Decreased total psoas muscle area after neoadjuvant therapy is a predictor of increased mortality in patients undergoing oesophageal cancer resection.

BACKGROUND: Oesophagectomy for locally advanced cancer carries high rates of morbidity and mortality. Patients require a thorough risk assessment alongside preoperative counselling. Total psoas area (TPA) measurements have been used as a surrogate marker of sarcopenia to predict post-operative complications in oesophageal cancer patients. No studies to date have determined whether there is an association between the proportion of TPA lost during neoadjuvant therapy and post-operative outcomes. METHODS: Clinical data and imaging of patients who underwent neoadjuvant therapy followed by open two-stage oesophagectomy between January 2008 and April 2018 were analysed retrospectively. Patients who did not undergo restaging computed tomography scan prior to surgery were excluded from the study. The TPA was measured on two cross-sectional slices at L4 on computed tomography scans pre- and post-neoadjuvant therapy. RESULTS: A total of 53 patients who met inclusion criteria were identified. The mean loss of TPA was 7.3%. Patients who had a decrease of TPA of more than 4% had significantly increased 30-day mortality compared to those who lost 4% or less (24% versus 0%, P = 0.02). Patients aged over 65 years who also had a loss of TPA >4% had significantly increased 30-day mortality (37% versus 2.9%, odds ratio 19, P = 0.008). CONCLUSION: A decrease in TPA of >4% is associated with a significantly higher risk of post-operative mortality in patients undergoing neoadjuvant therapy followed by oesophagectomy. Measuring the loss of TPA during neoadjuvant treatment could be a novel aid to preoperative risk assessment.

C-reactive protein is a useful negative predictor of anastomotic leak in oesophago-gastric resection.

BACKGROUND: Post-operative C-reactive protein (CRP) has been investigated as a predictor of anastomotic leak (AL) following colorectal surgery, but its role in oesophago-gastric surgery is not yet established. METHODS: Clinical data and post-operative CRP values of patients who underwent elective oesophago-gastric resection between January 2004 and July 2014 were analysed retrospectively. Only patients with an oesophageal anastomosis were included. AL was defined as leakage of contrast material seen on imaging or a leak confirmed intraoperatively on return to theatre. RESULTS: One hundred and forty-five patients were identified. Of the 145 patients, 13 (9%) developed AL. The CRP on post-operative days (POD) 2, 3 and 6 had the greatest diagnostic accuracy, with an area under the curve of 0.82, 0.80 and 0.91 respectively. Using a cut-off value of 209 mg/L on POD 2, the sensitivity was 100%, the specificity was 61%, the positive predictive value (PPV) was 21% and the negative predictive value (NPV) was 100%. Using a cut-off value of 190 mg/L on POD 3, the sensitivity was 100%, the specificity was 59%, the PPV was 21% and the NPV was 100%. Using a cut-off value of 154 mg/L on POD 6, the sensitivity was 100%, the specificity was 78%, the PPV was 29% and the NPV was 100%. CONCLUSION: Post-operative CRP is an accurate negative predictive test for the development of AL following oesophago-gastric surgery. It may help to discriminate between patients with a high risk of leak and those in which AL is unlikely to occur.