This document discusses sarcopenia and outcomes in emergency laparotomy patients. It finds that lower psoas major to L3 vertebral body ratio (PML3) is significantly associated with higher inpatient, 30-day and 90-day mortality rates. A PML3 cutoff of 0.35 had previously been associated with worse survival, but this study analyzes a larger dataset to determine sex-specific PML3 cutoff values with improved predictive ability. Multivariate analysis shows PML3 remains an independent predictor of mortality when accounting for other risk factors.

1. Sarcopenia
and outcomes
in emergency
laparotomy

2. Sex-Specific PML3 cut-offBackground
2016
2046

3. Sex-Specific PML3 cut-offBackground
2016
2046
18%

4. Sex-Specific PML3 cut-offBackground
2016
2046
18%
25%

5. Sex-Specific PML3 cut-offBackground
2016
2046
18%
25%
50%
Of all patients who underwent
emergency laparotomy in 2018
were over 70

6. Sex-Specific PML3 cut-offBackground
Emergency Laparotomy
Over-80s

7. Sex-Specific PML3 cut-offBackground
Emergency Laparotomy
Over-80s
30
Days

8. Sex-Specific PML3 cut-offBackground
Emergency Laparotomy
Over-80s
2
Year

9. Sex-Specific PML3 cut-offBackground
Urea Hb WCC Pulse
GCS Urgency Bloodloss
AF Major?

10. Sex-Specific PML3 cut-offBackground
Urea Hb WCC Pulse
GCS Urgency Bloodloss
AF Major?
Sarcopenia Frailty
Nutrition

11. Sex-Specific PML3 cut-offBackground

12. Sex-Specific PML3 cut-offBackground
FRAILTY
SARCOPENIA
The lack of physiological functional reserve
creating susceptibility and overall inability
to recover from an external
stressor/destabilising event.
The age related loss of skeletal
muscle mass and strength

13. Sex-Specific PML3 cut-offBackground
SARCOPENIA
The age related loss of skeletal
muscle mass and strength

14. Sex-Specific PML3 cut-offBackground
Methods of measuring sarcopenia include:
MRI
DEXA
Computed Tomography
Ultrasound
Bioelectric Impedence
Anthropometric analysis
Biochemical Markers

15. Sex-Specific PML3 cut-offBackground
Methods of measuring sarcopenia include:
MRI
DEXA
Computed Tomography
Ultrasound
Bioelectric Impedence
Anthropometric analysis
Biochemical Markers

16. Sex-Specific PML3 cut-offBackground
Psoas Major?

17. Sex-Specific PML3 cut-offBackground
Single Cross-
Section Image
Psoas Major?

18. Sex-Specific PML3 cut-offBackground
3D Analysis
Single Cross-
Section Image
Psoas Major?

19. Sex-Specific PML3 cut-offBackground
3D Analysis
Single Cross-
Section Image

20. Sex-Specific PML3 cut-offBackground
Psoas Major
√((height (cm) x
weight (kg))/3600).
Height (m)

21. Sex-Specific PML3 cut-offBackground
-151 trauma patients over 45
-Psoas major density outperformed psoas major index
-Psoas major density predicted 90-day mortality, LOS, complications and
dependency on discharge.

22. Sex-Specific PML3 cut-offBackground
-169 Patients who underwent colorectal resection with primary
anastomosis
-Psoas-based measurement of sarcopenia
-Odds ratio of 6.33: Clavien-Dindo class 3 and 4
-Odds ratio of 14.37: Anastomotic leak

23. Sex-Specific PML3 cut-offBackground
-259 patients underwent emergency laparotomy (NELA
database)
-Psoas-based measurement-normalised to BSA
-Significant difference in 30-day mortality (OR: 4.2) and 1 year
mortality (OR:6.05)
-Sarcopenic patients have longer inpatient stays (p<0.001)
and are less likely to live independently upon discharge
(p<0.001)

24. Sex-Specific PML3 cut-offBackground
-Meta-Analysis of 5267 patients
-High heterogeneity: Colorectal, HPB, OG, urological operations + differing methods of sarcopenia
calculation
-Sarcopenia was associated with increased major post-operative complications, 30 day survival, 1 year,
3 year and 5 year survival

