Impact of Sarcopenia on Outcomes Following Resection of Pancreatic Adenocarcinoma

Introduction

Assessing patient-specific risk factors for long-term mortality following resection of pancreatic adenocarcinoma can be difficult. Sarcopenia??the measurement of muscle wasting??may be a more objective and comprehensive patient-specific factor associated with long-term survival.

Methods

Total psoas area (TPA) was measured on preoperative cross-sectional imaging in 557 patients undergoing resection of pancreatic adenocarcinoma between 1996 and 2010. Sarcopenia was defined as the presence of a TPA in the lowest sex-specific quartile. The impact of sarcopenia on 90-day, 1-year, and 3-year mortality was assessed relative to other clinicopathological factors.

Results

Mean patient age was 65.7 years and 53.1?% was male. Mean TPA among men (611?mm²/m²) was greater than among women (454?mm²/m²). Surgery involved pancreaticoduodenectomy (86.0?%) or distal pancreatectomy (14.0?%). Mean tumor size was 3.4?cm; 49.9?% and 88.5?% of patients had vascular and perineural invasion, respectively. Margin status was R0 (59.0?%) and 77.7?% patients had lymph node metastasis. Overall 90-day mortality was 3.1?% and overall 1- and 3-year survival was 67.9?% and 35.7?%, respectively. Sarcopenia was associated with increased risk of 3-year mortality (HR?=?1.68; P?<?0.001). Tumor-specific factors such as poor differentiation on histology (HR?=?1.75), margin status (HR?=?1.66), and lymph node metastasis (HR?=?2.06) were associated with risk of death at 3-years (all P?<?0.001). After controlling for these factors, sarcopenia remained independently associated with an increased risk of death at 3?years (HR?=?1.63; P?<?0.001).

Conclusions

Sarcopenia was a predictor of survival following pancreatic surgery, with sarcopenic patients having a 63?% increased risk of death at 3?years. Sarcopenia was an objective measure of patient frailty that was strongly associated with long-term outcome independent of tumor-specific factors.     

Operational definitions of sarcopenia and their associations with 5-year changes in falls risk in community-dwelling middle-aged and older adults

Summary

Sarcopenia may be diagnosed in the clinic using operational definitions based on low muscle mass or function. This prospective, population-based study revealed that sex-specific associations may exist between operational definitions of sarcopenia and falls in community-dwelling middle-aged and older adults.

Introduction

The objective of this study is to verify associations between sarcopenia and falls risk and to determine changes in sarcopenia prevalence over 5 years in middle-aged and older men and women according to different anthropometric and performance-based operational definitions.

Methods

N?=?681 volunteers (48 % female; mean?±?SD age 61.4?±?7.0 years) participated in baseline and follow-up assessments (mean 5.1?±?0.5 years later). Appendicular lean mass (ALM) was assessed by dual-energy X-ray absorptiometry, hand grip (HGS) and lower-limb (LLS) strength were assessed by dynamometry, and falls risk was determined using the physiological profile assessment. Anthropometric definitions (ALM/height squared [ALM–H], ALM/weight × 100 and a residuals method [ALM–R]) and performance-based definitions (HGS, LLS and upper- and lower-limb muscle quality [LMQ]) of sarcopenia were examined. The lowest 20 % of the sex-specific distribution for each definition at baseline was classified as sarcopenia.

Results

Sarcopenia prevalence increased after 5 years for all operational definitions except ALM–H (men: ?4.0 %; women: ?5.5 %). Men classified with sarcopenia according to anthropometric definitions, and women classified with sarcopenia according to performance-based definitions, had significant increases in falls risk over 5 years (all P?<?0.05) compared to individuals without sarcopenia. Significant sex interactions were observed for ALM-R, LLS and LMQ (all P?<?0.05) definitions.

Conclusions

Sarcopenia prevalence generally increases at a higher rate when assessed using performance-based definitions. Sarcopenia is associated with increases in falls risk over 5 years in community-dwelling middle-aged and older adults, but sex-specific differences may exist according to different anthropometric or performance-based definitions.     

Sarcopenia and its relationship with bone mineral density in middle-aged and elderly European men

Summary

The aim of this study was to determine the relationship between reduced muscle mass (sarcopenia) and areal bone mineral density (BMD_a) in middle-aged and elderly community-dwelling European men. Men with sarcopenia had significantly lower BMD_a and were more likely to have osteoporosis compared with men without sarcopenia.

Introduction

In men, the relationship between reduced muscle mass (sarcopenia) and BMD_a is unclear. This study aimed to determine this relationship in middle-aged and elderly community-dwelling men.

