Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

Abstract

Background: Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

Methods: The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

Results: A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

Conclusion: Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Figure 1

Sarcopenia is the age-related loss of skeletal muscle mass, muscle strength, and muscle function. From a pathophysiological perspective, this disorder may be associated with muscle fiber and motor unit atrophy and a concomitant increase in intramuscular and perimuscular and intramyocellular fat. As such, sarcopenia is closely interwoven with the multifaceted frailty syndrome and is considered the key component of physical frailty. Accordingly, frailty and sarcopenia share similar characteristics, such as weak muscle strength and decreased gait speed. However, the concept of frailty reaches beyond physicality and also encompasses psychological and social dimensions.

Figure 2

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of the search and selection process. Supplementary Table 3 (Supplemental Digital Content 7, http://links.lww.com/JS9/A971) lists all potentially relevant studies (n=399) that were assessed in full-text form but excluded from any further analysis due to noncompliance with inclusion criteria and/or the presence of exclusion criteria.

Figure 3

Odds ratio estimates and mean differences with 95% confidence intervals (CI). Mortality and any complications, including all grades of the Clavien–Dindo (C–D) classification, were more likely to occur in patients with sarcopenia. Furthermore, patients with sarcopenia were less likely to be discharged home and had lower 1-year, 3-year and 5-year survival rates. The length of hospital stay was also prolonged in patients with sarcopenia. Focusing on surgical specialties, patients with sarcopenia undergoing transplant surgery had the highest correlation with mortality, while any complications were most likely to occur in patients with sarcopenia undergoing surgery for inflammatory bowel disease (IBD).