Hypoalbuminemia reflects nutritional risk, body composition and systemic inflammation and is independently associated with survival in patients with colorectal cancer

It has long been recognized that albumin has prognostic value in patients with cancer. However, although the Global Leadership Initiative on Malnutrition GLIM criteria (based on five diagnostic criteria, three phenotypic criteria and two etiologic criteria) recognize inflammation as an important etiologic factor in malnutrition, there are limited data regarding the association between albumin, nutritional risk, body composition and systemic inflammation, and whether albumin is associated with mortality independent of these parameters. The aim of this study was to examine the relationship between albumin, nutritional risk, body composition, systemic inflammation, and outcomes in patients with colorectal cancer (CRC). A retrospective cohort study (n = 795) was carried out in which patients were divided into normal and hypoalbuminaemic groups (albumin  <35 g/L) in the presence and absence of a systemic inflammatory response C-reactive protein (CRP >10 and <10 mg/L, respectively). Post-operative complications, severity of complications and mortality were considered as outcome measures. Categorical variables were analyzed using Chi-square test χ 2or linear-by-linear association. Survival data were analyzed using univariate and multivariate Cox regression. In the presence of a systemic inflammatory response, hypoalbuminemia was directly associated with Malnutrition Universal Screening Tool MUST (p < 0.001) and inversely associated with Body Mass Index BMI (p < 0.001), subcutaneous adiposity (p < 0.01), visceral obesity (p < 0.01), skeletal muscle index (p < 0.001) and skeletal muscle density (p < 0.001). There was no significant association between hypoalbuminemia and either the presence of complications or their severity. In the absence of a systemic inflammatory response (n = 589), hypoalbuminemia was directly associated with MUST (p < 0.05) and inversely associated with BMI (p < 0.01), subcutaneous adiposity (p < 0.05), visceral adiposity (p < 0.05), skeletal muscle index (p < 0.01) and skeletal muscle density (p < 0.001). Hypoalbuminemia was, independently of inflammatory markers, associated with poorer cancer-specific and overall survival (both p < 0.001). The results suggest that hypoalbuminemia in patients with CRC reflects both increased nutritional risk and greater systemic inflammatory response and was independently associated with poorer survival in patients with CRC

The relationship between body mass index and short term postoperative outcomes in patients undergoing potentially curative surgery for colorectal cancer: a systematic review and meta-analysis

Background: The prevalence of obesity has increased worldwide over the last few decades, and is a well-recognized risk factor for colorectal cancer. Surgical site infection is the most frequent complication following surgery for colorectal cancer, and the main cause of postoperative morbidity. The aim of the present systematic review and meta-analysis was to examine the relationship between increasing BMI and postoperative surgical site infection following surgery for colorectal cancer. Methods: A systemic literature search was conducted using Medline, PubMed, Embase (Ovid) and Web of Science databases from inception to the end of August 2016. Studies examining the relationship between obesity and surgical site infection following surgery for colorectal cancer were included. Analysis of the data was performed using Review Manager version 5.3(The Nordic Cochrane Centre, The Cochrane Collaboration, Copen-hagen, Denmark,) Results: In this meta-analysis, a total of 9535 patients from 16 studies were included. BMI <30 vs ≥30 kg/m2 was used to examine the association of obesity and surgical site infection in patients from Western countries. The estimated pooled OR demonstrated that obesity increased the risk of surgical site infection by approximately 100% (OR = 2.13; 95% CI 1.66-2.72, p < 0.001).BMI <25 vs ≥25 kg/m2 was used to examine the association of obesity and surgical site infection from Asian countries. The estimated pooled OR demonstrated that obesity increased the risk of surgical site infection by approximately 60% (OR = 1.63; 95% CI 1.29-2.06, p < 0.001). There was little evidence of publication bias in the meta-analysis. Conclusion: From this systematic review and meta-analysis there was good evidence that obesity was associated with a significantly higher risk of developing surgical site infection following surgery for colorectal cancer in both ethnic groups. The magnitude of the effect warrants further investigation

The relationship between body mass index, sex, and postoperative outcomes in patients undergoing potentially curative surgery for colorectal cancer

Background: There is increasing evidence that an increased BMI is associated with increased complications after surgery for colorectal cancer (CRC). However, the basis of this relationship is not clear. Since men and women have different fat distribution, with men more likely to have excess visceral fat in BMI defined obesity, there may be a sex difference in the surgical site infection (SSIs) rate in the obese. Therefore, the aim of this study was to examine the relationship between sex, BMI, clinic-pathological characteristics and the development of postoperative infective complications after surgery for CRC and to establish whether there were gender differences in complication following surgery for CRC. Design: Data were recorded prospectively for patients undergoing potentially curative surgery for CRC in a single centre between 1997 and 2016. Patient characteristics were recorded and complications were classified as either infective or non-infective. The relationship between sex, BMI, associated clinicopathological characteristics and presences of complications were examined by Chi-square test for linear association and multivariate binary logistic regression model. Results: A total of 1039 patients were included. There were significant differences in the presence of complications between male and female (p ≤ 0.001), the rate of complication was higher in obese male (44%); in particular SSIs, wound infection and anastomotic leak (p ≤ 0.05). The rate of surgical site infection was 12% in male patients with normal BMI compared with 26% in those with a BMI ≥30 (p ≤ 0.001), while the rate of SSIs in female patients was 10% in those with normal BMI and those with a BMI ≥30. In males, BMI remained significantly associated with SSI on multivariate analysis [(OR = 1.42, 95% CI 1.13–1.78) P = 0,002]. Conclusions: Obesity prior to surgery for CRC increases the risk of infective complications in both male and female. Increased BMI in male patients was associated greater risk of SSIs and wound infection compared to female patients. Male obese patients should be considered at high risk of developing post-operative infective complications

