Abstract
Background
Sarcopenia may adversely affect postoperative outcomes, but most studies in colorectal cancer (CRC) have relied solely on computed tomography (CT)-derived muscle mass. We evaluated the association between a comprehensive assessment based on the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria and short-term postoperative outcomes after curative CRC surgery.
Methods
In this prospective observational study, 70 consecutive patients who underwent curative CRC resection between July 2024 and July 2025 were assessed for muscle strength (handgrip strength), physical performance (4-m gait speed), and muscle mass (L3 CT skeletal muscle index). According to EWGSOP2 criteria, patients were classified as non-sarcopenic or into the hierarchical cumulative stages of probable, confirmed, and severe sarcopenia. Postoperative outcomes included major complications and length of hospital stay.
Results
Of the 70 patients, 41 (58.6%) were non-sarcopenic, whereas 29 (41.4%) had at least probable sarcopenia; within this hierarchical group, 27 (38.6%) had confirmed sarcopenia and 18 (25.7%) had severe sarcopenia. Patients with at least probable sarcopenia were older and had lower body mass index and serum albumin levels (all p < 0.01). Across the hierarchical EWGSOP2 stages, the frequency of major postoperative complications increased compared with non-sarcopenic patients (probable 34.4%, confirmed 37.0%, severe 55.5% vs. 9.7%, respectively; p < 0.01), and hospital stay was significantly longer (9.3–10.6 vs. 6.1 days; p < 0.001). Tumor characteristics did not differ significantly between groups. In exploratory multivariable analysis, at least probable sarcopenia was associated with major postoperative complications (adjusted odds ratio [aOR] 11.75, 95% confidence interval [CI] 1.27–108.82; p = 0.030) and prolonged hospital stay (aOR 8.33, 95% CI 1.01–68.38; p = 0.049), although these estimates should be interpreted cautiously because of the small sample size and wide confidence intervals.
Conclusion
EWGSOP2-based sarcopenia assessment was associated with worse short-term postoperative outcomes after curative CRC resection. Given the limited sample size and wide confidence intervals, these findings should be interpreted as exploratory and require external validation in larger prospective cohorts before clinical implementation.
Trial registration
ClinicalTrials.gov Identifier: NCT06698289.
Keywords: Sarcopenia, Colorectal Cancer, EWGSOP2, Postoperative Complications, Surgical Outcomes
Background
Colorectal cancer (CRC) is the third most common cancer worldwide, with more than 1.9 million new cases and 904,000 deaths in 2022 [1–3]. CRC surgery is associated with high complication rates, creating a significant economic and social burden [4–6]. Therefore, predicting postoperative complications is of paramount importance in clinical practice.
Sarcopenia is a progressive and generalized skeletal muscle disorder that increases the risk of falls, fractures, physical disability, and mortality [7]. The European Working Group on Sarcopenia in Older People 2 (EWGSOP2) and the Asian Working Group for Sarcopenia (AWGS) define sarcopenia based on low muscle strength, low muscle mass, and impaired physical performance. Probable sarcopenia is identified when low muscle strength is detected. Confirmed sarcopenia is diagnosed when low muscle mass is present in addition to low muscle strength. Severe sarcopenia is diagnosed when low physical performance is also present [7, 8].
In patients undergoing colorectal surgery, sarcopenia has increasingly been recognized as a clinically relevant marker of reduced physiological reserve and adverse postoperative outcomes. Recent studies and meta-analyses have reported associations between preoperative sarcopenia and increased postoperative morbidity, mortality, and prolonged hospital stay after colorectal cancer surgery [9–13]. However, much of the available evidence has relied on imaging-derived parameters, such as the skeletal muscle index (SMI) measured on computed tomography (CT) or the psoas muscle index, which may not fully capture the multidimensional nature of sarcopenia [10, 11, 14–16]. In particular, functional components such as muscle strength and physical performance, which are central to EWGSOP2-based assessment, are often underrepresented in surgical oncology studies.
Therefore, this prospective observational study aimed to determine the prevalence of preoperative sarcopenia according to EWGSOP2 criteria and to evaluate its association with short-term postoperative outcomes after curative colorectal cancer surgery.
Methods
Study design and participants
Between July 2024 and July 2025, consecutive patients who underwent surgical resection for CRC at the Department of General Surgery of a tertiary university hospital were enrolled in this prospective study. Inclusion criteria were: age ≥ 18 years; American Society of Anesthesiologists (ASA) physical status class III or lower; elective surgery planned with curative intent for colorectal malignancy; availability of a preoperative abdominal CT scan obtained within 1 month before surgery; and provision of written informed consent. Exclusion criteria were: stage IV disease (distant metastasis); prior oncologic treatment, including neoadjuvant therapy; palliative surgery; physical impairment precluding muscle strength or physical performance testing; being bedridden or having severe mobility restrictions; and refusal to participate. The study protocol was approved by the Institutional Ethics Committee and conducted in accordance with the Declaration of Helsinki (Decision No: 2024/932). The study was prospectively registered at ClinicalTrials.gov before patient enrollment (Identifier: NCT06698289). The primary outcomes and main analysis plan were prespecified in the study protocol before data collection.
Data collection
All data were collected prospectively and stored in a digital database. Preoperative variables recorded for each patient included age, sex, body mass index (BMI), ASA physical status class, Charlson Comorbidity Index (CCI), unintentional weight loss > 10% within the previous 3 months, serum albumin level (hypoalbuminemia defined as < 35 g/L), hemoglobin level (anemia defined as < 13 g/dL for men and < 12 g/dL for women), and tumor location. Perioperative and postoperative variables included surgical approach (laparoscopic vs. open), operative time, length of hospital stay, and pathological findings. Postoperative complications were graded according to the Clavien–Dindo classification. Major postoperative complications were defined as Clavien–Dindo grade IIIB–V, corresponding to complications requiring intervention under general anesthesia, life-threatening complications requiring intensive care management, or death. Grade IIIA complications were reported separately but were not included in the primary major complication definition because they involve interventions without general anesthesia.
