Abstract
Introduction
Malnutrition and deconditioning impact postoperative morbidity and mortality. Computed tomography (CT) body composition variables are used as markers of nutritional status and sarcopenia. The objective of this study is to evaluate the impact of sarcopenia, using CT variables, on postoperative outcomes following transanal total mesorectal excision (TaTME) for rectal cancer.
Methods
This was an institutional retrospective cohort analysis of consecutive rectal cancer patients who underwent TaTME between April 2014 and May 2020. Psoas muscle index (PMI) was calculated from diagnostic CT scans. Based on previous studies, patients in the lowest PMI tertile by gender were considered sarcopenic. Fisher’s exact and Mann–Whitney U test were used to compare categorical and continuous variables, respectively. Readmission rates and postoperative complications were compared between groups. Backward stepwise logistic regression was used to determine the association between sarcopenia and 30-day postoperative complications.
Results
85 patients were analyzed, of which 63% were male, with a median age of 59 (IQR: 51–65), and median BMI of 28 (IQR: 24–32). Of the entire cohort, 34% (n = 29) were sarcopenic (median PMI 5.39 IQR: 4.49–6.71). No significant difference in baseline characteristics between sarcopenic and nonsarcopenic patients were observed. 55% of sarcopenic patients experienced a complication within 30 days compared to 24% of nonsarcopenic patients (p = 0.01). 41% of sarcopenic patients required hospital readmission within 30 days compared to 17% of their nonsarcopenic counterparts (p = 0.014). Sarcopenic patients also experienced significantly higher rates of post-operative small bowel obstruction (10% vs. 0%, p = 0.04). Multivariable analyses identified that sarcopenic patients have a fourfold increase in odds of experiencing a 30-day postoperative complication (OR: 4.44, 95%CI: 1.6–12.4, p < 0.05) after adjusting for gender.
Conclusion
Preoperative sarcopenia is associated with increased 30-day postoperative complications following TaTME for rectal cancer. Postoperative complications can have serious oncologic implications by delaying adjuvant chemotherapy. Therefore, preoperative recognition of sarcopenia prior to undergoing TaTME for rectal cancer may provide an opportunity for early intervention with prehabilitation programs.
Similar content being viewed by others
References
Heald RJ (1979) A new approach to rectal cancer. Br J Hosp Med 22:277–281
Heald RJ (2013) A new solution to some old problems: transanal TME. Tech Coloproctol 17:257–258
Weaver KL, Grimm LM, Fleshman JW (2015) Changing the way we manage rectal cancer-standardizing TME from open to robotic (including laparoscopic). Clin Colon Rectal Surg 28:28–37
Suwanabol P, Maykel J (2017) Transanal total mesorectal excision: a novel approach to rectal surgery. Clin Colon Rectal Surg 30:120–129
Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP (2019) Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision. Ann Surg 269:700–711
Rasulov AO, Mamedli ZZ, Gordeyev SS, Kozlov NA, Dzhumabaev HE (2016) Short-term outcomes after transanal and laparoscopic total mesorectal excision for rectal cancer. Tech Coloproctol 20:227–234
Chen CC, Lai YL, Jiang JK, Chu CH, Huang IP, Chen WS, Cheng AYM, Yang SH (2016) Transanal total mesorectal excision versus laparoscopic surgery for rectal cancer receiving neoadjuvant chemoradiation: a matched case-control study. Ann Surg Oncol 23:1169–1176
Lacy AM, Tasende MM, Delgado S, Fernandez-Hevia M, Jimenez M, De Lacy B, Castells A, Bravo R, Wexner SD, Heald RJ (2015) Transanal total mesorectal excision for rectal cancer: outcomes after 140 patients. J Am Coll Surg 221:415–423
