Impact on postoperative complications of changes in skeletal muscle mass during neoadjuvant chemotherapy for gastro-oesophageal cancer.

BACKGROUND: Risk assessment is relevant to predict postoperative outcomes in patients with gastro-oesophageal cancer. This cohort study aimed to assess body composition changes during neoadjuvant chemotherapy and investigate their association with postoperative complications. METHODS: Consecutive patients with gastro-oesophageal cancer undergoing neoadjuvant chemotherapy and surgery with curative intent between 2016 and 2019 were identified from a specific database and included in the study. CT images before and after neoadjuvant chemotherapy were used to assess the skeletal muscle index, sarcopenia, and subcutaneous and visceral fat index. RESULTS: In a cohort of 199 patients, the mean skeletal muscle index decreased during neoadjuvant therapy (from 51·187 to 49·19 cm2 /m2 ; P < 0·001) and the rate of sarcopenia increased (from 42·2 to 54·3 per cent; P < 0·001). A skeletal muscle index decrease greater than 5 per cent was not associated with an increased risk of total postoperative complications (odds ratio 0·91, 95 per cent c.i. 0·52 to 1·59; P = 0·736) or severe complications (odds ratio 0·66, 0·29 to 1·53; P = 0·329). CONCLUSION: Skeletal muscle index decreased during neoadjuvant therapy but was not associated with postoperative complications.

ANTECEDENTES: La evaluación de riesgo es importante para predecir los resultados postoperatorios en pacientes con cáncer gastroesofágico. Este estudio de cohortes tuvo como objetivo evaluar los cambios en la composición corporal durante la quimioterapia neoadyuvante e investigar su asociación con complicaciones postoperatorias. MÉTODOS: Los pacientes consecutivos con cáncer gastroesofágico sometidos a quimioterapia neoadyuvante y cirugía con intención curativa entre 2016 y 2019, identificados a partir de una base de datos específica, se incluyeron en el estudio. Se utilizaron las imágenes de tomografía computarizada, antes y después de la quimioterapia neoadyuvante, para evaluar el índice de masa muscular esquelética, la sarcopenia y el índice de grasa visceral y subcutánea. RESULTADOS: En una cohorte de 199 pacientes, el índice de masa muscular esquelética disminuyó durante el tratamiento neoadyuvante (de 51,87 cm2 /m2 a 49,19 cm2 /m2 , P < 0,001) y las tasas de sarcopenia aumentaron (de 42,2% a 54,2%, P < 0,001). Una disminución del índice de masa muscular esquelética > 5% no se asoció con un mayor riesgo de complicaciones postoperatorias globales (razón de oportunidades, odds ratio: 0,908; ic. del 95%: 0,520-1,587, P = 0,736) ni de complicaciones graves (odds ratio: 0,661; i.c. del 95%: 0,286-1,525, P = 0,329). CONCLUSIÓN: El índice de masa muscular esquelética disminuyó durante el tratamiento neoadyuvante, pero no se asoció con complicaciones postoperatorias.

Assessing surgeon stress when operating using heart rate variability and the State Trait Anxiety Inventory: will surgery be the death of us?

AIM: Performance in the operating room is affected by a combination of individual, patient and environmental factors amongst others. Stress has a potential negative impact on performance with the quality of surgical practice and patient safety being affected as a result. In order to appreciate the level of stress encountered during surgical procedures both objective and subjective methods can be used. This study reports the use of a combined objective (physiological) and subjective (psychological) method for evaluating stress experienced by the operating surgeon. METHOD: Six consultant colorectal surgeons were evaluated performing eighteen anterior resections. Heart rate was recorded using a wireless chest strap at eight pre-determined operative steps. Heart Rate Variability indices were calculated offline using computerized software. Surgeon reported stress was collected using the State Trait Anxiety Inventory, a validated clinical stress scale. RESULTS: A significant increase in stress was demonstrated in all surgeons whilst operating as indicated by sympathetic tone (control: 4.02 ± 2.28 vs operative: 11.42 ± 4.63; P < 0.0001). Peaks in stress according to operative step were comparable across procedures and surgeons. There was a significant positive correlation with subjective reporting of stress across procedures (r = 0.766; P = 0.0005). CONCLUSION: This study demonstrates a significant increase in sympathetic tone in consultant surgeons measured using heart rate variability during elective colorectal resections. A significant correlation can be demonstrated between HRV measurements and perceived stress using the State Trait Anxiety Inventory. A combined approach to assessing operative stress is required to evaluate any effect on performance and outcomes.

Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications.

AIM: Radiologically assessed muscle mass has been suggested as a surrogate marker of functional status and frailty and may predict patients at risk of postoperative complications. We hypothesize that sarcopenia negatively impacts on postoperative recovery and is predictive of complications. METHOD: One hundred patients undergoing elective resection for colorectal carcinoma were included in this study. Lean muscle mass was estimated by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra identified on a preoperative CT scan, normalizing for patient height. Perioperative morbidity was scored according to the Clavien-Dindo classification. All statistical data analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 20.0. RESULTS: Fifteen per cent of patients were identified as sarcopenic. There were no deaths in the study group. Sarcopenia was associated with a significantly increased risk of developing major complications (Grade 3 or greater, OR = 5.41, 95% CI: 1.45-20.15, P = 0.01). Sarcopenia did not predict length of stay, critical care dependency or time to mobilization. CONCLUSION: Sarcopenia, as a marker of frailty, is an important risk factor in surgical patients but difficult to estimate using bedside testing. CT scans, performed for preoperative staging, provide an opportunity to quantify lean muscle mass without additional cost or exposure to radiation and eliminate the inconvenience of further investigations.