25. Sex-Specific PML3 cut-offBackground

26. Sex-Specific PML3 cut-offBackground
-103 patients over the age of 80 who underwent emergency laparotomy
-PML3 significantly greater in survivors than non-survivors
-Area under the curve on ROC analysis superior for PML3 when compared to P-
POSSUM
-Cut-off value of 0.35 was associated with significantly worse survival (p<0.001)

27. PM:L3 Ratio: Cut off of 0.35
PM:L3 Ratio
>0.35
PM:L3 Ratio of
<0.35
Inpatient Mortality
17.8% 70%
Background
P<0.0001

28. PM:L3 Ratio: Cut off of 0.35
PM:L3 Ratio
>0.35
PM:L3 Ratio of
<0.35
30-day Mortality
5.5% 53.3%
Background
P<0.0001

29. PM:L3 Ratio: Cut off of 0.35
PM:L3 Ratio
>0.35
PM:L3 Ratio of
<0.35
90-day Mortality
8.2% 63.3%
f
Background
P<0.0001

30. Sex-Specific PML3 cut-offBackground
Which method of psoas-based measurement
of sarcopenia is optimal?

31. Sex-Specific PML3 cut-offBackground
PBSA PMI PML3Vs. Vs.
√((height (cm) x
weight (kg))/3600).
Height (m)

32. Sex-Specific PML3 cut-offMethods

33. Sex-Specific PML3 cut-offMethods

34. Sex-Specific PML3 cut-offMethods
L3
Inferior End Plate

35. Sex-Specific PML3 cut-offMethods
L3
Inferior End Plate

36. Sex-Specific PML3 cut-offMethods
L3
Inferior End Plate

37. Sex-Specific PML3 cut-offMethods
PSOAS
MAJOR
Cross-Sectional
Area
L3
Cross-Sectional
Area
PM:L3
Ratio

38. Sex-Specific PML3 cut-offMethods
PSOAS
MAJOR
Cross-Sectional
Area
Height
PMI

39. Sex-Specific PML3 cut-offMethods
PSOAS
MAJOR
Cross-Sectional
Area
BSA
PBSA

40. Sex-Specific PML3 cut-offMethods
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
PM:L3

41. Sex-Specific PML3 cut-offMethods
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
COCH
Sites
PM:L3

42. Sex-Specific PML3 cut-offMethods
Mann-Whitney U Test, Binomial logistic regression
Chi Squared, Receiver Operating Characteristics
Statistical Analysis
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
COCH
Sites
PM:L3

43. Sex-Specific PML3 cut-offMethods
Mann-Whitney U Test, Binomial logistic regression
Chi Squared, Receiver Operating Characteristics
Statistical Analysis
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
Inpatient, 30-day and 90-day mortality
Outcome Measures
COCH
Sites
PM:L3

44. Sex-Specific PML3 cut-offResults
264
PATIENTS
Over 65s underwent Emergency
laparotomy

45. Sex-Specific PML3 cut-offResults
264
PATIENTS
Over 65s underwent Emergency
laparotomy
75Years
Interquartile Range: 70-
81 years

46. Sex-Specific PML3 cut-offResults
264
PATIENTS
Over 65s underwent Emergency
laparotomy
75Years
Interquartile Range: 70-
81 years
132:132
Male:Female Ratio

47. Sex-Specific PML3 cut-offResults
0
5
10
15
20
25

48. Sex-Specific PML3 cut-offResults
PMI PBSA PML3
Sig.
95% C.I.
Sig.
95% C.I.
Sig.
95% C.I
Lower Upper Lower Upper Lower Upper
age 0.073 .996 .027 1.007 1.126 .118 .990 1.092
sex 0.020 .162 .854 .016 .138 .819 .137 .271 1.196
Psoas
measurement
0.001 1.393 3.419 .001 1.423 3.706 .000 .000 .043
asa 0.165 .948 1.369 .026 .523 .960 .000 1.604 3.930
oss 0.765 .840 1.269 .595 .853 1.320 .053 .998 1.430
malignancy 0.000 .383 .758 .000 2.477 11.268 .819 .828 1.269
Multivariate analysis

49. Sex-Specific PML3 cut-offResults
AUC:0.77 AUC:0.71 AUC:0.70
PML3 PBSA PMI
90-day mortality

50. Sex-Specific PML3 cut-offResults
PML3 PBSA PMI

51. Sex-Specific PML3 cut-offConclusion
-PMI, PBSA and PML3 are all independently associated with
outcome in patients over the age of 65 undergoing
emergency laparotomy
-PML3 demonstrates the greatest predictive value out of the
psoas-major based prognostic indicators.

