Impact and risk factors for clinically relevant surgery-related muscle loss in patients after major abdominal cancer surgery: study protocol for a prospective observational cohort study (MUSCLE POWER)

Actual physical activity after major abdominal cancer surgery: Far from optimal

BACKGROUND

Enhanced recovery after surgery protocols emphasize the importance of early postoperative mobilization. However, literature quantifying actual physical activity after major abdominal cancer surgery is scarce and inconclusive.

MATERIAL AND METHODS

A single-center prospective cohort study was conducted at the University Medical Center Groningen from 2019 to 2021. Patients' postoperative physical activity was measured using an accelerometer, with the primary aim of assessing daily physical activity. Secondary aims were identifying patient-related factors associated with low physical activity and studying the consequences of low physical activity in terms of complication rate and length of hospital stay.

RESULTS

143 patients included (48 % male; mean age 65 years), 38.5 %, 24.5 %, 19.6 %, and 14 % underwent pancreatic, hepatic, colorectal, or cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, respectively. Median daily step count was low; from median 71 steps on the first to 918 steps on the seventh postoperative day. An association between physical activity and age (OR 3.597, p = 0.013), preoperative weight loss ≥10 % (OR 4.984, p = 0.004), Eastern Cooperative Oncology Group performance status ≥2 (OR 4.016, p = 0.001), midline laparotomy (OR 2.851, p = 0.025), and operation duration (OR 1.003, p = 0.044) was found. An association was observed between physical activity and the occurrence of complications (OR 3.197, p = 0.039) and prolonged hospital stay (β 4.068, p = 0.013).

CONCLUSION

Postoperative physical activity is low in patients undergoing major abdominal cancer surgery and is linked to postoperative outcomes. Although physical activity should be encouraged in all patients, patient-specific risk factors were identified that can aid early recognition of patients at risk of low physical activity.

Surgery-Related Muscle Loss after Pancreatic Resection and Its Association with Postoperative Nutritional Intake

To study the occurrence of surgery-related muscle loss (SRML) and its association with in-hospital nutritional intake, we conducted a prospective observational cohort study including patients who underwent pancreatic surgery because of (suspected) malignant diseases. Muscle diameter was measured by using bedside ultrasound 1 day prior to surgery and 7 days postoperatively. Clinically relevant SRML was defined as ≥10% muscle diameter loss in minimally one arm and leg muscle within 1 week after surgery. Protein and caloric intake was measured by nutritional diaries. The primary endpoint included the number of patients with SRML. Secondary endpoints included the association between SRML and postoperative nutritional intake. Of the 63 included patients (60.3% men; age 67.1 ± 10.2 years), a total of 24 patients (38.1%) showed SRML. No differences were observed in severe complication rate or length of hospital stay between patients with and without SRML. During the first postoperative week, patients with clinically relevant SRML experienced more days without any nutritional intake compared with the non-SRML group (1 [0-4] versus 0 [0-1] days, p = 0.007). Significantly lower nutritional intake was found in the SRML group at postoperative days 2, 3 and 5 (p < 0.05). Since this study shows that SRML occurred in 38.1% of the patients and most of the patients failed to reach internationally set nutritional goals, it is suggested that more awareness concerning direct postoperative nutritional intake is needed in our surgical community.

Thickness of Biceps and Quadriceps Femoris Muscle Measured Using Point-of-Care Ultrasound as a Representation of Total Skeletal Muscle Mass

Generalized loss of muscle mass is associated with increased morbidity and mortality in patients with cancer. The gold standard to measure muscle mass is by using computed tomography (CT). However, the aim of this prospective observational cohort study was to determine whether point-of-care ultrasound (POCUS) could be an easy-to-use, bedside measurement alternative to evaluate muscle status. Patients scheduled for major abdominal cancer surgery with a recent preoperative CT scan available were included. POCUS was used to measure the muscle thickness of mm. biceps brachii, mm. recti femoris, and mm. vasti intermedius 1 day prior to surgery. The total skeletal muscle index (SMI) was derived from patients’ abdominal CT scan at the third lumbar level. Muscle force of the upper and lower extremities was measured using a handheld dynamometer. A total of 165 patients were included (55% male; 65 ± 12 years). All POCUS measurements of muscle thickness had a statistically significant correlation with CT-derived SMI (r ≥ 0.48; p < 0.001). The strongest correlation between POCUS muscle measurements and SMI was observed when all POCUS muscle groups were added together (r = 0.73; p < 0.001). Muscle strength had a stronger correlation with POCUS-measured muscle thickness than with CT-derived SMI. To conclude, this study indicated a strong correlation between combined muscle thickness measurements performed by POCUS- and CT-derived SMI and measurements of muscle strength. These results suggest that handheld ultrasound is a valid tool for the assessment of skeletal muscle status.