Methods

Men aged 40–79 years from the Manchester (UK) and Leuven (Belgium) cohorts of the European Male Ageing Study were invited to attend for assessment including dual-energy X-ray absorptiometry, from which appendicular lean mass (aLM), fat mass (FM) and whole-body, spine and hip BMD_a were determined. Relative appendicular skeletal muscle mass (RASM) was calculated as aLM/height². Muscle strength was assessed in subjects from Leuven. Sarcopenia was defined by RASM at <7.26 kg/m² and by the recent definition of the European Working Group on Sarcopenia in Older People (RASM at <7.26 kg/m² plus low muscle function). Linear regression was used to determine the associations between aLM, FM, muscle strength and BMD_a and logistic regression to determine the association between sarcopenia and osteoporosis.

Results

Six hundred seventy-nine men with a mean age of 59.6 (SD?=?10.7), contributed data to the analysis; 11.9 % were sarcopenic by the conventional definition. After adjustment for age and centre, aLM, RASM and FM were positively associated with BMD_a. Men with RASM at <7.26 kg/m² had significantly lower BMD_a compared with those with RASM at ≥7.26 kg/m². In a multivariable model, aLM was most consistently associated with BMD_a. Men with sarcopenia were more likely to have osteoporosis compared with those with normal RASM (odds ratio?=?3.0; 95 % CI?=?1.6–5.8).

Conclusions

Sarcopenia is associated with low BMD_a and osteoporosis in middle-aged and elderly men. Further studies are necessary to assess whether maintaining muscle mass contributes to prevent osteoporosis.     

Pre-operative Sarcopenia Identifies Patients at Risk for Poor Survival After Resection of Biliary Tract Cancers

Introduction

Biliary tract cancers (BTC) are aggressive malignancies that require complex surgical procedures. Patients with BTC can present with skeletal muscle depletion, yet the effects of muscle wasting (sarcopenia) on outcomes have not been well studied. The objective of the current study was to define the impact of sarcopenia on survival among patients undergoing resection of BTC.

Methods

Patients who underwent exploration for BTC who had a pre-operative CT scan available for review were identified. Body composition variables including total and psoas muscle area (cm²), muscle density (Hounsfield units), visceral fat area, subcutaneous fat area, and waist-to-hip ratio were analyzed at the level of L3. Outcomes were assessed according to the presence or absence of sarcopenia defined using sex- and BMI-specific threshold values for Psoas Muscle Index (PMI, cm²/m²).

Results

Among 117 patients with BTC, 78 (67%) underwent curative-intent resection and 39 (33%) were explored but did not undergo resection due to metastatic/locally advanced disease. Tumor type included distal cholangiocarcinoma (n?=?18, 15.4%), hilar cholangiocarcinoma (n?=?27, 23.1%), gallbladder carcinoma (n?=?52, 44.4%), and intrahepatic cholangiocarcinoma (n?=?20, 17.1%). Median patient age was 65.6 years and 43.6% were male. Mean patient BMI was 26.1 kg/m² among men and 27.5 kg/m² among women. Overall, 41 (35.0%) patients had sarcopenia. Sarcopenia was associated with an increased risk of death among patients who underwent resection (HR 3.52, 95%CI 1.60–7.78, p?=?0.002), which was comparable to patients with unresectable metastatic disease. Other factors such as low serum albumin (HR 3.17, 95% CI 1.30–7.74, p?=?0.011) and low psoas density (HR 2.96, 95% CI 1.21–7.21, p?=?0.017) were also associated with increased risk of death. Survival was stratified based on sarcopenia, psoas density, and serum albumin. The presence of each variable was associated with an incremental increased risk of death (0 variables ref.; 1 variable HR 3.8, 95% CI 1.0–14, p?=?0.043; 2 variables HR 13.1, 95% CI 3.0–57.7, p?=?0.001; 3 variables HR 14.6, 95% CI 2.5–87.1, p?=?0.003). Patients who had no adverse prognostic factors had a 3-year OS of 67% versus no survival among patients with all 3 factors.

Conclusions

Sarcopenia was common among patients undergoing resection of BTC, occurring in 1 of every 3 patients. Sarcopenia was associated with poor survival after resection, particularly among patients who experienced a recurrence. Body composition metrics such as sarcopenia and low psoas muscle density in addition to low albumin level were able to stratify patients into different prognostic categories.

     

Impact of sarcopenia on surgical site infection after restorative proctocolectomy for ulcerative colitis

Purpose

The coexistence of sarcopenia is associated with postoperative complications, including infection after abdominal surgery. We evaluated the association between sarcopenia and surgical site infection (SSI) after surgery for ulcerative colitis.