de’ Angelis N, Portigliotti L, Azoulay D, Brunetti F (2015) Transanal total mesorectal excision for rectal cancer: a single center experience and systematic review of the literature. Langenbeck’s Arch Surg 400:945–959
Fernández-Hevia M, Delgado S, Castells A, Tasende M, Momblan D, Del Gobbo GD, DeLacy B, Balust J, Lacy AM (2015) Transanal total mesorectal excision in rectal cancer short-term outcomes in comparison with laparoscopic surgery. Ann Surg 261:221–227
Wu Z, Zhou W, Chen F, Wang W, Feng Y (2019) Short-term outcomes of transanal versus laparoscopic total mesorectal excision: a systematic review and meta-analysis of cohort studies. J Cancer 10:341
Denost Q, Adam JP, Rullier A, Buscail E, Laurent C, Rullier E (2014) Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg 260:993–999
Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, Cesari M, Chumlea WC, Doehner W, Evans J, Fried LP, Guralnik JM, Katz PR, Malmstrom TK, McCarter RJ, Robledo LMG, Rockwood K, von Haehling S, Vandewoude MF, Walston J (2013) Frailty consensus: a call to action. J Am Med Dir Assoc 14:392
Heus C, Bakker N, Verduin WM, Doodeman HJ, Houdijk APJ (2019) Impact of body composition on surgical outcome in rectal cancer patients, a retrospective cohort study. World J Surg 43:1370–1376
Ozoya OO, Siegel EM, Srikumar T, Bloomer AM, DeRenzis A, Shibata D (2017) Quantitative assessment of visceral obesity and postoperative colon cancer outcomes. J Gastrointest Surg 21:534
Liu Y, Guo D, Niu Z, Wang Y, Fu G, Zhou Y, Xue Q, Jin X, Gong Z (2018) Prediction of the risk of laparoscopy-assisted gastrectomy by comparing visceral fat area and body mass index. Gastroenterol Res Pract. https://doi.org/10.1155/2018/1359626
Prado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, Baracos VE (2008) Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol 9:629
Bardou M, Barkun AN, Martel M (2013) Obesity and colorectal cancer. Gut 62:933
Gibson DJ, Burden ST, Strauss BJ, Todd C, Lal S (2015) The role of computed tomography in evaluating body composition and the influence of reduced muscle mass on clinical outcome in abdominal malignancy: a systematic review. Eur J Clin Nutr 69:1079
Levolger S, Van Vugt JLA, De Bruin RWF, IJzermans JNM (2015) Systematic review of sarcopenia in patients operated on for gastrointestinal and hepatopancreatobiliary malignancies. Br J Surg 102:1448–1458
Choi MH, Oh SN, Lee IK, Oh ST, Won DD (2018) Sarcopenia is negatively associated with long-term outcomes in locally advanced rectal cancer. J Cachexia Sarcopenia Muscle 9:53–59
Joglekar S, Nau PN, Mezhir JJ (2015) The impact of sarcopenia on survival and complications in surgical oncology: a review of the current literature. J Surg Oncol 112:503
Shachar SS, Williams GR, Muss HB, Nishijima TF (2016) Prognostic value of sarcopenia in adults with solid tumours: a meta-analysis and systematic review. Eur J Cancer 57:58–67
Huang DD, Wang SL, Zhuang CL, Zheng BS, Lu JX, Chen FF, Zhou CJ, Shen X, Yu Z (2015) Sarcopenia, as defined by low muscle mass, strength and physical performance, predicts complications after surgery for colorectal cancer. Color Dis. 17:O256
Mv N, N M, (2010) Sarcopenia: characteristics, mechanisms and functional significance. Br Med Bull 95:139
Kayano H, Nomura E, Abe R, Ueda Y, Machida T, Fujita C, Uchiyama S, Endo K, Murakami K, Mukai M, Makuuchi H (2019) Low psoas muscle index is a poor prognostic factor for lower gastrointestinal perforation: a single-center retrospective cohort study. BMC Surg. https://doi.org/10.1186/s12893-019-0629-y
