Longitudinal changes in skeletal muscle and adipose tissue during surgical treatment of oesophagogastric cancer: a prospective study.

Longitudinal changes in skeletal muscle and adipose tissue during surgical treatment of oesophagogastric cancer: a prospective study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Longitudinal changes in skeletal muscle and adipose tissue during surgical treatment of oesophagogastric cancer: a prospective study. Lisa Murnane, Adrienne Forsyth, Jim Koukounaras, Kalai Shaw, Eldho Paul, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4704469/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Low muscle mass, myosteatosis, and excess adiposity are associated with adverse outcomes after oesophagogastric (OG) cancer surgery. There is limited prospective data to evaluate body composition throughout treatment. We aimed to measure longitudinal changes in skeletal muscle and adipose tissue and describe variations according to baseline BMI. Methods This prospective longitudinal study included patients having OG cancer surgery at Alfred Health, Melbourne, Australia. CT images and bioimpedance spectroscopy (BIS) were used to assess body composition at multiple time points up to 12 months postoperatively. Low skeletal muscle, myosteatosis and visceral obesity were defined using published thresholds. BMI groups were defined as ≥ 30kg/m 2 (obese) and < 30kg/m 2 (non-obese). Results There were 50 patients. During neoadjuvant treatment, CT-muscle declined (152.7 vs 142.4cm 2 , p<0.001) and adipose tissue was stable. Postoperatively, total adipose tissue reduced (357.7 vs 224.4cm 2 , p<0.001), but muscle did not (142.4 vs 133.6cm 2 , p=0.064). Low CT-muscle prevalence increased during neoadjuvant treatment (diagnosis 33%, restaging 49%, p=0.02) but not at 12 months (54%, p=0.21). Visceral obesity was common and stable between diagnosis and restaging (58% vs 54%, p=1.00) with a marked reduction at 12 months (19%, p<0.001). BIS-muscle declined rapidly early after surgery and did not recover. The proportion of muscle and adipose tissue loss between BMI groups was comparable. Conclusion Weight loss during OG cancer treatment is significant. Skeletal muscle loss occurs during neoadjuvant treatment, while adipose tissue loss is predominant postoperatively. Anticipated changes in body composition should be considered throughout treatment, focusing on early muscle loss. Health sciences/Health care/Diagnosis/Physical examination Health sciences/Medical research/Translational research Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Significant weight loss is a common consequence of the surgical management of oesophagogastric (OG) cancer and is associated with adverse oncological and surgical outcomes ( 1 – 3 ). A BMI < 18.5kg/m 2 increases the risk of complications and poorer overall survival after oesophagectomy ( 4 ). Obesity (BMI ≥ 30 kg/m 2 ) also negatively impacts surgical outcomes ( 5 ), specifically, the association between visceral obesity and anastomotic leaks and pneumonia post-oesophagectomy ( 6 ). Retrospective studies have demonstrated preoperative low muscularity, defined as low skeletal muscle index (SMI), and myosteatosis, a consequence of intramuscular fat infiltration, are associated with pulmonary complications, anastomotic leaks, and poorer survival after OG cancer surgery ( 7 – 10 ). Limited prospective longitudinal studies examine weight and body composition changes during OG cancer treatment, particularly in Western populations where obesity is prevalent. Understanding weight loss patterns and differentiating between skeletal muscle and adipose tissue loss, particularly in patients with obesity, may influence nutrition goals and interventions. Body composition analysis using computed tomography (CT) segments skeletal muscle and visceral, subcutaneous, and intramuscular adipose tissue. CT analysis is precise, validated against dual-energy x-ray absorptiometry (DXA) to predict total body muscle mass ( 11 ), and accessible in oncology settings. However, accessing CT images for body composition analysis is opportunistic, limiting sequential measures. Bioimpedance spectroscopy (BIS) is convenient, has reasonable precision with 2–3% variability between repeated measures, and can be utilised longitudinally ( 12 ). This study aims to a) determine the longitudinal changes in body weight, skeletal muscle, and adipose tissue compartments using CT and BIS body composition assessment techniques in patients undergoing surgical resection of oesophageal and gastric cancer, and b) describe the variation in body composition changes between patients with a preoperative BMI in obese (≥ 30 kg/m 2 ) and non-obese (< 30 kg/m 2 ) categories. METHODS Study design and patient selection This prospective single-centre longitudinal observational study included adults who had OG cancer surgery with curative intent at The Alfred Hospital, Melbourne, Australia, from 2018 to 2021. Patients with non-cancer resections, benign tumours, and surgery with palliative intent were excluded. Ethics approval was obtained from the Alfred Health Human Research and Ethics Committee (HREC number 104/18). Clinical management Patients with primary tumours (T2 or greater) received preoperative chemotherapy (MAGIC protocol ( 13 ) pre-2019 and FLOT protocol( 14 ) thereafter for gastric tumours) or concurrent chemoradiotherapy (CROSS protocol ( 15 ) for oesophageal and junctional tumours). Surgical resection was a modified radical en bloc oesophagectomy or gastrectomy (D1+). The inpatient nutrition management approach was individualised per standard clinical practice, including feeding jejunostomy tube insertion. A dietitian (LM) provided outpatient dietary counselling. Data collection Demographic data were collected at enrolment. Comorbidities, oncological characteristics, and surgical data were sourced from a prospectively maintained database housed by the Department of Oesophago-Gastric and Bariatric Surgery. Disease stage was based on the AJCC Cancer Staging Manual 8th edition ( 16 ). Complications were graded according to the Clavien-Dindo Classification (severe ≥ Grade 3) ( 17 ). Study assessments Enrolment occurred preoperatively, and initial study assessments were conducted within one month before surgery. Study assessments were conducted approximately 2-, 6-, and 12 weeks post-discharge and 6 and 12 months postoperatively. CT images at diagnosis, restaging, and 12 months postoperatively were used for body composition analysis. Anthropometric and BIS measures were taken preoperatively and at each time point postoperatively. Anthropometric measures Anthropometric protocols were used to measure body weight and height ( 12 ). Patients were classified into BMI categories based