Annals of Surgical Oncology

, Volume 22, Issue 11, pp 3625–3631 | Cite as

Skeletal Muscle Depletion is Associated with Severe Postoperative Complications in Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Colorectal Cancer

  • Jeroen L. A. van Vugt
  • Hidde J. Braam
  • Thijs R. van Oudheusden
  • Asra Vestering
  • Thomas L. Bollen
  • Marinus J. Wiezer
  • Ignace H. J. T. de Hingh
  • Bert van Ramshorst
  • Djamila BoermaEmail author
Gastrointestinal Oncology



In patients undergoing colorectal cancer surgery, skeletal muscle depletion (sarcopenia) is associated with impaired postoperative recovery and decreased survival. This study aimed to determine whether skeletal muscle depletion can predict postoperative complications for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for peritoneal carcinomatosis of colorectal cancer.


All consecutive patients with an available preoperative computed tomography (CT) scan who underwent CRS-HIPEC for peritoneal carcinomatosis of colorectal cancer in two centers were analyzed. Skeletal muscle mass was determined using the L3 muscle index on the preoperative CT scan. The cutoff values defined by Prado et al. were used to classify the patients as sarcopenic or nonsarcopenic.


Of the study’s 206 patients, 90 (43.7 %) were classified as sarcopenic. The sarcopenic patients underwent significantly more reoperations than the nonsarcopenic patients (25.6 vs. 12.1 %; p = 0.012). The mean L3 muscle index was significantly lower for the patients who experienced severe postoperative complications than for the patients without severe postoperative complications (85.6 vs. 110.2 cm2/m2; p = 0.008). In a multivariable logistic regression model, L3 muscle index was the only parameter independently associated with the risk of severe postoperative complications (odds ratio 0.93; 95 % confidence interval 0.87–0.99; p = 0.018).


Skeletal muscle mass depletion, assessed using CT-based muscle mass measurements, is associated with an increased risk of severe postoperative complications in patients undergoing CRS-HIPEC for colorectal peritoneal carcinomatosis and could therefore be used in preoperative risk assessment.


Peritoneal Carcinomatosis Cytoreductive Surgery Skeletal Muscle Mass Enhance Recovery After Surgery Peritoneal Cancer Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.





  1. 1.
    Koppe MJ, Boerman OC, Oyen WJ, Bleichrodt RP. Peritoneal carcinomatosis of colorectal origin: incidence and current treatment strategies. Ann Surg. 2006;243:212–22.PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Cao C, Yan TD, Black D, Morris DL. A systematic review and meta-analysis of cytoreductive surgery with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal origin. Ann Surg Oncol. 2009;16:2152–65.CrossRefPubMedGoogle Scholar
  3. 3.
    Chua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure? A systematic review of morbidity and mortality. Ann Surg. 2009;249:900–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Baratti D, Kusamura S, Iusco D, et al. Postoperative complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy affect long-term outcome of patients with peritoneal metastases from colorectal cancer: a two-center study of 101 patients. Dis Colon Rectum. 2014;57:858–68.CrossRefPubMedGoogle Scholar
  5. 5.
    Simkens GA, van Oudheusden TR, Luyer MD, et al. Serious postoperative complications affect early recurrence after cytoreductive surgery and HIPEC for colorectal peritoneal carcinomatosis. Ann Surg Oncol. 2014. doi: 10.1245/s10434-014-4297-y.
  6. 6.
    Lieffers JR, Bathe OF, Fassbender K, Winget M, Baracos VE. Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. Br J Cancer. 2012;107:931–6.PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    van Vledder MG, Levolger S, Ayez N, Verhoef C, Tran TC, Ijzermans JN. Body composition and outcome in patients undergoing resection of colorectal liver metastases. Br J Surg. 2012;99:550–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Miyamoto Y, Baba Y, Sakamoto Y, et al. Sarcopenia is a negative prognostic factor after curative resection of colorectal cancer. Ann Surg Oncol. 2015. doi: 10.1245/s10434-014-4281-6.
  9. 9.
    Reisinger KW, van Vugt JL, Tegels JJ, et al. Functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery. Ann Surg. 2015;261:345–52.CrossRefPubMedGoogle Scholar
  10. 10.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6,336 patients and results of a survey. Ann Surg. 2004;240:205–13.PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Braam HJ, Boerma D, Wiezer MJ, van Ramshorst B. Hyperthermic intraperitoneal chemotherapy during primary tumour resection limits extent of bowel resection compared to two-stage treatment. Eur J Surg Oncol. 2013;39:988–93.CrossRefPubMedGoogle Scholar
  12. 12.
    Swellengrebel HA, Zoetmulder FA, Smeenk RM, Antonini N, Verwaal VJ. Quantitative intraoperative assessment of peritoneal carcinomatosis: a comparison of three prognostic tools. Eur J Surg Oncol. 2009;35:1078–84.CrossRefPubMedGoogle Scholar
  13. 13.
    Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466–77.CrossRefPubMedGoogle Scholar
  14. 14.
    Prado CM, Lieffers JR, McCargar LJ, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9:629–35.CrossRefPubMedGoogle Scholar
  15. 15.
    Peng PD, van Vledder MG, Tsai S, et al. Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis. HPB Oxford. 2011;13:439–46.PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Mak PH, Campbell RC, Irwin MG; American Society of A. The ASA physical status classification: interobserver consistency. American Society of Anesthesiologists. Anaesth Intensive Care. 2002;30:633–40.PubMedGoogle Scholar
  18. 18.
    Fearon K, Arends J, Baracos V. Understanding the mechanisms and treatment options in cancer cachexia. Natl Rev Clin Oncol. 2013;10:90–9.Google Scholar
  19. 19.
    Levolger S, Van Vledder MG, Huisman SA, De Bruin RWF, Ijzermans JNM. Inhibition of ALK 4/5 inhibits cancer cachexia associated muscle wasting. Eur Surg Res. 2014;52:105.Google Scholar
  20. 20.
    Han HQ, Zhou X, Mitch WE, Goldberg AL. Myostatin/activin pathway antagonism: molecular basis and therapeutic potential. Int J Biochem Cell Biol. 2013;45:2333–47.CrossRefPubMedGoogle Scholar
  21. 21.
    Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12:489–95.CrossRefPubMedGoogle Scholar
  22. 22.
    Du Y, Karvellas CJ, Baracos V, Williams DC, Khadaroo RG. Sarcopenia is a predictor of outcomes in very elderly patients undergoing emergency surgery. Surgery. 2014;156:521–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Chiba F, Soda K, Yamada S, et al. The importance of tissue environment surrounding the tumor on the development of cancer cachexia. Int J Oncol. 2014;44:177–86.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2015

Authors and Affiliations

  • Jeroen L. A. van Vugt
    • 1
  • Hidde J. Braam
    • 1
  • Thijs R. van Oudheusden
    • 2
  • Asra Vestering
    • 1
  • Thomas L. Bollen
    • 3
  • Marinus J. Wiezer
    • 1
  • Ignace H. J. T. de Hingh
    • 2
  • Bert van Ramshorst
    • 1
  • Djamila Boerma
    • 1
    Email author
  1. 1.Department of SurgerySt Antonius HospitalNieuwegeinThe Netherlands
  2. 2.Department of SurgeryCatharina HospitalEindhovenThe Netherlands
  3. 3.Department of RadiologySt Antonius HospitalNieuwegeinThe Netherlands

Personalised recommendations