Methods

The subjects of this retrospective study were 69 patients who underwent restorative proctocolectomy with perioperative abdominal computed tomography (CT). Sarcopenia was diagnosed by measuring the cross-sectional area of the right and left psoas muscles as the total psoas muscle area on CT images. We assessed whether sarcopenia was associated with SSI and clinical factors, including nutritional and inflammatory markers.

Results

The lowest quartiles defined as sarcopenia in men and women were 567.4 and 355.8 mm²/m², respectively. According to this classification, 12 men and 6 women had sarcopenia. Patients with sarcopenia had a lower body mass index (p = 0.0004) and a higher C-reactive protein concentration (p = 0.05) than those without sarcopenia. SSIs were identified in 12 patients (17.3 %) and included six pelvic abscesses and seven wound infections. According to multivariate analysis, sarcopenia was an independent risk factor for SSI (odds ratio = 4.91, 95 % confidence interval 1.09–23.5, p = 0.03).

Conclusion

Sarcopenia is predictive of SSI after pouch surgery for ulcerative colitis.

     

Discriminating sarcopenia in community-dwelling older women with high frequency of overweight/obesity: the São Paulo Ageing & Health Study (SPAH)

Summary

The criteria most used for the definition of sarcopenia, those based on the ratio between the appendicular skeletal muscle mass (ASM) and the square of the height (h²) underestimate prevalence in overweight/obese people whereas another criteria consider ASM adjusted for total fat mass. We have shown that ASM adjusted for fat seems to be more appropriate for sarcopenia diagnosis.

Introduction

Since the prevalence of overweight and obesity is a growing public health issue, the aim of this study was to evaluate the prevalence and risk factors associated with sarcopenia, based on these two criteria, among older women.

Methods

Six hundred eleven community-dwelling women were evaluated by specific questionnaire including clinical data. Body composition and bone mineral density were evaluated by dual X-ray absorptiometry. Logistic regression models were used to identify factors independently related to sarcopenia by ASM/h² and ASM adjusted for total fat mass criteria.

Results

The prevalence of overweight/obesity was high (74.3 %). The frequency of sarcopenia was lower using the criteria of ASM/h² (3.7 %) than ASM adjusted for fat (19.9 %) (P?<?0.0001). We also note that less than 5 %(1/23) of sarcopenic women, according to ASM/h², had overweight/obesity, whereas 60 % (74/122) of sarcopenic women by ASM adjusted for fat had this complication. Using ASM/h², the associated factors observed in regression models were femoral neck T-score (OR?=?1.90; 95 % CI 1.06–3.41; P?=?0.03) and current alcohol intake (OR?=?4.13, 95 % CI 1.18–14.45, P?=?0.03). In contrast, we have identified that creatinine (OR?=?0.21; 95 % CI 0.07–0.63; P?=?0.005) and the White race (OR?=?1.81; 95 % CI 1.15–2.84; P?=?0.01) showed a significant association with sarcopenia using ASM adjusted for fat.

Conclusions

In women with overweight/obesity, ASM adjusted for fat seems to be the more appropriate criteria for sarcopenia diagnosis. This finding has relevant public health implications, considering the high prevalence of overweight/obesity in older women.     

Prevalence of sarcopenia and associated risk factors by two diagnostic criteria in community-dwelling older men: the São Paulo Ageing & Health Study (SPAH)

Summary

Sarcopenia is an aging syndrome that can be characterized by many criteria adjusted or not by fat mass. This study suggested that the optimal criteria should be selected according to body mass index (BMI) in older men and identified age, BMI, race, smoking, physical activity, hip bone mineral density (BMD) as risk factors for this syndrome.

Introduction

This study aims to analyze the prevalence of sarcopenia and associated risk factors using appendicular skeletal mass (ASM)/height² and ASM adjusted for total fat mass criteria in older men from community.

Methods

Three hundred ninety-nine men were included and answered a questionnaire about lifestyle and medical history. Individuals were classified by their BMI using the classification adjusted by age. Body composition and bone mineral density were measured by dual X-ray absorptiometry. Sarcopenia was classified according to both criteria. Logistic regression models were used to analyze risk factors associated with sarcopenia.

Results

The mean BMI was 26.46 kg/m²: 12.5 % underweight, 43.6 % normal, and 43.9 % overweight/obese. Fifty-four (13.5 %) were considered sarcopenic by ASM/height² and 79 (19.8 %) by ASM adjusted for fat (p?=?0.001). Fifty-one (12.8 %) individuals had discordant sarcopenia classification: 13 were classified only by ASM/height² and 38 only by ASM adjusted for fat. Of the 13 subjects classified as sarcopenic only by ASM/height², 84.6 % (11/13) were underweight and solely one (7.7 %) was considered overweight/obese. In contrast, of those 38 older men classified as sarcopenic only by ASM adjusted for fat, none were underweight and 53 % (20/38) were overweight/obese. Subjects classified as sarcopenic according to both criteria had the same risk factors in the final model analyses (age, BMI, race, smoking, physical activity, hip BMD; p?<?0.05).