Sarcopenia assessment
Preoperative sarcopenia risk was additionally screened using the SARC-F (Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls) questionnaire, a previously published five-item screening tool assessing strength, assistance with walking, rising from a chair, climbing stairs, and falls [17]. Each item is scored from 0 to 2, yielding a total score ranging from 0 to 10, with scores ≥ 4 indicating high risk for sarcopenia. In the present study, SARC-F was recorded as an adjunct screening parameter and was not used as a diagnostic component of EWGSOP2 classification, which was based on handgrip strength, skeletal muscle index, and gait speed.
Sarcopenia was diagnosed according to the EWGSOP2 consensus criteria [7].
Muscle strength was assessed by handgrip strength testing of the dominant hand using a handheld hydraulic dynamometer (EH101; CAMRY, Guangdong, China), and values were recorded in kilograms (kg). Low muscle strength was defined as < 16 kg for women and < 27 kg for men [18].
Physical performance was assessed using the 4-meter usual gait speed test. Patients were instructed to walk a straight 4-meter course at their usual pace. Timing started at the first foot movement and stopped when the foot completely crossed the finish line. Three trials were performed, and gait speed was calculated in meters per second (m/s). According to EWGSOP2, gait speed ≤ 0.8 m/s indicated low physical performance; the fastest value from the three trials was used for analyses [7, 19].
Skeletal muscle mass evaluation was performed by a single radiologist using a standardized protocol. The radiologist was blinded to postoperative clinical outcomes during CT-based body composition analysis. Preoperative CT images were analyzed using dedicated body composition software. A single axial image at the level of the third lumbar vertebra (L3) was selected as the reference plane. Skeletal muscle area measurements included the psoas, paraspinal, and abdominal wall muscle groups. Semi-automated segmentation was performed with manual correction when necessary.
Skeletal muscle tissue was identified using attenuation thresholds ranging from − 29 to + 150 Hounsfield units (HU). The skeletal muscle index (SMI) was calculated by dividing skeletal muscle area (cm²) by height squared (m²). Low muscle mass was defined as an SMI < 52.4 cm²/m² for men and < 38.5 cm²/m² for women. These cut-off values were selected because they are widely used in oncologic body composition studies and allow comparability with previous colorectal cancer literature [20].
According to EWGSOP2, patients were classified as non-sarcopenic, probable sarcopenia, confirmed sarcopenia, or severe sarcopenia. Probable sarcopenia was defined by low muscle strength, confirmed sarcopenia by low muscle strength plus low muscle mass, and severe sarcopenia by the presence of confirmed sarcopenia together with reduced physical performance. Because these categories are hierarchical and cumulative by definition, confirmed sarcopenia represents a subset of probable sarcopenia, and severe sarcopenia represents a subset of confirmed sarcopenia [7].
Therefore, probable, confirmed, and severe sarcopenia were not considered mutually exclusive diagnostic groups. For the main inferential analyses, patients were dichotomized as non-sarcopenic or as having at least probable sarcopenia. This approach was selected to avoid statistically inappropriate comparisons between overlapping EWGSOP2 categories and to preserve interpretability in a relatively small cohort. Confirmed and severe sarcopenia were additionally presented descriptively to demonstrate the progressive burden of sarcopenia severity.
Patient follow-up
During the follow-up period after discharge, outpatient clinic visits were scheduled within the first two weeks, and conducted by the surgeon who performed the surgery.
Additionally, all patients were monitored through weekly telephone calls for 30 days after discharge. This follow-up method allowed for the assessment of the patients’ general health status, and hospitalization was recommended in cases where complications were suspected. Patients who developed complications after discharge were clinically evaluated upon hospitalization and received appropriate treatment.
Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 30.0 (IBM Corp., Armonk, NY, USA). The normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed variables were presented as mean ± standard deviation (SD), whereas non-normally distributed variables were expressed as median (interquartile range, IQR). Categorical variables were summarized as number (n) and percentage (%).
For the primary comparative analyses, patients were grouped as non-sarcopenic or as having at least probable sarcopenia. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. Continuous variables were compared using the independent samples t test or the Mann-Whitney U test, depending on data distribution.
Because EWGSOP2 stages are hierarchical and cumulative rather than mutually exclusive, probable, confirmed, and severe sarcopenia were not treated as independent exposure groups in the primary inferential analyses. Confirmed sarcopenia represents a subgroup of patients with at least probable sarcopenia who also have low muscle mass, whereas severe sarcopenia represents a subgroup of confirmed sarcopenia with additional impairment in physical performance. Therefore, the main comparative and regression analyses were performed by dichotomizing patients as non-sarcopenic versus at least probable sarcopenia. This approach was chosen to avoid statistically inappropriate comparisons between overlapping categories and to preserve model interpretability in a relatively small cohort. The hierarchical EWGSOP2 stages were presented descriptively to illustrate the progressive burden of sarcopenia severity.
Accordingly, p values in the main tables refer to comparisons between non-sarcopenic patients and patients with at least probable sarcopenia, not to comparisons among mutually exclusive EWGSOP2 stages.
In addition, logistic regression analyses were performed to evaluate the association between at least probable sarcopenia—defined as probable, confirmed, or severe sarcopenia according to EWGSOP2—and major postoperative complications and prolonged hospital stay. Unadjusted odds ratios were first calculated. Length of hospital stay was evaluated as a continuous postoperative outcome in the descriptive analyses.
For logistic regression, prolonged hospital stay was defined as hospitalization lasting more than 6 days and was considered an exploratory secondary outcome. This threshold was used to distinguish patients with delayed discharge relative to the early postoperative course of the non-sarcopenic group; however, because length of stay may be influenced by institutional discharge practices and non-clinical factors, this outcome was interpreted cautiously. The regression models were adjusted for age, sex, ASA physical status class, BMI, Charlson Comorbidity Index, serum albumin level, weight loss within the previous 3 months, and surgical approach (open vs. laparoscopic). BMI and serum albumin were included as clinically relevant covariates because of their known associations with nutritional status and postoperative outcomes; however, their potential role as markers within the nutritional/frailty pathway was considered when interpreting the adjusted estimates. These covariates were selected a priori based on clinical relevance and were entered simultaneously into the model; no stepwise variable selection was performed. Given the relatively small number of outcome events in relation to the number of covariates, the adjusted models were considered at risk of overfitting and were used only to explore covariate-adjusted associations. Therefore, the adjusted estimates were interpreted cautiously and were not considered evidence of independent effects.
