To the Editor,
We read with interest the study by Havan et al. entitled “Effect of sarcopenia on postoperative major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy: a retrospective cohort study” [1].
The findings that sarcopenia independently increases the risk of major postoperative complications are consistent with the literature that recognises muscle mass depletion as a critical factor affecting surgical outcomes in oncological populations [2–4]. Havan et al. [1] evaluated sarcopenia using the skeletal muscle index (SMI) at the L3 vertebral level, a recognised and validated approach. However, recent international guidelines emphasise a multidimensional approach that includes not only muscle mass but also strength and physical performance [5, 6]. Measures such as handgrip strength and gait speed have been shown to predict postoperative morbidity and long-term outcomes, with equal or even superior prognostic value compared to radiological parameters alone [7].
Sarcopenia is a modifiable preoperative risk factor in addition to being a prognostic marker. Randomised studies and meta-analyses provide evidence for the effectiveness of multimodal prehabilitation, which integrates tailored dietary assistance, resistance exercise, and psychological optimisation to enhance physiological reserve prior to major surgery [8–10]. Prehabilitation in colorectal cancer patients has been associated with shorter hospital stay, improved postoperative functional recovery, and reduced complication rates. Given the high physiologic burden of CRS/HIPEC and the prevalence of preexisting catabolic states in peritoneal carcinomatosis, this population may particularly benefit from such interventions.
Systemic inflammation is a primary catalyst of cancer-related sarcopenia. The relationship among inflammatory indicators (e.g. C-reactive protein, neutrophil-to-lymphocyte ratio), sarcopenia, and postoperative morbidity is thoroughly established [11, 12]. Incorporating these markers into preoperative assessment models may help identify “inflammatory sarcopenia”, which indicates poorer outcomes and requires more aggressive optimisation. We also suggest that recent advances in artificial intelligence (AI)-enabled imaging analysis, including automated segmentation of muscle tissue from routine preoperative CT scans, may facilitate large-scale, standardised screening for sarcopenia in surgical oncology workflows [13]. These technologies provide swift, objective measurement and can be incorporated into current radiology software to initiate automated referrals for prehabilitation in high-risk patients (Table 1).
Table 1.
A structured, multidimensional framework for sarcopenia management tailored to patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). The model integrates radiological, functional, biochemical, psychological, and digital tools for risk assessment and prehabilitation intervention
| Parameters | Assessment method | Intervention strategy |
|---|---|---|
| Muscle mass | CT-based skeletal muscle index (L3) AI-enabled automated segmentation |
High-protein nutritional supplementation Anabolic support if appropriate |
| Muscle strength |
Handgrip strength Chair stand test |
Progressive resistance training Physiotherapy-led strength programs |
| Physical performance |
Gait speed Timed Up and Go (TUG) test |
Aerobic training Functional mobility programs |
| Systemic inflammation |
C-reactive protein (CRP) Neutrophil-to-lymphocyte ratio (NLR) |
Anti-inflammatory dietary modulation Optimisation of comorbidities |
| Psychological readiness |
Anxiety/depression scales Psychosocial evaluation |
Counseling support Mindfulness and stress reduction strategies |
| Digital & AI integration |
Automated CT muscle segmentation Predictive modelling for risk stratification |
Embedding alerts in radiology reports Decision support for prehabilitation referral |
In conclusion, rigorous perioperative modelling of sarcopenia in patients undergoing CRS/HIPEC must encompass functional sarcopenia, inflammatory biomarkers, and structured prehabilitation. This modelling ought to be incorporated into preoperative standard protocols to enhance surgical outcomes and quality of life for patients undergoing CRS/HIPEC. Prospective studies incorporating functional sarcopenia measures, inflammatory profiling, and AI-assisted screening are necessary to validate and implement this methodology in clinical practices.
Author contributions
S.D.A. designed, prepared, and wrote the manuscript. A.E.C. and M.C.T. reviewed and supervised the manuscript preparation. All authors read and agreed to the published version of the manuscript.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Havan N, Gülmez S, Senger AS et al (2025) Influence of the effectiveness of sarcopenia on postoperative major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy: a retrospective cohort study. Int J Colorectal Dis 40:96 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.van Vugt JL, Braam HJ, van Oudheusden TR et al (2015) Skeletal muscle depletion is associated with severe postoperative complications in patients undergoing CRS/HIPEC. Ann Surg Oncol 22:3625–3631 [DOI] [PubMed] [Google Scholar]
- 3.Agalar C, Sokmen S, Arslan C et al (2020) Impact of sarcopenia on morbidity and long-term survival among patients with peritoneal metastases of colorectal origin treated with CRS/HIPEC. Tech Coloproctol 24:301–308 [DOI] [PubMed] [Google Scholar]
- 4.Di Giorgio A, Rotolo S, Cintoni M et al (2022) The prognostic value of skeletal muscle index in CRS and HIPEC: a systematic review and meta-analysis. Eur J Surg Oncol 48(3):649–656 [DOI] [PubMed] [Google Scholar]
- 5.Cruz-Jentoft AJ, Bahat G, Bauer J et al (2019) Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 48(1):16–31 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Chen LK, Woo J, Assantachai P et al (2020) Asian Working Group for Sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc 21(3):300–307 [DOI] [PubMed] [Google Scholar]
- 7.Shachar SS, Williams GR, Muss HB, Nishijima TF (2016) Prognostic value of sarcopenia in adults with solid tumours: a meta-analysis. Eur J Cancer 57:58–67 [DOI] [PubMed] [Google Scholar]
- 8.Gillis C, Fenton TR, Sajobi TT et al (2014) Trimodal prehabilitation for colorectal surgery attenuates post-surgical loss of functional capacity: a randomized control trial. Ann Surg 267(3):484–490 [Google Scholar]
- 9.Minnella EM, Awasthi R, Loiselle SE et al (2018) Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery. JAMA Surg 153(12):1081–1089 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Carli F, Scheede-Bergdahl C (2015) Prehabilitation to enhance perioperative care. Anesthesiol Clin 33(1):17–33 [DOI] [PubMed] [Google Scholar]
- 11.Durhan A, Koşmaz K, Şenlikci A et al (2021) Evaluation of the modified systemic ınflammation score and ınflammatory markers according to stage in colorectal cancer. Turk J Colorectal Dis 31(1):56–61. 10.4274/tjcd.galenos.2020.2020-6-2 [Google Scholar]
- 12.De Paula SN, Bruno KA, Azevedo MA et al (2018) Sarcopenia and skeletal muscle quality as predictors of postoperative complication in gynecologic cancer. Int J Gynecol Cancer 28:412–420 [DOI] [PubMed] [Google Scholar]
- 13.van Rijn-Dekker MI, van den Bosch L, van den Hoek JGM et al (2020) Deep learning-based body composition analysis predicts outcome in patients with head and neck cancer. Eur J Radiol 127:10899432305797 [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.