patients. None of the radiological markers appeared to be useful for the prediction of perioperative morbidity.

CT psoas calculations on the prognosis prediction of emergency laparotomy: a single-center, retrospective cohort study in eastern Asian population

Background

Emergency laparotomy (EL) has a high mortality rate. Clinically, frail patients have a poor tolerance for EL. In recent years, sarcopenia has been used as an important indicator of frailty and has received much attention. There have been five different calculation methods of psoas for computed tomography (CT) to measure sarcopenia, but lack of assessment of these calculation methods in Eastern Asian EL patients.

Methods

We conducted a 2-year retrospective cohort study of patients over 18 years of age who underwent EL in our institution. Five CT measurement values (PMI: psoas muscle index, PML3: psoas muscle to L3 vertebral body ratio, PMD: psoas muscle density, TPG: total psoas gauge, PBSA: psoas muscle to body face area ratio) were calculated to define sarcopenia. Patients with sarcopenia defined by the sex-specific lowest quartile of each measurement were compared with the rest of the cohort. The primary outcome was "ideal outcome", defined as: (1) No postoperative complications of Clavien-Dindo Grade ≥ 4; (2) No mortality within 30 days; (3) When discharged, no need for fluid resuscitation and assisted ventilation, semi-liquid diet tolerated, and able to mobilize independently. The second outcome was mortality at 30-days. Multivariate logistic regression and receiver operating characteristic (ROC) analysis were used.

Results

Two hundred and twenty-eight patients underwent EL met the inclusion criteria, 192 (84.2%) patients had an ideal outcome after surgery; 32 (14%) patients died within 30 days. Multivariate analysis showed that, except PMD, each calculation method of psoas was independently related to clinical outcome (ideal outcome: PML3, P < 0.001; PMI, P = 0.001; PMD, P = 0.157; TPG, P = 0.006; PBSA, P < 0.001; mortality at 30-days: PML3, P < 0.001; PMI, P = 0.002; PMD, P = 0.088; TPG, P = 0.002; PBSA, P = 0.001). In ROC analysis, the prediction model containing PML3 had the largest area under the curve (AUC) value (AUC value = 0.922 and 0.920, respectively).

Conclusion

The sarcopenia determined by CT psoas measurements is significantly related to the clinical outcome of EL. The calculation of CT psoas measurement is suitable for application in outcome prediction of EL. In the future, it is necessary to develop a scoring tool that includes sarcopenia to evaluate the risk of EL better.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00435-x.

"Sarcopenia is associated with increased risk of burst abdomen after emergency midline laparotomy: a matched case-control study"

PURPOSE

Burst abdomen is a serious complication commonly observed after emergency midline laparotomy. Sarcopenia has been associated with increased morbidity and mortality after abdominal surgery. This single-center, retrospective, matched case-control study aimed to investigate the association between sarcopenia and burst abdomen in patients undergoing emergency midline laparotomy.

METHODS

Patients who had burst abdomen after emergency midline laparotomy were matched 1:4 with controls based on age and sex. Abdominal wall closure was standardized in the study period with the small bites, small stitches technique. CT assessed psoas cross-sectional area was used as a surrogate measure of sarcopenia. Sarcopenia was defined as the sex-specific lowest quartile of psoas cross-sectional area adjusted for body surface area. The primary outcome was the incidence rate of sarcopenia amongst cases and controls. Secondary outcomes were risk factors for burst abdomen and death that were identified using multivariate logistic regression analysis.

RESULTS

67 cases were matched to 268 controls during May 2016-December 2019. BMI > 30 kg/m², liver cirrhosis, smoking, high ASA score and peritonitis were more frequently observed among cases. Multivariate analysis revealed that sarcopenia (odds ratio (OR) 2.3, p = 0.01), active smoking (OR 2.3, p = 0.006) and liver cirrhosis (OR 3.7, p = 0.042) were significantly associated with burst abdomen. ASA score ≥ 3 (OR 5.5, p = 0.001) and ongoing malignant disease (OR 3.2, p = 0.001) were significantly associated with increased 90-day mortality.

