A laparotomy in case of acute worsening of the situation (obstruction of the bowel, trauma of the abdomen/peritonitis) can save many lives. Further, the ability to care for this population in advanced ways has made the attempt to stabilize them more complex. Patients undergoing emergency laparotomy typically have a "unstable" type of multi-organ syndrome and severe sepsis with a 30-day mortality of 8-16% globally, and high rates of complications (over 50%).{1,2} They are likely elderly and/or to have multiple other complications. Due to the high mortality and complication rates, accurate risk stratification of patients before surgery is the only way to reduce out of control statistics particularly for emergency laparotomy patients. With age, the loss of skeletal muscle and strength have been shown to be directly related to a decrease in physiological reserve and frailty. Using CT imaging, skeletal muscle can be assessed and the diagnosis of sarcopenia can be made at the level of the 3rd lumbar vertebra. Laparotomy is the correct procedure for an emergency and typically a CT scan of the abdomen is required. Hence, the diagnosis of sarcopenia can be made preoperatively for majority of patients undergoing emergency laparotomy{3,4}. Sarcopenia can be a measure of disrupted nutritional and functional status of a patient and can be used to identify patients that are more likely to experience negative outcomes post-operatively. Recent studies have demonstrated that the presence of sarcopenia is related to poor surgical outcomes. A systematic review and meta-analysis published in 2023, looking at 3,492 patients that underwent emergency laparatomy, found the prevalence of sarcopenia to be between 24.6%-50.3%. There was a greater risk of 30-day post-operative mortality in sarcopenic patients (OR = 2.36, 95% CI 1.66–3.37), and even more so at 90 days, whilst the length of hospital stay was longer in patients with sarcopenia. Another meta-analysis, comprised of 3,795 patients, found a similar pattern, with sarcopenia being associated with 30-day post-operative mortality (OR = 2.42, 95% CI 1.93–3.05); post-operative complications (OR = 1.78); and increased length of stay and admissions to the intensive care unit{5}. Though these studies reflect the significance of sarcopenia and predicting the outcome of post surgery, there is a lack of sarcopenia studies in Pakistan and other low and middle-income countries. These differences in outcome may be observed, because of different nutritional status, late presentation, burden of disease and limited health care resources. In Pakistan, there is no study that has analyzed the effect of sarcopenia on the adults who underwent emergency laparatomy pre-operatively.

The study was a prospective cohort study that was conducted in the General Surgery Department of a Tertiary Care Hospital in Pakistan after approval from the Institutional Ethical Review Committee for six months. This paper aimed to describe the effect of preoperative sarcopenia on the postoperative outcomes following emergency laparotomy in adults. The patients were adult patients, who had presented to the emergency department for an emergency laparotomy for acute surgical pathology of the abdomen. The patients in the sample size comprised 101 patients; this sample size was comparable to the sample size reported by Park et al. in the parent prospective multicenter cohort study on prognosis of pre-operative sarcopenia in emergency laparotomy patients. The sample was obtained through consecutive, non-probability sampling, until the desired sample size was accomplished. Adults (≥18 years old), patients undergoing emergency laparotomy and with pre-operative computed tomography (CT) scan of the abdomen with contrast imaging (enough to assess body composition) were included. The subjects used in this study were those participants who had signed an informed consent form for the study. Patients were excluded if they were pregnant; had significant abdominal trauma requiring damage control surgery; had neuromuscular disorders affecting skeletal muscle mass; had undergone abdominal surgery within the previous 3 months or had palliative care for disseminated cancer with an exclusion due to incomplete clinical and/or radiological information. Some demographic and clinical data was collected on a data collection proforma with the consent of the participants before recording. These data encompassed comorbidities, smoking history, ASA class, surgery indication, lab data, procedure data and more. The area of skeletal muscle at the level of the 3rd lumbar vertebra (L3) was evaluated preoperatively using CT. The index of skeletal muscle (SMI) was calculated as the area of skeletal muscle (cm2) divided by height squared (m2). Patients were categorized as sarcopenia or non-sarcopenia using the cut-off values for sSMI for each sex as described in the literature. The main outcome was mortality within 30 days post-surgery. The other outcomes were post-surgical complications, surgical site infection, wound dehiscence, anastomotic leak, post-surgical pneumonia, admission into an intensive care unit, length of stay, reoperation or readmission within 30 days. Sarcopenia was the independent variable. All the other factors (age, sex, comorbidities, ASA, BMI, and operative diagnosis) were considered potential confounders. IBM SPSS Statistics 26.0 were used to analyze the data. The Shapiro-Wilk test was used to assess normality of continuous variables. Normally distributed ones were reported as mean ± standard deviation and compared by independent samples t test. Median and interquartile range (IQR) were used for those that were not normally distributed and were analysed using the Mann-Whitney U test. Categorical variables were presented as number and percentages. The Chi-Square test and Fisher's exact test, as appropriate, were used for analysis. Preoperative sarcopenia and postoperative outcomes were analyzed for independent association with the controlling of confounding variables by using multivariable logistic regression. Adjusted odds ratios (AOR) with a 95% confidence intervals (CIs) were reported. A p value of <0.05 was used to determine statistical significance. Ethical standards as outlined in the Declaration of Helsinki have been adhered to in this study. Ethical clearance was obtained from institutional ethical review committee prior to the start of the research. Informed consent was obtained from the legally authorized representatives of the research subjects before they entered the research. Patient confidentiality was assured by the assignment of a code which replaced personally identifying information. The only persons with access to the data were the investigators.

