Impact and risk factors for clinically relevant surgery-related muscle loss in patients after major abdominal cancer surgery: study protocol for a prospective observational cohort study (MUSCLE POWER)

Judith E. K. R. Hentzen, Laura van Wijk, Carlijn I. Buis, Alain R. Viddeleer, Geertruida H. de Bock, Cees P. van der Schans, Gooitzen M. van Dam, Schelto Kruijff, Joost M. Klaase


Background: Surgery-related muscle loss (SRML) occurs in at least one out of three cancer patients within one week after major surgery. Though, this important phenomenon has hardly been investigated.

Methods: The MUSCLE POWER is a prospective, observational cohort study that investigates the presence, impact, and predictors for clinically relevant SRML in 178 cancer patients after major abdominal surgery using ultrasound measurements, squeeze and force measurements, and QoL questionnaires. Primary endpoint is the proportion of patients with clinically relevant SRML defined as ≥5% muscle loss within one week after surgery, measured by the cross-sectional area (CSA) of three different muscles: m. biceps brachii, m. rectus femoris, and m. vastus intermedius. Possible correlation with QoL and fatigue up to six months after surgery will be investigated. Daily physical activity during hospital stay will be monitored by a motility tracker, and protein intake will be monitored by a dietician. Possible predictors for clinically relevant SRML—consisting of age ≥65 years, preoperative diabetes, preoperative sarcopenia, major postoperative complications (Clavien-Dindo ≥III), insufficient physical activity, and insufficient postoperative protein intake—will be investigated with a multivariable logistic regression analyses with a backward stepwise approach. Variables with a p<0.05 will be retrained in the final multivariable model.

Discussion: The MUSCLE POWER investigates the presence and impact of clinically relevant SRML in cancer patients after major abdominal surgery. Crucial information regarding possible predictors for clinically relevant SRML can be used in future intervention studies to prevent postoperative muscle loss and subsequently improve postoperative outcome and QoL.

Trial Registration: Medical Ethics Committee of the University Medical Center Groningen, the Netherlands (METc2018/361, version 3.0, January 21, 2019), and Netherlands Trial Register ([NTR], NTR NL7505, version 1.0, February 7, 2019).


Surgery-related muscle loss, Abdominal cancer surgery, Nutrition, Physical activity, Quality of life

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Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayaka G, Chan P, et al. Acute skeletal muscle wasting in critical illness. JAMA 2013;310:1591-600.

Campbell IT, Watt T, Withers D, England R, Sukumar S, Keegan MA, et al. Muscle thickness, measured with ultrasound, may be an indicator of lean tissue wasting in multiple organ failure in presence of edema. Am J Clin Nutr. 1995;62:533-9.

Weijs PJ, Looijaard WG, Dekker IM, Stapel SN, Girbes AR, Oudemans-van Straaten HM, et al. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. Crit Care. 2014;18:R12.

Moisey LL, Mourtzakis M, Cotton BA, Premji T, Heyland DK, Wade CE, et al. Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care. 2013;17:R206.

de Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA 2002;288:2859-67.

Chambers MA, Moylan JS, Reid MB. Physical inactivity and muscle weakness in the critically ill. Crit Care Med. 2009;37:337-46.

Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011;10:931-41.

Baldwin CE, Bersten AD. Alterations in respiratory and limb muscle strength and size in patients with sepsis who are mechanically ventilated. Phys ther. 2014;94:68-82.

Dos Santos C, Hussain SN, Mathur S, Picard M, Herridge M, Correa J, et al. Mechanism of chronic muscle wasting and dysfunction after an intensive care unit stay: a pilot study. Am J Respir Crit Care Med. 2016;194:821-30.

Bloch SA, Lee JY, Wort SJ, Polkey MI, Kemp PR, Griffiths MJ. Sustained elevation of circulating growth and differentiation factor-15 and a dynamic imbalance in mediators of muscle homeostasis are associated with the development of acute muscle wasting following cardiac surgery. Crit Care Med. 2013;41:982-9.

Huang DD, Ji YB, Zhou DL, Li B, Wang SL, Chen XL, et al. Effect of surgery-induced acute muscle wasting on postoperative outcomes and quality of life. J Surg Res. 2017;218:58-66.