Results
Patient distribution according to sarcopenia status
A total of 70 patients were included in the study (mean age, 64.8 ± 13.2 years; 57.1% male). According to EWGSOP2 criteria, 41 patients (58.6%) were classified as non-sarcopenic, whereas 29 patients (41.4%) had at least probable sarcopenia. Within this hierarchical cumulative group, 27 patients (38.6%) fulfilled the criteria for confirmed sarcopenia and 18 patients (25.7%) fulfilled the criteria for severe sarcopenia. Because confirmed sarcopenia is nested within probable sarcopenia and severe sarcopenia is nested within confirmed sarcopenia, these categories are not mutually exclusive.
Therefore, inferential comparisons were limited to non-sarcopenic patients versus patients with at least probable sarcopenia, whereas confirmed and severe sarcopenia were presented descriptively to show increasing sarcopenia severity (Fig. 1).
Fig. 1.
Diagram illustrating the comprehensive sarcopenia assessment and classification according to EWGSOP2 criteria in patients undergoing CRC surgery. (Created with https://BioRender.com)
Demographic and clinical characteristics
Compared with non-sarcopenic patients, those with at least probable sarcopenia were older and had lower body mass index, lower serum albumin levels, and higher Charlson Comorbidity Index scores. Overall, 53 patients (75.7%) had colon cancer and 17 patients (24.3%) had rectal cancer. Tumor location did not differ significantly between non-sarcopenic patients and those with at least probable sarcopenia (p = 0.778). No significant differences were observed with respect to sex, hemoglobin level, ASA physical status class, surgical approach, or operative time (Table 1).
Table 1.
Demographic and clinical characteristics of the study cohort
| Parameters | Non-sarcopenic (n = 41) (58.6%) |
Probable Sarcopenia (n = 29) (41.4%) |
Confirmed Sarcopenia (n = 27) (38.6%) |
Severe Sarcopenia (n = 18) (25.7%) |
Total (n = 70) | p value |
|---|---|---|---|---|---|---|
|
Age, mean ± SD (years) |
60.5 ± 13.5 | 71.0 ± 10.7 | 71.1 ± 11.1 | 74.7 ± 11.6 | 64.8 ± 13.2 | < 0.001* |
| Gender, n (%) | 0.412 | |||||
| Female | 19 (46.3%) | 11 (37.9%) | 11 (40.7%) | 9 (50.0%) | 30 (42.9%) | |
| Male | 22 (53.7%) | 18 (62.1%) | 16 (59.3%) | 9 (50.0%) | 40 (57.1%) | |
| BMI, mean ± SD (kg/m²) | 27.0 ± 3.7 | 24.1 ± 4.3 | 24.2 ± 4.4 | 24.3 ± 4.8 | 25.8 ± 4.3 | < 0.01* |
| Hemoglobin, mean ± SD (g/dL) | 11.6 ± 4.7 | 11.6 ± 4.2 | 11.7 ± 4.4 | 10.6 ± 1.9 | 11.4 ± 4.1 | 0.238 |
| Albumin, mean ± SD (g/L) | 37.2 ± 5.2 | 24.3 ± 5.0 | 23.9 ± 4.5 | 24.3 ± 3.7 | 32.1 ± 8.4 | < 0.001* |
| ASA physical status classification, n (%) | 0.682 | |||||
| I | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
| II | 11 (26.8%) | 5 (17.2%) | 5 (18.5%) | 3 (16.7%) | 16 (22.9%) | |
| III | 30 (73.2%) | 24 (82.8%) | 22 (81.5%) | 15 (83.3%) | 54 (77.1%) | |
| Weight loss (≥ 10% in last 3 months), n (%) | 0.417 | |||||
| Yes | 15 (36.6%) | 14 (48.3%) | 13 (48.1%) | 9 (50.0%) | 29 (41.4%) | |
| No | 26 (63.4%) | 15 (51.7%) | 14 (51.9%) | 9 (50.0%) | 41 (58.6%) | |
| CCI, mean ± SD | 4.2 ± 1.8 | 5.1 ± 2.1 | 5.2 ± 2.2 | 5.4 ± 2.0 | 4.6 ± 2.0 | < 0.05 * |
| Tumor location, n (%) | 0.778 | |||||
| Colon | 32 (78.0%) | 21 (72.4%) | 20 (74.1%) | 14 (77.8%) | 53 (75.7%) | |
| Rectum | 9 (22.0%) | 8 (27.6%) | 7 (25.9%) | 4 (22.2%) | 17 (24.3%) | |
| Laparoscopic surgery, n (%) | 0.322 | |||||
| Yes | 28 (68.3%) | 15 (51.7%) | 15 (55.6%) | 9 (50.0%) | 43 (61.4%) | |
| No | 13 (31.7%) | 14 (48.3%) | 12 (44.4%) | 9 (50.0%) | 27 (38.6%) | |
| Operative time, mean ± SD (min) | 183.7 ± 89.2 | 196.2 ± 102.8 | 201.5 ± 105.1 | 188.3 ± 95.7 | 189.2 ± 95.4 | 0.402 |
SD Standard deviation, BMI Body mass index, ASA American Society of Anesthesiologists, CCI Charlson Comorbidity Index, EWGSOP2, European Working Group on Sarcopenia in Older People 2
*Statistically significant (p < 0.05). Values are presented as mean ± standard deviation or n (%), as appropriate. P values represent comparisons between non-sarcopenic patients and patients with at least probable sarcopenia; confirmed and severe sarcopenia columns are presented descriptively and were not used as independent groups in inferential comparisons. Probable, confirmed, and severe sarcopenia are hierarchical cumulative EWGSOP2 stages and should not be interpreted as mutually exclusive categories. Confirmed sarcopenia is a subgroup of patients with probable sarcopenia, and severe sarcopenia is a subgroup of patients with confirmed sarcopenia. Therefore, percentages across these columns should not be summed
Sarcopenia assessment parameters
Compared with non-sarcopenic patients, patients with at least probable sarcopenia had significantly higher SARC-F scores and significantly lower handgrip strength, skeletal muscle index, and gait speed. Confirmed and severe sarcopenia were not analyzed as independent comparison groups because they represent hierarchical subgroups within at least probable sarcopenia. Descriptively, handgrip strength, skeletal muscle index, and gait speed showed progressive deterioration across the EWGSOP2 severity spectrum (Table 2).
