assessment and intervention before major surgery

1. Sarcopenia in surgical practice
Prepared by
Dr MD AB QUIYUM

2.  Sarcopenia, defined as a decrease in skeletal muscle
mass and strength.
 The prevalence in 60-70 year old people is 5-13%
 and increases to 11-50% in people over 80 years of age.
 This equates to >50 million people and is projected to affect >200 million in the next 40
years given the rising population of older adults.

3. cause
 Understanding of the causes of sarcopenia is incomplete,
however
 1.changes in hormones,
 2. immobility,
 3.age-related muscle changes,
 4.nutrition and
 5. neurodegenerative changes.
 6. chronic disease
 The degree of sarcopenia is determined by two factors:
 initial amount of muscle mass and rate at which muscle
mass declines

4. Pathophysiology
 multiple theories proposed :
 1. changes in satellite cell recruitment,
 2.changes in anabolic signalling,
 3.protein oxidation,
 4.inflammation, and
 5.developmental factors.
 The pathologic changes of sarcopenia include a reduction in muscle tissue
quality as reflected in the replacement of muscle fibers with fat, an increase
in fibrosis, changes in muscle metabolism, oxidative stress, and degeneration
of the neuromuscular junction.[7]

5. Diagnosis
Clinically
 1.muscle mass that is at least two standard deviations.
 2. a slow walking speed.3.
3.distance walked in 6 minutes,
4. grip strength.
Hand grip strength alone has also been advocated as a clinical marker of
sarcopenia that is simple and cost effective and has good predictive power,
although it does not provide comprehensive information.[11]
 5. daily activities such as walking, climbing stairs or standing from a chair and
have been shown to predict sarcopenia and poor functional outcomes.[12]

8. RADIOLOGICALY

11. Skeletal muscle mass can be evaluated by cross-sectional
imaging modalities such as CT at the L3 level or
assessing body composition using bioimpedance analysis
(BIA) and dual X-ray absorptiometry (DXA).
low SMI (low muscle mass), high IMAC (low muscle
quality), and high VSR (visceral adiposity) additively
contributed to an increased risk of post-LDLT
mortality. The lowest one-year survival rate after
LDLT was 41.2% (P<0.001) in 17 (6.1%) patients who
were beyond all three cut-offs.

12. Pubmed
 Average bilateral psoas muscle cross-sectional area at L3, normalized for
height (Total Psoas Index [TPI]), was calculated using computed tomography.
Sarcopenia was defined as TPI in the lowest sex-specific quartile.
Sarcopenia was independently associated with increased in-hospital mortality.
 1-year mortality was 32%

13.  Sarcopenia is an independent risk factor for DtW and ICU
mortality. TPA has predictive value when assessing weaning
outcomes and can be used as an effective adjunct predictor
along with conventional weaning parameters.

14.  Results
 Sarcopenia was present in 25.4% with digestive tract cancer before surgery based on the diagnostic cut-off values
(43.13 cm2/m2 for men and 37.81 cm2/m2 for women).
 The incidence of postoperative total and pulmonary complications, and 30-day readmission were significantly
higher in sarcopenic group than in nonsarcopenic group (37.4% vs 12.9%, P < 0.001; 3.1% vs 2.1%, P = 0.026; 1.1% vs
0.4%, P = 0.003, respectively).
 The postoperative hospital stay was significantly longer in sarcopenic patients (9.42 ± 3.40 vs 8.51 ± 3.17 days,
P < 0.001).
 more chemotherapy modifications including delay, dose reduction, or termination (48.5% vs 44.2%, P = 0.018).
 In addition, during the follow-up period, sarcopenic patients had significantly lower rate of overall survival and
disease-free survival than nonsarcopenic patients (53.9% vs 69.3%, P = 0.002; 36.8% vs 59.7%, P = 0.000,
respectively).
 In multivariate analysis, sarcopenia was found to be a risk factor for postoperative complications [odds ratio
(OR) = 5.418, 95% confidence interval (CI) = 2.986–9.828, P < 0.001], and was an unfavorable prognostic factor for
poor overall survival [hazard ratio (HR) = 0.649, 95% CI = 0.426–0.991, P = 0.045] and disease-free survival
(HR = 0.514, 95% CI = 0.348–0.757, P = 0.001).

16. Management
 1.Exercise
Progressive resistance training in older adults can improve physical performance (gait
speed) and muscular strength.
2. Medication
] Testosterone or other anabolic steroids
 DHEA and human growth insulin-like growth factor 1 (IGF-1),
 ghrelin, vitamin D, angiotensin converting enzyme inhibitors, and eicosapentaenoic acid
No one
approved

17. 3.Nutrition
 age groups to 1.0-1.2 g/kg body weight per day.
 Ensuring adequate nutrition in older adults is of interest in the preve
 4.Supplements
aging skeletal muscle to respond to anabolic stimuli such as amino acids, especially at lower
concentrations.[17]
β-hydroxy β-methylbutyrate (HMB)