Malnutrition screening with Nutritional Risk Screening 2002 prior to assessment as part of GLIM criteria in patients undergoing major abdominal surgery for gastrointestinal cancer.

INTRODUCTION: For diagnosing malnutrition as an important modifiable risk factor in surgical cancer patients, GLIM criteria offer a standardised diagnostic pathway. Before assessing malnutrition it is suggested to screen for malnutrition with an implemented screening tool, i.e. the NRS-2002. Validated data regarding the applied screening tool and its relevance for predicting outcome parameters in surgical patients is sparse. METHODS: 260 patients undergoing major abdominal surgery for cancer were retrospectively analysed. Between January 2017 and December 2019, patients were prospectively screened for malnutrition with the Nutritional Risk Score 2002 (NRS). Irrespective of their screening result malnutrition was assessed with GLIM criteria using CT scan at lumbar level 3 for measuring skeletal muscle mass (GLIM MMCT). Patients with negative screening results (NRS ≤ 2) were analysed regarding their malnutrition assessment and outcome parameters. RESULTS: 34 of 67 patients with NRS ≤ 2, posing no risk for malnutrition, were diagnosed malnourished according to GLIM MMCT (n=34, 50.7%). 19 patients (55.9%) with NRS ≤ 2 and malnutrition according to GLIM had at least one complication, 12 patients (35.3%) had a severe complication (Clavien-Dindo Grade ≥ 3a), in 26.5% re-laparotomy was necessary, re-admission within one month in 20.6% of patients, and length of hospital stay was 18.76 ± 12.66, which was in total worse in outcome compared to the whole study group (n=260). Patients with NRS ≤ 2 but diagnosed malnourished by GLIM were at significant higher risk to develop a severe complication (OR 2.256, 95% CI 1.038 - 4.9095, p=0.036) compared to patients with NRS ≤ 2 but not being diagnosed malnourished. The risk for overall complications was significantly increased in patients with malnutrition diagnosed by the GLIM criteria using MMCT (OR 2.028, 95% CI 1.188-3.463, p= 0,009). Patients screened at risk with NRS ≥ 3 and diagnosed malnourished by GLIM were also at significant higher risk for developing complications (OR 1.728, 95% CI 1.054 - 2.832, p=0.029). CONCLUSION: GLIM MMCT is suitable for diagnosing malnutrition and estimating postoperative risk in gastrointestinal cancer patients. Nutritional assessment only in patients with NRS > 2 may bear the risk to miss malnourished patients with high risk for poor clinical outcome. In every patient undergoing major cancer surgery regular assessment of nutritional status regardless of screening result should be performed exploiting CT body composition analysis.

Evaluation of malnutrition in patients undergoing major abdominal surgery using GLIM criteria and comparing CT and BIA for muscle mass measurement.

BACKGROUND & AIMS: GLIM criteria have become a worldwide standard for diagnosing malnutrition. They emphasize the measurement of muscle mass but do not provide clear recommendations for the use of different diagnostic tools and cut-offs. Measurements of body composition by using computerized tomography (CT) and bioelectrical impedance analysis (BIA) are both easily accessible in hospitalized patients. However, there is sparse data regarding the comparison for GLIM diagnosis of malnutrition and its prognostic impact for postoperative outcome in patients undergoing major abdominal surgery for cancer. METHODS: We retrospectively analysed 260 patients undergoing major abdominal surgery between January 2017 and December 2019. Patients were prospectively screened and assessed for malnutrition with Nutritional Risk Score (NRS) and Subjective Global assessment (SGA). Body composition was analysed with CT scan and BIA within 30 days before surgery. GLIM criteria were retrospectively determined referring to the Fat free Mass from BIA (FFMBIA) and Muscle Mass from axial CT scan at lumbar level 3 (MMCT). The prevalence of GLIM - malnutrition according to BIA and CT was evaluated. Multivariate logistic regression analysis was used to determine association between malnutrition and outcome parameters. ROC-curves specified sensitivity and specificity of the different tools and areas under the curve were calculated. RESULTS: From 260 patients in total, 179 patients (68.8%) had a confirmed malnutrition according to MMCT, 178 patients (68.5%) were malnourished according to SGA (grade B or C), whereas 66 patients (25.4%) were diagnosed with malnutrition using FFMBIA. The risk for developing a complication was significant associated with both methods, FFMBIA (OR 2.116, 95% CI 1.185-3.778, p = 0.01) and MMCT (OR 2.028, 95% CI 1..188-3.463, p = 0.009). Sensitivity for the prediction of overall complications was: MMCT 76.3%, FFMBIA 31.9%, and SGA 73.3%; specificity: MMCT 40.0%, FFMBIA 81.6%, and SGA 36.8%. CONCLUSION: When using GLIM criteria, the method for measuring muscle mass is pivotal resulting in considerable differences in prevalence, sensitivity, and specificity. GLIM criteria are predictive for the risk of developing complications in patients undergoing major abdominal surgery. With the pre-existing cut-offs, BIA seems to diagnose patients at an more advanced stage of malnutrition and indicates an advanced deterioration of nutritional status.

Automated tube voltage selection in thoracoabdominal computed tomography at high pitch using a third-generation dual-source scanner: image quality and radiation dose performance.

OBJECTIVES: The objective of this study was to evaluate the radiation dose and image quality performance of thoracoabdominal examinations with an automated tube voltage selection (tube voltage adaptation), tube current modulation, and high pitch using a third-generation dual-source computed tomography (CT) compared intraindividually with 120-kV examinations with tube current modulation with special attention on clinically relevant lesions in the liver, the lungs, and extrahepatic soft tissues. MATERIALS AND METHODS: This study was approved by the institutional review board. Computed tomography of the body was performed using a third-generation dual-source system in 95 patients (mean body mass index, 25 kg/m²; range, 18-35 kg/m²). For 49 of these patients, all calculated tube settings and resulting dose values were recorded for each of the 12 gradual contrast weightings of the tube voltage adaptation algorithm. Spiral CT was performed for all patients with an intermediate weighting (grade 7) in a portal venous phase at 120 reference kV, 180 reference mAs, and pitch of 1.55. Objective image quality was assessed on the basis of contrast-to-noise ratio. Subjective image quality was assessed on the basis of clarity and sharpness of anatomical and pathological structures as well as interfering beam hardening and spiral and motion artifacts (heart, lungs, diaphragm). Previous examinations on a 64-slice scanner served as reference. RESULTS: All examinations were rated good or excellent for clinical diagnosis. Automated tube voltage selection resulted in significantly lower effective radiation dose (9.5 mSv) compared with the reference (12.0 mSv; P < 0.01). Contrast-to-noise ratio and image quality of soft tissue lesions were significantly increased (P < 0.01). Motion artifacts were significantly reduced (P < 0.01). CONCLUSIONS: Automated tube voltage adaptation combined with high-pitch protocols allows for a substantial radiation dose reduction while substantially increasing the image quality, even at large-volume exposure.