Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery

Abstract

According to the United States census bureau 20% of Americans will be older than 65 years in 2030 and half of them will need an operation - equating to about 36 million older surgical patients. Older adults are prone to complications during gastrointestinal cancer treatment and therefore may need to undergo special pretreatment assessments that incorporate frailty and sarcopenia assessments. A focused, structured literature review on PubMed and Google Scholar was performed to identify primary research articles, review articles, as well as practice guidelines on frailty and sarcopenia among patients undergoing gastrointestinal surgery. The initial search identified 450 articles; after eliminating duplicates, reports that did not include surgical patients, case series, as well as case reports, 42 publications on the impact of frailty and/or sarcopenia on outcome of patients undergoing gastrointestinal surgery were included. Frailty is defined as a clinically recognizable state of increased vulnerability to physiologic stressors resulting from aging. Frailty is associated with a decline in physiologic reserve and function across multiple physiologic systems. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Unlike cachexia, which is typically associated with weight loss due to chemotherapy or a general malignancy-related cachexia syndrome, sarcopenia relates to muscle mass rather than simply weight. As such, while weight reflects nutritional status, sarcopenia - the loss of muscle mass - is a more accurate and quantitative global marker of frailty. While chronologic age is an important element in assessing a patient's peri-operative risk, physiologic age is a more important determinant of outcomes. Geriatric assessment tools are important components of the pre-operative work-up and can help identify patients who suffer from frailty. Such data are important, as frailty and sarcopenia have repeatedly been demonstrated among the strongest predictors of both short- and long-term outcome following complicated surgical procedures such as esophageal, gastric, colorectal, and hepato-pancreatico-biliary resections.

Keywords: Frailty; Morbidity; Mortality; Outcomes; Sarcopenia.

Figure 1

Flow chart depicting the review process for the inclusion of publications.

Figure 2

Power of frailty to predict worse outcomes was much higher than traditional peri-operative assessments. A: American Society of Anesthesiologists (ASA); B: Lee; C: Eagle risk indices. Each panel shows the area under the receiver operator characteristics (ROC) curve to demonstrate the ability of the specific risk index to predict surgical complications and discharge to an assisted or skilled nursing facility. Frailty was added to the risk index scoring to demonstrate the combined ability of these indices to predict discharge disposition. Used with permission Makary et al[22], 2010.

Figure 3

Define sarcopenia rather than a single axial image. A: Total psoas area is measured by circling both psoas muscles at the level of the patients computed tomography where both iliac crests are visible; B: Total psoas volume is measured at the full length of the psoas muscles and normalized for the patients body surface area. Used with permission Amini et al[47], 2015.

Figure 4

Sarcopenia was associated with an increased three year mortality. A: The presence of sarcopenia was also associated with the risk of death (no sarcopenia, 18.0 mo; 40.0% vs sarcopenia, 13.7 mo; 23.0% vs median, 3-yr survival, respectively; P = 0.01) in patients undergoing pancreatic surgery. Used with permission Peng et al[45], 2012; B: The overall survival according to total psoas volume stratified by sarcopenia patients vs no sarcopenia patients quartiles in patients undergoing pancreatic surgeries. Used with permission Amini et al[47], 2015.