Myosteatosis to predict inferior perioperative outcome in patients undergoing orthotopic liver transplantation

Myosteatosis as a New Risk Factor of Surgical Complications in Kidney Transplant Recipients: A Retrospective Study

BACKGROUND

Computed tomography (CT) scan-defined myosteatosis is a common feature in ESKD patients receiving kidney transplantation (KT) and is associated with mortality after KT. We aimed to explore the impact of myosteatosis and other CT scan based morphometric data on the occurrence of early surgical complications after KT.

METHODS

We retrospectively measured on an unenhanced cross-sectional CT scan taken at the middle of the third lumbar vertebra performed within the previous year or at the time of KT: surface muscle index (total lumbar cross-sectional muscle area [CSMA] divided by height squared), subcutaneaous adipose tissue index, visceral adipose tissue index and muscle density (MD: mean CT attenuation of CSMA). Vessel to skin distance was the distance between iliac vein and skin. Myosteatosis was defined as MD below age- and sex-specific normal values. Logistic regression models were constructed to identify predictive factor of 90 days postoperative surgical complications with Clavien-Dindo score greater than or equal to 2, CD ≥ 2).

RESULTS

Among the N = 200 patients, 61.5% were male with a mean age of 54.8 (± 13.8) years and a mean BMI of 25.1 (± 4.4) kg/m2. Sixty patients (30%) developed at least one postoperative complication (CD ≥ 2) in the first 3 months after KT. In two different multivariate analyses, MD (aOR: 0.95 for one Hounsfield unit increase, 95% CI: 0.91-0.99, p = 0.028) and myosteatosis status (aOR: 4.64, 95% CI: 2.18-9.90, p < 0.0001) were the only independent risk factors for postsurgical complication.

CONCLUSIONS

Myosteatosis is independently associated with the occurrence of CD ≥ 2 postoperative complication within 90 days of surgery.

Pre-transplant myosteatosis worsens the survival after liver transplantation: A systematic review and meta-analysis

OBJECTIVE

Sarcopenia worsens survival after liver transplantation (LT). However, it remains unclear whether myosteatosis, a pathological phenomenon involving excess fat deposition, also causes adverse effects. We performed a meta-analysis to evaluate the effect of myosteatosis on survival in this patient population.

METHODS

We searched PubMed, EMBASE, Web of Science, and Cochrane databases through March 30, 2025 for articles that focused on the association between myosteatosis and post-LT mortality. The Newcastle-Ottawa Scale was used to assess the quality of the studies. The primary outcome was mortality rate. Meta-analyses were performed using Review Manager software. Study quality, publication bias, and subgroup analyses were performed.

RESULT

28 studies involving 7068 patients were included. The studies were of moderate-to-high quality. The pooled results suggested that myosteatosis as a categorical variable was an independent predictor of mortality, both in univariate analyses (hazard ratio[HR] = 1.80, 95%CI 1.59-2.05) and multifactorial analyses (HR = 1.69, 95%CI 1.51-1.89). Similar results were found when myosteatosis was treated as a continuous variable. Further pooling of data comparing patients with and without myosteatosis within 6-month, one, three, and five years of follow-up (odds ratio[OR] = 5.49, 95%CI 3.69-8.17, OR = 1.93, 95%CI: 1.55-2.41, OR = 1.62, 95%CI 1.30-2.00, and OR = 1.68, 95%CI 1.28-2.19, respectively) also suggested a high mortality risk in myosteatosis patients. Finally, sensitivity analyses based on the different definitions of myosteatosis confirmed these results. In addition, patients with myosteatosis had significantly increased ICU stay (mean difference[MD] = 7.86 days; 95 % CI, 2.41-13.30), hospital stay (MD = 2.04 days, 95 % CI, 0.56-3.53), and more post-LT complications (OR = 2.35, 95 % CI 1.93-2.87) than those without myosteatosis.

CONCLUSIONS

Our results revealed that myosteatosis is associated with an increased risk of mortality in patients undergoing LT. These findings indicate that myosteatosis can be a tool to identify high-risk patients and make informed clinical decisions during perioperative management.

Correlation between sarcopenia and hypertrophy of the future liver remnant in patients undergoing portal vein embolization before liver resection

OBJECTIVES

To study the correlation between sarcopenia and hypertrophy of the future liver remnant (FLR) in patients undergoing portal vein embolization (PVE) before liver resection, and to assess the outcomes after resection.

METHODS

This retrospective study examined patients underwent PVE from May 2012 to May 2023. Demographic, clinical, and laboratory features were documented and total liver volumes and FLR volumes were measured before and 2-4 weeks after PVE. Degree of hypertrophy (DH), percentage hypertrophy (PH), and kinetic growth rate (KGR) of the FLR were calculated. Sarcopenia was defined using the skeletal muscle index (SMI) at the L3 vertebral level. Subcutaneous adipose index, visceral adipose index (VAI), cross-sectional area of psoas muscle at the largest diameter, and L3 vertebral level mean muscle attenuation (MA) were also assessed.

RESULTS

Forty patients were included in the analysis and the median age was 57.5 (IQR 51-64) and majority were males 27/40(67.5%). Twenty-two patients were non-sarcopenics and 18 were sarcopenics. All patients showed hypertrophy of FLR (P = 0.001). SMI demonstrated moderate positive correlations with DH (r = 0.46, P = 0.003), PH (r = 0.47, P = 0.002), and KGR (r = 0.44, P = 0.004). VAI showed weak positive correlations with DH (r = 0.22, P = 0.17), PH (r = 0.18, P = 0.27), and KGR (r = 0.14, P = 0.37). Pre-PVE FLR demonstrated a weak negative correlation with PH (r = -0.35, P = 0.03) and KGR (r = -0.12, P = 0.47).

CONCLUSIONS

Sarcopenia, specifically SMI, significantly correlates with FLR hypertrophy after PVE. Assessment of sarcopenia and body compartments prior to PVE could help in stratifying and treats patients with impaired FLR growth.

ADVANCES IN KNOWLEDGE

This study with data spanning over 11 years, is the first in the Indian population to demonstrate a significant correlation between SMI, a marker of sarcopenia, and FLR hypertrophy following PVE.

Sarcopenia As a Predictor of Survival and Complications of Patients With Cirrhosis After Liver Transplantation: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review/meta-analysis evaluated the impact of sarcopenia in patients with cirrhosis before liver transplantation (LT) on outcomes after LT.

METHODS

A systematic search was conducted in six medical databases until February 2022. The primary outcome was overall mortality after LT, while several secondary outcomes including liver graft survival and rejection, the need for transfusions, the length of the intensive care unit (ICU) and hospital stay, and surgical complications were evaluated. Sub-group analyses and meta-regression analyses were also performed.

RESULTS

Fifty-three studies were evaluated in the systematic review, of which 30, including 5875 patients, were included in the meta-analysis. All studies included were cohort studies of good/high quality on the Newcastle-Ottawa scale (NOS), while in our analysis no publication bias was found, although there was substantial heterogeneity between the studies. Muscle mass was assessed using skeletal muscle index (SMI) in 14 studies, psoas muscle area (PMA) in seven studies, and psoas muscle index (PMI) in four studies. The prevalence of pre-LT sarcopenia ranged from 14.7% to 88.3%. Pre-LT sarcopenia was significantly associated with post-LT mortality (Relative Risk [RR] = 1.84, 95% CI:1.41,2.39), as well as with a high risk of infections post-LT, surgical complications, fresh frozen plasma (FFP) transfusions, and ICU length of stay (LOS).

CONCLUSIONS

Pre-LT sarcopenia in patients with cirrhosis is a strong risk factor for clinically meaningful adverse outcomes after LT. Assessment may help identify patients at the highest risk for poor outcomes who may benefit from targeted interventions.

Skeletal Muscle 31P MR Spectroscopy Surpasses CT in Predicting Patient Survival After Liver Transplantation

BACKGROUND

Skeletal muscle alterations are associated with higher mortality and morbidity in patients with liver cirrhosis. Assessing these changes seems to be a promising method for identifying patients at a high risk of poor outcomes following liver transplantation (LT). This is particularly important given the current global shortage of organ donors. However, evidence of the impact of these alterations on the prognosis of patients undergoing LT is inconclusive. The aim of our prospective study was to evaluate the impact of skeletal muscle changes, reflected in sarcopenia, myosteatosis and metabolic changes in the calf muscles, on perioperative outcomes and long-term survival after LT. We also sought to determine the posttransplant evolution of the resting muscle metabolism.

METHODS

We examined 134 adult LT candidates. Of these, 105 underwent LT. Sarcopenia and myosteatosis were diagnosed by measuring the skeletal muscle index and mean psoas muscle radiation attenuation, respectively, which were obtained from computed tomography (CT) scans taken during pretransplant assessment. Additionally, patients underwent 31P MR spectroscopy (MRS) of the calf muscles at rest before LT and 6, 12 and 24 months thereafter. The median follow-up was 6 years.

RESULTS

Patients with abnormal 31P MRS results and CT-diagnosed myosteatosis prior to LT had significantly worse long-term survival after LT (hazard ratio (HR), 3.36; 95% confidence interval (CI), 1.48-7.60; p = 0.0021 and HR, 2.58; 95% CI, 1.06-6.29; p = 0.03, respectively). Multivariable analysis showed that abnormal 31P MR spectra (HR, 3.40; 95% CI, 1.50-7.71; p = 0.003) were a better predictor of worse long-term survival after LT than myosteatosis (HR, 2.78; 95% CI, 1.14-6.78; p = 0.025). Patients with abnormal 31P MR spectra had higher blood loss during LT (p = 0.038), required a higher number of red blood cell transfusions (p = 0.006) and stayed longer in ICU (p = 0.041) and hospital (p = 0.007). Myosteatosis was associated with more revision surgeries following LT (p = 0.038) and a higher number of received red blood cell transfusion units (p = 0.002). Sarcopenia had no significant effect on posttransplant patient survival. An improvement in the resting metabolism of the calf muscles was observed at 12 and 24 months after LT.

CONCLUSIONS

Abnormal 31P MRS results of calf muscles were superior to CT-based diagnosis of myosteatosis and sarcopenia in predicting perioperative complications and long-term survival after LT. Resting muscle metabolism normalized 1 year after LT in most recipients.