Table 2.
Sarcopenia assessment parameters
| Parameters | Non-sarcopenic (n = 41) (58.6%) |
Probable Sarcopenia (n = 29) (41.4%) |
Confirmed Sarcopenia (n = 27) (38.6%) |
Severe Sarcopenia (n = 18) (25.7%) |
Total (n = 70) | p value |
|---|---|---|---|---|---|---|
| SARC-F score, n (%) | < 0.001* | |||||
| ≥ 4 | 3 (7.3%) | 22 (75.9%) | 21 (77.8%) | 16 (88.9%) | 25 (35.7%) | |
| < 4 | 38 (92.7%) | 7 (24.1%) | 6 (22.2%) | 2 (11.1%) | 45 (64.3%) | |
| Handgrip strength, mean ± SD (kg) | 29.5 ± 7.9 | 16.9 ± 6.3 | 16.7 ± 6.5 | 14.8 ± 6.5 | 21.0 ± 9.4 | < 0.001* |
| SMI, mean ± SD (cm²/m²) | 55.6 ± 2.7 | 40.5 ± 1.3 | 40.1 ± 1.3 | 40 ± 1.2 | 47.4 ± 8.6 | < 0.001 * |
| Gait speed, mean ± SD (m/s) | 1.0 ± 0.3 | 0.7 ± 0.4 | 0.7 ± 0.4 | 0.5 ± 0.3 | 0.8 ± 0.4 | < 0.001* |
SD Standard deviation, SARC-F Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls questionnaire, SMI Skeletal muscle index, EWGSOP2 European Working Group on Sarcopenia in Older People 2
*Statistically significant (p < 0.05). Values are presented as mean ± standard deviation or n (%), as appropriate. P values represent comparisons between non-sarcopenic patients and patients with at least probable sarcopenia; confirmed and severe sarcopenia columns are presented descriptively and were not used as independent groups in inferential comparisons. Probable, confirmed, and severe sarcopenia are hierarchical cumulative EWGSOP2 stages and should not be interpreted as mutually exclusive categories. Confirmed sarcopenia is a subgroup of patients with probable sarcopenia, and severe sarcopenia is a subgroup of patients with confirmed sarcopenia. Therefore, percentages across these columns should not be summed. EWGSOP2 handgrip strength cut-offs were < 27 kg for men and < 16 kg for women, indicating low muscle strength. Sex-specific SMI cut-offs were < 52.4 cm²/m² for men and < 38.5 cm²/m² for women, indicating low muscle mass. A SARC-F score ≥ 4 indicates high risk for sarcopenia. A gait speed ≤ 0.8 m/s indicates low physical performance and was used to define severe sarcopenia according to EWGSOP2 criteria
Postoperative outcomes and pathological characteristics
Length of hospital stay, evaluated as a continuous variable, was longer among patients with sarcopenia. The mean length of stay was 6.1 ± 1.9 days in non-sarcopenic patients and ranged from 9.3 to 10.6 days across the hierarchical EWGSOP2 stages. Major postoperative complications, defined as Clavien–Dindo grade IIIB–V, were observed in 9.7% of non-sarcopenic patients and increased descriptively across the cumulative sarcopenia stages, reaching 34.4% in probable sarcopenia, 37.0% in confirmed sarcopenia, and 55.5% in severe sarcopenia. Grade IIIA and grade V events were also reported separately in Table 3 to allow transparent interpretation of the complication severity distribution. Because these stages are overlapping hierarchical categories, this pattern should be interpreted descriptively rather than as a comparison between independent groups. No statistically significant differences were observed in tumor size, T stage, N stage, lymphovascular invasion, perineural invasion, or microsatellite instability status (Table 3). Postoperative complications were classified and analyzed according to Clavien–Dindo severity grades. However, detailed complication subtypes, including anastomotic leakage, surgical site infection, ileus, intra-abdominal abscess, pulmonary complications, urinary complications, and reoperation, were not systematically recorded in a standardized format; therefore, subtype-specific descriptive summaries, subgroup analyses, and regression analyses could not be performed.
Table 3.
Clinical outcomes and pathological characteristics
| Parameters | Non-sarcopenic (n = 41) (58.6%) |
Probable Sarcopenia (n = 29) (41.4%) |
Confirmed Sarcopenia (n = 27) (38.6%) |
Severe Sarcopenia (n = 18) (25.7%) |
Total (n = 70) | p value |
|---|---|---|---|---|---|---|
| Length of stay, mean ± SD (days) | 6.1 ± 1.9 | 9.3 ± 3.7 | 9.5 ± 3.8 | 10.6 ± 3.6 | 7.9 ± 3.5 | < 0.001* |
| Clavien–Dindo complications, n (% | ||||||
| Grade I | 35 (85.4%) | 6 (20.7%) | 5 (18.5%) | 1 (5.6%) | 41 (58.6%) | < 0.001* |
| Grade II | 0 (0.0%) | 5 (17.2%) | 5 (18.5%) | 5 (27.8%) | 5 (7.1%) | |
| Grade IIIA | 2 (4.9%) | 8 (27.7%) | 7 (26.0%) | 2 (11.1%) | 10 (14.3%) | |
| Grade IIIB | 3 (7.3%) | 5 (17.2%) | 5 (18.5%) | 5 (27.8%) | 8 (11.4%) | |
| Grade IV | 1 (2.4%) | 3 (10.3%) | 3 (11.1%) | 3 (16.6%) | 4 (5.7%) | |
| Grade V | 0 (0.0%) | 2 (6.9%) | 2 (7.4%) | 2 (11.1%) | 2 (2.9%) | |
|
Minor complications (I-IIIA) |
37 (90.3%) | 19 (65.6%) | 17 (63.0%) | 8 (44.5%) | 56 (80.0%) | < 0.01* |
| Major complications (IIIB-V) | 4 (9.7%) | 10 (34.4%) | 10 (37.0%) | 10 (55.5%) | 14 (20%) | < 0.01* |
| Tumor size, mean ± SD (mm) | 48.8 ± 17.3 | 44.4 ± 16.0 | 44.6 ± 16.5 | 45.3 ± 15.2 | 46.8 ± 16.5 | 0.128 |
| T stage, n (%) | 0.214 | |||||
| T1 | 0 (0.0%) | 1 (3.4%) | 1 (3.7%) | 1 (5.6%) | 1 (1.4%) | |
| T2 | 5 (12.2%) | 6 (20.7%) | 6 (22.2%) | 3 (16.7%) | 11 (15.7%) | |
| T3 | 26 (63.4%) | 17 (58.6%) | 16 (59.3%) | 11 (61.1%) | 43 (61.4%) | |
| T4 | 10 (24.4%) | 5 (17.2%) | 4 (14.8%) | 3 (16.7%) | 15 (21.4%) | |
| N stage, n (%) | 0.337 | |||||
| N0 | 26 (63.4%) | 21 (72.4%) | 19 (70.4%) | 12 (66.7%) | 47 (67.1%) | |
| N1 | 8 (19.5%) | 7 (24.1%) | 7 (25.9%) | 5 (27.8%) | 15 (21.4%) | |
| N2 | 7 (17.1%) | 1 (3.4%) | 1 (3.7%) | 1 (5.6%) | 6 (11.4%) | |
| LVI, n (%) | 0.456 | |||||
| Yes | 7 (17.1%) | 4 (13.8%) | 4 (14.8%) | 3 (16.7%) | 11 (15.7%) | |
| No | 34 (82.9%) | 25 (86.2%) | 23 (85.2%) | 15 (83.3%) | 59 (84.3%) | |
