Measuring sarcopenia on pre-operative CT in older adults undergoing emergency laparotomy: a comparison of three different calculations.

INTRODUCTION: Sarcopenia is associated with outcomes in older-adults undergoing emergency surgery. Psoas major measurement is a surrogate marker of sarcopenia with multiple calculations existing normalising to body size and no consensus as to which is optimal. We compared three different psoas-major calculations to predict outcomes in older adults undergoing emergency laparotomy. METHODS: Consecutive over 65s were identified from the National Emergency Laparotomy Audit(NELA) database at a single centre between 2014 and 2018. Psoas major was measured at the L3 level and normalised to height (psoas muscle index, PMI), L3 vertebral body (psoas muscle:L3 ratio, PML3) or body surface area (psoas:body surface area, PBSA) and each correlated to outcomes. Outcome measures included inpatient, 30-day and 90-day mortality. A comparison of the three calculations was performed using the Mann-Whitney U, chi-squared, receiver operating characteristic curves (ROC) and binary logistic regression. RESULTS: Two hundred and sixty-four older adults underwent emergency laparotomy (median age, 75 years ((IQR, 70-81 years), 50% female)). Inpatient mortality was 19.6%, 30-day mortality was 15.1% and 90-day mortality was 18.5%. A total of 31.1% of males and 30% of females were sarcopenic (30.6% overall). A multivariate analysis confirmed each method of psoas major calculation (p < 0.0001) to be associated with mortality, as was ASA-grade (p < 0.0001). Area under the curve (AUC) was greatest for PML3 in predicting mortality (inpatient: PML3, 0.76; PMI, 0.71; PBSA, 0.70; 30-day: PML3, 0.74; PMI, 0.68; PBSA, 0.68; and 90-day: PML3, 0.78; PMI, 0.71; PBSA, 0.70). ASA-grade, P-POSSUM and PML3 were independently associated with mortality on multivariate analysis. ROC analysis of predictions from logistic regression models demonstrated PML3 to be more closely aligned to mortality than ASA or P-POSSUM (inpatient: AUC:PML3, 0.807; ASA, 0.783; P-POSSUM, 0.762; 30-day:AUC: PML3, 0.799; ASA, 0.784; P-POSSUM, 0.787; and 90-day: AUC:PML3, 0.805; ASA, 0.781; P-POSSUM, 0.756). CONCLUSIONS: Sarcopenia was present in 30.6% of older adults undergoing emergency surgery and is associated with a significantly increased mortality. PML3 is superior to PMI or PBSA and should be considered the method of calculation of choice. Additionally, PML3 compares favourably to ASA and P-POSSUM.

Evaluation of the utility of prognostic models for patients with resected hilar cholangiocarcinoma.

BACKGROUND: Several prognostic systems have been proposed to guide management strategies post-resection for patients with hilar cholangiocarcinoma. The objective of this study was to evaluate the efficacy of these conventional prognostic models, with respect to Overall Survival (OS), on patients in a modern single-centre resectional cohort. METHOD: Patients diagnosed with hilar cholangiocarcinoma, referred to a supra-regional tertiary referral centre between February 2009 and February 2016, were retrospectively analysed from a prospectively held database linked to Hospital Episode Statistics and Somerset Cancer Registry data. RESULTS: Two-hundred and one patients were assessed for suitability for surgery. Eighty-three (41%) patients considered to have potentially resectable disease underwent surgical assessment of resectability. Fifty-six (68%) patients proceeded to resection. Multivariate analysis demonstrated that pre-operative Serum CA 19-9 (p = 0.007), Radiological Arterial Involvement (p = 0.005) and Amsterdam Medical Centre (AMC) prognostic model score (p = 0.032) retained significance in association with OS. Multivariate models developed from this cohort out-performed the conventional prognostic systems for OS. CONCLUSION: The cohort-derived multivariate models demonstrated significantly improved prognostic capability compared to conventional systems in explaining OS.

Changing outlook for colorectal liver metastasis resection in the elderly.

BACKGROUND: This study sought to evaluate the impact of the advancements in clinical care, obtained over the last 20 years, for patients aged 70 and older undergoing liver resection for colorectal liver metastases (CRLM). METHODS: Consecutive patients age 70 or older who underwent liver resection for CRLM at Aintree University Hospital (Liverpool, UK) between May 2008 and May 2015 were compared to a dataset of consecutive patients, meeting the same criteria, between 1990 and 2007. An enhanced recovery programme after surgery (ERAS) combined with cardiopulmonary exercise testing (CPET) was introduced in January 2008. RESULTS: The proportion of patients over 70 years undergoing liver resection for CRLM increased over the study period (6% in 1990, 16.3% in 2000, 26.5% in 2005 and 25.8% in 2007). The patients in the later group were more often treated with neoadjuvant chemotherapy (58 vs 34, p = 0.006) and underwent parenchymal sparing surgery, resulting in fewer major hepatectomies (51 vs 111, p < 0.001) and less perioperative morbidity (49 vs 70, p = 0.043) and mortality (3 vs 9, p = 0.229). Although there was shorter disease free survival (DFS) in the later group (DFS at 1, 3 and 5 years was 52.1%, 31.6%, 29% vs. 71.8%, 49.1%, 44.0%)(p < 0.01), similar overall survival (OS) was achieved (OS at 1, 3 and 5 years was 85.4%, 51.6%, 32.8% vs. 81.7%, 42.1%, 27.3%)(p = 0.21). CONCLUSIONS: This study demonstrates that, with modern management (ERAS, CPET, neoadjuvant chemotherapy and parenchymal sparing surgery), a greater number of patients with CRLM, over the age of seventy, can undergo liver resection, with improved perioperative outcomes.

Acute parotitis due to MRSA causing Lemierre's syndrome.

We report a case of septic thrombophlebitis of the right internal jugular vein linked with right-sided acute parotitis caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient who had recently undergone a pylorus-preserving pancreaticoduodenectomy. Our case is unique because acute parotitis is a less-recognized cause of Lemierre's syndrome, never previously linked with MRSA infection in this context. We review the literature on diagnosis and management of Lemierre's syndrome caused by acute parotitis. Prompt diagnosis and aggressive antibiotics ensured a favourable outcome.

Hepatectomy for octogenarians with colorectal liver metastasis in the era of enhanced recovery.

BACKGROUND: Concern exists regarding the use of hepatectomy to treat colorectal liver metastasis (CRLM) in octogenarians due to prior studies suggesting elevated morbidity and mortality. Cardiopulmonary exercise testing (CPET) within pre-operative assessment and enhanced recovery after surgery (ERAS) have both been shown to be associated with low morbidity and mortality in patients undergoing hepatectomy. This study sought to compare the outcomes of octogenarians with patients aged 70-79 undergoing hepatectomy for CRLM, within a center utilizing both CPET and ERAS. METHODS: Consecutive patients age 70 or older who underwent hepatectomy for CRLM at Aintree University Hospital (Liverpool,UK), between May 2008 and May 2015 were identified from a prospectively maintained cancer database. Data were extracted and comparisons drawn. RESULTS: 127 patients aged 70-79 years and 34 octogenarians underwent respectively 137 and 35 hepatectomy for CRLM. There was no difference in hospital stay (6 days), morbidity and mortality between the groups. OS at 1, 3 and 5 years were 86.7%, 55% and 35.8% for those aged 70-79 compared to 79.4%, 37.3% and 20.4% for the octogenarians (p=0.127). DFS at 1,3 and 5 years was 52.5%, 31.7% and 31.7% for 70-79 group compared to 46.2%, 31.5% and 16.8% for the octogenarians (p=0.838). On multivariate analysis major hepatectomy was associated with an increased risk of post-operative complications, inferior OS and DFS. Chronological age was not a predictor of postoperative complications, poorer OS or DFS. CONCLUSIONS: Appropriately selected octogenarians can have similar postoperative outcomes to patients aged 70-79 when undergoing hepatectomy for CRLM using ERAS combined with CPET. This study advocates using CPET and ERAS in the selection and management of octogenarian patients with CRLM undergoing hepatectomy.