Conclusion

This study suggested that the optimal criteria for sarcopenia should be selected according to BMI in community-dwelling older men.     

Relationship of sarcopenia and body composition with osteoporosis

Summary

The purpose of the study is to investigate the relationship between sarcopenia and body composition and osteoporosis in cohorts of three different races with a total of 17,891 subjects. Lean mass and grip strength were positively associated with bone mineral densities (BMDs). Subjects with sarcopenia were two times more likely to have osteoporosis compared with normal subjects.

Introduction

The relationship between sarcopenia and osteoporosis is not totally clear. First, the present study assessed this relationship by using two different definitions for sarcopenia. Second, we examined the associations of body composition (including muscle mass as a major and important component) and muscle strength on regional and whole-body BMDs.

Methods

In total, 17,891 subjects of African American, Caucasian, and Chinese ethnicities were analyzed. Sarcopenia was defined by relative appendicular skeletal muscle mass (RASM) cut points and also by the definition of the European Working Group on Sarcopenia in Older People (low RASM plus low muscle function). Multiple regression analyses were conducted to examine the association of fat mass, lean mass (including muscle mass), and grip strength with regional and whole-body BMDs. Multivariate logistic regression analysis was performed to explore the association between sarcopenia and osteopenia/osteoporosis.

Results

BMDs were positively associated with lean mass and negatively associated with fat mass, after controlling for potential confounders. Grip strength was significantly associated with higher BMDs. Each standard deviation (SD) increase in RASM resulted in a ~37 % reduction in risk of osteopenia/osteoporosis (odds ratio (OR)?=?0.63; 95 % confidence interval (CI)?=?0.59, 0.66). Subjects with sarcopenia defined by RASM were two times more likely to have osteopenia/osteoporosis compared with the normal subjects (OR?=?2.04; 95 % CI?=?1.61, 2.60). Similarly, subjects with sarcopenia (low muscle mass and low grip strength) were ~1.8 times more likely to have osteopenia/osteoporosis than normal subjects (OR?=?1.87; 95 % CI?=?1.09, 3.20).

Conclusions

High lean mass and muscle strength were positively associated with BMDs. Sarcopenia is associated with low BMD and osteoporosis.

     

Sarcopenia and outcomes in ventral hernia repair: a preliminary review

Purpose

Sarcopenia, or loss of muscle mass, is associated with increased morbidity and mortality in oncologic resections and several other major surgeries. Complex ventral hernia repairs (VHRs) and abdominal wall reconstruction are often performed in patients at high risk for morbidity and recurrence, though limited data exist on outcomes related to sarcopenia. We aimed to determine if sarcopenia is associated with worse outcomes in patients undergoing VHR.

Methods

We reviewed patients undergoing VHRs from 2014 to 2015. Preoperative CT images were analyzed for cross-sectional muscle mass. Patients with and without sarcopenia underwent statistical analysis to evaluate differences in perioperative morbidity and hernia recurrence. Muscle indices were analyzed independently for outcomes.

Results

135 patients underwent VHR with/without fistula takedown, staged repairs or other concomitant procedures. 27% had sarcopenia (age 34–84, BMI 27–33, 62% male). Postoperative complications occurred in 43% of sarcopenic patients and 47% of non-sarcopenic patients (p?=?0.70). Surgical site infections (SSI) were seen in 16% of sarcopenic patients compared to 29% without sarcopenia (p?=?0.14). There was no difference in hernia recurrence between groups (p?=?0.90). However, after adjusting for diabetes and BMI, a 10 cm²/m² decrease in muscle index had 1.44 OR of postoperative complications (p?<?0.05).

Conclusions

Though prevalent in our population, sarcopenia was not associated with an increase in postoperative complications, surgical site occurences/infections,  or hernia recurrence when previously published oncologic sarcopenia cutoffs were utilized. Previously established sarcopenia outcomes in malignancy may be attributable to an altered metabolic state that is not present in hernia repair patients. Larger-scale studies are recommended to establish new sarcopenia cutoffs for VHRs.

     

Impact of Sarcopenia on Unplanned Readmission and Survival After Esophagectomy in Patients with Esophageal Cancer

Background

Although sarcopenia increases postoperative complications following esophagectomy, its effects on prognosis remain unclear. This study was performed to identify the effect of sarcopenia on 90-day unplanned readmission and overall survival (OS) after esophagectomy.