Amini N, Spolverato G, Gupta R, Margonis GA, Kim Y, Wagner D, Rezaee N, Weiss MJ, Wolfgang CL, Makary MM, Kamel IR, Pawlik TM (2015) Impact total psoas volume on short- and long-term outcomes in patients undergoing curative resection for pancreatic adenocarcinoma: a new tool to assess sarcopenia. J Gastrointest Surg 19:1593
Peng PD, Van Vledder MG, Tsai S, De Jong MC, Makary M, Ng J, Edil BH, Wolfgang CL, Schulick RD, Choti MA, Kamel I, Pawlik TM (2011) Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis. HPB 13:439
Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, Holcombe SA, Wang SC, Segev DL, Sonnenday CJ (2010) Sarcopenia and mortality after liver transplantation. J Am Coll Surg 211:271
Lee JSJ, He K, Harbaugh CM, Schaubel DE, Sonnenday CJ, Wang SC, Englesbe MJ, Eliason JL (2011) Frailty, core muscle size, and mortality in patients undergoing open abdominal aortic aneurysm repair. J Vasc Surg 53:912
Peng P, Hyder O, Firoozmand A, Kneuertz P, Schulick RD, Huang D, Makary M, Hirose K, Edil B, Choti MA, Herman J, Cameron JL, Wolfgang CL, Pawlik TM (2012) Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma. J Gastrointest Surg 16:1478
Lin H-S, Watts JN, Peel NM, Hubbard RE (2016) Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 16:157
Wagner D (2016) Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery. World J Gastrointest Surg 8:1–27
Buettner S, Wagner D, Kim Y, Margonis GA, Makary MA, Wilson A, Sasaki K, Amini N, Gani F, Pawlik TM (2016) Inclusion of sarcopenia outperforms the modified frailty index in predicting 1-year mortality among 1,326 patients undergoing gastrointestinal surgery for a malignant indication. J Am Coll Surg 222:397
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA (2001) Frailty in older adults: evidence for a phenotype. J Gerontol—Ser A Biol Sci Med Sci 56:146
Richards SJG, Senadeera SC, Frizelle FA (2020) Sarcopenia, as assessed by psoas cross-sectional area, is predictive of adverse postoperative outcomes in patients undergoing colorectal cancer surgery. Dis Colon Rectum 63:807
Kayano H, Nomura E, Abe R, Ueda Y, Machida T, Fujita C, Uchiyama S, Endo K, Murakami K, Mukai M, Makuuchi H (2019) Low psoas muscle index is a poor prognostic factor for lower gastrointestinal perforation: a single-center retrospective cohort study. BMC Surg 19:1–9
Galata C, Hodapp J, Weiß C, Karampinis I, Vassilev G, Reißfelder C, Otto M (2020) Skeletal muscle mass index predicts postoperative complications in intestinal surgery for Crohn’s disease. J Parenter Enter Nutr 44:714
Jones KI, Doleman B, Scott S, Lund JN, Williams JP (2015) Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications. Color Dis 17:O20
Lieffers JR, Bathe OF, Fassbender K, Winget M, Baracos VE (2012) Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. Br J Cancer 107:931
Wang XJ, Chi P, Lin HM, Lu XR, Huang Y, Bin XZ, Huang SH, Sun YW, Ye DX (2018) Risk factors for early postoperative small bowel obstruction after elective colon cancer surgery: an observational study of 1,244 consecutive patients. Dig Surg 35:49
Wick EC, Shore AD, Hirose K, Ibrahim AM, Gearhart SL, Efron J, Weiner JP, Makary MA (2011) Readmission rates and cost following colorectal surgery. Dis Colon Rectum 54:1475–1479
Benson AB, Venook AP, Al-Hawary MM, Arain MA, Chen YJ, Ciombor KK, Cohen S, Cooper HS, Deming D, Garrido-Laguna I, Grem JL, Gunn A, Hoffe S, Hubbard J, Hunt S, Kirilcuk N, Krishnamurthi S, Messersmith WA, Meyerhardt J, Miller ED, Mulcahy MF, Nurkin S, Overman MJ, Parikh A, Patel H, Pedersen K, Saltz L, Schneider C, Shibata D, Skibber JM, Sofocleous CT, Stoffel EM, Stotsky-Himelfarb E, Willett CG, Johnson-Chilla A, Gurski LA (2020) Rectal cancer, version 6.2020: featured updates to the NCCN guidelines. JNCCN: J. Natl. Compr. Cancer Netw 18:807