52. Sex-Specific PML3 cut-offBackground
Does adding a measure of sarcopenia to
existing risk prediction models improve
accuracy?

53. Establish role of PM:L3 in a larger
patient population using
multivariate analysis
PML3 as a prognosticator
Sex-Specific PML3 cut-offAims
PM:L3

54. Establish role of PM:L3 in a larger
patient population using
multivariate analysis
PML3 as a prognosticator
Improve upon previous value of
0.35 as a cut-off by defining sex-
specific cut-off values.
Sex-specific cut-off values
Sex-Specific PML3 cut-offAims
PM:L3

55. Establish role of PM:L3 in a larger
patient population using
multivariate analysis
PML3 as a prognosticator
Expand upon previous age range
of over-80s to include all patients
over age 65.
Expand age range of
analysis
Improve upon previous value of
0.35 as a cut-off by defining sex-
specific cut-off values.
Sex-specific cut-off values
Sex-Specific PML3 cut-offAims
PM:L3

56. Establish role of PM:L3 in a larger
patient population using
multivariate analysis
PML3 as a prognosticator
Expand upon previous age range
of over-80s to include all patients
over age 65.
Expand age range of
analysis
Improve upon previous value of
0.35 as a cut-off by defining sex-
specific cut-off values.
Sex-specific cut-off values
Investigate if the addition of PM:L3
to existing prognostic models
improves their accuracy.
Improvement of existing
prognostic markers
Sex-Specific PML3 cut-offAims
PM:L3

57. Sex-Specific PML3 cut-offMethods
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
PM:L3

58. Sex-Specific PML3 cut-offMethods
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
Data Collected from 3 Merseyside hospitals:
APH, RLUH, COCH
Sites
PM:L3

59. Sex-Specific PML3 cut-offMethods
Mann-Whitney U Test, Binomial logistic regression
Chi Squared, Receiver Operating Characteristics
Statistical Analysis
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
Data Collected from 3 Merseyside hospitals:
APH, RLUH, COCH
Sites
PM:L3

60. Sex-Specific PML3 cut-offMethods
Mann-Whitney U Test, Binomial logistic regression
Chi Squared, Receiver Operating Characteristics
Statistical Analysis
Retrospective Analysis of NELA Database
Data collected between 2014-18
Data Collection
ITU stay
Inpatient, 30-day and 90-day mortality
Outcome Measures
Data Collected from 3 Merseyside hospitals:
APH, RLUH, COCH
Sites
PM:L3

61. Sex-Specific PML3 cut-offResults
944
PATIENTS
Over 65s underwent Emergency
laparotomy

62. Sex-Specific PML3 cut-offResults
944
PATIENTS
Over 65s underwent Emergency
laparotomy
76Years
Interquartile Range: 70-
82 years

63. Sex-Specific PML3 cut-offResults
944
PATIENTS
Over 65s underwent Emergency
laparotomy
76Years
Interquartile Range: 70-
82 years
442:502
Male:Female Ratio

64. Sex-Specific PML3 cut-offResults
0 50 100 150 200 250 300 350 400 450
ASA I
ASA II
ASA III
ASA IV
ASA V

65. Sex-Specific PML3 cut-offResults
0
20
40
60
80
100
120
140
160
180

66. Sex-Specific PML3 cut-offResults
21.9%207 of 944 Patients
16.3%154 of 944 Patients
20.7%195 of 944 Patients
90-Day Mortality
Inpatient Mortality 30-Day Mortality