Methods

Ninety-eight patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Unplanned readmission was defined as any emergent hospitalization within 90 days after discharge. Sarcopenia, defined as low muscle mass plus low muscle strength and/or low physical performance according to the Asian consensus definition, was assessed prior to esophagectomy. Multivariate logistic regression analysis was performed to identify factors that contributed to 90-day unplanned readmission. OS was estimated using the Kaplan–Meier method, and a Cox proportional hazards model was used to assess the relationship between sarcopenia and OS.

Results

Thirty-one patients (31.6%) were diagnosed with sarcopenia. The 90-day unplanned readmission rate was significantly higher in patients with sarcopenia than those without (42.9% vs. 16.4%, respectively; p = 0.01). Multivariable logistic regression analysis showed that sarcopenia was an independent predictor of 90-day unplanned readmission [odds ratio 3.71, 95% confidence interval (CI) 1.29–11.05; p = 0.02], and the log-rank test showed that sarcopenia was associated with OS (p = 0.01). Moreover, sarcopenia was a significant predictor of OS after adjustment for age, sex, and pathological stage (hazard ratio 2.35, 95% CI 1.21–4.54; p = 0.01).

Conclusions

Sarcopenia is a risk factor for 90-day unplanned readmission and OS following esophagectomy. Assessment of sarcopenia could help to identify patients at higher risk of a poor prognosis after esophagectomy.

     

Early-stage chronic kidney disease,insulin resistance,and osteoporosis as risk factors of sarcopenia in aged population: The Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV), 2008–2009

Summary

Sarcopenia means the progressive loss of skeletal muscle mass and strength with aging. In this study, we found that insulin resistance, chronic kidney disease stage 3, and osteoporosis at the femur neck were closely associated with sarcopenia in elderly men. These conditions modified to slow down the progression of sarcopenia.

Introduction

Sarcopenia is known to have multiple contributing factors; however, its modifiable risk factors have not yet been determined. The aim of this study was to identify the most influential and modifiable risk factors for sarcopenia in elderly.

Methods

This was a population-based, cross-sectional study using data from the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV), 2008–2009. This study included 940 men and 1,324 women aged 65 years and older who completed a body composition analysis using dual-energy X-ray absorptiometry. Sarcopenia was defined as an appendicular skeletal muscle mass divided by height² of less than 1 standard deviation below the sex-specific mean for a younger reference group.

Results

Using univariate analysis, age, body mass index (BMI), homeostasis model assessment for insulin resistance (HOMA-IR), limitations in daily activities, regular exercise, high-risk drinking, family income, osteoporosis, daily energy, and protein intake were associated with sarcopenia in men; age, BMI, limitations in daily activities, regular exercise, occupation, osteoporosis at the total hip, and daily energy intake were associated with sarcopenia in women. In the multivariate logistic regression analysis, HOMA-IR ≥2.5 (odds ratio [OR] for sarcopenia, 2.27; 95 % confidence interval [CI], 1.21–4.25), chronic kidney disease stage 3 (OR, 3.13; 95 % CI, 1.14–8.61), and osteoporosis at the femur neck (OR, 6.83; 95 % CI, 1.08–43.41) were identified as risk factors for sarcopenia in men.

Conclusions

Insulin resistance, chronic kidney disease, and osteoporosis at the femur neck should be modified to prevent the acceleration of skeletal muscle loss in elderly men.     

Predictive Value of Preoperative Sarcopenia in Patients with Gastric Cancer: a Meta-analysis and Systematic Review

Purpose

The impact of preoperative sarcopenia on postoperative complications and overall survival has been recently debated. Our meta-analysis aims to ascertain whether preoperative sarcopenia increases the risk of poor outcomes and to attempt to provide new ideas for the prognosis of outcomes for patients with gastric cancer.

Methods

We searched for all relevant articles on PubMed, the EMBASE database, and Web of Science (up to September 1, 2017). Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

Results

Thirteen studies involving 4262 patients who underwent gastrectomy for gastric cancer were analyzed (sarcopenia group?=?1234; non-sarcopenia group?=?3028). The results showed that preoperative sarcopenia significantly associated with poor pathological staging (high pT: OR?=?1.86, 95% CI?=?1.49–2.31; P?<?0.01; pN+: OR?=?1.61, 95% CI?=?1.33–1.94; P?<?0.01; high TNM category: OR?=?1.84, 95% CI?=?1.53–2.22; P?<?0.01). Patients with preoperative sarcopenia had an increased risk of total postoperative complications (OR?=?2.17, 95% CI?=?1.53–3.08; P?<?0.01), severe complications (OR?=?1.65, 95% CI?=?1.09–2.50; P?=?0.02), and poorer OS (HR?=?1.70, 95% CI?=?1.45–1.99; P?<?0.01). The results of subgroup analyses revealed that patients with preoperative sarcopenia over 65 years old and those from Asian populations had higher risks for total postoperative complications and severe complications.