Ma B, Gao P, Wang H, Xu Q, Song Y, Huang X, Sun J, Zhao J, Luo J, Sun Y, Wang Z (2017) What has preoperative radio(chemo)therapy brought to localized rectal cancer patients in terms of perioperative and long-term outcomes over the past decades? A systematic review and meta-analysis based on 41,121 patients. Int J Cancer 141:1052
Jy WU, Kuo CC, Ting LL, Kuo LJ, Lee HL, Huang Y, Cheng CJ, Chiou JF, Lu LS (2018) Sarcopenia is associated with inferior response to neoadjuvant chemoradiation in patients with locally advanced rectal cancer. Int J Radiat Oncol 102:e23–e24
Chung E, Lee HS, Cho ES, Park EJ, Baik SH, Lee KY, Kang J (2020) Prognostic significance of sarcopenia and skeletal muscle mass change during preoperative chemoradiotherapy in locally advanced rectal cancer. Clin Nutr 39:820
Heberton GA, Nassif M, Bierhals A, Novak E, LaRue SJ, Lima B, Hall S, Silvestry S, Joseph SM (2016) Usefulness of psoas muscle area determined by computed tomography to predict mortality or prolonged length of hospital stay in patients undergoing left ventricular assist device implantation. Am J Cardiol 118:1363
Bruns ERJ, van den Heuvel B, Buskens CJ, van Duijvendijk P, Festen S, Wassenaar EB, van der Zaag ES, Bemelman WA, van Munster BC (2016) The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review. Color. Dis 18:O267
Heger P, Probst P, Wiskemann J, Steindorf K, Diener MK, Mihaljevic AL (2020) A systematic review and meta-analysis of physical exercise prehabilitation in major abdominal surgery (PROSPERO 2017 CRD42017080366). J Gastrointest Surg 24:1375
Chia CLK, Mantoo SK, Tan KY (2016) “Start to finish trans-institutional transdisciplinary care”: a novel approach improves colorectal surgical results in frail elderly patients. Color Dis 18:O43
Trépanier M, Minnella EM, Paradis T, Awasthi R, Kaneva P, Schwartzman K, Carli F, Fried GM, Feldman LS, Lee L (2019) Improved disease-free survival after prehabilitation for colorectal cancer surgery. Ann Surg 270:493
Derksen JWG, Kurk SA, Oskam MJ, Peeters PHM, Punt CJA, Koopman M, May AM (2019) Factors contributing to cancer-related muscle wasting during first-line systemic treatment for metastatic colorectal cancer. JNCI Cancer Spectr. https://doi.org/10.1093/jncics/pkz016
Funding
None.
Author information
Authors and Affiliations
Contributions
Dr. JES, Dr. KA, and Dr. CB were responsible for the conception, design, data analysis, and editing of this manuscript. Dr. JES, Dr. DC and Ms. DC were responsible for data collection and Ms. AC was responsible for data analysis. Dr. JAB, Dr. LJM, Dr. JSD, Dr. PRS, and Dr. JAM contributed to the design, interpretation of the data, and revisions for the final approval of this manuscript. All authors provided substantial contributions to this manuscript.
Corresponding author
Ethics declarations
Disclosures
Justin A. Maykel MD—Applied Medical Clinical Educator. Jeremy E. Springer MD, Catherine Beauharnais MD, Derek Chicarilli MD, Danielle Coderre BS, Allison Crawford MS, Jennifer A. Baima MD, Lacey J. McIntosh DO, Jennifer S. Davids MD, Paul R. Sturrock MD, and Karim Alavi MD have no conflict of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Springer, J.E., Beauharnais, C., Chicarilli, D. et al. S184: preoperative sarcopenia is associated with worse short-term outcomes following transanal total mesorectal excision (TaTME) for rectal cancer. Surg Endosc 36, 5408–5415 (2022). https://doi.org/10.1007/s00464-021-08872-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-021-08872-6