| PNI, n (%) | 0.682 | |||||
| Yes | 10 (24.4%) | 6 (20.7%) | 6 (22.2%) | 4 (22.2%) | 16 (22.9%) | |
| No | 31 (75.6%) | 23 (79.3%) | 21 (77.8%) | 14 (77.8%) | 54 (77.1%) | |
| MSI status, n (%) | 0.874 | |||||
| MSS | 33 (80.5%) | 25 (86.2%) | 23 (85.2%) | 15 (83.3%) | 58 (82.9%) | |
| MSI | 8 (19.5%) | 4 (13.8%) | 4 (14.8%) | 3 (16.7%) | 12 (17.1%) | |
SD Standard deviation, LVI Lymphovascular invasion, PNI Perineural invasion, MSI Microsatellite instability, MSS: Microsatellite stable, EWGSOP2 European Working Group on Sarcopenia in Older People 2
*Statistically significant (p < 0.05). Values are presented as mean ± standard deviation or n (%), as appropriate. P values represent comparisons between non-sarcopenic patients and patients with at least probable sarcopenia; confirmed and severe sarcopenia columns are presented descriptively and were not used as independent groups in inferential comparisons. Probable, confirmed, and severe sarcopenia are hierarchical cumulative EWGSOP2 stages and should not be interpreted as mutually exclusive categories. Confirmed sarcopenia is a subgroup of patients with probable sarcopenia, and severe sarcopenia is a subgroup of patients with confirmed sarcopenia. Therefore, percentages across these columns should not be summed. Postoperative complications were graded according to the Clavien–Dindo classification. Major postoperative complications were defined as Clavien–Dindo grade IIIB–V. Grade IIIA complications were reported separately but were not included in the major complication definition
Multivariable logistic regression analysis
In unadjusted logistic regression analysis, at least probable sarcopenia was associated with higher odds of major postoperative complications (OR, 4.87; 95% CI, 1.35–17.58; p = 0.015). An exploratory adjusted logistic regression model was then fitted to estimate covariate-adjusted associations with postoperative outcomes. In this model, at least probable sarcopenia showed an association with major postoperative complications (aOR, 11.75; 95% CI, 1.27–108.82; p = 0.030) and prolonged hospital stay (aOR, 8.33; 95% CI, 1.01–68.38; p = 0.049). A higher ASA physical status class also showed an association with prolonged hospital stay (aOR, 4.22; 95% CI, 1.25–14.25; p = 0.020).
However, because the number of outcome events was limited relative to the number of covariates and the confidence intervals were wide, these estimates should not be interpreted as precise effect estimates or as evidence of independent effects. Therefore, the adjusted regression findings should be considered exploratory and hypothesis-generating rather than confirmatory (Table 4).
Table 4.
Multivariable analyses of postoperative outcomes according to at least probable sarcopenia
| Variable | Major postoperative complications * aOR (95% CI) |
p-value | Prolonged hospital stay † aOR (95% CI) |
p-value |
|---|---|---|---|---|
| At least probable sarcopenia (probable, confirmed, or severe sarcopenia according to EWGSOP2) | 11.75 (1.27–108.82) | 0.030* | 8.33 (1.01–68.38) | 0.049* |
| Age, years | 0.98 (0.90–1.06) | 0.569 | 1.05 (0.93–1.18) | 0.419 |
| Female sex | 3.41 (0.85–13.64) | 0.083 | 1.58 (0.31–8.00) | 0.584 |
| ASA physical status classification | 2.07 (0.76–5.67) | 0.157 | 4.22 (1.25–14.25) | 0.020 |
| BMI, kg/m² | 0.95 (0.79–1.14) | 0.580 | 1.04 (0.83–1.32) | 0.723 |
| Charlson Comorbidity Index | 0.94 (0.57–1.53) | 0.800 | 1.39 (0.71–2.73) | 0.343 |
| Albumin | 0.98 (0.87–1.11) | 0.802 | 0.93 (0.82–1.06) | 0.301 |
| Weight loss in the last 3 months | 0.90 (0.19–4.27) | 0.893 | 1.83 (0.32–10.56) | 0.501 |
| Open surgery | 1.57 (0.45–5.48) | 0.478 | 4.59 (0.86–24.49) | 0.075 |
OR Odds ratio, aOR Adjusted odds ratio, CI Confidence interval, ASA American Society of Anesthesiologists, BMI Body mass index, EWGSOP2 European Working Group on Sarcopenia in Older People 2
*Statistically significant (p < 0.05). Values are presented as odds ratios with 95% confidence intervals. Major postoperative complications were defined as Clavien–Dindo grade IIIB–V. Prolonged hospital stay was defined as hospitalization lasting more than 6 days and was evaluated as an exploratory secondary outcome. The adjusted models included age, sex, ASA physical status class, BMI, Charlson Comorbidity Index, serum albumin level, weight loss within the previous 3 months, and surgical approach. Covariates were selected a priori based on clinical relevance and entered simultaneously into the model; no stepwise variable selection was performed. Given the limited number of outcome events relative to the number of covariates, the adjusted estimates should be interpreted cautiously as exploratory and should not be considered precise effect estimates or evidence of independent effects
Discussion
Study originality and importance of EWGSOP2 criteria
This study adds to the limited prospective evidence evaluating sarcopenia in patients undergoing CRC surgery using a multidimensional EWGSOP2 framework that incorporates muscle strength and physical performance in addition to muscle mass. In many previous studies, sarcopenia has been assessed solely using CT-derived indices such as the SMI, which may overlook functional impairment. According to EWGSOP2, low muscle strength indicates probable sarcopenia, the diagnosis is confirmed by the presence of low muscle mass, and severity is determined by low physical performance [7]. Using this comprehensive approach, our study provides a novel evaluation of EWGSOP2-defined sarcopenia and its association with postoperative outcomes in patients undergoing curative CRC resection.