Conclusion

This meta-analysis reveals that preoperative sarcopenia may be used as a new indicator of poor pathological staging, impaired overall survival, and increased postoperative complications. Notably, patients with gastric cancer who are over 65 years old and from Asia should be routinely screened for sarcopenia before surgery to adequately assess the risk of postoperative complications in clinical practice.

     

Bisphosphonates reduced the risk of acute myocardial infarction: a 2-year follow-up study

Summary

This population-based matched cohort analysis explored the effects of bisphosphonate treatment on acute myocardial infarction (AMI). We found that patients who received bisphosphonate therapy had a lower risk of AMI during a 2-year follow-up period (hazard ratio (HR)?=?0.35). Our data support that bisphosphonates may provide protective effects against cardiovascular events.

Introduction

Although bisphosphonates have been suggested to have anti-atherosclerotic effects in animal models, evidence in human subjects is still conflicting. Therefore, this study aimed to explore the effects of bisphosphonate treatment on AMI using a population-based cohort study.

Methods

We identified 1,548 patients who received bisphosphonate therapy for osteoporotic fractures and randomly extracted 4,644 subjects with vertebral or hip fractures as a comparison cohort. Each patient was individually tracked for 2 years to identify those who subsequently suffered an AMI. Stratified Cox proportional hazards regressions were performed to assess the effect of bisphosphonate treatment on the risk of AMI.

Results

Six (0.4 %) of the patients who received bisphosphonate therapy and 49 (1.1 %) of the comparison subjects suffered an AMI during the 2-year follow-up period. The incidence rate of AMI was 1.94 (95 % CI?=?0.79–4.03) per 1,000 person-years in patients who received bisphosphonate therapy and 5.28 (95 % CI?=?3.95–6.92) per 1,000 person-years in comparison patients. Regression analysis revealed that patients who received bisphosphonate therapy had a lower hazard of AMI during the 2-year follow-up period than comparison patients (HR?=?0.37, 95 % CI?=?0.16–0.85, p?=?0.020). After censoring cases that died from non-AMI causes and adjusting for both demographic and risk factors, the HR of AMI for patients who received bisphosphonate therapy was 0.35 (95 % CI?=?0.14–0.84, p?=?0.020) than that of comparison patients.

Conclusions

Patients who received bisphosphonate therapy had a lower risk of AMI during the 2-year follow-up period. Our data support that bisphosphonates may provide protective effects against cardiovascular events.     

Resection for Hilar Cholangiocarcinoma: Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Long-term Outcome

Introduction

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

Methods

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

Results

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR?=?0.03, 95 % CI 0–0.19, p?<?0.001), caudate lobe invasion (HR?=?6.33, 95 % CI 1.31–30.46, p?=?0.021), adjuvant gemcitabine-based chemotherapy (HR?=?0.38, 95 % CI 0.15–0.94, p?=?0.037), and the neutrophil-to-lymphocyte ratio (HR?=?0.78, 95 % CI 0.62–0.98, p?=?0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR?=?0.03, 95 % CI 0–0.22, p?<?0.001), caudate lobe invasion (HR?=?11.75, 95 % CI 1.65–83.33, p?=?0.014), and adjuvant gemcitabine-based chemotherapy (HR?=?0.19, 95 % CI 0.06–0.56, p?=?0.003).

Conclusions

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.     

Novel effects of sarcopenic osteoarthritis on metabolic syndrome,insulin resistance,osteoporosis, and bone fracture: the national survey

Summary

This study compared the effects sarcopenic osteoarthritis on metabolic syndrome, insulin resistance, osteoporosis, and bone fracture. By using national survey data, we suggest that the relationship between sarcopenia and metabolic syndrome or insulin resistance is potentiated by the severity of osteoarthritis and is independent of body weight.

Introduction

Sarcopenia and osteoarthritis are known risk factors for metabolic syndrome. However, their combined effects on metabolic syndrome, insulin resistance and osteoporosis remain uncertain.

Methods

We used data from the fifth Korean National Health and Nutrition Examination Survey using a total of 3158 adults (age >50 years). Sarcopenia was defined as a skeletal muscle index score (appendicular skeletal muscle mass/body weight) within the fifth percentile of sex-matched younger reference participants. Radiographic knee osteoarthritis was defined as a Kellgren-Lawrence (K-L) grade of 2 or greater. Metabolic syndrome was diagnosed using the National Cholesterol Education Program criteria. Insulin resistance was evaluated using the homeostasis model assessment-estimated insulin resistance index (HOMA-IR). Osteoporosis was defined using the World Health Organization T-score criteria.