67. Sex-Specific PML3 cut-offResults
Survivors
Median PM:L3 Ratio
0.49
Non-Survivors
Median PM:L3 Ratio
0.25
P<0.0001

68. Sex-Specific PML3 cut-offResults
Survivors
Median PM:L3 Ratio
0.48
Non-Survivors
Median PM:L3 Ratio
0.25
P<0.0001

69. Sex-Specific PML3 cut-offResults
Survivors
Median PM:L3 Ratio
0.49
Non-Survivors
Median PM:L3 Ratio
0.25
P<0.0001

70. Sex-Specific PML3 cut-offMortality:PML3 Deciles
survival (days)
percentage

71. Sex-Specific PML3 cut-offMortality:PML3 Quartiles
survival (days)
percentage

72. Sex-Specific PML3 cut-off
PML3=0.39
Sensitivity:0.89
Specificity: 0.80
AUC: 0.89 PML3=0.31
Sensitivity:0.91
Specificity: 0.82
AUC: 0.89
Sex-Specific Cut-off Values

73. Sex-Specific PML3 cut-offMultivariate Analysis
Inpatient Mortality 30-day Mortality 90-day Mortality
Sig.
95% C.I.
Sig.
95% C.I.
Sig.
95% C.I
Lower Upper Lower Upper Lower Upper
PML3 .000 .028 .084 .000 .031 .102 .000 .023 .072
Time to theatre .939 .965 1.033 .597 .977 1.041 .727 .958 1.030
Critical Care stay .865 .523 2.163 .937 .488 2.174 .869 .457 1.936
Age .595 .973 1.049 .982 .962 1.040 .881 .959 1.037
ASA .000 1.661 3.388 .000 1.692 3.594 .000 1.707 3.544
Blood Loss .017 1.052 1.684 .015 1.058 1.681 .010 1.080 1.749
Peritoneal Soiling .025 1.013 1.207 .082 .990 1.184 .068 .994 1.189
Malignancy .255 .939 1.268 .469 .787 1.117 .276 .934 1.270

74. Sex-Specific PML3 cut-offMultivariate Analysis
Inpatient Mortality 30-day Mortality 90-day Mortality
Sig.
95% C.I.
Sig.
95% C.I.
Sig.
95% C.I
Lower Upper Lower Upper Lower Upper
PML3 .000 .028 .084 .000 .031 .102 .000 .023 .072
Time to theatre .939 .965 1.033 .597 .977 1.041 .727 .958 1.030
Critical Care stay .865 .523 2.163 .937 .488 2.174 .869 .457 1.936
Age .595 .973 1.049 .982 .962 1.040 .881 .959 1.037
ASA .000 1.661 3.388 .000 1.692 3.594 .000 1.707 3.544
Blood Loss .017 1.052 1.684 .015 1.058 1.681 .010 1.080 1.749
Peritoneal Soiling .025 1.013 1.207 .082 .990 1.184 .068 .994 1.189
Malignancy .255 .939 1.268 .469 .787 1.117 .276 .934 1.270

75. Sex-Specific PML3 cut-off
AUC:0.74 AUC:0.78
inpatient mortality
P-POSSUM-equation predictions P-POSSUM variables-LR model

76. Sex-Specific PML3 cut-off
AUC:0.74 AUC:0.78 AUC:0.91
inpatient mortality
P-POSSUM-equation predictions P-POSSUM variables-LR model P-POSSUM-+ PML3

77. Sex-Specific PML3 cut-off
AUC:0.76 AUC:0.81
30-day mortality
P-POSSUM-equation predictions P-POSSUM variables-LR model

78. Sex-Specific PML3 cut-off
AUC:0.76 AUC:0.81 AUC:0.91
30-day mortality
P-POSSUM-equation predictions P-POSSUM variables-LR model P-POSSUM-+ PML3

79. Sex-Specific PML3 cut-off
AUC:0.74 AUC:0.79
90-day mortality
P-POSSUM-equation predictions P-POSSUM variables-LR model

80. Sex-Specific PML3 cut-off
AUC:0.74 AUC:0.79 AUC:0.91
90-day mortality
P-POSSUM-equation predictions P-POSSUM variables-LR model P-POSSUM-+ PML3

81. Sex-Specific PML3 cut-offConclusion
-PML3 as a measure of sarcopenia is associated with
mortality in over 65s undergoing emergency laparotomy.
-Psoas major in relation to L3 is better than BSA or height
-Sex-specific cut off values have been defined
-Addition of PML3 to P-POSSUM improves its prognostic
ability in this patient population