Construction and validation of a nomogram prediction model for the occurrence of complications in patients following robotic radical surgery for gastric cancer

BACKGROUND

In the last two decades, robotic-assisted gastrectomy has become a widely adopted surgical option for gastric cancer (GC) treatment. Despite its popularity, postoperative complications can significantly deteriorate patient quality of life and prognosis. Therefore, identifying risk factors for these complications is crucial for early detection and intervention.

OBJECTIVE

This research is designed to construct and validate a predictive model for assessing the risk of postoperative complications in patients undergoing robotic-assisted radical gastrectomy.

METHODS

A retrospective analysis was conducted on 500 GC patients from Gansu Provincial People's Hospital between December 2016 and October 2023. These patients formed the training cohort. An additional 136 patients from the 940th Hospital of Joint Logistic Support Force, the Chinese People's Liberation Army as the external validation cohort. Patients were categorized into groups with and without complications. Data collected included demographic details, laboratory results, CT quantitative body composition analysis, and clinical information. Variable selection was conducted through Lasso regression, succeeded by multivariable logistic regression to pinpoint independent risk factors. These elements facilitated the construction of a nomogram for prediction. The model's performance underwent internal validation via bootstrap techniques and external validation through a validation cohort. The efficacy of the model was quantified by the area under the receiver operating characteristic (ROC) curve (AUC), evaluated for calibration using calibration curves and the Hosmer-Lemeshow test, and assessed for clinical utility through decision curve analysis (DCA).

RESULTS

Of the 500 patients in the training cohort, 65 experienced complications, a rate of 13%. The validation cohort had a similar complication rate of 13.24% (18 out of 136 patients). Independent risk factors identified included tumor diameter (OR = 1.99, 95% CI = 1.07-3.73), TNM stage III (OR = 2.12, 95% CI = 1.03-4.36), ASA class I (OR = 0.26, 95% CI = 0.13-0.53), ASA class III (OR = 4.75, 95% CI = 2.12-10.62), and visceral fat area (VFA) (OR = 2.52, 95% CI = 1.10-5.79). The nomogram demonstrated good discrimination (AUC = 0.81, 95% CI: 0.76-0.87) in internal validation and (AUC = 0.79, 95% CI: 0.67-0.90) in external validation. Both validations confirmed the model's accurate calibration and significant clinical utility, with net benefits observed at probability thresholds ranging from 2 to 79% and 2-71%.

CONCLUSION

The developed nomogram, based on five independent risk factors-tumor diameter, TNM stage III, ASA class I, ASA class III, and VFA-effectively predicts the risk of complications in patients undergoing robotic-assisted radical gastrectomy, offering a valuable tool for clinical decision-making.

Sarcopenia and myosteatosis are associated with low survival in patients receiving lenvatinib for unresectable hepatocellular carcinoma

PURPOSE

To investigate the association of skeletal muscle mass and quality with survival outcomes in patients with advanced hepatocellular carcinoma (HCC) treated with lenvatinib (LEN).

METHODS

In this retrospective study, LEN-treated patients with HCC were enrolled. Sarcopenia and myosteatosis were evaluated on the basis of baseline skeletal muscle index and mean muscle attenuation, respectively, on computed tomography at the L3 level. Low skeletal muscle mass (LSMM) was determined on the basis of index value, and bioinformatics tools were used to determine reliable cutoff values. Myosteatosis was defined on the basis of mean Hounsfield unit values and predefined cutoff values. A logrank test and Cox proportional hazards model were used to compare overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 81 patients were included. Patients with LSMM exhibited significantly lower PFS (p = 0.003) and OS (p = 0.010) than did patients without LSMM. Patients with myosteatosis exhibited significantly lower PFS (p = 0.012) and OS (p < 0.001) than did patients without myosteatosis. In multivariate analysis adjusted for tumor extent and liver function reserve, LSMM and myosteatosis remained independent predictors of low PFS (p = 0.028, p = 0.031) and OS (p = 0.027, p = 0.001), respectively.

CONCLUSION

LSMM and myosteatosis are independent prognostic factors for PFS and OS in advanced patients with HCC who received LEN and may exert synergistic effects on these survival outcomes.

Influence of body fat tissue on outcomes in patients undergoing hepatectomy or liver transplantation: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study is to investigate potential associations between body fat composition and postoperative outcomes in patients with hepatectomy or liver transplantation.

METHODS

Three online databases, including Embase, PubMed, and the Cochrane Library, were thoroughly searched for literature describing the relationship between body fat composition and outcomes of patients with liver surgery from the start of each database to 29 October 2023. The Newcastle-Ottawa Scale was used to rate the quality of the studies.

RESULTS

This analysis included a total of 29 articles with a combined patient cohort of 6435 individuals. The results demonstrated that patients with high intramuscular fat content (IMFC) had significantly inferior overall survival (OS) [hazard ratio (HR): 2.07, 95% CI: 1.69-2.53, P <0.001] and recurrence-free survival (RFS) (HR: 1.61, 95% CI: 1.20-2.16, P =0.002) and a higher risk of major complications (HR: 2.20, 95% CI: 1.59-3.05, P <0.001). We also found that the presence of high visceral-to-subcutaneous fat tissue ratio (VSR) in patients with liver surgery was significantly related to poorer OS (HR: 1.70, 95% CI: 1.44-2.00, P <0.001) and progression-free survival (PFS) (HR: 1.29, 95% CI: 1.11-1.50, P =0.001) and a higher major complication rate (HR: 2.31, 95% CI: 1.17-4.56, P =0.016). Besides, the synthesized findings indicated there is no significant correlation between visceral fat tissue and survival outcomes or postoperative complications.

CONCLUSION

In summary, preoperative IMFC and VSR have the potential to forecast poorer OS and RFS and a higher risk of complications for patients undergoing hepatectomy or liver transplantation.

Sarcopenic obesity is significantly associated with poorer overall survival after liver transplantation: a systematic review and meta-analysis

Background

Sarcopenia has been shown to worsen survival after liver transplantation. However, it remains unclear whether coexisting sarcopenia and obesity, so-called sarcopenic obesity (SO), may also synergistically increase their adverse effects. This meta-analysis aimed to evaluate whether pre-transplant SO independently predicts survival in this population.

Methods

We conducted this study according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. The PubMed, Embase, Web of Science, Wanfang, CNKI, and Cochrane databases were searched up to 15 October 2023, for studies with any study design evaluating the relationship between SO and post-transplant survival in patients undergoing liver transplantation. We used ROBINS-E to assess the study quality. The primary outcome was all-cause mortality at any length of follow-up. We calculated pooled odds risks (ORs) or hazard risks (HRs) with 95% confidence intervals (CIs). Heterogeneity was quantified with I 2 statistics. Subgroup analyses and publication bias evaluations were also conducted.

Results

We included nine cohort studies with 2,416 patients. These studies were moderate to high quality. Pre-liver transplant patients commonly experience SO, with a mean prevalence as high as 34%. Overall, patients with SO exhibited a significantly higher overall mortality than patients without SO, as demonstrated by pooled studies using both univariate analysis [HR = 1.76, 95%C 1.33-2.33, p < 0.0001] and multivariate analysis (HR = 2.33, 95%CI 1.34-4.04, p = 0.003). Similar results were also found when comparing patients with or without SO at 1, 3, and 5 years of follow-up (OR = 1.86, 95%CI 1.22-2.83; OR = 1.83, 95%CI: 1.27-2.64; and OR = 1.54, 95% CI 1.02-2.34, respectively). In addition, subgroup analysis based on studies that reported HRs of both sarcopenia and SO indicated both had independent negative effects on post-transplant survival.

Conclusion

Our meta-analysis showed that SO occurs frequently in liver transplant patients. SO is associated with an increased risk of mortality in such patient populations.

Systematic review registration

https://doi.org/10.37766/inplasy2024.2.0069 [inplasy2024.2.0069].

Myosteatosis and muscle loss impact liver transplant outcomes in male patients with hepatocellular carcinoma

BACKGROUND

Sarcopenia is associated with unfavourable long-term survival in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). However, the impact of myosteatosis and muscle loss on patient prognosis has not been investigated.

METHODS

Seven hundred fifty-six HCC patients who received LT at 3 transplant centres were included. Computed tomography (CT) images of recipients were collected to measure skeletal muscle index (SMI) and skeletal muscle radiodensity (SMRA). The impact of myosteatosis on the prognosis of sarcopenic and non-sarcopenic patients was studied separately. Muscle status was evaluated based on the presence of sarcopenia and myosteatosis. The muscle loss of 342 males was calculated as the relative change of SMI between pre- and post-LT evaluations. Cox regression models were used to identify predictors of overall survival (OS) and recurrence-free survival (RFS).

RESULTS

The study comprised 673 males and 83 females. The median follow-up time was 31 months (interquartile range, 19-43 months). Prior to LT, 267 (39.7%) and 187 (27.8%) males were defined as sarcopenic (low-SMI) and myosteatotic (low-SMRA), respectively. For sarcopenic recipients, the presence of myosteatosis was followed by a 23.6% decrease in 5 year OS (P < 0.001) and a 15.0% decrease in 5 year RFS (P = 0.014). Univariate and multivariate analyses revealed that muscle status was an independent predictor of OS [hazard ratio (HR), 1.569; 95% confidence interval (CI), 1.317-1.869; P < 0.001] and RFS (HR, 1.369; 95% CI, 1.182-1.586; P < 0.001). Postoperatively, a muscle loss >14.2% was an independent risk factor for poor OS (HR, 2.286; 95% CI, 1.358-3.849; P = 0.002) and RFS (HR, 2.219; 95% CI, 1.418-3.471; P < 0.001) in non-sarcopenic recipients (N = 209).

CONCLUSIONS

Pre-transplant myosteatosis aggravated the adverse impact of sarcopenia on liver transplant outcomes in male HCC patients. Post-transplant muscle loss might assist in prognostic stratification of recipients without pre-existing sarcopenia, intriguing new insights into individualized management.

Impact of CT-relevant skeletal muscle parameters on post-liver transplantation survival in patients with hepatocellular carcinoma

BACKGROUND

The specific CT-related skeletal muscle parameters predictive of postoperative survival in liver transplant (LT) patients with hepatocellular carcinoma (HCC) remain unclear. There is increasing evidence supporting the role of fatty acids and their lipid intermediates in regulating skeletal muscle mass and function, the relationship between lipoprotein subfractions and body composition remains unclear.