Otsuji H, Yokoyama Y, Ebata T, Igami T, Sugawara G, Mizuno T, et al. Surgery-related muscle loss and its association with postoperative complications after major hepatectomy with extrahepatic bile duct resection. World J Surg. 2017;41:498-507.

Kouw IWK, Groen BBL, Smeets JSJ, Kramer IF, van Kranenburg JMX, Nilwik R, et al. One week of hospitalization following elective hip surgery induces substantial muscle atrophy in older patients. JAMDA. 2019;20:35-42.

Douma RKW, Soer R, Krijnen WP, Reneman M, van der Schans CP. Reference values for isometric muscle force among workers for the Netherlands: a comparison of reference values. BMC Sports Science Medicine and Rehabilitation. 2014;6:10.

Singer P, Reintam Blaser A, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2018.

Ottery D. Patient Generated Subjective Global Assessment. In: McCallum P, Polisena C, Ed. The clinical guide to oncology nutrition, The American Dietetic Association, Chicago; 11-23.

Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age and Ageing. 2010;39:412-23.

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schullick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-96.

Stam SP, Osté MCJ, Eisenga MF, Blokzijl H, van den Berg AP, Bakker SJL, et al. Posttransplant muscle mass measured by urinary creatinine excretion rate predicts long-term outcomes after liver transplantation. Am J Transplant. 2018;19:540-50.

The WHOQOL group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med. 1998;28:551-8.

Skevington SM, Lotfy M, O’Connell KA, WHOQOL group. The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004;13:299-310.

Van der Zee K, Sanderman R, Heyink JW, de Haes H. Psychometric qualities of the RAND 36-item Health Survey 1.0: a multidimensional measure of general health status. Int J Behav Med. 1996;3:104-22.

Smets EM, Garssen B, Bonke B, De Haes JC. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39:315-25.

Bunnell A, Ney J, Gellhorn A, Hough CL. Quantitative neuromuscular ultrasound in intensive care unit-acquired weakness: a systematic review. Muscle Nerve 2015;52:701-8.

Connolly B, MacBean V, Crowley C, Lunt A, Moxham J, Rafferty GF, et al. Ultrasound for the assessment of peripheral skeletal muscle architecture in critical illness: a systematic review. Crit Care Med. 2014;7:1-10.

Sabatino A, Regolisti G, Bozzoli I, Fani F, Antoniotti R, Maggiore U, et al. Reliability of bedside ultrasound for measurement of quadriceps muscle thickness in critically ill patients with acute kidney injury. Clin Nutr. 2017;36:1710-5.

Parry SM, El-Ansary D, Cartwright MS, Sarwal A, Berney S, Koopman R, et al. Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function. J Crit Care. 2015;30:1151.

Koopman R, van Loon LJ. Aging, exercise, and muscle protein metabolism. J Appl Physiol. 2009;106:2040-8.

Gillis C, Nguyen TH, Liberman AS, Carli F. Nutrition adequacy in enhanced recovery after surgery: a single academic center experience. Nutr Clin Pract. 2015;30:414-9.

English KL, Paddon-Jones D. Protecting muscle mass and function in older adults during bed rest. Curr Opin Clin Nutr Metab Care 2010;13:34-39.

Paddon-Jones D, Sheffield-Moore M, Urban RJ, Sanford AP, Aarsland A, Wolfe RR, et al. Essential amino acid and carbohydrate supplementation ameliorates muscle protein loss in humans during 28 days bedrest. J Clin Endocrinol Metab. 2004;89:4351-8.

Wall BT, van Loon LJC. Nutritional strategies to attenuate muscle disease atrophy. Nutr Rev. 2013;71:195-208.

Ticinesi A, Meschi T, Narici MV, Laurentani F, Maggio M. Muscle ultrasound and sarcopenia in older individuals: a clinical perspective. J Am Med Dir Assoc. 2017;18:290-300.

Berger J, Bunout D, Barrera G, de la Maza MP, Henriquez S, Leiva L, et al. Rectus femoris (RF) ultrasound for the assessment of muscle mass in older people. Arch. Gerontol. Geriatr. 2015;61:33-8.