title: Inclusion of Sarcopenia Outperforms the Modified Frailty Index in Predicting 1-Year Mortality among 1,326 Patients Undergoing Gastrointestinal Surgery for a Malignant Indication.
abstract: BACKGROUND
  Although it is a useful metric for preoperative risk stratification, frailty can be difficult to identify in patients before surgery. We sought to develop a preoperative frailty-risk model combining sarcopenia with clinical parameters to predict 1-year mortality using a cohort of patients undergoing gastrointestinal cancer surgery.
  
  
  METHODS
  We identified 1,326 patients undergoing hepatobiliary, pancreatic, or colorectal surgery between 2011 and 2014. Sarcopenia defined by psoas density was measured using preoperative cross-sectional imaging. Multivariable Cox regression analysis was performed to identify preoperative risk factors associated with 1-year mortality and used to develop a preoperative risk-stratification score.
  
  
  RESULTS
  Among all patients identified, 640 (48.3%) patients underwent pancreatic surgery, 347 (26.2%) underwent a hepatobiliary procedure, and 339 (25.5%) a colorectal procedure. Using sex-specific cut-offs, 398 (30.0%) patients were categorized as sarcopenic. Sarcopenic patients were more likely to develop postoperative complications vs non-sarcopenic patients (odds ratio [OR] 1.80, 95% CI 1.42 to 2.29; p < 0.001). Overall 1-year mortality was 9.4%. On multivariable analysis, independent risk factors for 1-year mortality included increasing age (65 to 75 years: [hazard ratio (HR) 1.81, 95% CI 1.05 to 3.14] greater than 75 years [HR 2.79, 95% CI 1.55 to 5.02]), preoperative anemia hemoglobin < 12.5 g/dL (HR 1.68, 95% CI 1.17 to 2.40), and preoperative sarcopenia (HR 1.98, 95% CI 1.36 to 2.88; all p < 0.05). Using these variables, a 28-point weighed composite score was able to stratify patients by their risk for mortality 1 year after surgery (C-statistic = 0.70). The proposed score outperformed other indices of frailty including the modified Frailty Index (C-statistic = 0.55) and the Eastern Cooperative Oncology Group (ECOG) performance score (C-statistic = 0.57) (both p < 0.05).
  
  
  CONCLUSIONS
  Sarcopenia was combined with clinical factors to generate a composite risk-score that can be used to identify frail patients at greatest risk for 1-year mortality after gastrointestinal cancer surgery.
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Stefan
authors.initials: S
authors.lastname: Buettner
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Doris
authors.initials: D
authors.lastname: Wagner
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Georgios A
authors.initials: GA
authors.lastname: Margonis
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Ana
authors.initials: A
authors.lastname: Wilson
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Kazunari
authors.initials: K
authors.lastname: Sasaki
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Neda
authors.initials: N
authors.lastname: Amini
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Faiz
authors.initials: F
authors.lastname: Gani
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD. Electronic address: tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000367:Age Factors; D000368:Aged; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000150:complications / Q000401:mortality* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D016658:Psoas Muscles; D012372:ROC Curve; D012307:Risk Factors; D055948:Sarcopenia / Q000150:complications* / Q000401:mortality / Q000473:pathology