METHODS

Adult patients with HCC who underwent LT between January 2015 and September 2022 were retrospectively analyzed. CT parameters, including skeletal muscle index (SMI), psoas muscle index (PMI), skeletal muscle density (SMD), visceral and subcutaneous adipose tissue (VAT and SAT), and the VAT/SAT ratio at the L3 level, and lipid profiles, were assessed prior to LT.

RESULTS

Of the 284 LT patients with HCC, 224 underwent CT (L3 level) within 3 months of LT, and 82 (37%) were diagnosed with myosteatosis. Patients with myosteatosis exhibited significantly lower 1- and 3-year survival rates (p = 0.002, p = 0.01), a trend persisting even beyond the Milan criteria (p = 0.004, p = 0.04). After adjusting for covariates, SMD demonstrated a significant negative correlation with post-transplant survival (HR: 0.90, [95% Confidence Interval(CI): 0.83-0.98], C-statistic: 0.78, p = 0.009). Pearson's correlation analysis revealed a positive correlation between high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1(ApoA1) levels and SMD. Multivariate stepwise regression analysis demonstrated that every 10 Hounsfield unit decrease in SMD was associated with a 0.16 mmol/L decrease in HDL-C and a 0.18 g/L decrease in ApoA1.

CONCLUSION

Routine abdominal CT scans for assessing skeletal muscle density before LT were significantly associated with post-transplant mortality. Furthermore, abnormal HDL-C and ApoA1 levels before LT were associated with myosteatosis.

Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting

Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.

The Effect of Enhanced Recovery After Surgery Nursing on the Recovery in Patients After Liver Transplantation

OBJECTIVE

To explore the effect of enhanced recovery after surgery nursing on the recovery in patients after liver transplantation.

METHODS

This study was performed in 128 patients underwent liver transplantation in our hospital. According to the random number table, these patients were divided into the control group (n = 64) and the experimental group (n = 64). Patients in the control group received traditional nursing, while those in the experimental group received enhanced recovery after surgery nursing. Completion time of the operation, the amount of infused red blood cells during operation, intraoperative anhepatic period, intensive care unit (ICU) stay, the total length of hospitalization, the number of patients reintubated after surgery, the survival rate within 1 year after surgery, and the incidence of postoperative complications were compared between the two groups.

RESULTS

Intraoperative anhepatic period and the amount of infused red blood cells during operation in the experimental group were lower than those in the control group (both P < .05). Postoperative ICU stay, the total length of hospitalization, and the number of patients reintubated after surgery in the experimental group were decreased when compared with the control group, while postoperative ventilator weaning time was increased (all P < .05). The survival rates at 3 months, 6 months, and 1 year after surgery in the experimental group were higher than those in the control group (all P < .05). Compared with the control group, the total incidence of complications in the experimental group was reduced (P < .05).

CONCLUSION

The application of enhanced recovery after surgery nursing in liver transplantation patients contributes to the accelerated recovery of body function, shortened total length of hospitalization and ICU stay, declined complications, and increased survival rate within 1 year.

Integrated impact of multiple body composition parameters on overall survival in gastrointestinal or genitourinary cancers: A descriptive cohort study

BACKGROUND

This study aimed to evaluate if combining low muscle mass with additional body composition abnormalities, such as myosteatosis or adiposity, could improve survival prediction accuracy in a large cohort of gastrointestinal and genitourinary malignancies.

METHODS

In total, 2015 patients with surgically-treated gastrointestinal or genitourinary cancer were retrospectively analyzed. Skeletal muscle index, skeletal muscle radiodensity, and visceral/subcutaneous adipose tissue index were determined. The primary outcome was overall survival determined by hospital records. Multivariate Cox hazard models were used to identify independent predictors for poor survival. C-statistics were assessed to quantify the prognostic capability of the models with or without incorporating body composition parameters.

RESULTS

Survival curves were significantly demarcated by all 4 measures. Skeletal muscle radiodensity was associated with non-cancer-related deaths but not with cancer-specific survival. The survival outcome of patients with low skeletal muscle index was poor (5-year OS; 65.2%), especially when present in combination with low skeletal muscle radiodensity (5-year overall survival; 50.2%). All examined body composition parameters were independent predictors of lower overall survival. The model for predicting overall survival without incorporating body composition parameters had a c-index of 0.68 but increased to 0.71 with the inclusion of low skeletal muscle index and 0.72 when incorporating both low skeletal muscle index and low skeletal muscle radiodensity/visceral adipose tissue index/subcutaneous adipose tissue index.

CONCLUSION

Patients exhibiting both low skeletal muscle index and other body composition abnormalities, particularly low skeletal muscle radiodensity, had poorer overall survival. Models incorporating multiple body composition prove valuable for mortality prediction in oncology settings.

Shining a spotlight on sarcopenia and myosteatosis in liver disease and liver transplantation: Potentially modifiable risk factors with major clinical impact

Muscle-wasting and disease-related malnutrition are highly prevalent in patients with chronic liver diseases (CLD) as well as in liver transplant (LT) candidates. Alterations of body composition (BC) such as sarcopenia, myosteatosis and sarcopenic obesity and associated clinical frailty were tied to inferior clinical outcomes including hospital admissions, length of stay, complications, mortality and healthcare costs in various patient cohorts and clinical scenarios. In contrast to other inherent detrimental individual characteristics often observed in these complex patients, such as comorbidities or genetic risk, alterations of the skeletal muscle and malnutrition are considered as potentially modifiable risk factors with a major clinical impact. Even so, there is only limited high-level evidence to show how these pathologies should be addressed in the clinical setting. This review discusses the current state-of-the-art on the role of BC assessment in clinical outcomes in the setting of CLD and LT focusing mainly on sarcopenia and myosteatosis. We focus on the disease-related pathophysiology of BC alterations. Based on these, we address potential therapeutic interventions including nutritional regimens, physical activity, hormone and targeted therapies. In addition to summarizing existing knowledge, this review highlights novel trends, and future perspectives and identifies persisting challenges in addressing BC pathologies in a holistic way, aiming to improve outcomes and quality of life of patients with CLD awaiting or undergoing LT.

Utilizing a novel MRI technique to identify adverse muscle composition in end-stage liver disease: A pilot study

INTRODUCTION AND OBJECTIVES

Sarcopenia is a common complication of end-stage liver disease (ESLD), but its exact relationship to myosteatosis and frailty remains unclear. In this pilot study, we tested the feasibility of a specialized MRI protocol and automated image analysis in patients with ESLD.

MATERIALS AND METHODS

In a single-center prospective study, adult liver transplant candidates with ESLD underwent assessment of muscle composition between 3/2022 and 6/2022 using the AMRA® MAsS Scan. The primary outcome of interest was feasibility of the novel MRI technique in patients with ESLD. We also tested if thigh muscle composition correlated with validated measures of frailty and sarcopenia.

RESULTS

Eighteen subjects (71 % male, mean age 59 years) were enrolled. The most common etiologies of cirrhosis were alcohol-related liver disease (44 %) and non-alcohol-associated fatty liver disease (33 %), with a mean MELD-Na of 13 (± 4). The mean time needed to complete the MRI protocol was 14.9 min and only one patient could not complete it due to metal hardware in both knees. Forty-one percent of patients had adverse muscle composition (high thigh fat infiltration and low-fat free muscle volume) and these patients were more likely to have undergone a recent large volume paracentesis (43 % vs. 0 %, p < 0.02). The adverse muscle composition group performed significantly worse on the 6-minute walk test compared to the remainder of the cohort (379 vs 470 m, p < 0.01).

CONCLUSIONS

The AMRA® MAsS Scan is feasible to perform in patients with ESLD and can be used to quantify myosteatosis, a marker of muscle quality and potentially muscle functionality in ESLD.

Prognostic impact of myosteatosis in patients with colorectal cancer undergoing curative surgery: an updated systematic review and meta-analysis

Background

Colorectal cancer (CRC) is a global health concern, and identifying prognostic factors can improve outcomes. Myosteatosis is fat infiltration into muscles and is a potential predictor of the survival of patients with CRC.

Methods

This systematic review and meta-analysis aimed to assess the prognostic role of myosteatosis in CRC. PubMed, Embase, and Cochrane CENTRAL were searched up to 1 August 2023, for relevant studies, using combinations of the keywords CRC, myosteatosis, skeletal muscle fat infiltration, and low skeletal muscle radiodensity. Case-control, prospective, and retrospective cohort studies examining the association between myosteatosis and CRC outcomes after curative intent surgery were eligible for inclusion. Primary outcomes were overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS).

Results

A total of 10 studies with a total of 9,203 patients were included. The pooled hazard ratio (HR) for OS (myosteatosis vs. no myosteatosis) was 1.52 [95% confidence interval (CI), 1.38-1.67); for CSS, 1.67 (95% CI, 1.40-1.99); and for DFS, 1.89 (95% CI, 1.35-2.65).

Conclusion

In patients with CRC undergoing curative intent surgery, myosteatosis is associated with worse OS, CSS, and DFS. These findings underscore the importance of evaluating myosteatosis in patients with CRC to improve outcomes.

Association of myosteatosis with short-term outcomes in patients with acute-on-chronic liver failure

Sarcopenia (low muscle mass, i.e., quantity) is associated with poor clinical outcomes in patients with acute-on-chronic liver failure (ACLF). In this study, we aimed to illustrate the clinical prognostic value of myosteatosis (muscle fat infiltration) for short-term mortality in patients with ACLF. We retrospectively enrolled consecutive patients with ACLF between January 2019 and January 2022. Computed tomography-based body composition analysis was performed at the third lumbar vertebral level to determine skeletal muscle radiation attenuation. Fine and Gray's competing risk regression model, with liver transplantation as a competing risk, was used to assess the factors associated with 90-day mortality. A total of 431 patients with ACLF were included. Myosteatosis and sarcopenia were observed in 261 (60.6%) and 87 (20.2%) patients, respectively. Competitive risk regression showed that age (HR 1.021, 95% CI 1.000-1.043, P = 0.042), APASL ACLF Research Consortium (AARC) score (HR 1.498, 95% CI 1.312-1.710, P < 0.001), and sarcopenia (HR 1.802, 95% CI 1.062-3.060, P = 0.029) were independently associated with increased 90-day mortality. Subgroup analysis of male patients with HBV-ACLF revealed that myosteatosis (HR 2.119, 95% CI 1.101-4.078, P = 0.025) was promising prognostic factors for 90-day mortality after being adjusted for ascites, acute kidney injury, AARC score, and sarcopenia. Myosteatosis is predictive of short-term outcomes in male patients with HBV-ACLF. Our results emphasise the importance of focusing on muscle fat infiltration in patients with HBV-ACLF. Further studies are warranted to investigate the underlying mechanisms and potential therapies for myosteatosis.

