OBJECTIVES: Although sarcopenia is recognized as one of the risk factors for increased morbidity after resection for colorectal cancer, the question of the most appropriate way to identify and quantify it is still unresolved. MATERIAL AND METHODS: This is a retrospective unicentric study following patients undergoing elective resection of the rectum for carcinoma with available staging computed tomography (CT) of the trunk. Psoas muscle density (PMD) and its area relative to patient height psoas muscle index (PMI) at the level of inferior vertebral end plate of third lumbar vertebra (L3) were assessed using an initial staging CT scan of the trunk. Post-operative complications, evaluated according to the Clavien-Dindo classification, and blood samples on post-operative days (POD) 3 and 5 were also recorded in the study population. Patients were divided into groups with complicated and uncomplicated post-operative course, and observed parameters were then statistically compared. RESULTS: The correlation of PMI values with the development of post-operative complications was not confirmed in a data set of 206 patients. PMD values were found to be borderline statistically significant in patients with complicated post-operative course, while in the group of patients with severe complications (Clavien-Dindo III-IV), there was no statistically significant difference in PMI or PMD values. The same results were obtained when comparing patients with anastomotic leak (AL). It was confirmed that operations on the lower rectum are riskier for the development of post-operative complications. The secondary objective of our study regarding serum C-reactive protein (CRP) levels of 3rd and 5th POD gave us the answer in the form of cutoff values of 115.7 mg/L (3rd POD) and 76 mg/L (5th POD). CONCLUSION: PMD appears to be a promising tool for predicting post-operative morbidity in patients after rectal resection, but a clear consensus on the method of measurement, interpretation of results and cutoff values is needed. Lower rectal resections are burdened with a higher risk of post-operative complications, especially AL. Monitoring of CRP levels remains an important marker in the prediction of AL due to its negative predictive value.

Department of Field Surgery University of Defence Military Faculty of Medicine Hradec Kralove Czech Republic

Department of Medical Biophysics Medical Faculty Hradec Kralove Hradec Kralove Charles University Hradec Kralove Czech republic

Department of Pediatric Surgery and Traumatology University Hospital Hradec Kralove Hradec Kralove Czech Republic

Department of Radiology University Hospital Hradec Kralove Hradec Kralove Czech Republic

Department of Surgery University Hospital Hradec Kralove Hradec Kralove Czech Republic

Department of Urgent Medicine University Hospital Hradec Kralove Hradec Kralove Czech republic

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Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71:209–49. doi: 10.3322/caac.21660. PubMed DOI

Araghi M, Soerjomataram I, Bardot A, Ferlay J, Cabasag CJ, Morrison DS, et al. Changes in colorectal cancer incidence in seven high-income countries: A population-based study. Lancet Gastroenterol Hepatol. 2019;4:511–8. doi: 10.1016/S2468-1253(19)30147-5. PubMed DOI PMC

Vuik FE, Nieuwenburg SA, Bardou M, Lansdorp-Vogelaar I, Dinis-Ribeiro M, Bento MJ, et al. Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years. Gut. 2019;68:1820–6. doi: 10.1136/gutjnl-2018-317592. PubMed DOI PMC

Chai VW, Chia M, Cocco A, Bhamidipaty M, D'Souza B. Sarcopenia is a strong predictive factor of clinical and oncological outcomes following curative colorectal cancer resection. ANZ J Surg. 2021;91:E292–7. doi: 10.1111/ans.16706. PubMed DOI

Zhuang CL, Huang DD, Pang WY, Zhou CJ, Wang SL, Lou N, et al. Sarcopenia is an independent predictor of severe postoperative complications and long-term survival after radical gastrectomy for gastric cancer: Analysis from a large-scale cohort. Medicine (Baltimore) 2016;95:e3164. doi: 10.1097/MD.0000000000003164. PubMed DOI PMC

Trejo-Avila M, Bozada-Gutierrez K, Valenzuela-Salazar C, Herrera-Esquivel J, Moreno-Portillo M. Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: A systematic review and meta-analysis. Int J Colorectal Dis. 2021;36:1077–96. doi: 10.1007/s00384-021-03839-4. PubMed DOI

Herrod PJ, Boyd-Carson H, Doleman B, Trotter J, Schlichtemeier S, Sathanapally G, et al. Quick and simple; psoas density measurement is an independent predictor of anastomotic leak and other complications after colorectal resection. Tech Coloproctol. 2019;23:129–34. doi: 10.1007/s10151-019-1928-0. PubMed DOI PMC