120 patients were analysed who had emergency laparotomy. Thirty-eight (31.7%) patients were sarcopenic and 82 (68.3%) patients were non-sarcopenic preoperatively. Demographic and clinical features of the study group are presented in Table 1. The average age of the population studied was 56.8 ± 14.2 years. There were 68 (56.7%) males and 52 (43.3%) females. Diabetes mellitus was found in 37 (30.8%) of the patients and 46 (38.3%) had hypertension. Thirty-five (29.2%) patients were found to have ASA grade III. There was no significant difference in the sex distribution between the two groups (p=0.412). The sarcopenic patients were older (p=0.018) and had a higher ASA Grade III (p=0.041). Detailed baseline characteristics are shown in Table 1. Postoperative outcomes are shown in Table 2 based on the preoperative sarcopenia status. An overall postoperative complication rate was noted in 46 (38.3%) patients. Nineteen (15.8%) patients had surgical site infection, 11 (9.2%) had wound dehiscence, and 14 (11.7%) developed postoperative pneumonia. There were 23 (19.2%) patients admitted to the Intensive care unit and 30 days postoperative mortality was found in 14 (11.7%) patients. The patients with preoperative sarcopenia had a significantly higher rate of overall postoperative complications (57.9% vs 29.3%; p=0.003), surgical site infection (26.3% vs 11.0%; p=0.031), ICU admission (31.6% vs 13.4%; p=0.019), prolonged hospital stay (11.0 ± 4.6 days vs 8.1 ± 3.8 days; p=0.012), and 30-day mortality (21.1% vs 7.3%; p=0.028) compared to the non-sarcopenic patients. The analysis of multivariable logistic regression is presented in Table 3. The adjusted odds ratio of sarcopenia (with respect to the ASA scale) was 2.84 (CI 1.19 to 6.76, p=0.019), meaning that sarcopenia was an independent risk factor for poor postoperative outcome, even after controlling for all other variables. The adjusted odds ratio for ASA Grade III to be an independent risk factor for postoperative complications was 2.36 (CI 1.03 to 5.39, p=0.041). In the adjusted model, the age ≥60 years and diabetes mellitus were not significant independent risk factors (p>0.05).