on the World Health Organisation BMI scale ( 18 ). Loss of weight (LOW) at diagnosis was patient reported. Subsequent LOW was determined from the weight at the previous assessment. Patients were categorised into groups according to their preoperative BMI (non-obese BMI < 30 kg/m 2 , obese BMI ≥ 30 kg/m 2 ). Computed Tomography (CT) body composition assessment SliceOmatic Version 5.0 (Tomovision, Montreal, Canada) software measured skeletal muscle quantity and quality and visceral, subcutaneous, and intramuscular adipose tissue from CT images. All skeletal muscles in a single contrast-enhanced axial abdominal slice at L3 were assessed. Tissue quantity was reported as cross-sectional area (CSA) and density as mean attenuation, measured in Hounsfield Units (HU). Body compartments were identified using predefined HU thresholds of -29 to + 150 HU skeletal muscle (SM), -190 to -30 HU subcutaneous adipose tissue (SAT), -50 to -150 HU visceral adipose tissue (VAT), and − 190 to -30 HU intramuscular adipose tissue (IMAT) ( 11 , 19 ). Two trained assessors (LM and KL) blinded to patient outcomes analysed images; the mean inter-rater coefficient was 0.73%. Skeletal muscle CSA was normalised for height (m 2 ) to obtain skeletal muscle index (SMI). Low SMI for Caucasians was males < 52.4 cm 2 /m 2 and females < 38.5 cm 2 /m 2 ( 20 ). Low SMI for Asian ethnicity was males < 40.8 cm 2 /m 2 and females < 34.9 cm 2 /m 2 ( 21 ). Muscle attenuation thresholds defining myosteatosis were < 41 HU for BMI ≤ 24.9 kg/m 2 and < 33 HU for BMI ≥ 25 kg/m 2 ( 22 ). VAT thresholds for visceral obesity were < 163.8 cm 2 in males and < 80.1 cm2 in females ( 23 ). To convert CSA to kg: lean body mass (LBM, kg) = 0.30 x [skeletal muscle cm 2 ] + 6.06 and fat mass (FM, kg) = 0.042 x [total adipose tissue cm 2 ] + 11.2 ( 11 , 24 ). Bioimpedance Spectroscopy (BIS) body composition assessment Impedimed SF-B7 multifrequency bioimpedance spectroscopy device (ImpediMed Limited, Pinkenba, Queensland, Australia) was used to estimate fat-free mass (FFM, kg), fat mass (FM, kg). The fixed frequencies were 5, 10, 50, 100 and 500kHz. BIS assessment protocol was standardised per Earthman et al. ( 12 ), and measures were repeated three times. Patients with an electronic implantable device, severe oedema or those using diuretics were excluded from BIS measurements. Results files were exported to the Impedimed software program (Bioimp, version 5.5.0.1, Impedimed Ltd, Pinkemaba, Queensland, Australia). Reliability was assessed by ensuring frequency limits were 0 to 1000 kHz, half-semi-circular Cole-Cole plots, adjusting the standard error of the estimate (SEE) to < 1, extracellular resistance (Re) was approximately half of intracellular resistance (Ri), and fat-free mass (FFM) was within physiological limits. Exclusion occurred when test conditions were unmet and the extracellular to intracellular body water ratio (ECW: IBW) approached 1. FFM was normalised for height to obtain fat-free mass index (FFMI, kg/m 2 ). Low FFMI was males < 17kg/m 2 and females < 15kg/m 2 ( 25 ). Statistics Statistical analysis was undertaken using SPSS Statistics Version 23 (IBM Corp., New York, USA) or SAS version 9.4 (SAS Institute, Cary, USA). Continuous variables were summarised using means, standard deviations (SD), medians, and interquartile ranges (IQR) according to data type and distribution. Categorical variables were expressed as frequency counts and percentages. Group comparisons were performed using Student’s t-tests or Wilcoxon rank-sum tests as appropriate for continuous variables and chi-square or Fisher’s exact tests (where numbers were small) for categorical variables. Changes in body composition measures over time were assessed using the PROC MIXED procedure in SAS, with each patient treated as a random effect. Models were fitted using main effects for time, group (obese vs non-obese) and an interaction between group and time to ascertain if the groups behaved differently over time. Post-hoc comparisons were performed using Bonferroni adjustment for multiple comparisons. All calculated p values were two-tailed; a p < 0.05 indicated statistical significance. The study was powered to detect a mean difference in CT-derived SMI of 10.5cm/m 2 (SD 11.9) ( 26 ) between low SMI and normal SMI groups with 80% power at a significance level of 0.05. RESULTS Baseline characteristics There were 50 patients; 45 (90%) had accessible measures at diagnosis, and 36 (72%) at 12 months. Patients were predominantly male (n = 31, 62%), mean age of 64 ± 10.3 years, had tumours located at the oesophagogastric junction (n = 30, 60%), and oesophagectomy was most common (n = 34, 68%) (Table 1 ). Table 1 Baseline characteristics and postoperative outcomes in oesophagogastric cancer surgery patients (n = 50). Age (years), mean (SD) 64 ( 10 ) Adjuvant therapy, n (%) Gender, n (%) Chemotherapy 11 ( 22 ) Male 31 (62) No adjuvant therapy 39 (78) Female 19 ( 38 ) Resection type, n (%) Comorbidities, n (%) Distal gastrectomy 1 ( 2 ) History of smoking 33 (66) Subtotal gastrectomy 5 ( 10 ) Cardiac 11 ( 22 ) Total Gastrectomy 3 ( 6 ) Respiratory 11 ( 22 ) Total extended gastrectomy 7 ( 14 ) Diabetes 8 ( 16 ) 3 stage oesophagectomy 7 ( 14 ) Renal 3 ( 6 ) Ivor Lewis oesophagectomy - open 3 ( 6 ) Primary tumour site, n (%) Ivor Lewis oesophagectomy - hybrid 24 (48) Gastric 8 ( 16 ) Feeding jejunostomy tube, n (%) 14 ( 28 ) Oesophageal 12 ( 24 ) Postoperative complications, n (%) Oesophago-gastric junction 30 (60) Overall 30 (60) Disease pathology, n (%) Anastomotic leak 6 ( 12 ) Adenocarcinoma 39 (78) Atelectasis 0 (0) Squamous cell carcinoma 6 ( 12 ) Bacteraemia 5 ( 10 ) Signet ring 5 ( 10 ) Cardiac arrythmia 8 ( 16 ) Neoadjuvant therapy, n (%) Chyle leak 2 ( 4 ) Chemotherapy 13 ( 26 ) Pleural effusion 6 ( 12 ) Chemoradiation 30 (60) Pneumonia 9 ( 18 ) No neoadjuvant therapy 7 ( 14 ) Pneumothorax 1 ( 2 ) Pathological TNM stage, n (%) Wound infection 4 ( 8 ) Stage 0 0 (0) Severe complication 13 ( 26 ) Stage 1 9 ( 18 ) Postoperative outcomes Stage 2a 5 ( 10 ) LOS (days), median (IQR) 11 ( 8 – 16 ) Stage 2b 7 ( 14 ) Readmitted ≤ 90 days, n (%) 9 ( 18 ) Stage 3 21 ( 42 ) Disease recurrence at 1 year, n (%) 13 ( 26 ) Stage 4a 8 ( 16 ) Overall survival at 1 year, n (%) 40 (78) Stage 4b 0 (0) LOS: length of stay; SD: standard deviation; TNM: tumour, node, metastasis. Anthropometry At diagnosis, mean body weight was 85.2kg (± 27.3), BMI 29.0 kg/m 2 (± 9.2), and 47% (n = 21) were overweight or obese (Table 2 ). Weight loss was most prominent from surgery to week two post-discharge and continued for 12 months (Fig. 1 a). The proportion of underweight patients increased with a marked reduction in obesity, and the incidence of severe weight loss (≥ 10%) increased from 13% (n = 6) at diagnosis to 66% (n = 24) at 12 months (Table 2 ). Table 2 Body mass index (BMI) and weight loss from diagnosis to 12 months postoperatively. Percentage weight loss was recorded as total weight lost from premorbid weight. Diagnosis n = 45 Preoperative n = 50 Week 2 n = 42 Week 6 n = 36 Week 12 n = 37 6 months n = 36 12 months n = 36 P value BMI (kg/m 2 ) mean (SE) 29.0 (1.1) 27.9 (1.1) 26.0 (1.1) 25.3 (1.1) 24.9 (1.1) 24.4 (1.1) 24.5 (1.1) < 0.001* BMI categories n (%) Underweight (≤ 18.5 kg/m 2 ) 5 ( 11 ) 4 ( 8 ) 8 ( 19 ) 11 ( 31 ) 10 ( 27 ) 13 ( 36 ) 9 ( 25 ) Healthy weight (18.5–24.9 kg/m 2 ) 19 ( 43 ) 23 (46) 19 ( 45 ) 13 ( 36 ) 13 ( 35 ) 12 ( 33 ) 16 ( 44 ) Overweight (25-29.9 kg/m 2 ) 8 ( 17 ) 9 ( 18 ) 12 ( 29 ) 9 ( 18 ) 10 ( 27 ) 8 ( 23 ) 8 ( 22 ) Obese (≥ 30 kg/m 2 ) 13 ( 30 ) 14 ( 28 ) 3 ( 7 ) 3 ( 8 ) 4 ( 11 ) 3 ( 8 ) 3 ( 8 ) LOW (%) mean (SE) 3.3 (1.1) 6.0 (0.7) 9.1 (0.7) 10.7 (0.8) 9.8 (0.9) 12.1 (1.1) 13.0 (1.4) 0.002* Weight loss categories n (%) < 5% 33 (73) 23 (46) 6 ( 14 ) 1 ( 3 ) 7 ( 19 ) 7 ( 21 ) 5 ( 13 ) 5-9.9% 6 ( 13 ) 16 ( 32 ) 24 (57) 18 (50) 13 ( 35 ) 6 ( 18 ) 7 ( 20 ) 10-14.9% 4 ( 9 ) 8 ( 16 ) 9 ( 21 ) 13 ( 37 ) 11 ( 29 ) 14 ( 38 ) 13 ( 37 ) 15-19.9% 1 ( 2 ) 2 ( 4 ) 2 ( 6 ) 0 (0) 4 ( 10 ) 2 ( 6 ) 4 ( 10 ) ≥ 20% 1 ( 2 ) 1 ( 2 ) 1 ( 3 ) 4 ( 10 ) 2 ( 6 ) 6 ( 18 ) 7 ( 20 ) BMI: body mass index (kg/m 2 ); LOW: loss of weight; SE: standard error * p value indicates a significant overall time effect (Linear mixed model) Body composition assessment Computed Tomography (CT) During neoadjuvant treatment, skeletal muscle CSA (p = 0.0004) and skeletal muscle index (SMI) (50.4 ± 1.38 cm/m 2 diagnosis vs 47.2 ± 1.36 restaging, p = 0.002) reduced significantly without change in total adipose tissue (p = 0.919) (Fig. 2 a). Postoperatively, changes in skeletal muscle were not statistically significant (p = 0.064), and SMI (47.2 ± 1.36 cm 2 /m 2 vs 45.1 ± 1.44 12 months, p = 0.047) and total adipose tissue (p < 0.0001) reduced with greater VAT loss (-93.5 cm 2 ) compared to SAT (-38.36 cm 2 ). Skeletal muscle attenuation remained stable during neoadjuvant treatment (37.16 ± 1.40 HU at diagnosis vs 36.16 ± 1.38 HU, p = 0.786) and increased at 12 months (40.09 ± 1.48 HU, p = 0.001). Figure 2 b describes the proportion of patients with low SMI, myosteatosis, and visceral obesity. The prevalence of low SMI and obesity was 6.7% (n = 3) at diagnosis, 6% (n = 3) preoperatively, and 3.2% (n = 1) at 12 months. Females had lower skeletal muscle CSA than males (127.18 ± 8.07 cm 2 vs 153.36 ± 6.29 cm 2 , p = 0.013) but no difference in SMI (44.68 ± 2.09 cm 2 /m 2 females vs 49.31 ± 1.63 cm 2 /m 2 , p = 0.084). Males and females had similar VAT (p = 0.531), SAT (p = 0.731) and muscle attenuation (p = 0.396). There were no gender differences in skeletal muscle or total adipose tissue CSA change over time (p = 0.892 and p = 0.533, respectively). There were no differences between age groups (< or ≥ 65 years) for skeletal muscle (p = 0.727), total adipose tissue (p = 0.515) and skeletal muscle attenuation (p = 0.625). Bioimpedance Spectroscopy (BIS) Fat-free mass (FFM) reduced significantly from surgery to week two (p < 0.0001), with no significant changes after (Fig. 3 a). FM loss was not significant until six months postoperatively (p = 0.0004) (Fig. 3 b). The proportion with low FFMI increased from surgery to week two (n = 4, 8% vs n = 9, 18% p = 0.031), with no significant change at week 6 (n = 6, 12%), week 12 (n = 8, 16%), six months (n = 7, 14%) or 12 months (n = 6, 12%). Overall, males had higher FFM than females (59.6 ± 2.5 kg vs 51.2 ± 3.2 kg, p = 0.037) and similar FM (17.7 ± 1.9 kg vs 21.7 ± 2.4 kg, p = 0.195), but there was significant time effect (p = 0.992 and p = 0.083, respectively). Age groups had comparable FFM (p = 0.855) and FM (p = 0.959), with similar postoperative changes. BMI group differences There were no differences in baseline, oncological and surgical characteristics of patients with obesity and those without (data not shown). Anthropometric and CT body composition variables are shown in Table 3 . Preoperatively, both groups had 5% LOW, whereas patients with obesity had a higher percentage LOW than those without at 12 months (18.4 ± 4.3% vs 11.4 ± 1.3%, p = 0.048). Table 3 The absolute values for anthropometric and CT body composition variables at diagnosis, preoperatively and 12 months postoperatively, comparing patients who were in obese (BMI ≤ 30kg/m 2 ) and non-obese (BMI < 30kg/m 2 ) groups before surgery. Linear mixed models assessed overall within-group (time effect) and between-group (obese vs non-obese) differences for 32 patients with CT body composition analysis at each time point. Post-hoc analyses compared differences at each time point. Diagnosis Preoperative Postoperative (12 months) Overall group effect Non-obese n = 24 Obese n = 8 P value Non-obese n = 24 Obese n = 8 P value Non-obese n = 24 Obese n = 8 P value P value Anthropometrics Weight (kg) # 73.7 (2.8) 118.2 (9.5) < 0.001 72.7 (2.6) 113.1 (9.3) < 0.001 66.8 (2.9) 92.2 (9.2) 0.003 < 0.001 a,b % LOW 2.9 (0.9) 0 (0) 0.082 5.2 (1.2) 5.1 (1.7) 0.160 11.4 (1.3) 18.4 (4.3) 0.048 0.069 CT body composition Skeletal muscle (cm 2 ) # 135.3 (7.1) 191.8 (18.1) < 0.001 127.5 (6.8) 178.1 (15.7) 0.002 124.6 (7.0) 160.5 (12.3) 0.016 0.006 a,b Visceral AT (cm 2 )* 116.2 (18.5) 415.8 (56.6) < 0.001 114.5 (18.0) 380.7 (46.9) < 0.001 63.6 (12.7) 140.8 (32.2) 0.011 < 0.001 b Subcutaneous AT (cm 2 )* 145.7 (8.9) 302.8 (57.2) < 0.001 138.5 (12.3) 301.4 (59.3) < 0.001 117.4 (12.5) 179.0 (47.3) 0.267 < 0.001 b Total AT (cm 2 )* 237.7 (22.2) 808.8 (149.6) < 0.001 264.2 (26.5) 742.6 (135.4) < 0.001 192.0 (24.0) 315.0 (91.6) 0.204 < 0.001 b Muscle density (HU) # 40.6 (1.6) 27.1 (4.9) < 0.001 38.7 (1.6) 28.6 (3.9) < 0.001 41.5 (1.6) 36.0 (3.8) 0.126 0.006 b Lean muscle mass (kg) # 46.7 (2.1) 63.6 (5.4) < 0.001 44.3 (2.0) 59.5 (4.7) 0.002 43.4 (2.21) 54.2 (3.7) 0.016 0.006 a,b Fat mass (kg)* 22.7 (0.9) 45.2 (6.3) < 0.001 22.3 (1.1) 42.4 (5.7) < 0 .001 19.3 (1.0) 24.4 (3.8) 0.204 < 0.001 b AT: adipose tissue; HU: Hounsfield Units; LOW: loss of weight. #mean (SE); *median (IQR); a p < 0.05 within-group time effect difference between diagnosis and preoperative. b p < 0.05 within-group time effect difference between preoperative and postoperative. At surgery, the absolute change in skeletal muscle CSA (-13.69 ± 6.27 cm 2 obese vs -7.86 ± 1.63 cm 2 , p = 0.077) and muscle attenuation (-1.84 ± 1.08 HU obese vs 1.50 ± 2.13 HU, p = 0.601) between groups was not significant, but the obese group had lost more TAT than the non-obese group (-66.21 ± 66.43 cm 2 vs -8.80 ± 10.27 cm 2 , p = 0.045). At 12 months, patients with obesity at diagnosis had greater absolute muscle loss (-31.36 ± 9.95 cm 2 obese vs 10.71 ± 2.36 cm 2 , p = 0.006), improved muscle attenuation (8.89 ± 2.75 HU obese vs 0.94 ± 1.03 HU, p = 0.002) and higher TAT (-493.80 ± 131.60 cm 2 obese vs -81.75 ± 20.61 cm 2 , p = 0.001) than patients without obesity. The percentage change in muscle quantity, TAT and muscle attenuation from diagnosis stratified by baseline obesity are shown in Fig. 4. DISCUSSION This prospective longitudinal study found that patients undergoing oesophagogastric cancer surgery experience substantial weight loss, predominantly muscle loss during neoadjuvant treatment and adipose tissue after surgery. Body composition changes were not influenced by the presence of obesity at diagnosis. Mean weight loss of 13% at 12 months was consistent with studies reporting weight loss rates of 8.8–10.1% one-year post-oesophagectomy ( 27 , 28 ) and 16% after total gastrectomy ( 29 ). Weight loss was rapid in the early postoperative period, with 46% of patients losing ≥ 10% of weight at 12 weeks. Early and severe weight loss, defined as 14–17% LOW within 1.5-3 months, predicts reduced survival after oesophagectomy ( 1 , 30 ), poorer adjuvant chemotherapy tolerance, and disease-free survival after gastrectomy ( 3 ). Skeletal muscle loss was observed throughout treatment, with the most significant reduction during neoadjuvant treatment. Skeletal muscle loss resulted in almost half of patients having CT-derived low SMI before surgery. Adipose tissue stores remained stable during the same period. Studies have shown muscle atrophy with the preservation of adipose tissue during neoadjuvant chemoradiation ( 31 ) and chemotherapy ( 32 ). Anecdotally, weight regain may occur after obstructive symptoms subside or neoadjuvant treatment completion. Frequent anthropometric and body composition assessments are required to determine whether weight regain is attributable to increased adipose tissue or skeletal muscle. Although CT-muscle loss continues, changes from surgery to 12 months were not significant. Contradictory data show a significant decline in skeletal muscle within one year postoperatively ( 29 , 31 , 33 , 34 ). Regardless, 36% of patients had low SMI at 12 months, aligning with 35% reported by Elliott et al ( 31 ). Boshier et al. demonstrated that one year after oesophagectomy, a greater than 10% decrease in SMI and low SMI was associated with poorer 5-year survival, whereas low SMI at diagnosis was not ( 33 ). The marked reduction in total and visceral fat is consistent with retrospective reports ( 33 , 35 ). Assessing longitudinal fat and fat-free mass using BIS provides unique insight into body composition variability within one year of surgery. Like weight loss, significant skeletal muscle loss occurred within one month after surgery without subsequent muscle mass recovery. In contrast, ongoing weight loss at 6 and 12 months coincided with a significant reduction in fat mass. There are limited studies utilising prospective bioimpedance measurements. Yoshida et al. showed muscle mass recovered from six months post-oesophagectomy, whereas fat mass was at the lowest point and remained stable ( 34 ). Contrasting results may be attributable to fewer patients with BMI ≥ 25 kg/m 2 (17% vs 46%), the predominance of squamous cell carcinoma, and different preoperative treatments; overall, a vastly different population to OG adenocarcinomas in the present study and Western centres. Patients with obesity had significantly more weight loss at 12 months compared to the non-obese group (18% vs 11.4%). Although patients with obesity had higher baseline skeletal muscle and adipose tissue compared to patients without obesity, experiencing a greater absolute loss of both, the percentage change in muscle and adipose tissue was comparable between groups. These findings are relevant during neoadjuvant treatment when muscle loss is predominant and fat mass is maintained. The negative implications of preoperative myosteatosis have been identified ( 9 , 36 , 37 ), but changes in muscle attenuation throughout treatment have not been described. Muscle attenuation was stable at surgery but increased postoperatively, indicating an overall improvement in muscle quality. However, the percentage increase in muscle attenuation after surgery for patients with obesity (55%) was significantly greater than in the non-obese group (3.3%). Muscle attenuation increases with reduced fat infiltration ( 38 ), explaining muscle quality improvement with adipose tissue loss. The mechanisms for body composition changes are likely multifactorial and may differ depending on the phase of treatment. Muscle loss during neoadjuvant treatment and early postoperatively corresponds with inflammatory processes associated with chemotherapy-induced muscle wasting and the surgical stress response driving catabolism ( 39 , 40 ). Negative energy balance in the absence of inflammation leads to the mobilisation of adipose tissue while preserving skeletal muscle ( 41 ) and may explain ongoing weight and fat mass loss observed 6 to 12 months after surgery. Clinical oncology nutrition guidelines recommend body composition analysis forms part of a comprehensive nutrition assessment to provide individualised interventions ( 42 ). Yet, measuring weight alone, without knowledge of body composition changes, remains common. Weight loss experienced by patients with obesity during neoadjuvant treatment may be viewed favourably. Yet, our results demonstrate that weight loss during this period results from muscle wasting rather than fat loss, irrespective of BMI. Conversely, the negative implications of excess central adiposity may not be considered if weight maintenance is the primary focus before surgery. The preoperative period presents an opportunity to improve body composition. Halliday et al. showed that a multimodal prehabilitation program attenuated skeletal muscle loss and reduced visceral adiposity ( 43 ). The marked reduction in weight at 12 months in patients with premorbid obesity, predominantly due to adipose tissue loss, is less concerning if muscle mass is preserved. Interventions to minimise muscle loss after surgery include individualised nutrition counselling for 12 months post-gastrectomy ( 44 ) and perioperative multi-disciplinary management ( 45 ). To our knowledge, this is the first study to prospectively measure weight and body composition change, using multiple methods, throughout the curative treatment of oesophagogastric cancer and stratify changes based on premorbid BMI. A key strength is CT body composition analysis, which segments skeletal muscle and adipose tissue, delineating changes between compartments. Less comprehensive techniques that measure muscle circumference may misinterpret changes in muscle size with fluctuations in fat deposition. The