The relationship between computed tomography‐derived body composition, systemic inflammatory response, and survival in patients undergoing surgery for colorectal cancer

Introduction: Colorectal cancer (CRC) is the fourth leading cause of cancer mortality in developed countries. There is evidence supporting a disproportionate loss of skeletal muscle as an independent prognostic factor. The importance of the systemic inflammatory response (SIR) as a unifying mechanism for specific loss of skeletal muscle mass in patients with cancer is increasingly recognised. The aim of the present study was to delineate the relationship between the SIR, skeletal muscle index (SMI), skeletal muscle density (SMD) and overall survival in patients with colorectal cancer. Patients and Methods: The study included 650 patients with primary operable colorectal cancer. CT scans were used to define the presence of visceral obesity (VO), sarcopenia (low SMI) and myosteatosis (low SMD). Tumour and patient characteristics were recorded. Survival analysis was carried out using univariate and multivariate Cox regression. Results: A total of 650 patients (354 males, 296 females) were included. The majority of patients were over 65 years of age (64%) and overweight or obese (68%). On univariate survival analysis, age, ASA, TNM stage, mGPS, BMI, SFI, VO, SMI and SMD were significantly associated with overall survival (all p<0.05). A low SMI and SMD were significantly associated with an elevated mGPS (<0.05). On multivariate analysis, SMI (Martin) (HR 1.50, 95%CI 1.04-2.18, p=0.031), SMD (Xiao) (HR 1.42, 95%CI 0.98-2.05, p=0.061) and mGPS (HR 1.44, 95%CI 1.15-1.79, p=0.001) were independently associated with overall survival. SMD but not SMI was significantly associated with ASA (P<0.001). Conclusions: This study delineates the relationship between the loss of quantity and quality of skeletal muscle mass, the systemic inflammatory response and survival in patients with operable colorectal cancer

The relation between Malnutrition Universal Screening Tool (MUST), computed tomography-derived body composition, systemic inflammation, and clinical outcomes in patients undergoing surgery for colorectal cancer.

Nutritional status is an important factor affecting a patient's clinical outcomes. Early identification of patients who are at risk of malnutrition is important to improve clinical outcomes and reduce health cost. The Malnutrition Universal Screening Tool (MUST) has been recommended as part of the routine nursing assessment for all patients at hospital admission. The aim of this study was to examine the association between nutritional status (MUST), systemic inflammatory response (SIR), body composition, and clinical outcomes in patients undergoing surgery for colorectal cancer. The malnutrition risk was examined using MUST in patients admitted for surgery for colorectal cancer between March 2013 and June 2016. Preoperative computed tomography scans were used to define the body composition. The presence of SIR was evidenced by the modified Glasgow prognostic score and the neutrophil to lymphocyte ratio. Postoperative complications, severity of complication, length of hospital stay, and mortality were considered as outcome measures. The study included 363 patients (199 males, 164 females); 21% of the patients presented with a medium or high nutritional risk. There were significant associations between MUST and subcutaneous adiposity (P < 0.001), visceral obesity (P < 0.001), and low skeletal muscle index (P < 0.001). No statistically significant association was identified between MUST score and presence of any complication or severity of complication. On multivariate analysis, MUST remained independently associated with the length of hospital stay (OR: 2.17; 95% CI: 1.45, 3.26; P < 0.001). Kaplan-Meier survival curves showed an increased number of deaths for patients at medium or high risk of malnutrition (P < 0.001). This association was found to be independent of other confounding factors (HR: 1.45; 95% CI: 1.06, 1.99; P = 0.020). MUST score is an independent marker of risk in those undergoing surgery for colorectal cancer and should remain a key part of preoperative assessment

Relationship between computed tomography-derived body composition, sex, and post-operative complications in patients with colorectal cancer

Introduction: In the UK, colorectal cancer is the fourth most common cancer and the second most common cause of cancer death. Surgery is the primary modality of treatment, but it is not without complications. Post-operative complications have been linked to preoperative of weight loss and loss of lean tissue, and also to obesity. Given sex differences in body composition, an examination of body composition and post-operative complications may provide valuable information. Therefore, the aim was to examine the relationship between male/female body composition and post-operative complications in patients with operable colorectal cancer. Methods: Patients (n = 741) undergoing operation for colorectal cancer were examined. Preoperative CT scans were used to define the muscle mass and quality, visceral obesity, and subcutaneous adiposity. Post-operative complications, in particular, surgical site infection (SSI) and wound infection (WI) were considered as outcome measures. Results: Male patients with greater subcutaneous adiposity had higher risk of SSI and WI (p < 0.01 and p ≤ 0.001, respectively). On multivariate analysis, Post-operative Glasgow Prognostic Score (poGPS) on Day 4 (OR 2.11, 95% CI 1.53–2.92, P = 0.001) laparoscopic surgery (OR 0.50, 95% CI 0.26–0.98, P = 0.044), and subcutaneous adiposity (OR 2.71, 95% CI 1.26–5.82, P = 0.011) remained significantly independently associated with overall SSI. Subcutaneous adiposity remained significantly independently associated with WI (OR 3.93, 95% CI 1.33–11.57, P = 0.013). In female patients, however, no significant association was found between any body composition measure and complications. Conclusion: This study showed that increased subcutaneous and visceral adiposity were associated with infective complications in male, but not female patients, after colorectal cancer surgery. Therefore, it is important that sex be taken into account when evaluating the potential impact of body composition on post-operative outcomes in patients undergoing surgery for colorectal cancer