Sarcopenia prevalence: triple assessment vs. CT-based approach
In our study, the prevalence of EWGSOP2-confirmed sarcopenia was 38.6%, and severe sarcopenia was identified in 25.7% of patients. When the same cohort was evaluated using CT-derived skeletal muscle index (SMI) alone, the sarcopenia prevalence increased to 57.1%. Similar patterns have been reported in the literature. Confirmed and severe sarcopenia prevalences of 19.4% and 9.7%, respectively, were reported using a multidimensional (triple) assessment; however, when SMI alone was used, the prevalence increased to 48.4% [21]. Likewise, a sarcopenia prevalence of 12.0% was reported using EWGSOP-based multidimensional assessment, whereas the proportion of patients with low muscle mass alone was 14.8% [18]. Collectively, these findings suggest that CT-based muscle-mass assessments may yield higher prevalence estimates than EWGSOP2-based multidimensional definitions, and that incorporating functional measures refines patient classification. In a prospective study that included only patients with malnutrition, sarcopenia prevalence was 46.7% [11]. Reported prevalences in retrospective studies using CT/SMI vary widely, ranging from 25% to 49.5%, 60.3%, and 68.2% [22–25]. In a meta-analysis pooling 20 studies, the overall sarcopenia prevalence was estimated as 34% [26]. Overall, our prevalence estimates using both CT-based SMI and EWGSOP2-based multidimensional assessment are consistent with prior reports.
Patient demographics and clinical characteristics
In our study, the mean age was 64.8 years, and 57.1% of patients were male, which is broadly consistent with the demographic profile reported in the CRC literature.
Sarcopenic patients had significantly lower BMI and albumin levels than non-sarcopenic patients. Weight loss ≥ 10% in the last 3 months was observed in 41.4% of the overall cohort and in approximately half of the sarcopenia groups, without a statistically significant difference between non-sarcopenic patients and those with at least probable sarcopenia (p = 0.417). Similar associations have been reported previously, with multiple studies showing that sarcopenia is linked to lower BMI and more frequent hypoalbuminemia/hypoproteinemia [18, 21–24]. Collectively, these findings suggest that sarcopenia reflects a more frail patient phenotype and may be relevant to preoperative risk evaluation.
Postoperative outcomes and complications
Many studies have reported an association between sarcopenia and increased postoperative morbidity after CRC surgery, although reported complication rates vary according to sarcopenia definition, patient population, operative approach, and outcome definitions. Huang et al. reported an overall postoperative complication rate of 58.8% among sarcopenic patients using a multidimensional definition incorporating muscle mass, muscle strength, and physical performance [18]. Nakanishi et al., using CT-based muscle mass assessment, reported an association between sarcopenia and postoperative complications, with an overall complication rate of 45.6% among sarcopenic patients [24]. More recently, Su et al. reported a postoperative complication rate of 46.8% in patients with CT-derived sarcopenia undergoing laparoscopic radical resection for non-metastatic CRC [11]. In addition, Li et al. demonstrated in a prospective cohort that sarcopenia was associated with postoperative complications and survival among CRC patients with GLIM-defined malnutrition [12]. An updated meta-analysis by Keshavjee et al. also supported the association between preoperative sarcopenia and poorer short-term postoperative outcomes after curative CRC surgery [13].
In the present study, major postoperative complications increased across the hierarchical EWGSOP2 spectrum, from 9.7% in non-sarcopenic patients to 34.4% in probable sarcopenia, 37.0% in confirmed sarcopenia, and 55.5% in severe sarcopenia.
Although direct comparison between studies is limited by differences in sarcopenia criteria and complication definitions, our findings are broadly consistent with previous reports showing a higher postoperative risk among sarcopenic patients [11, 12, 18, 24]. However, given the limited sample size, low number of outcome events relative to the number of covariates, and wide confidence intervals in the adjusted analyses, these findings should be interpreted cautiously and considered hypothesis-generating rather than evidence of independent effects.
Sarcopenia was also associated with longer hospitalization in our cohort. This finding is consistent with previous studies reporting prolonged postoperative length of stay among sarcopenic CRC patients [11, 12, 18]. Huang et al. and Su et al. both reported significantly longer hospital stay in sarcopenic patients, supporting the concept that reduced muscle reserve may adversely affect early postoperative recovery [11, 18].
However, length of stay is influenced not only by clinical recovery but also by institutional discharge protocols, surgeon preference, social factors, and perioperative care pathways. Therefore, the association between EWGSOP2-defined sarcopenia and prolonged hospitalization in our study should be interpreted as supportive but not definitive evidence of impaired postoperative recovery.
Functional parameters in sarcopenia assessment
Prospective studies suggest that multidimensional definitions of sarcopenia incorporating muscle strength and physical performance, in addition to muscle mass, may be associated with postoperative outcomes in CRC surgery. It has been reported that a multidimensional sarcopenia definition incorporating low muscle mass, low muscle strength, and impaired physical performance was associated with postoperative complications after CRC surgery [18]. Similarly, functional parameters have been evaluated as part of preoperative sarcopenia assessment in patients with CRC [21].