CONCLUSION

Sarcopenia is associated with increased risk of burst abdomen after midline laparotomy. Prospective trials are needed.

Association of Serum Creatinine Level with Prognosis of Laparotomy for Acute Mesenteric Ischemia after Cardiovascular Surgery

Introduction

Acute mesenteric ischemia is a life-threatening complication after cardiovascular surgery with a mortality rate of 52.9–81.3%. However, few studies have evaluated the predictors of clinical outcome after treatment for acute mesenteric ischemia following cardiovascular surgery. Therefore, this study aimed to elucidate prognostic factors in patients who underwent laparotomy for acute mesenteric ischemia after cardiovascular surgery.

Methods

We retrospectively analyzed 29 patients (20 men and 9 women; median age, 71.0 years) who underwent laparotomy for acute mesenteric ischemia after cardiovascular surgery between January 2010 and August 2020. These patients were classified into the survivor group (comprising patients who were discharged or referred to another hospital, n = 16) and the nonsurvivor group (comprising those who experienced in-hospital mortality, n = 13). We compared clinical parameters between the groups to identify the predictors of outcomes.

Results

More patients in the nonsurvivor group underwent emergency cardiovascular surgery (62.5% vs. 100%, p = 0.017) and received hemodialysis (12.5% vs. 61.5%, p = 0.008) at the onset of acute mesenteric ischemia than those in the survivor group. The prelaparotomy serum creatinine level was higher in the nonsurvivor group than in the survivor group (1.27 vs. 2.33 mg/dL, p = 0.004). Logistic regression analysis revealed an association between preoperative serum creatinine level and in-hospital mortality (odds ratio 5.047, p = 0.046), and Cox regression analysis demonstrated a relationship between serum creatinine level and in-hospital mortality (hazard ratio 1.610, p = 0.009). The area under the curve (receiver operating characteristic analysis) for the serum creatinine level was 0.813. Furthermore, the optimal cutoff value of the serum creatinine level was 1.59 mg/dL with a sensitivity and specificity of 0.846 and 0.687, respectively, in predicting in-hospital mortality.

Conclusions

The elevated serum creatinine level was associated with a poor clinical outcome after surgery for acute mesenteric ischemia following cardiovascular surgery.

Prediction of ICU admission after orthopedic surgery in elderly patients

Objectives:

Prediction of ICU admission after surgery are important for rational decision-making for different patients in clinical practice. Little information is available about the risk factors of postoperative ICU admission in elderly patients undergoing orthopedic surgery. This study aimed to identify risk factors and develop a predictive model for postoperative ICU admission in elderly patients undergoing orthopedic surgery.

Methods:

A total of 2826 cases of elderly patients receiving orthopedic surgery from October 2010 to September 2016 were retrospectively collected and analyzed. Logistic regression was used to evaluate the impacts of covariates. Support vector machine (SVM) was employed to develop a predictive model based on all pre-operative covariates and the demographic information.

Results:

There were 256 patients transferred to ICU after surgery. ASA III or IV and emergency surgery were found to be independent risk factors while neuraxial anesthesia and joint surgery were protective factors. In addition, a SVM-based predictive model was developed, which had a sensitivity of 90.99%, a specificity of 99.10% and an area under ROC curve of 0.9678.

Conclusions:

Our study revealed that emergency surgery, anesthesia method, surgery type and ASA grade were risk factors to predict postoperative ICU admission in elderly orthopedic patients.

Application of POSSUM and P-POSSUM in Surgical Risk Assessment of Elderly Patients Undergoing Hepatobiliary and Pancreatic Surgery

Purpose

To investigate the efficacy and accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scoring systems in the risk assessment of postoperative complications and death in elderly patients undergoing hepatobiliary and pancreatic surgery.