Results

In multivariable logistic regression analysis, the sarcopenic osteoarthritis group had a higher odds ratio (OR) for metabolic syndrome (OR?=?11.00, 95 % confidential interval (CI)?=?2.12–56.99, p?=?0.013) than the non-sarcopenic osteoarthritis (OR?=?1.02, 95 % CI?=?0.65–1.62, p?=?0.972) and sarcopenic non-osteoarthritis groups (OR?=?7.15, 95 % CI?=?1.57–32.53, p?=?0.027). Similarly, sarcopenic osteoarthritis had a greater OR of highest HOMA-IR quartiles (OR?=?8.19, 95 % CI?=?2.03–33.05, p?=?0.003) than the other groups. Overall, the association between the K-L grade and body mass index was significant; however, this significance was lower in individuals with sarcopenia and was lost in those with sarcopenic osteoarthritis. Additionally, osteoporosis and bone fracture were not associated to sarcopenic osteoarthritis (p?>?0.05).

Conclusions

These results suggest that the relationship between sarcopenia and metabolic syndrome or insulin resistance is potentiated by the severity of osteoarthritis and is independent of body weight.

     

Preoperative Sarcopenia Strongly Influences the Risk of Postoperative Pancreatic Fistula Formation After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy (PD). Sarcopenia is a newly identified marker of frailty. We performed this study to assess whether preoperative sarcopenia has an impact on clinically relevant POPF formation.

Methods

A total of 266 consecutive patients who underwent a PD between 2010 and 2014 were enrolled in this retrospective study. Skeletal muscle mass was measured using preoperative computed tomography images. The impact of preoperative sarcopenia on clinically relevant POPF formation was analyzed using univariate and multivariate analyses.

Results

Of the 266 patients, 132 (49.6 %) were classified as having preoperative sarcopenia. The rate of clinically relevant POPF formation was significantly higher in the sarcopenia group (22.0 vs. 10.4 %; P?=?0.011). A multivariate logistic regression analysis showed that sarcopenia (odds ratio, 2.869; P?=?0.007) was an independent risk factor for the development of clinically relevant POPF, along with a soft pancreas and a parenchymal thickness at the pancreatic resection site of ≥8 mm.

Conclusions

Preoperative sarcopenia was identified as a strong and independent risk factor for clinically relevant POPF formation after PD. Perioperative rehabilitation and nutrition therapy may contribute to the prevention of POPF formation and a safer PD.

     

Visceral Obesity and Colorectal Cancer: Are We Missing the Boat with BMI?

Introduction

Compared to subcutaneous fat, visceral fat is more metabolically active, leading to chronic inflammation and tumorigenesis. The aim of this study is to describe the effect of visceral obesity on colorectal cancer outcomes using computed tomography (CT) imaging to measure visceral fat.

Materials and Methods

We conducted a retrospective chart review of patients who underwent surgical resection for colorectal cancer. Visceral fat volume was measured by preoperative CT scans. Final analysis was performed by stratifying patients based on oncologic stage.

Results

Two hundred nineteen patients met the inclusion criteria, 111 viscerally obese and 108 nonobese. Body mass index (BMI) weakly correlated with visceral fat volume measurements (R ²?=?0.304). Whereas obese patients had no difference in survival when categorizing obesity by BMI, categorizing based on visceral fat volume resulted in significant differences in stage II and stage III patients. In stage II cancer, viscerally obese patients had a nearly threefold decrease in disease-free survival (hazard ratio (HR)?=?2.72; 95 % confidence interval (CI)?=?1.21, 6.10). In stage III cancer, viscerally obese patients had a longer time to recurrence (HR?=?0.39; 95 % CI?=?0.16, 0.99).

Conclusion

This study shows that viscerally obese patients with stage II colorectal cancer are at higher risk for poor outcomes and should be increasingly considered for adjuvant chemotherapy.     

Serum Blood Urea Nitrogen and Serum Albumin on the First Postoperative Day Predict Pancreatic Fistula and Major Complications After Pancreaticoduodenectomy

Introduction

Pancreaticoduodenectomy (PD) has a high morbidity rate. Previous work has shown that hypoalbuminemia on postoperative day 1 (POD) to be contributory to post-esophagectomy complications. We set out to determine the impact of blood urea nitrogen (BUN) and albumin on POD 1 for patients undergoing PD.

