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Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study

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Abstract

Introduction

Emergency laparotomy is a considerable component of a colorectal surgeon’s workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65 s who underwent emergency laparotomy and emergency colorectal resection.

Methods

An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann–Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3.

Results

Nine-hundred and forty-four over-65 s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76 years (IQR 70–82 years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91).

Conclusion

PML3 is an accurate predictor of mortality in over-65 s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction.

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Funding

None to declare.

Author information

Authors and Affiliations

  1. Wirral University Teaching Hospitals, Birkenhead, UK

    Jeremy Wilson & Conor Magee

  2. Countess of Chester Hospital, Chester, UK

    Dale Vimalachandran

  3. Royal Liverpool University Hospital, Liverpool, UK

    Gregory Simpson & Frances McNicol

  4. University of Chester, Chester, UK

    Conor Magee

  5. 27 Stanley Avenue, Wirral, CH63 5QE, UK

    Gregory Simpson

Authors
  1. Gregory Simpson
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  2. Jeremy Wilson
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  4. Frances McNicol
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  5. Conor Magee
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Contributions

GS: data collection, analysis, write up of article. JW: data collection, study design, write up of article. DV: write up of article, study design. FM: data collection, write up of article. CM: supervising author, study design, write up of article.

Corresponding author

Correspondence to Gregory Simpson.

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No conflicts of interest or competing interests to declare.

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No ethical approval required as study of a retrospective, observational design. No intervention made in patients care.

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Appendix

Appendix

Multivariate analysis of pre-operative factors and mortality.

 

Inpatient mortality

30-day mortality

90-day mortality

Sig

OR

95% CI

 

Sig

OR

95% CI

 

Sig

OR

95% CI

 

Critical care stay (days)

0.916

1.040

0.496

2.181

0.967

0.984

0.452

2.139

0.751

0.886

0.418

1.875

Time to theatre (hours)

0.889

1.003

0.968

1.038

0.482

1.012

0.979

1.046

0.836

0.996

0.959

1.034

PML3

0.000

11.031

5.359

16.272

0.000

10.125

5.612

17.702

0.000

11.243

5.481

16.956

ASA

0.000

   

0.000

   

0.000

   

 ASA 1 (ref)

 ASA 2

0.293

0.346

0.048

2.500

0.129

0.217

0.030

1.557

0.227

0.298

0.042

2.126

 ASA 3

0.488

0.509

0.075

3.437

0.193

0.285

0.043

1.884

0.553

0.565

0.086

3.727

 ASA 4

0.487

1.966

0.293

13.208

0.797

1.278

0.197

8.286

0.460

2.036

0.309

13.405

 ASA 5

0.179

4.776

0.488

46.754

0.164

4.965

0.520

47.362

0.140

5.528

0.571

53.512

 Age

0.403

1.017

0.978

1.056

0.614

1.010

0.954

1.053

0.937

1.002

0.963

1.042

Blood loss

0.031

   

0.006

   

0.010

   

 < 100 ml (ref)

            

 101–500 ml

0.021

2.225

1.126

4.396

0.001

3.670

1.675

8.042

0.004

2.814

1.389

5.702

 501–999 ml

0.316

2.071

0.498

8.603

0.148

3.022

0.674

13.546

0.210

2.556

0.589

11.096

 > 1000 ml

0.014

10.183

1.597

64.949

0.014

9.348

1.569

55.708

0.012

11.221

1.704

73.887

Soiling

0.084

   

0.084

   

0.332

   

 None (ref)

            

 Serous fluid

0.292

1.502

0.705

3.202

0.255

1.611

0.709

3.663

0.473

1.327

0.612

2.876

 Localised pus

0.362

0.574

0.174

1.894

0.750

1.211

0.373

3.936

0.532

0.689

0.215

2.213

 Free pus, blood or bowel content

0.044

2.029

1.020

4.035

0.216

1.581

0.765

3.270

0.146

1.680

0.835

3.380

Malignancy

0.453

   

0.221

   

0.608

   

 None (ref)

            

 Primary only

0.567

0.771

0.317

1.876

0.047

0.328

0.109

0.987

0.761

0.873

0.363

2.099

 Nodal metastases

0.742

1.294

0.278

6.023

0.778

1.253

0.261

6.013

0.853

1.161

0.239

5.638

 Distant metastases

0.160

2.175

0.735

6.429

0.557

0.683

0.192

2.435

0.207

2.042

0.674

6.183

Multivariate analysis of P-POSSUM variables with PML3.