Berkel AE, Klaase JM, De Graaff F, Brusse-Keizer MG, Bongers BC, Van Meeteren NL. Patient's Skeletal muscle radiation attenuation and sarcopenic obesity are associated with postoperative morbidity after neoadjuvant chemoradiation and resection for rectal cancer. Dig Surg. 2019;36:376–83. doi: 10.1159/000490069. PubMed DOI

Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European working group on sarcopenia in older people. Age Ageing. 2010;39:412–23. doi: 10.1093/ageing/afq034. PubMed DOI PMC

Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age Ageing. 2019;48:16–31. doi: 10.1093/ageing/afy169. PubMed DOI PMC

Van Vugt JL, Coebergh van den Braak RR, Lalmahomed ZS, Vrijland WW, Dekker JW, Zimmerman DD, et al. Impact of low skeletal muscle mass and density on short and long-term outcome after resection of stage I-III colorectal cancer. Eur J Surg Oncol. 2018;44:1354–60. doi: 10.1016/j.ejso.2018.05.029. PubMed DOI

Wu XL, Shen J, Danzeng CD, Xu XS, Cao ZX, Jiang W. CT psoas calculations on the prognosis prediction of emergency laparotomy: A single-center, retrospective cohort study in Eastern Asian population. World J Emerg Surg. 2022;17:31. doi: 10.1186/s13017-022-00435-x. PubMed DOI PMC

Miao SL, Ye XN, Lin TT, Qiu YH, Huang JY, Zheng XW, et al. The psoas muscle density as a predictor of postoperative complications and 30-day mortality for acute mesenteric ischemia patients. Abdom Radiol (NY) 2022;47:1644–53. doi: 10.1007/s00261-020-02714-0. PubMed DOI

Shen W, Punyanitya M, Wang Z, Gallagher D, St-Onge MP, Albu J, et al. Total body skeletal muscle and adipose tissue volumes: Estimation from a single abdominal cross-sectional image. J Appl Physiol (1985) 2004;97:2333–8. doi: 10.1152/japplphysiol.00744.2004. PubMed DOI

Mourtzakis M, Prado CM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab. 2008;33:997–1006. doi: 10.1139/H08-075. PubMed DOI

Rutten IJ, Ubachs J, Kruitwagen R, Beets-Tan RG, Olde Damink SW, Van Gorp T. Psoas muscle area is not representative of total skeletal muscle area in the assessment of sarcopenia in ovarian cancer. J Cachexia Sarcopenia Muscle. 2017;8:630–8. doi: 10.1002/jcsm.12180. PubMed DOI PMC

Benedek Z, Todor-Boer S, Kocsis L, Bauer O, Suciu N, Coro? MF. Psoas muscle index defined by computer tomography predicts the presence of postoperative complications in colorectal cancer surgery. Medicina (Kaunas) 2021;57:472. doi: 10.3390/medicina57050472. PubMed DOI PMC

Pekarova A, Pekar M, Soltes M, Havrlentová L, Chovancová T. Psoas density-an optimal sarcopaenic indicator associated with postoperative complications after colorectal resection for cancer? Wideochir Inne Tech Maloinwazyjne. 2021;16:91–7. doi: 10.5114/wiitm.2020.100880. PubMed DOI PMC

Cuijpers AC, Bongers BC, Heldens A, Bours MJ, Van Meeteren NL, Stassen LP, et al. Aerobic fitness and muscle density play a vital role in postoperative complications in colorectal cancer surgery. J Surg Oncol. 2022;125:1013–23. doi: 10.1002/jso.26878. PubMed DOI PMC

Xiao YZ, Wen XT, Ying YY, Zhang XY, Li LY, Wang ZC, et al. The psoas muscle density as a predictor of postoperative complications in elderly patients undergoing rectal cancer resection. Front Oncol. 2023;13:1189324. doi: 10.3389/fonc.2023.1189324. PubMed DOI PMC

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. doi: 10.1097/01.sla.0000133083.54934.ae. PubMed DOI PMC

Clavien PA, Barkun J, De Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg. 2009;250:187–96. doi: 10.1097/SLA.0b013e3181b13ca2. PubMed DOI

Rahbari NN, Weitz J, Hohenberger W, Moran B, Ulrich A, Holm T, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: A proposal by the International Study Group of rectal cancer. Surgery. 2010;147:339–51. doi: 10.1016/j.surg.2009.10.012. PubMed DOI

Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: A randomized multicenter trial. Ann Surg. 2007;246:207–14. doi: 10.1097/SLA.0b013e3180603024. PubMed DOI PMC

Kostov G, Dimov R, Doykov M. Diverting ileostomy in low anterior resection: Single center retrospective analysis. Pol Przegl Chir. 2022;94:26–32. doi: 10.5604/01.3001.0015.8171. PubMed DOI