Low serum manganese as a noninvasive marker predicting the presence of myosteatosis among hospitalized patients with cirrhosis

Emerging evidence expands on a close connection between trace elements and muscular abnormalities, mostly focusing on sarcopenia. We hypothesized an association between concentrations of serum trace elements and myosteatosis, given that myosteatosis has a more pronounced clinical implication relative to sarcopenia, but there is a paucity of data in patients with cirrhosis. Consecutive patients were hospitalized for cirrhosis-associated complications. Serum trace elements (zinc, copper, manganese [Mn], magnesium, calcium, and iron) were measured by inductively coupled plasma mass spectrometry. The presence of myosteatosis was defined according to computed tomography-demarcated intramuscular adipose tissue content. In total, the 295 patients with cirrhosis analyzed had a median age of 63 years and 53.6% were male. Among them, 42 patients presented with myosteatosis (14.2%) and concomitant higher Model for End-stage Liver Disease-Sodium and triglyceride concentrations and lower neutrophil counts and serum Mn concentrations (all P < .05). No differences were found regarding other 5 trace elements in patients with versus without myosteatosis. The median serum Mn concentrations were 1.16 µg/L, and this population was categorized into high-Mn and low-Mn groups. The proportion of myosteatosis was significantly lower in high-Mn group than that in low-Mn group (8.1% vs 20.4%, P < .001). Univariable binary logistic regression indicated that low Mn was associated with myosteatosis (odds ratio, 2.906; 95% confidence interval, 1.424-5.932; P = .003) in the context of cirrhosis. This result was validated according to multivariable analysis by adjusting for confounding factors. In conclusion, low serum Mn can be predictive of myosteatosis, a novel muscular abnormality representing more clinical relevance and close relation to inferior outcomes among cirrhosis.

Relationship among low baseline muscle mass, skeletal muscle quality, and mortality in critically ill children

BACKGROUND

Studies in adults have shown that low baseline muscle mass at intensive care unit (ICU) admission was associated with poor clinical outcomes. However, no information on the relationship between baseline muscle quality or mass and clinical outcomes in critically ill children was found.

METHODS

3775 children were admitted to the pediatric ICU (PICU), 262 were eligible for inclusion. Abdominal computed tomography was performed to assess baseline skeletal muscle mass and quality. Patients were categorized to normal or low group based on the cutoff value for predicting hospital mortality of the skeletal muscle index (SMI; 30.96 cm2/m2) and skeletal muscle density (SMD; 41.21 Hounsfield units).

RESULTS

Body mass index (BMI) (18.07 ± 4.44 vs 15.99 ± 4.51) and BMI-for-age z score (0.46 [-0.66 to 1.74] vs -0.87 [-1.69 to 0.05]) were greater in the normal-SMI group, the length of PICU stay was longer in the low-SMI group (16.00 days [8.50-32.50] vs 13.00 days [7.50-20.00]), and the in-PICU mortality rate in the normal-SMI group (10.00%) was lower than the low-SMI group (22.6%). Children with low SMD had a higher in-PICU mortality rate (25.6% vs 7.7%), were younger (36.00 months [12.00-120.00] vs 84.00 months [47.50-147.50]) and weighed less (16.40 kg [10.93-37.25] vs 23.00 kg [16.00-45.00]). Mortality was greater in patients with lower SMD and prolonged hospital stay (log-rank, P = 0.007). SMD was an independent predictor for length of PICU stay and in-PICU mortality.

CONCLUSIONS

Low baseline skeletal muscle quality in critically ill children is closely tied with a higher in-PICU mortality and longer PICU stay and is an independent risk factor for unfavorable clinical outcomes.

Evolving concepts on perioperative nutrition of sarcopenic cancer patients

The recent recognition of the association of sarcopenia with an increased risk of complications after a surgical procedure calls for rethinking the proper approach of the perioperative care in cancer patients. Sarcopenia is broadly considered in literature according to three different definitions: loss of muscle mass, loss of muscle mass plus reduced muscle function and myosteatosis. The aim of this short review on this issue is to define the excess of risk by type of primary and of surgical procedure, depending on the definition of sarcopenia, to speculate on this association (casual versus causal) and to examine the current therapeutical approaches. The analysis of the data shows that sarcopenia, defined as loss of muscle mass plus reduced muscle function, has the higher predictive power for the occurrence of postoperative complications than the two other definitions, and any definition of sarcopenia works better than the usual indexes or scores of surgical risk. Our analysis supports the concept that: a) sarcopenia is frequently associated with inflammation, but inflammation cannot be considered the only or the absolute cause for sarcopenia, b) sarcopenia is not a simple marker of risk but can have a direct role in the increase of risk. Data on perioperative care of sarcopenic cancer patients are scanty but a correct approach cannot rely on nutritional support alone but on a combined approach of optimized nutrition and exercise, hopefully associated with an anti-inflammatory treatment. This strategy should be applied proactively in keeping with the recent recommendations of the American Society of Clinical Oncology for the medical treatment of advanced cancer patients even if a clear demonstration of effectiveness is still lacking.

Prevalence and impact on the outcome of myosteatosis in patients with cirrhosis: a systematic review and meta-analysis

BACKGROUND

Myosteatosis in cirrhotic patients has been evaluated in limited studies with conflicting results and no systematic review or meta-analysis have been performed in this setting.

METHODS

We searched for all articles published until June 2023 to evaluate the prevalence of myosteatosis in cirrhosis and chronic liver disease.

RESULTS

Seventeen studies focused on cirrhosis and five studies in patients with chronic liver disease were included: the overall pooled prevalence of myosteatosis was 46% [95% Confidence Interval (CI) 36-57%] and 33% (95% CI 15-59%), respectively (p = 0.35). Among the studies with cirrhosis, the prevalence of myosteatosis was higher in those using the body mass index-based definition of myosteatosis (56%), than gender-based (36%) or other criteria (21%) (p < 0.01); was higher in women than in men (61% vs 45%), in Child-Pugh class C than A or B (57% vs 49% vs 50%), in non-alcoholic fatty liver disease (NAFLD)- than viral-associated cirrhosis (57% vs 43%), but these differences were not statistically significant (p > 0.05). Cirrhotic patients with myosteatosis, compared to those without myosteatosis, had more frequently a previous history of hepatic encephalopathy (32% vs 15%, p = 0.04), less frequently a previous history of variceal bleeding (46% vs 65%, p < 0.01), were more likely to suffer from diabetes mellitus (27% vs 18%, p < 0.01), while they had higher mortality rates (40% vs 14%, p = 0.02).

CONCLUSION

Myosteatosis is highly prevalent in patients with cirrhosis, particularly in those with NAFLD-associated cirrhosis. Myosteatosis is associated with hepatic encephalopathy, while it seems to have a negative impact on the outcome.

Abdominal computed tomography measurements of body composition and waitlist mortality in kidney transplant candidates

Body mass index is often used to determine kidney transplant (KT) candidacy. However, this measure of body composition (BC) has several limitations, including the inability to accurately capture dry weight. Objective computed tomography (CT)-based measures may improve pre-KT risk stratification and capture physiological aging more accurately. We quantified the association between CT-based BC measurements and waitlist mortality in a retrospective study of 828 KT candidates (2010-2022) with clinically obtained CT scans using adjusted competing risk regression. In total, 42.5% of candidates had myopenia, 11.4% had myopenic obesity (MO), 68.8% had myosteatosis, 24.8% had sarcopenia (probable = 11.2%, confirmed = 10.5%, and severe = 3.1%), and 8.6% had sarcopenic obesity. Myopenia, MO, and sarcopenic obesity were not associated with mortality. Patients with myosteatosis (adjusted subhazard ratio [aSHR] = 1.62, 95% confidence interval [CI]: 1.07-2.45; after confounder adjustment) or sarcopenia (probable: aSHR = 1.78, 95% CI: 1.10-2.88; confirmed: aSHR = 1.68, 95% CI: 1.01-2.82; and severe: aSHR = 2.51, 95% CI: 1.12-5.66; after full adjustment) were at increased risk of mortality. When stratified by age, MO (aSHR = 2.21, 95% CI: 1.28-3.83; P interaction = .005) and myosteatosis (aSHR = 1.95, 95% CI: 1.18-3.21; P interaction = .038) were associated with elevated risk only among candidates <65 years. MO was only associated with waitlist mortality among frail candidates (adjusted hazard ratio = 2.54, 95% CI: 1.28-5.05; P interaction = .021). Transplant centers should consider using BC metrics in addition to body mass index when a CT scan is available to improve pre-KT risk stratification at KT evaluation.

Approaching the Sarcopenic Patient with Nonalcoholic Steatohepatitis-related Cirrhosis

Sarcopenia is a well-known complication of chronic liver disease (CLD), and it is almost always observed in patients with cirrhosis, at least in those with decompensated disease. Since nonalcoholic fatty liver disease (NAFLD), recently renamed metabolic dysfunction-associated steatotic liver disease (MASLD), is becoming the leading cause of end-stage liver disease, a new scenario characterized by the frequent coexistence of NAFLD, obesity, and sarcopenia is emerging. Although it is not yet resolved whether the bidirectional relationship between sarcopenia and NAFLD subtends causal determinants, it is clear that the interaction of these two conditions is associated with an increased risk of poor outcomes. Notably, during the course of CLD, deregulation of the liver-muscle-adipose tissue axis has been described. Unfortunately, owing to the lack of properly designed studies, specific therapeutic guidelines for patients with sarcopenia in the context of NAFLD-related CLD have not yet been defined. Strategies aimed to induce the loss of fat mass together with the maintenance of lean body mass seem most appropriate. This can be achieved by properly designed diets integrated with specific nutritional supplementations and accompanied by adequate physical exercise. Future studies aiming to add to the knowledge of the correct assessment and approach to sarcopenia in the context of NAFLD-related CLD are eagerly awaited.