study’s generalisability may be limited by challenges in achieving reproducible conditions for valid BIS measures in clinical practice. Finally, obtaining detailed perioperative dietary intake data linked with body composition changes may provide a focus for future nutrition intervention studies. CONCLUSION Weight loss during neoadjuvant treatment is primarily attributable to skeletal muscle loss. Despite continued muscle decline, adipose tissue loss is more substantial postoperatively, an important consideration for patients with obesity. CT body composition analysis provides a precise and validated method accessible to the surgical oncology population. In clinical practice, body composition should be assessed rather than focusing solely on body weight. Future research requires exploring interventions to preserve muscle, particularly during neoadjuvant therapy, and understanding the clinical impact of preoperative adipose tissue loss. Declarations Data availability statement The datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request. Acknowledgements The authors would like to acknowledge the support and contributions of Dr Kate Lambell, Senior Dietitian at Alfred Health, Melbourne, Australia, for validating CT image analysis methodology, and Julie Playfair, research nurse at Monash University Department of Surgery, for assistance with study coordination and data collection. Author contribution statement Lisa C. Murnane, Paul R. Burton, Audrey C. Tierney, and Adrienne K. Forsyth contributed to the conception and design of the research. Lisa C. Murnane, Kalai Shaw, Paul R. Burton, Wendy A Brown, and Jim Koukounaras contributed to data acquisition. Lisa C. Murnane and Eldho Paul conducted the statistical analysis of data. Lisa C. Murnane, Audrey C. Tierney, and Adrienne K. Forsyth contributed to data interpretation. Lisa C. Murnane drafted the manuscript. All authors provided a critical appraisal of the manuscript and provided approval for publication of the final version. Funding No funding was received to conduct this research. Ethics approval Full ethics approval was obtained from the Alfred Human Research and Ethics Committee (HREC number 104/18). Informed consent was obtained from all participants. Competing interests Lisa Murnane has received a speaker honorarium from Fresenius-Kabi and Nestle Health Science outside of the submitted work. Prof. Wendy Brown has received grants from Johnson and Johnson, Medtronic, GORE and Novo Nordisc, and personal fees from GORE, Novo Nordisc, Merck Sharpe and Dohme, outside of the submitted work. For the remaining authors, no conflicts of interest were declared. References Yamamoto K, Tanaka K, Yamasaki M, Yamashita K, Makino T, Saito T, et al. Early postoperative weight loss is associated with poor prognosis in patients with esophageal cancer. 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Visceral obesity with and without metabolic syndrome: incidence and clinical impact in esophageal adenocarcinoma treated with curative intent. Dis Esophagus. 2022;35(9). Jogiat UM, Sasewich H, Turner SR, Baracos V, Eurich DT, Filafilo H, et al. Sarcopenia Determined by Skeletal Muscle Index Predicts Overall Survival, Disease-free Survival, and Postoperative Complications in Resectable Esophageal Cancer: A Systematic Review and Meta-analysis. Ann Surg. 2022;276(5):e311-e8. Rinninella E, Cintoni M, Raoul P, Pozzo C, Strippoli A, Bria E, et al. Muscle mass, assessed at diagnosis by L3-CT scan as a prognostic marker of clinical outcomes in patients with gastric cancer: A systematic review and meta-analysis. Clin Nutr. 2020;39(7):2045–54. Murnane LC, Forsyth AK, Koukounaras J, Pilgrim CH, Shaw K, Brown WA, et al. Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery. Eur J Surg Oncol. 2021;47(9):2295–303. Murnane LC, Forsyth AK, Koukounaras J, Pilgrim CHC, Shaw K, Brown WA, et al. Low muscularity increases the risk for post-operative pneumonia and delays recovery from complications after oesophago-gastric cancer resection. ANZ J Surg. 2021;91(12):2683–9. Mourtzakis M, Prado CM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme. 2008;33(5):997–1006. Earthman CP. Body Composition Tools for Assessment of Adult Malnutrition at the Bedside: A Tutorial on Research Considerations and Clinical Applications. JPEN J Parenter Enteral Nutr. 2015;39(7):787–822. Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11–20. Al-Batran SE, Homann N, Pauligk C, Goetze TO, Meiler J, Kasper S, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948–57. van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366(22):2074–84. Edge S, Amin MB, Greene F. American Joint Committee on Cancer (AJCC) Cancer Staging Manual. 8 ed: New York: Springer International Publishing 2017. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Annals of Surgery. 2009;250(2):187–96. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1–253. Heymsfield SB, Smith R, Aulet M, Bensen B, Lichtman S, Wang J, et al. Appendicular skeletal muscle mass: measurement by dual-photon absorptiometry. The American journal of clinical nutrition. 1990;52(2):214–8. Prado CM, 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. Zhuang CL, Huang DD, Pang WY, Zhou CJ, Wang SL, Lou N, et al. Sarcopenia is an Independent Predictor of Severe Postoperative Complications and Long-Term Survival After Radical Gastrectomy for Gastric Cancer: Analysis from a Large-Scale Cohort. Medicine (Baltimore). 2016;95(13):e3164. Martin L, Birdsell L, MacDonald N, Reiman T, Clandinin MT, McCargar LJ, et al. Cancer Cachexia in the Age of Obesity: Skeletal Muscle Depletion Is a Powerful Prognostic Factor, Independent of Body Mass Index. Journal of Clinical Oncology. 2013;31(12):1539–47. Doyle SL, Bennett AM, Donohoe CL, Mongan AM, Howard JM, Lithander FE, et al. Establishing computed tomography-defined visceral fat area thresholds for use in obesity-related cancer research. Nutr Res. 2013;33(3):171–9. Barazzoni R, Jensen GL, Correia M, Gonzalez MC, Higashiguchi T, Shi HP, et al. Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition (GLIM) diagnosis of malnutrition. Clin Nutr. 2022;41(6):1425–33. Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr. 2015;34(3):335–40. Tamandl D, Paireder M, Asari R, Baltzer PA, Schoppmann SF, Ba-Ssalamah A. Markers of sarcopenia quantified by computed tomography predict adverse long-term outcome in patients with resected oesophageal or gastro-oesophageal junction cancer. European Radiology. 2016;26(5):1359–67. Murphy CF, Fanning M, Raftery N, Elliott JA, Docherty NG, Donohoe CL, et al. Early experience with a nutrition and survivorship clinic in esophageal cancer. Dis Esophagus. 2020. D'Journo XB, Ouattara M, Loundou A, Trousse D, Dahan L, Nathalie T, et al. Prognostic impact of weight loss in 1-year survivors after transthoracic esophagectomy for cancer. Dis Esophagus. 