Table 1. Baseline demographic and clinical characteristics of the study population (N=120)

Table 2. Comparison of postoperative outcomes according to preoperative sarcopenia

Table 3. Multivariable logistic regression analysis for adverse postoperative outcomes

In this study, the effects of sarcopenia on patients who had undergone emergency laparotomies and their surgical outcomes were assessed. This study reveals that patients with sarcopenia have a higher risk of complications, surgical site infection, longer duration of stay in the ICU, longer hospital stays and higher 30-day mortality rate{6}. Furthermore, multiple logistic regression showed that sarcopenia was an independent risk factor for poor surgical outcome, regardless of the other risk factors. The prevalence of sarcopenia was 31.7%, which is in line with other studies. Humphry et al. reported ranging rates of sarcopenia among emergency laparotomy patients from 24.6% to 50.3%. This variation was explained by the different types of patients undergoing emergency laparotomy as well as the diagnosis of sarcopenia{7,8}. The prevalence of sarcopenia among emergency laparotomy patients was also high, indicating that skeletal muscle depletion is mainly observed in emergency abdominal patients, according to Yang and colleagues. These results confirm the clinical relevance of sarcopenia and its importance for the preoperative evaluation. The patients with sarcopenia had a higher number of complications after surgery than patients without sarcopenia{9}. This is consistent with a systematic review by Yang et al. that showed that sarcopenic patients had significantly worse postoperative complications, increased length of stay and increased ICU admissions. Another finding from Humphry et al. was a correlation between sarcopenia and longer hospital stays following surgery and higher mortality rates. The studies reviewed by Humphry et al., however, showed a mixed association between sarcopenia and major complications, which involves both physiologic and immune and nutritional reserves that all negatively affect recovery after major surgery {10,11}. From the same study, it was also revealed that sarcopenia prior to surgery was linked to increased 30-day mortality rate. Similar results were found by Park et al., who conducted a systematic review in over 6700 patients with sarcopenia who underwent an emergency laparotomy, demonstrating a significantly poorer short- and long-term prognosis in patients with sarcopenia. {12} More recently, Park et al., in a prospective multi-center cohort study, found that sarcopenia, myosteatosis and frailty, were all independently related to a higher risk of death post-emergency laparotomy, and a lower risk of recovery to a functional status and to an optimal out-of- hospital status. The studies highlight how vital it is to evaluate body composition, using CT, in surgical patients before they go into surgery. In this study, preoperative sarcopenia continued to be an independent predictor for negative postoperative consequences, even after adjustments were made. Although age and comorbidities/ASA status were adjusted for, there are increasing studies that show that combining sarcopenia with the more standard risk assessment models has the potential to improve prediction of peri-operative outcomes. {13} Such results are even more important in low resource health care systems. Since CT imaging of the abdomen is routinely done in many patients prior to conducting an emergency laparotomies, skeletal muscle mass assessment could be easily added to normal imaging reports, and done without incurring extra costs and/or additional studies. {14} Identifying patients with sarcopenia early on may help guide the optimization of nutrition, perioperative management and monitoring, and also help make the best use of available resources in the ICU. It could also be useful to combine frailty and sarcopenia assessment to enhance perioperative planning and counselling. {15} There are some limitations to this study. It was done in a single tertiary care centre with a small sample size which can affect the degree to which the results can be extrapolated. Measures of postoperative outcomes that are longer than the short-term and functional assessment of muscle strength were not included. However, the planned evaluation of sarcopenia preoperatively and the prospective study design support the findings of this study. Further, there is a need for larger, multicenter prospective studies, to test the findings of this study, and to assess whether addressing the problem of sarcopenia could enhance postoperative results after emergency laparotomy.

In adults who underwent emergency laparotomies, there was a significant preoperative sarcopenia association with poor postoperative outcomes. Patients with sarcopenia also had a higher rate of postoperative complications, higher rates of admission to the intensive care unit, higher lengths of hospital stay and a higher rate of death within 30 days, compared to those without sarcopenia. Further, in multivariable analysis, poor postoperative outcomes were still associated with preoperative sarcopenia. These findings indicate that it is advisable to routinely check for sarcopenia in emergency laparotomy. More detailed evaluation of the need of each patient is required, and likely improved results after surgery, particularly in a tertiary care center where resources are scarce, because there is more sarcopenia in a laparotomy population.

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