Impact of cumulative complications on 1-year treatment-related healthcare costs in patients with colorectal peritoneal metastases undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Background

The aim of this study was to evaluate the impact of all minor and major complications on treatment-related healthcare costs in patients who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of colorectal peritoneal metastases (PMs).

Method

Patients with histologically proven colorectal PMs who underwent CRS + HIPEC from March 2006 to October 2019 in a tertiary referral centre were retrospectively identified from a prospectively maintained database. Patients were divided into six subgroups according to the severity of the complications, which were scored using the comprehensive complication index (CCI) (CCI 0–9.9, CCI 10–19.9, CCI 20–29.9, CCI 30–39.9, CCI 40–49.9, and CCI 50 or higher). Treatment-related healthcare costs up to 1 year after CRS + HIPEC were obtained from the financial department. Differences in costs and survival outcomes were compared using the chi-squared test and Kruskal–Wallis H test.

Results

A total of 142 patients were included (CCI 0–9.9, 53 patients; CCI 10–19.9, 0 patients; CCI 20–29.9, 45 patients; CCI 30–39.9, 14 patients; CCI 40–49, 9 patients; and CCI 50 or higher, 21 patients). Median (interquartile range) treatment-related healthcare costs increased significantly and exponentially for the CCI 30–39, CCI 40–49, and CCI 50 or higher groups (€48 993 (€44 262–€84 805); €57 167 (€43 047–€67 591); and €82 219 (€55 487–€145 314) respectively) compared with those for the CCI 0–9.9 and CCI 20–29.9 groups (€33 856 (€24 433–€40 779) and €40 621 (€31 501–€58 761) respectively, P < 0.010).

Conclusion

Treatment-related healthcare costs increase exponentially as more complications develop among patients who undergo CRS + HIPEC for the treatment of colorectal PMs. Anastomotic leakages after CRS + HIPEC lead to an increase of 295 per cent of treatment-related healthcare costs.

Actual postoperative protein and calorie intake in patients undergoing major open abdominal cancer surgery: A prospective, observational cohort study

Background

Adequate nutritional protein and energy intake are required for optimal postoperative recovery. There are limited studies reporting the actual postoperative protein and energy intake within the first week after major abdominal cancer surgery. The main objective of this study was to quantify the protein and energy intake after major abdominal cancer surgery.

Methods

We conducted a prospective cohort study. Nutrition intake was assessed with a nutrition diary. The amount of protein and energy consumed through oral, enteral, and parenteral nutrition was recorded and calculated separately. Based on the recommendations of the European Society for Clinical Nutrition and Metabolism (ESPEN), protein and energy intake were considered insufficient when patients received <1.5 g/kg protein and 25 kcal/kg for 2 or more days during the first postoperative week.

Results

Fifty patients were enrolled in this study. Mean daily protein and energy intake was 0.61 ± 0.44 g/kg/day and 9.58 ± 3.33 kcal/kg/day within the first postoperative week, respectively. Protein and energy intake were insufficient in 45 [90%] and 41 [82%] of the 50 patients, respectively. Patients with Clavien‐Dindo grade ≥III complications consumed less daily protein compared with the group of patients without complications and patients with grade I or II complications.

Conclusion

During the first week after major abdominal cancer surgery, the majority of patients do not consume an adequate amount of protein and energy. Incorporating a registered dietitian into postoperative care and adequate nutrition support after major abdominal cancer surgery should be a standard therapeutic goal to improve nutrition intake.

Risk factors for surgery-related muscle quantity and muscle quality loss and their impact on outcome

Background

Surgery-related loss of muscle quantity negatively affects postoperative outcomes. However, changes of muscle quality have not been fully investigated. A perioperative intervention targeting identified risk factors could improve postoperative outcome. This study investigated risk factors for surgery-related loss of muscle quantity and quality and outcomes after liver resection for colorectal liver metastasis (CRLM).

Methods

Data of patients diagnosed with CRLM who underwent liver resection between 2006 and 2016 were analysed. Muscle quantity (psoas muscle index [PMI]), and muscle quality, (average muscle radiation attenuation [AMA] of the psoas), were measured using computed tomography. Changes in PMI and AMA of psoas after surgery were assessed.

Results

A total of 128 patients were analysed; 67 (52%) had surgery-related loss of muscle quantity and 83 (65%) muscle quality loss. Chronic obstructive pulmonary disease (COPD) (P = 0.045) and diabetes (P = 0.003) were risk factors for surgery-related loss of muscle quantity. A higher age (P = 0.002), open resection (P = 0.003) and longer operation time (P = 0.033) were associated with muscle quality loss. Overall survival was lower in patients with both muscle quantity and quality loss compared to other categories (P = 0.049). The rate of postoperative complications was significantly higher in the group with surgery-related loss of muscle quality.

Conclusions

Risk factors for surgery-related muscle loss were identified. Overall survival was lowest in patients with both muscle quantity and quality loss. Complication rate was higher in patients with surgery-related loss of muscle quality.