2012;25(6):527–34. Asaoka R, Irino T, Makuuchi R, Tanizawa Y, Bando E, Kawamura T, et al. Changes in body weight, skeletal muscle and adipose tissue after gastrectomy: a comparison between proximal gastrectomy and total gastrectomy. ANZ J Surg. 2019;89(1–2):79–83. Koterazawa Y, Oshikiri T, Takiguchi G, Urakawa N, Hasegawa H, Yamamoto M, et al. Severe weight loss after minimally invasive oesophagectomy is associated with poor survival in patients with oesophageal cancer at 5 years. BMC Gastroenterol. 2020;20(1):407. Elliott JA, Doyle SL, Murphy CF, King S, Guinan EM, Beddy P, et al. Sarcopenia: Prevalence, and Impact on Operative and Oncologic Outcomes in the Multimodal Management of Locally Advanced Esophageal Cancer. Ann Surg. 2017;266(5):822–30. Rinninella E, Strippoli A, Cintoni M, Raoul P, Vivolo R, Di Salvatore M, et al. Body Composition Changes in Gastric Cancer Patients during Preoperative FLOT Therapy: Preliminary Results of an Italian Cohort Study. Nutrients. 2021;13(3). Boshier PR, Klevebro F, Jenq W, Puccetti F, Muthuswamy K, Hanna GB, et al. Long-term variation in skeletal muscle and adiposity in patients undergoing esophagectomy. Dis Esophagus. 2021;34(11). Yoshida S, Nishigori T, Tsunoda S, Tanaka E, Okabe H, Kobayashi A, et al. Chronological Changes in Skeletal Muscle Mass Two Years after Minimally Invasive Esophagectomy: A Prospective Cohort Study. Surg Endosc. 2021. Birnstein E, Schattner M. Nutritional Support in Esophagogastric Cancers. Surg Oncol Clin N Am. 2017;26(2):325–33. Srpcic M, Jordan T, Popuri K, Sok M. Sarcopenia and myosteatosis at presentation adversely affect survival after esophagectomy for esophageal cancer. Radiol Oncol. 2020;54(2):237–46. Zhuang CL, Shen X, Huang YY, Zhang FM, Chen XY, Ma LL, et al. Myosteatosis predicts prognosis after radical gastrectomy for gastric cancer: A propensity score-matched analysis from a large-scale cohort. Surgery. 2019;166(3):297–304. Goodpaster BH, Kelley DE, Thaete FL, He J, Ross R. Skeletal muscle attenuation determined by computed tomography is associated with skeletal muscle lipid content. Journal of applied physiology. 2000;89(1):104–10. Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12(5):489–95. Damrauer JS, Stadler ME, Acharyya S, Baldwin AS, Couch ME, Guttridge DC. Chemotherapy-induced muscle wasting: association with NF-kappaB and cancer cachexia. Eur J Transl Myol. 2018;28(2):7590. Gillis C, Carli F. Promoting Perioperative Metabolic and Nutritional Care. Anesthesiology. 2015;123(6):1455–72. Arends J, Baracos V, Bertz H, Bozzetti F, Calder PC, Deutz NEP, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr. 2017;36(5):1187–96. Halliday LJ, Boshier PR, Doganay E, Wynter-Blyth V, Buckley JP, Moorthy K. The effects of prehabilitation on body composition in patients undergoing multimodal therapy for esophageal cancer. Dis Esophagus. 2023;36(2). Takata N, Kikuchi S, Kuroda S, Tanabe S, Maeda N, Noma K, et al. Effect of Patient-Participation Continuous Nutritional Counseling in Gastric Cancer Patients who Underwent Gastrectomy. Ann Surg Oncol. 2023;30(2):1110–8. Kawata S, Hiramatsu Y, Shirai Y, Watanabe K, Nagafusa T, Matsumoto T, et al. Multidisciplinary team management for prevention of pneumonia and long-term weight loss after esophagectomy: a single-center retrospective study. Esophagus. 2020;17(3):270–8. Additional Declarations Yes there is potential conflict of interest. Supplementary Files Table2.Murnaneetal.BodycompositionOGcancersurgery.8Jul24.docx Table 2 Table1.Murnaneetal.BodycompositionOGcancersurgery.8Jul24.docx Table 1 Table3.Murnaneetal.BodycompositionOGcancersurgery.8Jul24.docx Table 3 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4704469","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":338928637,"identity":"f86408cc-c3ba-4c9d-a6e8-1c51a5377551","order_by":0,"name":"Lisa Murnane","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBACPjiLvYHxQAUDA2MDIS1scBbPAYYDZ0jTIpFAtBbuNOnKHXZ5/JKPHxw4uMdGtoG99/ELhprDeLTwbpM8eya5WHJ2msGBA8/SjBt4jptZMBwjoKWxjTlxw+0Eg8MfDhxObJBIYzNgYCOopT5x/83jHw4cOPAfquUfQS2HEzdI8AAdduAASAvzA8Y2PFqYeTdbNrYdT5xxJqcAqCPZuI3nGBtDYl86Ti387L0bbza2VSf2tx/f+ODAATvZfvY25g8fvlnj1MLAjOlUBjZgHJEImD+QqmMUjIJRMAqGNQAAnxRY8IAC3HYAAAAASUVORK5CYII=","orcid":"","institution":"La Trobe University","correspondingAuthor":true,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Murnane","suffix":""},{"id":338928638,"identity":"ff128f95-2283-41bb-844b-90559ea0e72c","order_by":1,"name":"Adrienne Forsyth","email":"","orcid":"https://orcid.org/0000-0002-1692-2638","institution":"La Trobe University","correspondingAuthor":false,"prefix":"","firstName":"Adrienne","middleName":"","lastName":"Forsyth","suffix":""},{"id":338928639,"identity":"a9ea91b9-9ed3-4ff1-97e3-62a4a498f500","order_by":2,"name":"Jim Koukounaras","email":"","orcid":"","institution":"Alfred Health","correspondingAuthor":false,"prefix":"","firstName":"Jim","middleName":"","lastName":"Koukounaras","suffix":""},{"id":338928640,"identity":"881b2283-6916-48ed-b337-f0f16efa0bc4","order_by":3,"name":"Kalai Shaw","email":"","orcid":"https://orcid.org/0000-0002-9476-0419","institution":"Alfred Health","correspondingAuthor":false,"prefix":"","firstName":"Kalai","middleName":"","lastName":"Shaw","suffix":""},{"id":338928641,"identity":"c1a65ab1-9fc9-467e-aa6c-2d9a4c37c026","order_by":4,"name":"Eldho Paul","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Eldho","middleName":"","lastName":"Paul","suffix":""},{"id":338928642,"identity":"23744285-26dd-4863-9b01-2b40ec82f301","order_by":5,"name":"Wendy Brown","email":"","orcid":"","institution":"Alfred Health","correspondingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Brown","suffix":""},{"id":338928643,"identity":"445fa96f-5d48-4f2c-acce-f3f3a30b94ac","order_by":6,"name":"Audrey Tierney","email":"","orcid":"","institution":"University of Limerick","correspondingAuthor":false,"prefix":"","firstName":"Audrey","middleName":"","lastName":"Tierney","suffix":""},{"id":338928644,"identity":"1e09ba31-0a84-41d9-bde2-4b585e958612","order_by":7,"name":"Paul Burton","email":"","orcid":"","institution":"Alfred Health","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Burton","suffix":""}],"badges":[],"createdAt":"2024-07-08 09:46:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4704469/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4704469/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66117735,"identity":"02739684-9c4a-47fd-a3ec-88466a8922f9","added_by":"auto","created_at":"2024-10-08 00:56:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68879,"visible":true,"origin":"","legend":"\u003cp\u003eChange in weight and bioimpedance spectroscopy (BIS) derived body composition up to 12 months postoperatively.