Patients and Methods

Using POSSUM and P-POSSUM, 274 elderly patients undergoing hepatobiliary and pancreatic surgery were evaluated, and the complications and deaths predicted by the systems were compared with the actual situation. The accuracy and predictive ability of POSSUM and P-POSSUM were evaluated using chi-squared and t-tests, consistency of predicted and actual complication rates (observed/expected, OE ratio), and receiver operating characteristic (ROC) curve.

Results

The complication rate predicted by POSSUM (R1) was 22.57%, while the actual postoperative complication rate was 17.88% (P>0.05). The mortality rate predicted by POSSUM (R2) was 4.61%, while the actual rate was 1.09% (P<0.05). The mortality rate predicted by P-POSSUM (R) was 1.42%, while the actual rate was 1.09% (P>0.05). Patients with complications had higher physiology scores (PS), operative severity scores (OS), and POSSUM scores than those without complications (P<0.05). Furthermore, PS, OS, and POSSUM scores were higher in the mortality group than in the survival group. However, the number of individuals in the mortality group was too small to accurately reflect the overall situation. Stratified analysis showed that consistency of the OE ratio in different subgroups was close to 1. The ROC curve showed that the area under the curve for the complication rate predicted by POSSUM was 0.76.

Conclusion

Although the postoperative mortality rate was higher than the actual value, POSSUM could accurately predict the postoperative complication rate in elderly patients undergoing hepatobiliary and pancreatic surgery. The P-POSSUM accurately predicted the postoperative mortality rate in this population. Patients with complications had higher POSSUM scores.

The statistical importance of P-POSSUM scores for predicting mortality after emergency laparotomy in geriatric patients

Background

Geriatric patients frequently undergo emergency general surgery and accrue a greater risk of postoperative complications and fatal outcomes than the general population. It is highly relevant to develop the most appropriate care measures and to guide patient-centered decision-making around end-of-life care.

Portsmouth - Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) has been used to predict mortality in patients undergoing different types of surgery. In the present study, we aimed to evaluate the relative importance of the P-POSSUM score for predicting 90-day mortality in the elderly subjected to emergency laparotomy from statistical aspects.

Methods

One hundred and fifty-seven geriatric patients aged ≥65 years undergoing emergency laparotomy between January 1st, 2015 and December 31st, 2016 were included in the study. Mortality and 27 other patient characteristics were retrieved from the computerized records of Örebro University Hospital in Örebro, Sweden. Two supervised classification machine methods (logistic regression and random forest) were used to predict the 90-day mortality risk. Three scalers (Standard scaler, Robust scaler and Min-Max scaler) were used for variable engineering. The performance of the models was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Importance of the predictors were evaluated using permutation variable importance and Gini importance.

Results

The mean age of the included patients was 75.4 years (standard deviation =7.3 years) and the 90-day mortality rate was 29.3%. The most common indication for surgery was bowel obstruction occurring in 92 (58.6%) patients. Types of post-operative complications ranged between 7.0–36.9% with infection being the most common type. Both the logistic regression and random forest models showed satisfactory performance for predicting 90-day mortality risk in geriatric patients after emergency laparotomy, with AUCs of 0.88 and 0.93, respectively. Both models had an accuracy > 0.8 and a specificity ≥0.9. P-POSSUM had the greatest relative importance for predicting 90-day mortality in the logistic regression model and was the fifth important predictor in the random forest model. No notable change was found in sensitivity analysis using different variable engineering methods with P-POSSUM being among the five most accurate variables for mortality prediction.

Conclusion

P-POSSUM is important for predicting 90-day mortality after emergency laparotomy in geriatric patients. The logistic regression model and random forest model may have an accuracy of > 0.8 and an AUC around 0.9 for predicting 90-day mortality. Further validation of the variables’ importance and the models’ robustness is needed by use of larger dataset.