Hoek VT, Sparreboom CL, Wolthuis AM, Menon AG, Kleinrensink GJ, D'Hoore A, et al. C-reactive protein (CRP) trajectory as a predictor of anastomotic leakage after rectal cancer resection: A multicentre cohort study. Colorectal Dis. 2022;24:220–7. doi: 10.1111/codi.15963. PubMed DOI PMC

Stephensen BD, Reid F, Shaikh S, Carroll R, Smith SR, Pockney P, et al. C-reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study. Br J Surg. 2020;107:1832–7. doi: 10.1002/bjs.11812. PubMed DOI

Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG, et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg. 2014;101:339–46. doi: 10.1002/bjs.9354. PubMed DOI

Gaillard M, Tranchart H, Maitre S, Perlemuter G, Lainas P, Dagher I. Preoperative detection of sarcopenic obesity helps to predict the occurrence of gastric leak after sleeve gastrectomy. Obes Surg. 2018;28:2379–85. doi: 10.1007/s11695-018-3169-0. PubMed DOI

Miyamoto Y, Baba Y, Sakamoto Y, Ohuchi M, Tokunaga R, Kurashige J, et al. Sarcopenia is a negative prognostic factor after curative resection of colorectal cancer. Ann Surg Oncol. 2015;22:2663–8. doi: 10.1245/s10434-014-4281-6. PubMed DOI

Nakanishi R, Oki E, Sasaki S, Hirose K, Jogo T, Edahiro K, et al. Sarcopenia is an independent predictor of complications after colorectal cancer surgery. Surg Today. 2018;48:151–7. doi: 10.1007/s00595-017-1564-0. PubMed DOI

Richards SJ, Senadeera SC, Frizelle FA. Sarcopenia, as assessed by psoas cross-sectional area, is predictive of adverse postoperative outcomes in patients undergoing colorectal cancer surgery. Dis Colon Rectum. 2020;63:807–15. doi: 10.1097/DCR.0000000000001633. PubMed DOI

Jones KI, Doleman B, Scott S, Lund JN, Williams JP. Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications. Colorectal Dis. 2015;17:O20–6. doi: 10.1111/codi.12805. PubMed DOI

Blackwell JE, Herrod PJ, Doleman B, Boyd-Carson H, Dolan D, Wheldon L, et al. CT-derived measures of muscle quantity and quality predict poorer outcomes from elective colorectal surgery: A UK multicentre retrospective cohort study. Tech Coloproctol. 2023;27:1091–8. doi: 10.1007/s10151-023-02769-3. PubMed DOI PMC

Rollins KE, Javanmard-Emamghissi H, Awwad A, Macdonald IA, Fearon KC, Lobo DN, et al. Body composition measurement using computed tomography: Does the phase of the scan matter? Nutrition. 2017;41:37–44. doi: 10.1016/j.nut.2017.02.011. PubMed DOI

Van Vugt JL, Coebergh van den Braak RR, Schippers HJ, Veen KM, Levolger S, De Bruin RW, et al. Contrast-enhancement influences skeletal muscle density, but not skeletal muscle mass, measurements on computed tomography. Clin Nutr. 2018;37:1707–14. doi: 10.1016/j.clnu.2017.07.007. PubMed DOI

Rollins KE, Awwad A, Macdonald IA, Lobo DN. A comparison of two different software packages for analysis of body composition using computed tomography images. Nutrition. 2019;57:92–96. doi: 10.1016/j.nut.2018.06.003. PubMed DOI PMC

Van Vugt JL, Levolger S, Gharbharan A, Koek M, Niessen WJ, Burger JW, et al. A comparative study of software programmes for cross-sectional skeletal muscle and adipose tissue measurements on abdominal computed tomography scans of rectal cancer patients. J Cachexia Sarcopenia Muscle. 2017;8:285–97. doi: 10.1002/jcsm.12158. PubMed DOI PMC

Teigen LM, Kuchnia AJ, Nagel E, Deuth C, Vock DM, Mulasi U, et al. Impact of Software selection and imagej tutorial corrigendum on skeletal muscle measures at the third lumbar vertebra on computed tomography scans in clinical populations. JPEN J Parenter Enteral Nutr. 2018;42:933–41. doi: 10.1002/jpen.1036. PubMed DOI

Simpson G, Manu N, Magee C, Wilson J, Moug S, Vimalachandran D. Measuring sarcopenia on pre-operative CT in older adults undergoing emergency laparotomy: A comparison of three different calculations. Int J Colorectal Dis. 2020;35:1095–102. doi: 10.1007/s00384-020-03570-6. PubMed DOI