\u0026nbsp; a) Mean body weight (kg) ± standard error at diagnosis (n = 45), preoperatively (n = 50), and postoperatively at week 2 (n = 42), week 6 (n = 36), week 12 (n = 37), six months (n = 36), and\u0026nbsp; 12 months (n = 36). The overall time effect was statistically significant for body weight (p \u0026lt; 0.001). b) BIS estimates of mean (± standard error) fat-free mass (FFM) and fat mass (FM) (kg) preoperatively (n = 45) and postoperatively at week 2 (n = 31), week 6 (n = 25), week 12 (n = 29), six months (n = 31), and 12 months (n = 25). There was a significant overall time effect on estimates of BIS-derived fat-free mass (FFM) (p \u0026lt;0.001) and fat mass (FM) (p=0.001). **\u003csup\u003e \u003c/sup\u003ep \u0026lt; 0.05\u0026nbsp; from preoperative to every time point up to 12 months. \u0026nbsp;* p \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/145f01db0c2f1858641cdfac.jpg"},{"id":66117732,"identity":"c8203b55-8118-4bf1-a137-0370737b1692","added_by":"auto","created_at":"2024-10-08 00:56:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71967,"visible":true,"origin":"","legend":"\u003cp\u003eCT-derived skeletal muscle and adipose tissue depot changes and the prevalence of abnormal body composition at diagnosis, preoperatively and 12 months after surgery. a) CT body composition assessment results at diagnosis (n = 43), preoperatively (n = 50), and 12 months (n = 36) postoperatively describing a) the mean cross-sectional area (CSA) of skeletal muscle (SM), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and total adipose tissue (TAT); and b) the prevalence of low skeletal muscle index (SMI), myosteatosis, and visceral obesity. *p \u0026lt; 0.05\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/59f3ee72a80b0f6828b614c8.jpg"},{"id":66117733,"identity":"86f0eda8-0e13-49db-9c12-81914cf4af21","added_by":"auto","created_at":"2024-10-08 00:56:10","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":66314,"visible":true,"origin":"","legend":"\u003cp\u003eThe percentage change in CT body composition variables from diagnosis to the preoperative and 12-month time points in a matched cohort of 32 patients, comparing patients who had obesity (n = 8) before surgery and those without (non-obese, n = 24). The p values from the linear mixed models indicate the overall group effect for the percentage change in a) skeletal muscle (CSA), b) skeletal muscle attenuation (HU), and c) total adipose tissue (CSA).\u003c/p\u003e\n\u003cp\u003eCSA: cross-sectional area; HU: Hounsfield Units.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea \u003c/sup\u003ep value for overall within-group (time effect) and between-group (obese groups) difference\u003c/p\u003e\n\u003cp\u003e* between-group difference \u0026lt;0.05\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/8891226bb91904de859c0b9e.jpg"},{"id":80549443,"identity":"9d7f5638-219f-4a35-a4e4-582c39bd1d29","added_by":"auto","created_at":"2025-04-14 14:33:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1303011,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/12d038c7-46e9-495a-8ded-634f9f4d79ab.pdf"},{"id":66118273,"identity":"c2d75ea5-ad7c-4b1d-ad32-904cd6b2632b","added_by":"auto","created_at":"2024-10-08 01:04:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23946,"visible":true,"origin":"","legend":"Table 2","description":"","filename":"Table2.Murnaneetal.BodycompositionOGcancersurgery.8Jul24.docx","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/86df966aef7a5c838ce948d6.docx"},{"id":66117736,"identity":"cddcf5ab-dd8b-4e99-b4c0-5777ea1d2277","added_by":"auto","created_at":"2024-10-08 00:56:11","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25424,"visible":true,"origin":"","legend":"Table 1","description":"","filename":"Table1.Murnaneetal.BodycompositionOGcancersurgery.8Jul24.docx","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/e46bb7c015a272b38c9cfb55.docx"},{"id":66117737,"identity":"86e5326f-0934-448d-9405-738e43a1617a","added_by":"auto","created_at":"2024-10-08 00:56:11","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":27162,"visible":true,"origin":"","legend":"Table 3","description":"","filename":"Table3.Murnaneetal.BodycompositionOGcancersurgery.8Jul24.docx","url":"https://assets-eu.researchsquare.com/files/rs-4704469/v1/df929a14db14d1b46cf5338c.docx"}],"financialInterests":"\u003cb\u003eYes\u003c/b\u003e there is potential conflict of interest.","formattedTitle":"Longitudinal changes in skeletal muscle and adipose tissue during surgical treatment of oesophagogastric cancer: a prospective study.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSignificant weight loss is a common consequence of the surgical management of oesophagogastric (OG) cancer and is associated with adverse oncological and surgical outcomes (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5kg/m\u003csup\u003e2\u003c/sup\u003e increases the risk of complications and poorer overall survival after oesophagectomy (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e) also negatively impacts surgical outcomes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), specifically, the association between visceral obesity and anastomotic leaks and pneumonia post-oesophagectomy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRetrospective studies have demonstrated preoperative low muscularity, defined as low skeletal muscle index (SMI), and myosteatosis, a consequence of intramuscular fat infiltration, are associated with pulmonary complications, anastomotic leaks, and poorer survival after OG cancer surgery (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Limited prospective longitudinal studies examine weight and body composition changes during OG cancer treatment, particularly in Western populations where obesity is prevalent. Understanding weight loss patterns and differentiating between skeletal muscle and adipose tissue loss, particularly in patients with obesity, may influence nutrition goals and interventions.\u003c/p\u003e \u003cp\u003eBody composition analysis using computed tomography (CT) segments skeletal muscle and visceral, subcutaneous, and intramuscular adipose tissue. CT analysis is precise, validated against dual-energy x-ray absorptiometry (DXA) to predict total body muscle mass (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and accessible in oncology settings. However, accessing CT images for body composition analysis is opportunistic, limiting sequential measures. Bioimpedance spectroscopy (BIS) is convenient, has reasonable precision with 2\u0026ndash;3% variability between repeated measures, and can be utilised longitudinally (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to a) determine the longitudinal changes in body weight, skeletal muscle, and adipose tissue compartments using CT and BIS body composition assessment techniques in patients undergoing surgical resection of oesophageal and gastric cancer, and b) describe the variation in body composition changes between patients with a preoperative BMI in obese (\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e) and non-obese (\u0026lt;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e) categories.