Influence of nutritional status and body composition on postoperative events and outcome in patients treated for primary localized retroperitoneal sarcoma

BACKGROUND

Retroperitoneal sarcomas (RPS) are rare tumours of mesenchymal origin, commonly presented as a large tumour mass at time of diagnosis. We investigated the impact of body composition on outcome in patients operated on for primary localized RPS.

PATIENTS AND METHODS

We retrospectively analysed data for all patients operated on for primary RPS at our institution between 1999 and 2020. Preoperative skeletal muscle area (SMA), visceral and subcutaneous adipose tissue area (VAT and SAT) and muscle radiation attenuation (MRA) were calculated using computed tomography scans at the level of third lumbar vertebra. European Working Group on Sarcopenia in Older People (EWGSOP2) criteria were applied to define myopenia. Using maximum log-rank statistic method we determined the optimal cut-off values of body composition parameters. Myosteatosis was defined based on determined MRA cut-offs.

RESULTS

In total 58 patient were eligible for the study. With a median follow-up of 116 months, the estimated 5-year overall survival (OS) and local-recurrence free survival (LRFS) were 66.8% and 77.6%, respectively. Patients with myopenia had significantly lower 5-year OS compared to non-myopenic (p = 0.009). Skeletal muscle index and subcutaneous adipose tissue index predicted LRFS on univariate analysis (p = 0.052 and p = 0.039, respectively). In multivariate analysis high visceral-to-subcutaneous adipose tissue area ratio (VSR) independently predicted higher postoperative complication rate (89.2% vs. 10.8%, p = 0.008). Myosteatosis was associated with higher postoperative morbidity.

CONCLUSIONS

Myopenia affected survival, but not postoperative outcome in RPS. Visceral obesity, VSR (> 0.26) and myosteatosis were associated with higher postoperative morbidity. VSR was better prognostic factor than VAT in RPS.

Prevalence and clinical impact of sarcopenia in liver transplant recipients: A meta-analysis

BACKGROUND

The prevalence of sarcopenia in patients undergoing liver transplantation (LT) remains to be determined partly because of different diagnostic criteria. Sarcopenia has recently been recognized as a new prognostic factor for predicting outcomes in LT candidates.

AIM

To estimate the prevalence of sarcopenia and evaluate its clinical effect on LT candidates.

METHODS

This systematic search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for original English-language articles that investigated the prevalence and influence of sarcopenia in patients undergoing LT from database inception to November 30, 2022. Cohort studies of the definition of sarcopenia that estimate sarcopenia prevalence and evaluate its effect on clinical outcomes and the risk of mortality were included.

RESULTS

Twenty-five studies involving 7760 patients undergoing LT were included. The pooled prevalence of sarcopenia in patients undergoing LT was 40.7% [95% confidence intervals (95%CI): 32.1-49.6]. The 1-, 3-, and 5-year cumulative probabilities of post-LT survival in patients with preoperative sarcopenia were all lower than those without sarcopenia (P < 0.05). Sarcopenia was associated with an increased risk of post-LT mortality in patients undergoing LT (adjusted hazard ratio: 1.58; 95%CI: 1.21-2.07). Patients with preoperative sarcopenia had a longer intensive care unit stay, a high risk ratio of sepsis, and serious post-LT complications than those without sarcopenia.

CONCLUSION

Sarcopenia is prevalent in a substantial proportion of patients undergoing LT and is strongly and independently associated with higher a risk of mortality risk.

How best to combine liver transplantation and bariatric surgery?-Results from a global, web-based survey

BACKGROUND AND AIMS

Obesity is a growing healthcare challenge worldwide and a significant risk factor for liver failure as seen with non-alcoholic steatohepatitis (NASH). Combining metabolic-bariatric surgery (MBS) with liver transplantation (LT) appears as attractive strategy to treat both, the underlying liver disease and obesity. However, there is an ongoing debate on best timing and patient selection. This survey was designed to explore the current treatment practice for patients with NASH and obesity worldwide.

METHODS

A web-based survey was conducted in 2022 among bariatric and LT surgeons, and hepatologists from Europe, North and South America and Asia.

RESULTS

The survey completion rate was 74% (145/196). The average respondents were 41-50 years (38%), male (82.1%) and had >20 years of clinical experience (42.1%). Centres with a high LT-caseload for NASH were mainly located in the USA and United Kingdom. Almost 30% have already performed a combination of LT with MBS and 49% plan to do it. A majority of bariatric surgeons prefer MBS before LT (77.2%), whereas most of LT surgeons (52%) would perform MBS during LT. Most respondents (n = 114; 80%) favour sleeve gastrectomy over other bariatric techniques. One third (n = 42; 29.4%) has an established protocol regarding MBS for LT candidates.

CONCLUSION

The most experienced centres doing LT for NASH are in the USA and United Kingdom with growing awareness worldwide. Overall, a combination of MBS and LT has already been performed by a third of respondents. Sleeve gastrectomy is the bariatric technique of choice-preferably performed either before or during LT.

Trajectory of Abdominal Skeletal Muscle Changes During Cardiac Rehabilitation in Patients With Aortic Disease

OBJECTIVE

This study focused on routine computed tomography imaging for aortic disease management and evaluated the trajectory of skeletal muscle changes through inpatient and outpatient cardiac rehabilitation.

DESIGN

Prospective observational study included patients who underwent abdominal computed tomography three times (baseline, postacute care, and follow-up). The area and density of the all-abdominal and erector spine muscles and intramuscular adipose tissue were measured. A generalized linear model with patients as random effects was used to investigate skeletal muscle changes.

RESULTS

Thirty-nine patients completed outpatient cardiac rehabilitation, and 60 were incomplete. Skeletal muscle area significantly decreased from baseline to the follow-up period only in the incomplete rehabilitation group. Skeletal muscle density significantly decreased from baseline to postacute care and increased at the follow-up period, but only patients who completed rehabilitation showed recovery up to baseline at the follow-up period. These trajectories were more pronounced in the erector spine muscle. Intramuscular adipose tissue showed a trend of gradual increase, but only the incomplete rehabilitation group showed a significant difference from baseline to the follow-up period.

CONCLUSIONS

The density of skeletal muscle may reflect the most common clinical course; skeletal muscle area and intramuscular adipose tissue are unlikely to improve positively, and their maintenance seemed optimal.

Myosteatosis: Diagnosis, pathophysiology and consequences in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with an increased risk of multisystemic complications, including muscle changes such as sarcopenia and myosteatosis that can reciprocally affect liver function. We conducted a systematic review to highlight innovative assessment tools, pathophysiological mechanisms and metabolic consequences related to myosteatosis in MASLD, based on original articles screened from PUBMED, EMBASE and COCHRANE databases. Forty-six original manuscripts (14 pre-clinical and 32 clinical studies) were included. Microscopy (8/14) and tissue lipid extraction (8/14) are the two main assessment techniques used to measure muscle lipid content in pre-clinical studies. In clinical studies, imaging is the most used assessment tool and included CT (14/32), MRI (12/32) and ultrasound (4/32). Assessed muscles varied across studies but mainly included paravertebral (4/14 in pre-clinical; 13/32 in clinical studies) and lower limb muscles (10/14 in preclinical; 13/32 in clinical studies). Myosteatosis is already highly prevalent in non-cirrhotic stages of MASLD and correlates with disease activity when using muscle density assessed by CT. Numerous pathophysiological mechanisms were found and included: high-fat and high-fructose diet, dysregulation in fatty acid transport and ketogenesis, endocrine disorders and impaired microRNA122 pathway signalling. In this review we also uncover several potential consequences of myosteatosis in MASLD, such as insulin resistance, MASLD progression from steatosis to metabolic steatohepatitis and loss of muscle strength. In conclusion, data on myosteatosis in MASLD are already available. Screening for myosteatosis could be highly relevant in the context of MASLD, considering its correlation with MASLD activity as well as its related consequences.

Development and External Validation of a Nomogram Including Body Composition Parameters for Predicting Early Recurrence of Hepatocellular Carcinoma After Hepatectomy

RATIONALE AND OBJECTIVES

Body composition, including adipose and muscle tissues, evaluated by computer tomography is correlated with the prognosis of hepatocellular carcinoma (HCC). However, its relationship with early recurrence (ER) remains unclear. This study aimed at establishing and validating a nomogram based on body composition and clinicopathological indices to predict ER of HCC.

MATERIALS AND METHODS

One hundred ninety-five patients from institution A formed the training cohort and internal validation cohort, and 50 patients from institution B formed the external validation cohort. Independent predictors of ER were identified using LASSO and Cox regression analyses. The performance of nomogram was evaluated using the calibration curve, concordance index (C-index), area under the curve (AUC), and decision curve analysis (DCA).

RESULTS

After data screening, the nomogram was constructed using eight independent predictors of ER, including the tumor size, alpha fetoprotein, body mass index, Edmondson Steiner grade, visceral adipose tissue radiodensity, intermuscular adipose tissue index, intramuscular adipose tissue content, and skeletal muscle area. The calibration curve exhibited excellent concordances, with C-indices of 0.808 (95%CI: 0.771-0.860), 0.802 (95%CI: 0.747-0.942), and 0.804 (95%CI: 0.701-0.861) in training, internal validation, and external validation cohorts, respectively. In addition, compared to conventional staging systems and pure clinical model, the nomogram exhibited a higher AUC and wider range of threshold probabilities in DCA, which indicated better discriminative ability and greater clinical benefit. Finally, patients with nomogram scores of <183.07, 183.07-243.09, and >243.09 were considered to have low, moderate, and high risks of ER, respectively.

CONCLUSION

The nomogram exhibits excellent ER predictive ability for patients with HCC who underwent hepatectomy.

Body composition is associated with disease aetiology and prognosis in patients undergoing resection of intrahepatic cholangiocarcinoma

BACKGROUND

Body composition alterations are frequent in patients with cancer or chronic liver disease, but their prognostic value remains unclear in many cancer entities.