Supporting the importance of nutritional and functional reserve, sarcopenia was associated with postoperative complications and survival in a prospective CRC cohort [12].
Consistent with these findings, our study observed that patients with at least probable sarcopenia had lower handgrip strength, lower SMI, slower gait speed, and higher postoperative morbidity. Nevertheless, because we did not perform a formal head-to-head comparison between SMI alone and the full EWGSOP2 definition, our findings should be interpreted as showing an association between multidimensional sarcopenia assessment and postoperative outcomes rather than demonstrating superiority over CT-based assessment alone. This cautious interpretation is also important given the limited sample size and exploratory nature of the multivariable findings. Because the primary exposure variable was defined as at least probable sarcopenia, it included patients with low muscle strength even before the additional confirmation of low muscle mass or impaired physical performance. Therefore, this variable should be interpreted not only as a marker of established multidimensional sarcopenia, but also as a broader indicator of reduced functional reserve, dynapenia, and frailty-related vulnerability. Because at least probable sarcopenia includes patients with low muscle strength alone as well as patients with confirmed or severe sarcopenia, the observed associations cannot determine whether postoperative risk was driven by sarcopenia itself, impaired muscle strength, or their combined effect.
Relationship between sarcopenia and pathological parameters
From a pathological perspective, we found no statistically significant differences between sarcopenic and non-sarcopenic patients regarding T stage, N stage, LVI, PNI, MSI status, or tumor size. This finding suggests that sarcopenia reflects the patient’s systemic physiological reserve rather than tumor anatomical or pathological features.
Consistent with this, prior studies have reported that sarcopenia is not necessarily linked to tumor stage, size, or invasion characteristics. Sarcopenia was reported to be independent of TN stage and tumor location [24]. Similarly, no significant association was found between sarcopenia and tumor stage in a CRC cohort [12]. Overall, the available evidence indicates that associations between sarcopenia and pathological tumor parameters are limited and may vary across cohorts and definitions.
Strengths and limitations
The main strength of this study is its prospective design and multidimensional sarcopenia assessment based on EWGSOP2 criteria. However, the small sample size and limited number of major complications may have reduced model stability; therefore, the regression findings should be interpreted as exploratory. Because EWGSOP2 stages are hierarchical, at least probable sarcopenia was used as the primary exposure, while confirmed and severe sarcopenia were reported descriptively. In addition, because the primary exposure was defined as at least probable sarcopenia, which combines patients with low muscle strength alone and those with confirmed or severe sarcopenia, the relative contribution of low muscle strength versus established multidimensional sarcopenia to postoperative outcomes could not be determined.
Generalizability may be limited by the single-center design, colon-predominant cohort, exclusion of patients receiving neoadjuvant treatment or unable to complete functional tests, lack of Turkish population-specific SMI cut-offs, absence of CT measurement reliability analyses, and the lack of systematically recorded postoperative complication subtypes. Residual confounding remains possible because inflammatory status, GLIM-defined malnutrition, and formal performance status were not systematically assessed; therefore, the observed associations should not be interpreted as causal. In addition, length of hospital stay may be influenced by institutional practices, the Clavien–Dindo IIIB–V threshold may limit comparability, and adjustment for BMI and albumin may have introduced potential overadjustment.
Conclusions
Preoperative sarcopenia defined according to EWGSOP2 criteria was associated with worse short-term postoperative outcomes after curative colorectal cancer surgery in this colon-predominant cohort. However, because of the limited sample size, low number of outcome events, and wide confidence intervals, these findings should be considered exploratory and require external validation in larger multicenter cohorts with balanced representation of colon and rectal cancer patients before clinical implementation.
Acknowledgements
Not applicable.
Abbreviations
- ASA
American Society Of Anesthesiologists
- AWGS
Asian Working Group For Sarcopenia
- BMI
Body Mass Index
- CCI
Charlson Comorbidity Index
- CI
Confidence Interval
- CRC
Colorectal Cancer
- CT
Computed Tomography
- EWGSOP2
European Working Group on Sarcopenia in Older People 2
- GLIM
Global Leadership Initiative on Malnutrition
- IQR
Interquartile Range
- L3
Third Lumbar Vertebral Level
- LVI
Lymphovascular Invasion
- MSI
Microsatellite Instability
- MSS
Microsatellite Stable
- OR
Odds Ratio
- PNI
Perineural Invasion
- SARC-F
Strength, Assistance with Walking, Rise from a Chair, Climb Stairs, And Falls Questionnaire
- SD
Standard Deviation
- SMI
Skeletal Muscle Index
Authors' contributions
Conceptualization, M.Y. and H.B.; Methodology, M.Y., M.E.B., G.A., M.B. T.Ç. and C.Ö.; Formal Analysis, M.Y., M.B. and C.Ö.; Investigation, M.Y., S.T., H.B.K. and M.E.B.; Data Curation, M.Y., S.T. and H.B.K.; Radiologic Assessment, G.A.; Writing – Original Draft Preparation, M.Y. and M.B.; Writing – Review & Editing, S.T., H.B.K., M.E.B., G.A., T.Ç., C.Ö. and H.B.; Visualization, M.Y.; Supervision, T.Ç. and H.B.; Project Administration, H.B. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.
Funding
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of Mersin University. Written informed consent was obtained from all participants.
Consent for publication
Not applicable.
