Sarcopenia no Longer Impacts Survival After LDLT Managed with Early Enteral Feeding Protocols but its Postoperative Prevalence is Still Significant
Riccardo Pravisani1,2, Akihiko Soyama 1, Miriam Isola3, Mitsuhisa Takatsuki 1, Masaaki Hidaka1, Tomohiko Adachi 1, Shinichiro Ono1, Takanobu Hara1, Takashi Hamada 1, Umberto Baccarani2, Andrea Risaliti2, Susumu Eguchi1.
1Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki, Japan; 2General Surgery and Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy; 3Division of Medical Statistics, University of Udine, Udine, Italy
Introduction: Sarcopenia is defined as pathological reduction of muscle mass and strength, frequently diagnosed in patients with end-stage liver cirrhoses. Independently from MELD score, it is associated with high morbidity and mortality before and after liver transplantation. The introduction of early enteral feeding (EEF) protocols in the postoperative management of transplanted patients have enhanced promising results. The aim of the study was to evaluate the outcome of LDLT patients managed with EEF in terms of impact on survival of preoperative sarcopenia and clinical evolution of sarcopenia after transplantation.
Materials and Methods: During the period January 2008 - June 2016 138 LDLT patients were investigated for preoperative sarcopenia. The skeletal muscle index at L3 level (L3-SMI) was used as method of muscle mass measurement and it was calculated with SYNPSE VINCENT. The cutoff for the diagnosis of sarcopenia was L3-SMI<42 cm2/m2 for men and L3-SMI<38 cm2/m2 for women, as stated by the Japan Society of Hepatology guidelines. The study population was divided in 2 groups (preLT-sarcopenia group: 86pts Vs control: 52pts) and the overall survival was compared. Among the patients with an overall survival >1year (114 pts) the trend of SMI was analyzed at 1 month and 1 year after LDLT and the risk factors for presence of sarcopenia at 1 year follow up were determined.
Results: Preoperative sarcopenia was recognized in 37.5% of cases. PreLT-sarcopenia and control groups were homogenous in terms of age, sex, MELD, GV/SLV% and HCV-HBV status. HCC diagnosis was higher in control group (p<0.01) but did not have any impact on survival (p=0.43). Overall survival at 1,3,5 year was 82.6%, 76.5% and 69.5% respectively without any significant difference between pre-LT sarcopenic and control groups (p=0.30). At 1 year after LDLT, 28.9% of patients were sarcopenic, without any significant change of prevalence in comparison to the preoperative phase (37.5%, p=0.52) nor 1 month post-LT (30.7%, p=0.42). At univariate analysis BMI (HR 0.04, p<0.01), MELD score (HR 0.03, p=0.02), post-LT ICU length of stay (HR 0.05, p=0.02), biliary complications (HR 1.48, p=0.05), preoperative sarcopenia (HR 4.62, p<0.01), 1 month post-LT sarcopenia (HR 5.8, p<0.01) resulted significant risk factors for sarcopenia at 1 year post-LT. Post-LT ICU length of stay (HR 0.07, p 0.03), biliary complications (HR 4.4, p=0.02), preoperative sarcopenia (HR 2.07, p=0.05), 1 month post-LT sarcopenia (HR 7, p<0.01), maintained significance even at multivariate analysis.
Conclusion: Postoperative EEF protocols do reverse the negative impact on survival of preoperative sarcopenia but they currently do not reduce its prevalence at 1 year after LDLT. Interventions aimed to reverse sarcopenia before LT and to reduce the incidence of biliary complications after LT may also improve the patients' long-term recovery from sarcopenia.