OBJECTIVE

We investigated the impact of disease aetiology and body composition after surgery for intrahepatic cholangiocarcinoma (iCCA), a rare and understudied cancer entity in European and North American cohorts.

METHODS

Computer tomography-based assessment of body composition at the level of the third lumbar vertebra was performed in 173 patients undergoing curative-intent liver resection for iCCA at the Department of Surgery, Charité - Universitätsmedizin Berlin. Muscle mass and -composition as well as subcutaneous and visceral adipose tissue quantity were determined semi-automatically. (Secondary) sarcopenia, sarcopenic obesity, myosteatosis, visceral and subcutaneous obesity were correlated to clinicopathological data.

RESULTS

Sarcopenia was associated with post-operative morbidity (intraoperative transfusions [p = 0.027], Clavien-Dindo ≥ IIIb complications [p = 0.030], post-operative comprehensive complication index, CCI [p < 0.001]). Inferior overall survival was noted in patients with myosteatosis (33 vs. 23 months, p = 0.020). Fifty-eight patients (34%) had metabolic (dysfunction)-associated fatty liver disease (MAFLD) and had a significantly higher incidence of sarcopenic (p = 0.006), visceral (p < 0.001) and subcutaneous obesity (p < 0.001). Patients with MAFLD had longer time-to-recurrence (median: 38 vs. 12 months, p = 0.025, log-rank test). Multivariable cox regression analysis confirmed only clinical, and not body, composition parameters (age > 65, fresh frozen plasma transfusions) as independently prognostic for overall survival.

CONCLUSION

This study evidenced a high prevalence of MAFLD in iCCA, suggesting its potential contribution to disease aetiology. Alterations of muscle mass and adipose tissue were more frequent in patients with MAFLD.

AI-based CT Body Composition Identifies Myosteatosis as Key Mortality Predictor in Asymptomatic Adults

Background Body composition data have been limited to adults with disease or older age. The prognostic impact in otherwise asymptomatic adults is unclear. Purpose To use artificial intelligence-based body composition metrics from routine abdominal CT scans in asymptomatic adults to clarify the association between obesity, liver steatosis, myopenia, and myosteatosis and the risk of mortality. Materials and Methods In this retrospective single-center study, consecutive adult outpatients undergoing routine colorectal cancer screening from April 2004 to December 2016 were included. Using a U-Net algorithm, the following body composition metrics were extracted from low-dose, noncontrast, supine multidetector abdominal CT scans: total muscle area, muscle density, subcutaneous and visceral fat area, and volumetric liver density. Abnormal body composition was defined by the presence of liver steatosis, obesity, muscle fatty infiltration (myosteatosis), and/or low muscle mass (myopenia). The incidence of death and major adverse cardiovascular events were recorded during a median follow-up of 8.8 years. Multivariable analyses were performed accounting for age, sex, smoking status, myosteatosis, liver steatosis, myopenia, type 2 diabetes, obesity, visceral fat, and history of cardiovascular events. Results Overall, 8982 consecutive outpatients (mean age, 57 years ± 8 [SD]; 5008 female, 3974 male) were included. Abnormal body composition was found in 86% (434 of 507) of patients who died during follow-up. Myosteatosis was found in 278 of 507 patients (55%) who died (15.5% absolute risk at 10 years). Myosteatosis, obesity, liver steatosis, and myopenia were associated with increased mortality risk (hazard ratio [HR]: 4.33 [95% CI: 3.63, 5.16], 1.27 [95% CI: 1.06, 1.53], 1.86 [95% CI: 1.56, 2.21], and 1.75 [95% CI: 1.43, 2.14], respectively). In 8303 patients (excluding 679 patients without complete data), after multivariable adjustment, myosteatosis remained associated with increased mortality risk (HR, 1.89 [95% CI: 1.52, 2.35]; P < .001). Conclusion Artificial intelligence-based profiling of body composition from routine abdominal CT scans identified myosteatosis as a key predictor of mortality risk in asymptomatic adults. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Tong and Magudia in this issue.

Efficacy of supervised exercise prehabilitation programs to improve major abdominal surgery outcomes: A systematic review and meta-analysis

The optimal package of components for a prehabilitation intervention remains unclear. The aim was to determine the efficacy of supervised exercise prehabilitation programs to enhance patient fitness and improve surgical outcomes. The protocol was preregistered (PROSPERO: CRD42020180693). PubMed, MEDLINE, CINAHL, AMED, CENTRAL, PeDro, ClinicalTrials.gov and the WHO International Clinical Trials Registry were searched. Randomized controlled trials (RCTs) of supervised prehabilitation programs before major abdominal surgery were included. Physical function, cardiorespiratory capacity and surgical outcomes were the primary outcomes measures. Risk of bias was assessed according to the Cochrane Risk of Bias 1.0 tool for RCTs. Data are summarized narratively, and where possible, quantitavely. Meta-analyses results are reported as risk ratios (RR), mean difference of changes between baseline and follow-up time points or mean difference between groups and 95% confidence interval (CI). Twenty RCTs were included in the analysis with a total of 1258 patients. The average 6-min walking distance change was +33 m in the prehabilitation group compared to the usual care (UC) group after prehabilitation (95% CI: [13, 53], P < 0.01). Only in studies with more than one supervised session per week changes in 6-min-walk distance were significantly higher in the prehabilitation group compared to the UC group after prehabiliatation (Mean difference: 47 m, 95% [CI]: [20-75], P < 0.01). The change in peak volume of oxygen uptake during a maximum cardiopulmonary test was +1.47 mL·kg^-1·min^-1 in the prehabilitation group compared to the UC group (95% CI: [0.68, 2.25], P < 0.01). There was no significant difference in the change in oxygen uptake at anaerobic threshold between groups (Mean differences: 0.47, 95% CI: [-0.16, 1.10], P:0.14). Post-operative complications incidence was similar between groups (RR: 0.80, 95% CI: [0.61, 1.05], P:0.11), irrespective of the frequency of supervised session per week (RR: 0.67, 95% CI: [0.43, 1.03], P:0.07). In conclusion, prehabilitation programmes with more than one supervised session per week improved physical function but did not enhance surgical outcomes.

CT-derived psoas muscle area and density are associated with length of stay and discharge disposition after liver transplantation

BACKGROUND & AIMS

Prolonged length of stay (LOS) and discharge disposition following liver transplantation are associated with postoperative complications and increased healthcare utilization. This study evaluated the relationship between CT-derived psoas muscle measurements and hospital LOS, intensive care unit (ICU) LOS, and discharge disposition after liver transplant. The psoas muscle was chosen given its ease of measurement with any radiological software. A secondary analysis assessed the relationship between the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics (ASPEN/AND) malnutrition diagnosis criteria and CT-derived psoas muscle measures.

METHODS

CT-derived measures of psoas muscle density (mHU) and cross-sectional area at the level of the third lumbar vertebrae were obtained from preoperative CT scans of liver transplant recipients. Cross-sectional area measures were corrected for body size to generate a psoas area index variable (cm²/m²; PAI).

RESULTS

Each 1-unit increase in PAI was associated with a reduced hospital LOS of 4 days (R² = 0.07). Each 5-unit increase in mean Hounsfield units (mHU) was associated with a reduced hospital and ICU LOS of 5 and 1.6 days, respectively (R² = 0.22 and 0.14, respectively). Mean PAI and mHU were higher in patients who discharged to home. PAI was reasonably identified through ASPEN/AND malnutrition criteria, but there was no difference in mHU between those with and without malnutrition.

CONCLUSION

Measures of psoas density were associated with both hospital and ICU LOS and discharge disposition. PAI was associated with hospital LOS and discharge disposition. CT-derived measures of psoas density may be a valuable complement to preoperative liver transplant nutrition assessment using traditional ASPEN/AND malnutrition criteria.

Radiological assessment of skeletal muscle index and myosteatosis and their impact postoperative outcomes after liver transplantation

BACKGROUND

Liver transplantation offers curative treatment to patients with acute and chronic end-stage liver disease. The impact of nutritional status on postoperative outcomes after liver transplantation remains poorly understood. The present study investigated the predictive value of radiologically assessed skeletal muscle index (SMI) and myosteatosis (MI) on postoperative outcomes.

PATIENTS AND METHODS

Data of 138 adult patients who underwent their first orthotopic liver transplantation were retrospectively analysed. SMI and MI in computer tomography (CT) scan at the third lumbar vertebra level were calculated. Results were analyzed for the length of hospitalisation and postoperative outcomes.

RESULTS

In 63% of male and 28.9% of female recipients, low SMI was found. High MI was found in 45(32.6%) patients. Male patients with high SMI had longer intensive care unit (ICU) stay (P < 0.025). Low SMI had no influence on ICU stay in female patients (P = 0.544), length of hospitalisation (male, P > 0.05; female, P = 0.843), postoperative complication rates (males, P = 0.883; females, P = 0.113), infection rate (males, P = 0.293, females, P = 0.285) and graft rejection (males, P = 0.875; females, P = 0.135). The presence of MI did not influence ICU stay (P = 0.161), hospitalization (P = 0.771), postoperative complication rates (P = 0.467), infection rate (P = 0.173) or graft rejection rate (P = 0.173).

CONCLUSIONS

In our study, changes in body composition of liver transplant recipients observed with SMI and MI had no impact on postoperative course after liver transplantation. CT body composition analysis of recipients and uniformly accepted cut-off points are crucial to producing reliable data in the future.

Muscle quality determined by computed tomography predicts short-term and long-term survival after liver transplantation

Sarcopenia, the loss of muscle mass and quality, contributes to worse clinical outcome in patients with end-stage liver disease, but its impact on short- and long-term survival remains insufficiently understood. The aim of this study was to evaluate the development of computed tomography (CT) muscle parameters and their impact on short-term and long-term survival after liver transplantation. This retrospective study included patients with liver transplantation between 2011 and 2015 and a pre-transplant CT scan. Clinical characteristics, CT muscle mass and density were assessed pre-transplant, and in available CT scans at short-term (11 months) and long-term follow-up (56 months). Overall, 93/152 (61%) patients (109 male, 55 ± 10 years) suffered from sarcopenia pre-transplant. In short- (n = 50) and long-term follow-up (n = 52) the muscle mass (- 2.65 cm²/m² 95% CI [- 4.52, - 0.77], p = 0.007; - 2.96 cm²/m² [- 4.7, - 1.23], p = 0.001, respectively), and muscle density (- 3 HU [- 6, - 1], p = 0.007; - 2 HU [- 4, 0], p = 0.069) decreased. Myosteatosis was associated with a higher post-transplant mortality (survival probability: 3 months 72% vs. 95%, 1 year 63% vs. 90%, 5 years 54% vs. 84%, p = 0.001), while muscle mass was not. In conclusion, muscle mass and quality did not improve after transplant. Muscle quality predicts short- and long-term survival and could help to identify a patient's risk profile.