Methods

We examined 446 consecutive patients who underwent PD at the Thomas Jefferson University Hospital between January 1, 2000 and December 31, 2008. Complications were graded using the Clavien scale. We examined the incidence of complications based on POD 1 albumin <2.5 versus ≥2.5 mg/dl, as well as POD 1 BUN <10 vs. ≥10 g/dL.

Results

Patients with a BUN <10 had a significantly decreased risk of any complication (p?<?0.001), serious complication (p?<?0.001), and pancreatic fistula (p?=?0.011). On multivariate analysis, BUN?≥?10 was the most significant predictor of grade III or above complication (p?=?0.0019, hazard ration (HR)?=?2.7) and pancreatic fistula (p?=?0.016, HR?=?2.6). POD 1 albumin <2.5 mg/dl was also an independent predictor of serious complication (p?=?0.01, HR?=?2.3). Patients with both risk factors had a 31 % chance of developing serious complications and 18.5 % risk of developing pancreatic fistula, while those patients with neither risk factor had a 6.5 and 3.6 % risk, respectively.

Conclusion

Serum albumin and BUN on POD 1 are important predictors of perioperative morbidity following PD. These low-cost and easily accessible tests can be used as a prognostic tool to predict adverse surgical outcomes.     

Exercise habits during middle age are associated with lower prevalence of sarcopenia: the ROAD study

Summary

The present cross-sectional study investigated the prevalence of sarcopenia and clarified its associated factors in 1,000 elderly participants of Japanese population-based cohorts. Exercise habit in middle age was associated with low prevalence of sarcopenia in older age, suggesting that it is a protective factor against sarcopenia in older age.

Introduction

The present study investigated the prevalence of sarcopenia using the European Working Group on Sarcopenia in Older People (EWGSOP) definition, and clarified the association of sarcopenia with physical performance in the elderly participants of Japanese population-based cohorts of the Research on Osteoarthritis/osteoporosis Against Disability (ROAD) study.

Methods

We enrolled 1,000 participants (aged ≥65 years) from the second visit of the ROAD study who had completed assessment of handgrip strength, gait speed, and skeletal muscle mass measured by bioimpedance analysis. Presence of sarcopenia was determined according to the EWGSOP algorithm. Information collected included exercise habits in middle age.

Results

Prevalence of sarcopenia was 13.8 % in men and 12.4 % in women, and tended to be significantly higher according to increasing age in both sexes. Factors associated with sarcopenia, as determined by logistic regression analysis, were chair stand time (odds ratio [OR], 1.09; 95 % confidence interval [CI], 1.04–1.14), one-leg standing time (OR, 0.97; 95 % CI, 0.96–0.99), and exercise habit in middle age (OR, 0.53; 95 % CI, 0.31–0.90). Exercise habit in middle age was associated with low prevalence of sarcopenia in older age. Furthermore, linear regression analysis revealed that exercise habits in middle age were significantly associated with grip strength (P?<?.001), gait speed (P?<?.001), and one-leg standing time (P?=?.005) in older age.

Conclusions

This cross-sectional study suggests that exercise habit in middle age is a protective factor against sarcopenia in older age and effective in maintaining muscle strength and physical performance in older age.     

Mortality Risk After Preoperative Versus Postoperative Chemotherapy and Radiotherapy in Lymph Node-Positive Rectal Cancer

Introduction

Persistent lymph node-positive disease after preoperative radiotherapy for rectal cancer is associated with adverse outcomes. We quantified mortality risks of persistent pathologic lymph nodes in lymph node-positive rectal cancer patients treated with preoperative versus postoperative chemoradiation.

Methods

This was a retrospective population-based analysis of 2,038 patients with stage III rectal cancer diagnosed 1994–2005 with follow-up through 2007 using data from the California Cancer Registry. Survival estimates were generated using the Kaplan–Meier method. Multivariate cancer-specific and overall mortality analyses were performed using Cox proportional hazard ratios with adjustment for age, gender, race/ethnicity, tumor grade, T stage, N stage, socioeconomic status, and time period (1994–1997, 1998–2001, and 2002–2005).

Results

Overall survival was higher among lymph node-positive patients receiving postoperative chemoradiation compared to lymph node-positive patients receiving preoperative chemoradiation (median overall survival?=?87 versus 62 months, P?=?0.0002). In adjusted analyses, patients with persistent lymph node-positive disease after preoperative chemoradiation treatment had increased overall (HR?=?1.69; 95 % CI, 1.42–2.01) and CRC-specific (HR?=?1.78; 95 % CI, 1.44–2.19) mortality risk compared to lymph node-positive disease after postoperative chemoradiation treatment.

Conclusions

Stage III rectal cancer patients with persistent pathologic lymph nodes after preoperative chemoradiation represent a high-risk group, with higher mortality than those treated with postoperative chemoradiation.