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.Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. 10.3322/caac.21834. [DOI] [PubMed] [Google Scholar]
- 2.Morgan E, Arnold M, Gini A, Lorenzoni V, Cabasag CJ, Laversanne M, et al. Global burden of colorectal cancer in 2020 and 2040: incidence and mortality estimates from GLOBOCAN. Gut. 2023;72(2):338–44. 10.1136/gutjnl-2022-327736. [DOI] [PubMed] [Google Scholar]
- 3.Agrawal N, Lanjhiyana SK, Jaiswal M, Siddiqui MA, Gupta S. Colorectal cancer spectrum: from subtypes and epidemiology to oncotherapies. Gastroenterol Endosc (Amst). 2025;3(2):55–64. 10.1016/j.gande.2025.01.002. [Google Scholar]
- 4.Benbouzid A, Tabchouri N, Denet C, Ferraz JM, Laforest A, Gayet B, et al. Enhanced recovery protocols in colonic surgery: retrospective cohort analysis of economic impact from an institutional point of view. Int J Colorectal Dis. 2019;34(2):301–7. 10.1007/s00384-018-3201-9. [DOI] [PubMed] [Google Scholar]
- 5.Jafari A, Hosseini FA, Jalali FS. A systematic review of the economic burden of colorectal cancer. Health Sci Rep. 2024;7(8):e70002. 10.1002/hsr2.70002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: risk factors and preventive strategies. Patient Saf Surg. 2010;4(1):5. 10.1186/1754-9493-4-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31. 10.1093/ageing/afy169. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, et al. Asian working group for sarcopenia: 2019 Consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21(3):300–e3072. 10.1016/j.jamda.2019.12.012. [DOI] [PubMed] [Google Scholar]
- 9.Vergara-Fernandez O, Trejo-Avila M, Salgado-Nesme N. Sarcopenia in patients with colorectal cancer: a comprehensive review. World J Clin Cases. 2020;8(7):1188–202. 10.12998/wjcc.v8.i7.1188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sun G, Li Y, Peng Y, Lu D, Zhang F, Cui X, et al. Can sarcopenia be a predictor of prognosis for patients with non-metastatic colorectal cancer? A systematic review and meta-analysis. Int J Colorectal Dis. 2018;33(10):1419–27. 10.1007/s00384-018-3128-1. [DOI] [PubMed] [Google Scholar]
- 11.Su S, Lin Z, Cai Z, Huang L, Xiao Y, Yang F, et al. Preoperative CT-derived sarcopenia as a predictor of postoperative complications in patients undergoing laparoscopic radical resection for non-metastatic colorectal cancer: a retrospective study. Int J Colorectal Dis. 2025;40(1):140. 10.1007/s00384-025-04932-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Li ZZ, Yan XL, Jiang HJ, Ke HW, Chen ZT, Chen DH, et al. Sarcopenia predicts postoperative complications and survival in colorectal cancer patients with GLIM-defined malnutrition: Analysis from a prospective cohort study. Eur J Surg Oncol. 2024;50(1):107295. 10.1016/j.ejso.2023.107295. [DOI] [PubMed] [Google Scholar]
- 13.Keshavjee S, Mckechnie T, Shi V, Abbas M, Huang E, Amin N, et al. The impact of sarcopenia on postoperative outcomes in colorectal cancer surgery: an updated systematic review and meta-analysis. Am Surg. 2025;91(5):887–900. 10.1177/00031348251329748. [DOI] [PubMed] [Google Scholar]
- 14.Portale G, Zuin M, Spolverato YC, Bartolotta P, Gregori D, Rettore C, et al. Prognostic effect of sarcopenia in patients undergoing laparoscopic rectal cancer resection. ANZ J Surg. 2023;93(6):1631–7. 10.1111/ans.18269. [DOI] [PubMed] [Google Scholar]
- 15.Klassen P, Baracos V, Gramlich L, Nelson G, Mazurak V, Martin L. Computed-tomography body composition analysis complements pre-operative nutrition screening in colorectal cancer patients on an enhanced recovery after surgery pathway. Nutrients. 2020;12(12):3745. 10.3390/nu12123745. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Gigic B, Nattenmüller J, Schneider M, Kulu Y, Syrjala KL, Böhm J, et al. The role of CT-quantified body composition on longitudinal health-related quality of life in colorectal cancer patients: The Colocare Study. Nutrients. 2020;12(5):1247. 10.3390/nu12051247. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28–36. 10.1002/jcsm.12048. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Huang DD, Wang SL, Zhuang CL, Zheng BS, Lu JX, Chen FF, et al. Sarcopenia, as defined by low muscle mass, strength and physical performance, predicts complications after surgery for colorectal cancer. Colorectal Dis. 2015;17(11):O256–64. 10.1111/codi.13067. [DOI] [PubMed] [Google Scholar]
- 19.Studenski S, Perera S, Patel K, Rosano C, Faulkner K, Inzitari M, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50–8. 10.1001/jama.2010.1923. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Prado CMM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9(7):629–35. 10.1016/S1470-2045(08)70153-0. [DOI] [PubMed] [Google Scholar]
- 21.Nunes GD, Cardenas LZ, Miola TM, de Oliveira Souza J, Carniatto LN, Vieira Bitencourt AG. Preoperative evaluation of sarcopenia in patients with colorectal cancer: a prospective study. Rev Assoc Med Bras (1992). 2023;69(2):222–7. 10.1590/1806-9282.20220339. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Miyamoto Y, Baba Y, Sakamoto Y, Ohuchi M, Tokunaga R, Kurashige J, et al. Sarcopenia is a negative prognostic factor after curative resection of colorectal cancer. Ann Surg Oncol. 2015;22(8):2663–8. 10.1245/s10434-014-4281-6. [DOI] [PubMed] [Google Scholar]
- 23.Lee C, Park IJ, Kim KW, Shin Y, Lim SB, Kim CW, Yoon YS, et al. Influence of postoperative changes in sarcopenia on long-term survival in non-metastatic colorectal cancer patients. Cancers (Basel). 2021;13(10):2410. 10.3390/cancers13102410. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nakanishi R, Oki E, Sasaki S, Hirose K, Jogo T, Edahiro K, et al. Sarcopenia is an independent predictor of complications after colorectal cancer surgery. Surg Today. 2018;48(2):151–7. 10.1007/s00595-017-1564-0. [DOI] [PubMed] [Google Scholar]
- 25.Han JS, Ryu H, Park IJ, Kim KW, Shin Y, Kim SO, et al. Association of body composition with long-term survival in non-metastatic rectal cancer patients. Cancer Res Treat. 2020;52(2):563–72. 10.4143/crt.2019.249. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.He J, Luo W, Huang Y, Song L, Mei Y. Sarcopenia as a prognostic indicator in colorectal cancer: an updated meta-analysis. Front Oncol. 2023;13:1247341. 10.3389/fonc.2023.1247341. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Data Availability Statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.