TOTAL PSOAS AREA IS A MEASURE FOR DECONDITIONING IN COLORECTAL SURGERY PATIENTS
Brittany E. Levy*1, Yu-Wei Wayne Chang2, Daniel Yackzan1, Daniel L. Davenport1, Sandra J. Beck1, Avinash Bhakta1
1General Surgery, University of Kentucky Medical Center, Lexington, KY; 2Anne Arundel County, Annapolis, MD
Physical fitness serves as an important prognostic indicator for surgical outcomes, however standard approaches to measure fitness are subjective. Therefore, an objective measure deconditioning is needed to determine patient fitness. Objective psoas muscle measurements delineate fitness and are correlated with post-operative outcomes. However, the method to measure psoas area is not standardized or well defined. This study aims to describe a methodology to standardized psoas measurements and correlate them with post-operative outcomes.
After obtaining institutional review board approval, the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for patients over 18 years old, undergoing colectomies for non-trauma indications from 1/1/13 to 12/31/18.
In on CT imaging, the psoas muscle was identified at the joint in the transverse plane. Imaging software calculated the total cross-sectional area of the left and right psoas muscle. The area was normalized by dividing by height squared to achieve our Total Psoas Index in cm2/m2. A TPI less than or equal to the gender-specific 25th percentile defined sarcopenia. Statistically, TPI was correlated with primary outcomes of 30-day mortality, and secondary outcomes including length of stay, discharge disposition, anastomotic leak rate, and morbidity.
1,173 patients met study criteria, all of which had a TPI measurement calculated. Preoperatively 88 patients (7.5%) had partial or total functional dependence. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. Sarcopenic patients were more likely to have an ASA greater than IV (19.4% vs. 9%, p<0.001), a degree of functional dependence (13.9% vs. 5.5%, p<0.001), recent weight loss (17.7% vs. 8.4%, p<0.001), and preoperative inflammatory state (29.2% vs. 16.9% p<0.001). Sarcopenic patients were more likely to undergo an open operation (59.7% vs. 43.7%, p<0.001), have an ostomy (63.9% vs. 52.3%, p=0.001), or have an emergent indication (37.2% vs. 23.5%, p<0.001). A higher percentage of sarcopenic patients died either during their hospitalization or after enrolling in hospice (8% vs. 2.6%, p<0.001). Complication rates were higher for sarcopenic patients of 36.5% (n=105) compared to 27.3% (n=242) for the nonsarcopenic group (p=0.004) including septic shock (22.9% vs. 13.8%, p<0.001) and unplanned mechanical ventilation (12.8% vs. 6.6%, p=0.001).
Measuring the TPI at the lumbosacral joint is an appropriate method for determining sarcopenia in a patient. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population. Using an objective measure to better categorize patient fitness should lead to more preoperative counseling and pre-habilitation to improve patient readiness for surgery.
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