 

Inpatient mortality

30-day mortality

90-day mortality

Sig

OR

95% CI

 

Sig

OR

95% CI

 

Sig

OR

95% CI

 

Age

0.091

1.028

0.996

1.061

0.301

1.018

0.984

1.053

0.780

1.005

0.972

1.038

Creatinine

0.001

1.006

1.002

1.010

0.048

1.004

1.000

1.007

0.001

1.006

1.003

1.010

Sodium

0.199

1.030

0.985

1.076

0.227

1.029

0.982

1.078

0.079

1.042

0.995

1.092

Potassium

0.658

0.916

0.621

1.350

0.956

1.012

0.670

1.528

0.416

0.847

0.568

1.263

Urea

0.281

1.009

0.993

1.026

0.301

1.009

0.992

1.027

0.316

1.009

0.992

1.026

Haemoglobin

0.021

0.988

0.978

0.998

0.334

0.995

0.984

1.005

0.036

0.989

0.979

0.999

WCC

0.663

0.996

0.979

1.014

0.648

0.996

0.978

1.014

0.717

0.997

0.980

1.014

Pulse

0.254

1.007

0.995

1.020

0.687

1.003

0.989

1.016

0.446

1.005

0.992

1.018

BP

0.434

0.996

0.987

1.006

0.019

0.988

0.978

0.998

0.381

0.996

0.986

1.005

GCS

0.349

0.940

0.825

1.070

0.371

0.943

0.828

1.073

0.340

0.937

0.821

1.071

ECG

0.279

   

0.115

   

0.309

   

 Normal (ref)

            

 AF, rate 60–90

0.154

1.840

0.796

4.254

0.039

2.495

1.047

5.945

0.187

1.794

0.753

4.272

 Any other abnormality

0.750

0.911

0.512

1.619

0.748

1.103

0.606

2.009

0.693

0.887

0.488

1.610

Cardiac

0.603

   

0.118

   

0.628

   

 No cardiac failure (ref)

            

 Diuretic, digoxin, Rx for angina/HTN

0.283

1.347

0.783

2.318

0.038

1.818

1.033

3.199

0.193

1.452

0.828

2.546

 Peripheral oedema, warfarin, borderline cardiomyopathy

0.770

0.884

0.386

2.023

0.643

0.813

0.338

1.956

0.757

1.144

0.488

2.678

 Raised JVP, cardiomegaly

0.763

0.804

0.195

3.325

0.770

1.234

0.302

5.050

0.902

1.095

0.259

4.633

Respiratory

0.007

   

0.021

   

0.016

   

 No dyspnoea

            

 Dyspnoea on exertion, mild COAD

0.516

0.824

0.460

1.477

0.260

0.699

0.375

1.303

0.873

0.952

0.524

1.732

 Limiting dyspnoea, moderate COAD

0.105

1.749

0.890

3.437

0.188

1.598

0.795

3.211

0.148

1.675

0.833

3.368

 Dyspnoea at rest, pulmonary fibrosis

0.005

3.878

1.510

9.956

0.031

2.812

1.100

7.193

0.004

4.086

1.560

10.698

Operative severity

0.784

1.072

0.653

1.760

0.402

1.249

0.743

2.098

0.813

0.940

0.565

1.565

No. of operations

0.619

   

0.710

   

0.507

   

 One (ref)

            

 Two

0.633

0.832

0.391

1.772

0.843

0.923

0.417

2.041

0.672

0.845

0.387

1.846

 More than 2

0.423

2.687

0.239

30.170

0.438

2.467

0.252

24.149

0.300

3.663

0.315

42.611

Blood loss

0.020

   

0.012

   

0.005

   

 < 100mls (ref)

            

 101–500 mls

0.062

1.679

0.974

2.894

0.006

2.320

1.277

4.213

0.014

2.041

1.152

3.617

 501–999 mls

0.825

1.158

0.314

4.268

0.915

1.077

0.278

4.166

0.791

1.200

0.312

4.612

 > 1000 mls

0.004

9.641

2.106

44.133

0.020

7.039

1.352

36.643

0.002

12.044

2.536

57.200

Peritoneal soiling

0.180

   

0.391

   

0.288

   

 No soiling(ref)

            

 Minor soiling

0.559

1.195

0.657

2.175

0.239

1.482

0.770

2.851

0.434

1.282

0.688

2.391

 Local pus

0.636

0.787

0.292

2.119

0.947

1.037

0.357

3.012

0.777

0.862

0.308

2.413

 Free bowel content, pus or blood

0.061

1.793

0.974

3.302

0.117

1.672

0.880

3.176

0.086

1.740

0.925

3.273

Malignancy

0.194

   

0.045

   

0.055

   

 Not malignant (ref)

            

 Primary malignancy only

0.281

0.672

0.326

1.385

0.005

0.289

0.122

0.686

0.280

0.663

0.315

1.398

 Malignancy + nodal mets

0.469

1.535

0.481

4.901

0.514

0.652

0.181

2.355

0.891

0.918

0.270

3.124

 Malignancy + distant mets

0.110

2.014

0.853

4.757

0.683

0.821

0.320

2.112

0.017

2.884

1.209

6.881

PML3

0.000

12.782

7.900

18.462

0.000

10.716

6.735

17.273

0.000

13.135

7.974

20.995

*Age, creatinine, sodium, potassium, urea, haemoglobin, WCC, pulse, BP and GCS included as ordinal data. ECG, cardiac and respiratory findings, operative severity, no. of operation, blood loss, peritoneal soiling, malignancy and PML3 included as nominal data. Cut-off for PML3 was 0.35.

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Simpson, G., Wilson, J., Vimalachandran, D. et al. Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study. Eur J Trauma Emerg Surg 48, 2003–2012 (2022). https://doi.org/10.1007/s00068-021-01669-1

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