The Impact of Body Mass Composition on Outcome in Multiple Traumatized Patients—Results from the Fourth Thoracic and Third Lumbar Vertebrae: A Single-Center Retrospective Observational Study

Background: Body mass composition (BC) was shown to correlate with outcome in patients after surgery and minor trauma. As BC is assessed using computed tomography (CT) and routinely applied in multiple trauma (MT), this study will help to analyze whether BC variables also correlate with outcome in trauma patients. Materials and Methods: Inclusion criteria were MT (Injury Severity Score (ISS) > 15) and whole-body CT (WBCT) scan on admission. Muscle and fat tissue were assessed at the level of the fourth thoracic vertebra (T4) and the third lumbar vertebra (L3) using Slice-O-matic software, version 5.0 (Tomovision, Montreal, QC, Canada). Univariate and multivariate regression models were used with regard to outcome parameters such as duration of ventilation, hospital stay, local (i.e., pneumonia, wound infection) and systemic (i.e., MODS, SIRS) complications, and mortality. Results: 297 patients were included. BC correlated with both the development and severity of complications. Skeletal muscle index (SMI) and subcutaneous adipose tissue index (SATI) at both T4 and L3 correlated positively with the occurrence of systemic infections. Local infections positively correlated with SMI at T4. Low muscle mass and high visceral adipose tissue (VAT) predicted the severity of systemic and local complications. Muscle tissue markers at both T4 and L3 predicted the severity of complications in roughly the same way. Moreover, higher muscle mass at the L3 level was significantly associated with higher overall survival, while SATI at the T4 level correlated positively with hospital stay, length of stay in the ICU, and duration of ventilation. Conclusions: A lower muscle mass and a high adipose tissue index are associated with a poor outcome in MT. For the first time, it was shown that BC at the fourth thoracic vertebra is associated with comparable results to those found at the third lumbar level.

Association between Abdominal CT Measurements of Body Composition before Deceased Donor Liver Transplant with Posttransplant Outcomes

Background Pre-liver transplant (LT) sarcopenia is associated with poor survival. Methods exist for measuring body composition with use of CT scans; however, it is unclear which components best predict post-LT outcomes. Purpose To quantify the association between abdominal CT-based body composition measurements and post-LT mortality in a large North American cohort. Materials and Methods This was a retrospective cohort of adult first-time deceased-donor LT recipients from 2009 to 2018 who underwent pre-LT abdominal CT scans, including at the L3 vertebral level, at Johns Hopkins Hospital. Measurements included sarcopenia (skeletal muscle index [SMI] <50 in men and <39 in women), sarcopenic obesity, myosteatosis (skeletal muscle CT attenuation <41 mean HU for body mass index [BMI] <25 and <33 mean HU for BMI ≥25), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and VAT/SAT ratio. Covariates in the adjusted models were selected with use of least absolute shrinkage and selection operator regression with lambda chosen by means of 10-fold cross-validation. Cox proportional hazards models were used to quantify associations with post-LT mortality. Model discrimination was quantified using the Harrell C-statistic. Results A total of 454 recipients (median age, 57 years [IQR, 50-62 years]; 294 men) were evaluated. In the adjusted model, pre-LT sarcopenia was associated with a higher hazard ratio (HR) of post-LT mortality (HR, 1.6 [95% CI: 1.1, 2.4]; C-statistic, 0.64; P = .02). SMI was significantly negatively associated with survival after adjustment for covariates. There was no evidence that myosteatosis was associated with mortality (HR, 1.3 [95% CI: 0.86, 2.1]; C-statistic, 0.64; P = .21). There was no evidence that BMI (HR, 1.2 [95% CI: 0.95, 1.4]), VAT (HR, 1.0 [95% CI: 0.98, 1.1]), SAT (HR, 1.0 [95% CI: 0.97, 1.0]), and VAT/SAT ratio (HR, 1.1 [95% CI: 0.90, 1.4]) were associated with mortality (P = .15-.77). Conclusions Sarcopenia, as assessed on routine pre-liver transplant (LT) abdominal CT scans, was the only factor significantly associated with post-LT mortality. © RSNA, 2022 See also the editorial by Ruehm in this issue.

The impact of myosteatosis on outcomes following surgery for gastrointestinal malignancy: a meta-analysis

INTRODUCTION

The aim of this review was to evaluate the impact of preoperative myosteatosis on long-term outcomes following surgery for gastrointestinal malignancy.

METHODS

We conducted a systematic search of the electronic information sources, including PubMed MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL and AMED. Studies were included if they reported the impact of preoperatively defined myosteatosis, or a similar term, on long-term survival outcomes following surgery for gastrointestinal malignancy. A subgroup analysis was performed for those studies reporting outcomes for colorectal cancer patients only.

FINDINGS

Thirty-nine full-text articles were reviewed for inclusion, with 19 being retained after the inclusion criteria were applied. The total number of included patients across all studies was 14,481. Patients with myosteatosis had significantly poorer overall survival, according to univariate (hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.67-1.99) and multivariable (HR 1.66, 95% CI 1.49-1.86) analysis. This was also demonstrated for cancer-specific survival (univariate HR 1.62, 95% CI 1.18-2.22; multivariable HR 1.73, 95% CI 1.48-2.03) and recurrence-free survival (univariate HR 1.28, 95% CI 1.10-1.48; multivariable HR 1.38, 95% CI 1.07-1.77).

CONCLUSIONS

This meta-analysis demonstrates that patients with preoperative myosteatosis have poorer long-term survival outcomes following surgery for gastrointestinal malignancy. Therefore, myosteatosis should be used for preoperative optimisation and as a prognostic tool before surgery. More standardised definitions of myosteatosis and further cohort studies of patients with non-colorectal malignancies are required.

Calcification of the visceral aorta and celiac trunk is associated with renal and allograft outcomes after deceased donor liver transplantation

PURPOSE

Atherosclerosis affects clinical outcomes in the setting of major surgery. Here we aimed to investigate the prognostic role of visceral aortic (VAC), extended visceral aortic (VAC+), and celiac artery calcification (CAC) in the assessment of short- and long-term outcomes following deceased donor orthotopic liver transplantation (OLT) in a western European cohort.

METHODS

We retrospectively analyzed the data of 281 consecutive recipients who underwent OLT at a German university medical center (05/2010-03/2020). The parameters VAC, VAC+, or CAC were evaluated by preoperative computed tomography-based calcium quantification according to the Agatston score.

RESULTS

Significant VAC or CAC were associated with impaired postoperative renal function (p = 0.0016; p = 0.0211). Patients with VAC suffered more frequently from early allograft dysfunction (EAD) (38 vs 26%, p = 0.031), while CAC was associated with higher estimated procedural costs (p = 0.049). In the multivariate logistic regression analysis, VAC was identified as an independent predictor of EAD (2.387 OR, 1.290-4.418 CI, p = 0.006). Concerning long-term graft and patient survival, no significant difference was found, even though patients with calcification showed a tendency towards lower 5-year survival compared to those without (VAC: 65 vs 73%, p = 0.217; CAC: 52 vs 72%, p = 0.105). VAC+ failed to provide an additional prognostic value compared to VAC.

CONCLUSION

This is the first clinical report to show the prognostic role of VAC/CAC in the setting of deceased donor OLT with a particular value in the perioperative phase. Further studies are warranted to validate these findings. CT computed tomography, OLT orthotopic liver transplantation.

Myosteatosis Is Not Associated with Complications or Survival in HCC Patients Undergoing Trans Arterial Embolization

Alterations in nutritional status, in particular sarcopenia, have been extensively associated with a poor prognosis in cirrhotic patients regardless of the etiology of liver disease. Less is known about the predictive value of myosteatosis, defined as pathological fat infiltration into the skeletal muscle. We retrospectively analyzed a cohort of 151 cirrhotic patients with unresectable hepatocellular carcinoma (HCC) who underwent their first trans-arterial embolization (TAE) between 1 March 2011 and 1 July 2019 at our Institution. Clinical and biochemical data were collected. Sarcopenia was assessed using the L3-SMI method while myosteatosis with a dedicated segmentation suite (3D Slicer), using a single slice at an axial plane located at L3 and calculating the IMAC (Intramuscular Adipose Tissue Content Index). The sex-specific cut-off values for defining myosteatosis were IMAC > −0.44 in males and >−0.31 in females. In our cohort, 115 (76%) patients were included in the myosteatosis group; 128 (85%) patients had a coexistent diagnosis of sarcopenia. Patients with myosteatosis were significantly older and showed higher BMI than patients without myosteatosis. In addition, male gender and alcoholic- or metabolic-related cirrhosis were most represented in the myosteatosis group. Myosteatosis was not associated with a different HCC burden, length of hospitalization, complication rate, and readmission in the first 30 days after discharge. Overall survival was not influenced by the presence of myosteatosis.

The modified computed tomography severity index combined with low skeletal muscle mass can better predict the severity of hypertriglyceridemia-induced pancreatitis

BACKGROUND

Body composition parameters are associated with hypertriglyceridemia-induced pancreatitis (HTGP). This study investigated the association between the quantity of muscle assessed using computed tomography (CT) and the severity of HTGP.

METHODS

The modified CT severity index (MCTSI) was calculated from admission examination data. Patients' characteristics and body composition parameters were collected. Univariate and multivariate logistic regression analyses were also performed. The receiver operating characteristic curves and corresponding area under the curves (AUC) were calculated to test the efficiency of the model. A nomogram was then constructed.

