The Impact Of Sarcopenia On Postoperative Short-term Outcomes For Esophageal Cancer Patients:a Prospective Cohort Study

Background:Esophageal cancer is the 11 th most common cancer and the sixth most common cause of perioperative mortality worldwide.Esophagectomy or neoadjuvant therapy followed by esophagectomy is the critical therapy for this malignant tumor.Although surgery techniques and perioperative management have significantly improved over the past few decades,esophagectomy for malignant disease is still associated with a high incidence of morbidity.Sarcopenia is common reported among esophageal cancer patients because of the old age,food intake obstruction,and tumor consumption.Several studies have investigated the association between preoperative sarcopenia and postoperative complications,with controversial outcomes.As a positive practice fast-track surgery,“non-tube no fasting” early oral feeding(EOF)strategy has been widely appreciated;however,the impact of preoperative sarcopenia on implementation of EOF is unclear.And the effect of sarcopenia on postoperative short-term quality of life(QOL)has not been validated.To explore the effect of preoperative sarcopenia on postoperative complications,EOF,short-term QOL will help to optimize perioperative management and guide nutritional intervention.Objective:To explore the predictive value of preoperative sarcopenia for postoperative complications after McKeown minimally invasive esophagectomy(McKeown-MIE).To observe the outcomes of sarcopenia patients underwent EOF.To compare the difference of postoperative short-term QOL(within 12 weeks after operation)between sarcopenia patients and non-sarcopenia patients.Methods:Esophageal cancer patients who underwent McKeown-MIE from April to October 2018 at the Department of Thoracic Surgery,Affiliated Cancer Hospital of Zhengzhou University were prospectively included.Patients' body composition was assessed at 7:00 a.m.on the operation day using multi-frequency bioelectrical impedance with eight tactile electrodes(BCA-IB Body Component Analyzer,Tsinghua Tongfang Co.Ltd.,Beijing,China).Patients were divided into the sarcopenia group and non-sarcopenia group according to the criteria established by the Asian Working Group for Sarcopenia(AWGS).Postoperative complications were defined according to the international consensus on the standardization of data collection for complications associated with esophagectomy produced by the Esophagectomy Complications Consensus Group,and graded according to the Clavien-Dindo classification.Grade ? III complications according to the Clavien-Dindo classification were considered severe complications.The “non-tube no fasting” EOF was the first choice for patients validated by preliminary assessment after surgery;EOF quit was defined as the occurrence of a delay in oral feeding for more than two days.Multivariate Logistic regression were applied to explore the association between preoperative sarcopenia and postoperative short-term outcomes.The European Organization for Research and Treatment of Cancer questionnaires C30 were used to assess QOL at baseline(1 week before surgery)and 2,4,8,and 12 weeks after surgery.Results:During the study period,130 patients were included in this study,with 60(46.2%)patients in the sarcopenia group and 70(53.8%)patients in the non-sarcopenia group.Patients with sarcopenia showed higher percentage of old age(67.2 vs.62.3 years,P < 0.001),worse performance status(KPS ? 80%,26.7% vs.10.0%,P = 0.013),and increased prevalence of severe preoperative weight loss(48.3% vs.28.6%,P = 0.020).Significantly more advanced clinical tumor stage(P = 0.026)were also observed in sarcopenia group than in non-sarcopenia group.The incidence rate of overall complications after surgery is 61.7% in sarcopenia group and 22.9% in non-sarcopenia group.The multivariate logistic regression analyses controlling for age ? 70 years,smoking history,diabetes,COPD,ASA-PS(3-4),KPS ? 80%,DLCO(% predictive value)< 80%,FEV1.0/FVC(%)< 80%,severe preoperative weight loss,neoadjuvant therapy,tumor histology,clinical stage,operative time,estimated blood loss,and attempt of EOF demonstrated that preoperative sarcopenia was statistically associated with pulmonary complications(OR 6.93,95%CI 2.25-20.42,P < 0.001),infection(OR 6.00,95%CI 1.24-28.97,P = 0.026),overall complications(OR 5.43,95%CI 2.53-11.64,P < 0.001),and severe complications(OR 3.47,95%CI 1.48-8.13,P = 0.004).Moreover,sarcopenia patients showed a higher incidence rate of EOF quit(OR 6.50,95%CI 1.31-32.16,P = 0.022),and significantly prolonged postoperative hospital stay(OR 3.83,95%CI 1.72-8.53,P = 0.001).No statistical differences were found in baseline QOL scores between the two groups.Two weeks after the operation,patients in the sarcopenia group reported lower global QOL(P = 0.013),physical functioning scores(P = 0.030),role function scores(P = 0.033),and social functioning scores(P = 0.045);and higher symptom scores of fatigue(P = 0.047),dyspnea(P = 0.043),insomnia(P = 0.025)than patients in non-sarcopenia group.The differences in QOL scores between the two groups minished gradually with the time,but the global QOL scores and physical functioning scores of sarcopenia patients were always lower than those of non-sarcopenia patients within eight weeks after operation.Conclusion:Preoperative sarcopenia was a risk factor for pulmonary complications,infection,any complications and severe complications after McKeown-MIE,contributing to delayed hospital discharge.Patients with sarcopenia need better perioperative management to ensure the smooth implementation of EOF.Postoperative intensive QOL guidance seems necessary for sarcopenia patients.