Simpson G, Wilson J, Vimalachandran D, McNicol F, Magee C. Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: Cross-sectional study. Eur J Trauma Emerg Surg. 2022;48:2003–12. doi: 10.1007/s00068-021-01669-1. PubMed DOI

Rollins KE, Gopinath A, Awwad A, Macdonald IA, Lobo DN. Computed tomography-based psoas skeletal muscle area and radiodensity are poor sentinels for whole L3 skeletal muscle values. Clin Nutr. 2020;39:2227–32. doi: 10.1016/j.clnu.2019.10.003. PubMed DOI PMC

Looijaard S, Meskers CG, Slee-Valentijn MS, Bouman DE, Wymenga AN, Klaase JM, et al. Computed tomography-based body composition is not consistently associated with outcome in older patients with colorectal cancer. Oncologist. 2020;25:e492–501. doi: 10.1634/theoncologist.2019-0590. PubMed DOI PMC

Hamaguchi Y, Kaido T, Okumura S, Kobayashi A, Hammad A, Tamai Y, et al. Proposal for new diagnostic criteria for low skeletal muscle mass based on computed tomography imaging in Asian adults. Nutrition. 2016;32:1200–5. doi: 10.1016/j.nut.2016.04.003. PubMed DOI

Lawlor MA, Oliveto JM, Geske JA, Khandalavala BN. Computerized tomography derived psoas muscle indices in a healthy young population in the United States. J Frailty Sarcopenia Falls. 2022;7:38–46. doi: 10.22540/JFSF-07-038. PubMed DOI PMC

De Marco D, Mamane S, Choo W, Mullie L, Xue X, Afilalo M, et al. Muscle area and density assessed by abdominal computed tomography in healthy adults: Effect of normal aging and derivation of reference values. J Nutr Health Aging. 2022;26:243–6. doi: 10.1007/s12603-022-1746-3. PubMed DOI

Abbass T, Tsz Ho YT, Horgan PG, Dolan RD, McMillan DC. The relationship between computed tomography derived skeletal muscle index, psoas muscle index and clinical outcomes in patients with operable colorectal cancer. Clin Nutr ESPEN. 2020;39:104–13. doi: 10.1016/j.clnesp.2020.07.010. PubMed DOI

Bahat G, Turkmen BO, Aliyev S, Catikkas NM, Bakir B, Karan MA, et al. Cut-off values of skeletal muscle index and psoas muscle index at L3 vertebra level by computerized tomography to assess low muscle mass. Clin Nutr. 2021;40:4360–5. doi: 10.1016/j.clnu.2021.01.010. PubMed DOI

Martin L, Birdsell L, Macdonald N, Reiman T, Clandinin MT, McCargar LJ, et al. Cancer cachexia in the age of obesity: Skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31:1539–47. doi: 10.1200/JCO.2012.45.2722. PubMed DOI

Malietzis G, Currie AC, Athanasiou T, Johns N, Anyamene N, Glynne-Jones R, et al. Influence of body composition profile on outcomes following colorectal cancer surgery. Br J Surg. 2016;103:572–80. doi: 10.1002/bjs.10075. PubMed DOI

McSorley ST, Black DH, Horgan PG, McMillan DC. The relationship between tumour stage, systemic inflammation, body composition and survival in patients with colorectal cancer. Clin Nutr. 2018;37:1279–85. doi: 10.1016/j.clnu.2017.05.017. PubMed DOI

Sueda T, Takahasi H, Nishimura J, Hata T, Matsuda C, Mizushima T, et al. Impact of low muscularity and myosteatosis on long-term outcome after curative colorectal cancer surgery: A propensity score-matched analysis. Dis Colon Rectum. 2018;61:364–74. doi: 10.1097/DCR.0000000000000958. PubMed DOI

Tamas K, Walenkamp AM, De Vries EG, Van Vugt MA, Beets-Tan RG, Van Etten B, et al. Rectal and colon cancer: Not just a different anatomic site. Cancer Treat Rev. 2015;41:671–9. doi: 10.1016/j.ctrv.2015.06.007. PubMed DOI

Kawada K, Sakai Y. Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis. World J Gastroenterol. 2016;22:5718–27. doi: 10.3748/wjg.v22.i25.5718. PubMed DOI PMC

Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: A retrospective analysis of 17 518 patients. Colorectal Dis. 2017;19:288–98. doi: 10.1111/codi.13476. PubMed DOI

Sciuto A, Merola G, De Palma GD, Sodo M, Pirozzi F, Bracale UM, et al. Predictive factors for anastomotic leakage after laparoscopic colorectal surgery. World J Gastroenterol. 2018;24:2247–60. doi: 10.3748/wjg.v24.i21.2247. PubMed DOI PMC