RESULTS

Of the 175 included patients, 138 were male, of which 85 had moderately severe to severe HTGP. Patients with low skeletal muscle mass (LSMM) and high MCTSI were significantly more likely to have moderately severe to severe HTGP. Patients with LSMM had lower body mass index, lower HDL-C level, higher amylase level, prevalence of surgery, shorter umbilical waist circumference, and longer length of hospital stay. Univariate and multivariate logistic regression analyses confirmed that female sex, lipase, total cholesterol, LSMM-MCTSI (P = .004, odds ratio = 23.105), and albumin were risk factors. The TOTAL model that combined LSMM-MCTSI and clinical risk parameters performed best (AUCs = 0.875), followed by other models (LSMM-MCTSI: AUCs = 0.762, MCTSI: AUCs = 0.728). The Delong test revealed significant difference. Finally, a nomogram was developed to predict the severity of HTGP.

CONCLUSION

The performance of MCTSI in predicting severity can be improved by considering LSMM, which is a promising strategy for the treatment of HTGP.

Myosteatosis predicting risk of transition to severe COVID-19 infection

BACKGROUND

About 10-20% of patients with Coronavirus disease 2019 (COVID-19) infection progressed to severe illness within a week or so after initially diagnosed as mild infection. Identification of this subgroup of patients was crucial for early aggressive intervention to improve survival. The purpose of this study was to evaluate whether computer tomography (CT) - derived measurements of body composition such as myosteatosis indicating fat deposition inside the muscles could be used to predict the risk of transition to severe illness in patients with initial diagnosis of mild COVID-19 infection.

METHODS

Patients with laboratory-confirmed COVID-19 infection presenting initially as having the mild common-subtype illness were retrospectively recruited between January 21, 2020 and February 19, 2020. CT-derived body composition measurements were obtained from the initial chest CT images at the level of the twelfth thoracic vertebra (T12) and were used to build models to predict the risk of transition. A myosteatosis nomogram was constructed using multivariate logistic regression incorporating both clinical variables and myosteatosis measurements. The performance of the prediction models was assessed by receiver operating characteristic (ROC) curve including the area under the curve (AUC). The performance of the nomogram was evaluated by discrimination, calibration curve, and decision curve.

RESULTS

A total of 234 patients were included in this study. Thirty-one of the enrolled patients transitioned to severe illness. Myosteatosis measurements including SM-RA (skeletal muscle radiation attenuation) and SMFI (skeletal muscle fat index) score fitted with SMFI, age and gender, were significantly associated with risk of transition for both the training and validation cohorts (P < 0.01). The nomogram combining the SM-RA, SMFI score and clinical model improved prediction for the transition risk with an AUC of 0.85 [95% CI, 0.75 to 0.95] for the training cohort and 0.84 [95% CI, 0.71 to 0.97] for the validation cohort, as compared to the nomogram of the clinical model with AUC of 0.75 and 0.74 for the training and validation cohorts respectively. Favorable clinical utility was observed using decision curve analysis.

CONCLUSION

We found CT-derived measurements of thoracic myosteatosis to be associated with higher risk of transition to severe illness in patients affected by COVID-19 who presented initially as having the mild common-subtype infection. Our study showed the relevance of skeletal muscle examination in the overall assessment of disease progression and prognosis of patients with COVID-19 infection.

Osteopenia is associated with inferior survival in patients undergoing partial hepatectomy for hepatocellular carcinoma

Osteopenia is known to be associated with clinical frailty which is linked to inferior outcomes in various clinical scenarios. However, the exact prognostic value of osteopenia in patients undergoing curative intent-surgery for hepatocellular carcinoma (HCC) is not completely understood. This retrospective study was conducted in a cohort of 151 patients who underwent partial hepatectomy for HCC in curative intent at a German university medical center (05/2008-12/2019). Preoperative computed tomography-based segmentation was used to assess osteopenia, and the prognostic impact of pathological changes in bone mineral density (BMD) on perioperative morbidity, mortality, and long-term oncological outcome was analyzed. Five-year overall survival of osteopenic patients was significantly worse compared to those with normal BMD (29% vs. 65%, p = 0.014). In line with this, the probability of disease-free survival at 5 years was significantly worse for patients with osteopenia (21% vs. 64%, p = 0.005). In our multivariable model, osteopenia was confirmed as an independent risk-factor for inferior overall survival (Hazard-ratio 7.743, p = 0.002). Concerning perioperative complications, osteopenic patients performed slightly worse, even though no statistical difference was detected (Clavien-Dindo ≥ 3b; 21% vs. 9%, p = 0.139). The present study confirms osteopenia as an independent risk-factor for inferior survival in patients undergoing partial hepatectomy for HCC in a European cohort. Further studies are warranted to validate these findings.

Improving the prognosis before and after liver transplantation: Is muscle a game changer?

Liver transplantation (LT) is currently the only curative treatment option for selected patients with end stage liver disease or hepatocellular carcinoma. Improving waiting list-mortality, post-transplant morbidity and mortality and refining the selection of the patients remain our current central objectives. In this field, different concepts dealing with nutrition and the muscle such as sarcopenia, malnutrition, frailty or myosteatosis have emerged as possible game changers. For more than a decade, many prospective studies have demonstrated that sarcopenia and frailty are major predictive factors of mortality in the waiting list but also after LT. Malnutrition is also a well-known risk factor for morbidity and mor-tality. Muscle composition is a newer concept giving insight on muscle quality which has also been shown to be linked to poorer outcomes. Each of these terms has a precise definition as well as pathophysiological mechanisms. The bi-directional liver-muscle axis makes sense in this situation. Defining the best, easy to use in clinical practice tools to assess muscle quality, quantity, and function in this specific population and developing quality prospective studies to identify interventional strategies that could improve these parameters as well as evaluate the effect on mortality are among the important challenges of today.

Preoperative myopenia and myosteatosis and their impact on postoperative complications in children with inflammatory bowel disease

PURPOSE

To assess the severity of preoperative myopenia and myosteatosis in pediatric patients with inflammatory bowel disease (IBD) and examine their impact on postoperative complications.

METHODS

The subjects of this retrospective study were 30 pediatric patients with IBD (22 with ulcerative colitis (UC) and 8 with Crohn's disease (CD)) and 67 age-matched controls. Preoperative body mass index (BMI), psoas muscle index (PMI), and intramuscular adipose tissue content were compared between the patient groups, to investigate their association with postoperative complications.

RESULTS

BMI and PMI were significantly lower in the IBD patients than in the controls (p < 0.0001, p < 0.0001, respectively). CD was associated with significantly lower BMI and PMI (p = 0.01, p = 0.01, respectively) than UC. Intramuscular adipose tissue content was comparable between the IBD patients and the controls and between the UC and CD patients. There were no significant differences among the three indices in relation to the presence or absence of postoperative complications in patients with IBD. When limited to surgical site infection (SSI), only PMI was significantly lower in the patients with SSI than in those without SSI (p = 0.04).

CONCLUSIONS

Although BMI and PMI were lower preoperatively in pediatric IBD patients than in controls, only myopenia seemed to affect the development of SSI.

High visceral adipose tissue area is independently associated with early allograft dysfunction in liver transplantation recipients: a propensity score analysis

OBJECTIVES

To evaluate the association between adipose tissue distribution and early allograft dysfunction (EAD) in liver transplantation (LT) recipients.

METHODS

A total of 175 patients who received LT from April 2015 to September 2020 were enrolled in this retrospective study. The areas of abdominal adipose tissue and skeletal muscle of all patients were measured based on the preoperative CT images. The appropriate statistical methods including the propensity score-matched (PSM) analysis were performed to identify the association between adipose tissue distribution and EAD.

RESULTS

Of 175 LT recipients, 55 patients (31.4%) finally developed EAD. The multivariate logistic analysis revealed that preoperative serum albumin (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.17-0.70), platelet-lymphocyte ratio (OR 2.35, 95% CI 1.18-4.79), and visceral adipose tissue (VAT) area (OR 3.17, 95% CI 1.56-6.43) were independent associated with EAD. After PSM analysis, VAT area was still significantly associated with EAD (OR 3.95, 95% CI 1.16-13.51). In survival analysis, no significant difference was identified in one-year graft failure (log-rank: p = 0.487), and conversely result was identified in overall survival (OS) (log-rank: p = 0.012; hazard ratio (HR) 4.10, 95% CI 1.27-13.16).

CONCLUSIONS

LT recipients with high VAT area have higher risk for the occurrence of EAD, and high VAT area might have certain clinical value for predicting the poor OS of patients. For LT candidates with large amount of VAT, the clinicians can take clinical interventions by suggesting physical and nutritional treatments to improve outcomes after LT.

Four Decades of Clinical Liver Transplantation Research: Results of a Comprehensive Bibliometric Analysis

BACKGROUND

Nearly 40 y have passed since the 1983 National Institutes of Health Consensus-Development-Conference, which has turned liver transplantation (LT) from a clinical experiment into a routine therapeutic modality. Since' clinical LT has changed substantially. We aimed to comprehensively analyze the publication trends in the most-cited top-notch literature in LT science over a 4-decade period.

METHODS

A total of 106 523 items were identified between January 1981 and May 2021 from the Web of Science Core Collection. The top 100 articles published were selected using 2 distinct citation-based strategies to minimize bias. Various bibliometric tools were used for data synthesis and visualization.

RESULTS

The citation count for the final dataset of the top 100 articles ranged from 251 to 4721. Most articles were published by US authors (n = 61). The most prolific institution was the University of Pittsburgh (n = 15). The highest number of articles was published in Annals of Surgery, Hepatology, and Transplantation ; however, Hepatology publications resulted in the highest cumulative citation of 9668. Only 10% of the articles were classified as evidence level 1. Over 90% of first/last authors were male. Our data depict the evolution of research focus over 40 y. In part, a disproportional flow of citations was observed toward already well-cited articles. This might also project a slowed canonical progress, which was described in other fields of science.

CONCLUSIONS

This study highlights key trends based on a large dataset of the most-cited articles over a 4-decade period. The present analysis not only provides an important cross-sectional and forward-looking guidance to clinicians, funding bodies, and researchers but also draws attention to important socio-academic or demographic aspects in LT.

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes.

OBJECTIVE

We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes.

METHODS

We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS.

RESULTS

Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications.

CONCLUSIONS

We identified four pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT.