WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).

“Knowing the risk of mortality increases significantly over the first year after surgery for elderly patients, identification of high-risk patients preoperatively gives surgeons an opportunity to tailor their care to best suit their patients,” said Dr. Rangel, who is a surgeon at Brigham and Women’s. “For example, for some elderly patients with limited life expectancy, an extended hospital stay or loss of independence could be more important than mortality as an outcome measure. For them, palliative or less-invasive treatments with lower immediate morbidity and mortality might be preferable to a high-risk operation. Helping patients to understand their long-term outcomes helps make the decision to operate based on their personal values.”

Traditionally, surgeons use subjective opinion or basic scoring systems such as the American Society of Anesthesiologists (ASA) classification to stratify risk for surgery in elderly patients. “However, the ASA score can be subjective, and there’s inconsistency between evaluators,” Dr. Rangel said. “The Charlson Comorbidity [Index] rates a patient based on the presence or absence of 19 comorbidities, but it doesn’t tell the surgeon anything about the patient’s functional status.” Frailty is a good measure of an elderly patient’s physiologic reserve to withstand an operation, she continued, but is difficult to measure in the acute care setting. One solution is to measure sarcopenia, which predicts postoperative complications, disability, and mortality in elderly elective surgery patients. “The problem is that very few studies have looked at the impact of sarcopenia in the emergency surgery populations, and the ones that exist only look at short-term outcomes, which don’t completely capture the mortality risk,” she said.

In an effort to better understand how sarcopenia affects long-term outcomes after emergency surgery in the elderly, the researchers retrospectively reviewed patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011. Patients were stratified by operative severity using the POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) score. Operations considered major included any laparotomy, open cholecystectomy, and bowel resection, while those considered moderate were laparoscopic cholecystectomy, appendectomy, and hernia repairs without bowel compromise. To measure sarcopenia, the researchers used preoperative CT images to calculate the average bilateral psoas muscle cross-sectional area at the L3 level, normalized for height. Primary outcome was 1-year mortality. Secondary outcomes were mortality at 30 days, 90 days, and 180 days.

Dr. Rangel reported results from 297 patients that were evaluated: 222 with no sarcopenia and 75 with sarcopenia. Their mean age was 78 years, 57% were female, and 84% were white. Compared with nonsarcopenic patients, sarcopenic patients did not differ in terms of age, sex, or race. Comorbidities were high in both groups, with 75% of patients having an ASA score of 3 or greater and 31% having a Charlson score of 4 or greater. More than 40% had some sort of underlying malignancy, yet there were no significant differences between the two groups in terms of ASA scores, Charlson scores, or the prevalence of malignancy.

Compared with nonsarcopenic patients, sarcopenic patients had longer hospital length of stay (14 vs. 11 days, respectively; P = .012), were more likely to require ICU care (67% vs. 50%; P = .012), and had higher in-hospital mortality (27% vs. 9%; P less than .01). In addition, sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (hazard ratio, 3.5; P = .01), 90 days (HR, 3.5; P less than .001), 180 days (HR, 2.6; P = .001), and at 1 year (HR, 2.5; P = .001).

“The measurement of sarcopenia is a practical tool that can be used at the bedside,” Dr. Rangel concluded. “It just takes 3 or 4 minutes using a single axial slice of a preoperative CT scan. Since it uses CT imaging that’s obtained for initial diagnostic purposes, it incurs no additional cost. The identification of sarcopenia has immediate applications for care of the geriatric patient. It should trigger the surgeon to set realistic goals of care and frame expectations about survival [and] should prompt processes of care that improve patient outcomes. High-risk patients might benefit from geriatric consultation or specialized geriatric pathways, early palliative care evaluation, and advance care planning.” She reported having no financial disclosures.

dbrunk@frontlinemedcom.com

Sarcopenia an effective measure of frailty in elderly patients