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patient selection\u003c/h2\u003e \u003cp\u003eThis prospective single-centre longitudinal observational study included adults who had OG cancer surgery with curative intent at The Alfred Hospital, Melbourne, Australia, from 2018 to 2021. Patients with non-cancer resections, benign tumours, and surgery with palliative intent were excluded. Ethics approval was obtained from the Alfred Health Human Research and Ethics Committee (HREC number 104/18).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical management\u003c/h2\u003e \u003cp\u003ePatients with primary tumours (T2 or greater) received preoperative chemotherapy (MAGIC protocol (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) pre-2019 and FLOT protocol(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) thereafter for gastric tumours) or concurrent chemoradiotherapy (CROSS protocol (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) for oesophageal and junctional tumours). Surgical resection was a modified radical en bloc oesophagectomy or gastrectomy (D1+). The inpatient nutrition management approach was individualised per standard clinical practice, including feeding jejunostomy tube insertion. A dietitian (LM) provided outpatient dietary counselling.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eDemographic data were collected at enrolment. Comorbidities, oncological characteristics, and surgical data were sourced from a prospectively maintained database housed by the Department of Oesophago-Gastric and Bariatric Surgery. Disease stage was based on the AJCC Cancer Staging Manual 8th edition (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Complications were graded according to the Clavien-Dindo Classification (severe\u0026thinsp;\u0026ge;\u0026thinsp;Grade 3) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy assessments\u003c/h2\u003e \u003cp\u003eEnrolment occurred preoperatively, and initial study assessments were conducted within one month before surgery. Study assessments were conducted approximately 2-, 6-, and 12 weeks post-discharge and 6 and 12 months postoperatively. CT images at diagnosis, restaging, and 12 months postoperatively were used for body composition analysis. Anthropometric and BIS measures were taken preoperatively and at each time point postoperatively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAnthropometric measures\u003c/h2\u003e \u003cp\u003eAnthropometric protocols were used to measure body weight and height (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Patients were classified into BMI categories based on the World Health Organisation BMI scale (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Loss of weight (LOW) at diagnosis was patient reported. Subsequent LOW was determined from the weight at the previous assessment. Patients were categorised into groups according to their preoperative BMI (non-obese BMI\u0026thinsp;\u0026lt;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e, obese BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComputed Tomography (CT) body composition assessment\u003c/h2\u003e \u003cp\u003eSliceOmatic Version 5.0 (Tomovision, Montreal, Canada) software measured skeletal muscle quantity and quality and visceral, subcutaneous, and intramuscular adipose tissue from CT images. All skeletal muscles in a single contrast-enhanced axial abdominal slice at L3 were assessed. Tissue quantity was reported as cross-sectional area (CSA) and density as mean attenuation, measured in Hounsfield Units (HU). Body compartments were identified using predefined HU thresholds of -29 to +\u0026thinsp;150 HU skeletal muscle (SM), -190 to -30 HU subcutaneous adipose tissue (SAT), -50 to -150 HU visceral adipose tissue (VAT), and \u0026minus;\u0026thinsp;190 to -30 HU intramuscular adipose tissue (IMAT) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Two trained assessors (LM and KL) blinded to patient outcomes analysed images; the mean inter-rater coefficient was 0.73%.\u003c/p\u003e \u003cp\u003eSkeletal muscle CSA was normalised for height (m\u003csup\u003e2\u003c/sup\u003e) to obtain skeletal muscle index (SMI). Low SMI for Caucasians was males\u0026thinsp;\u0026lt;\u0026thinsp;52.4 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e and females\u0026thinsp;\u0026lt;\u0026thinsp;38.5 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Low SMI for Asian ethnicity was males\u0026thinsp;\u0026lt;\u0026thinsp;40.8 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e and females\u0026thinsp;\u0026lt;\u0026thinsp;34.9 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Muscle attenuation thresholds defining myosteatosis were \u0026lt;\u0026thinsp;41 HU for BMI\u0026thinsp;\u0026le;\u0026thinsp;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e and \u0026lt;\u0026thinsp;33 HU for BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). VAT thresholds for visceral obesity were \u0026lt;\u0026thinsp;163.8 cm\u003csup\u003e2\u003c/sup\u003e in males and \u0026lt;\u0026thinsp;80.1 cm2 in females (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). To convert CSA to kg: lean body mass (LBM, kg)\u0026thinsp;=\u0026thinsp;0.30 x [skeletal muscle cm\u003csup\u003e2\u003c/sup\u003e]\u0026thinsp;+\u0026thinsp;6.06 and fat mass (FM, kg)\u0026thinsp;=\u0026thinsp;0.042 x [total adipose tissue cm\u003csup\u003e2\u003c/sup\u003e]\u0026thinsp;+\u0026thinsp;11.2 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBioimpedance Spectroscopy (BIS) body composition assessment\u003c/h2\u003e \u003cp\u003eImpedimed SF-B7 multifrequency bioimpedance spectroscopy device (ImpediMed Limited, Pinkenba, Queensland, Australia) was used to estimate fat-free mass (FFM, kg), fat mass (FM, kg). The fixed frequencies were 5, 10, 50, 100 and 500kHz. BIS assessment protocol was standardised per Earthman et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and measures were repeated three times. Patients with an electronic implantable device, severe oedema or those using diuretics were excluded from BIS measurements.\u003c/p\u003e \u003cp\u003eResults files were exported to the Impedimed software program (Bioimp, version 5.5.0.1, Impedimed Ltd, Pinkemaba, Queensland, Australia). Reliability was assessed by ensuring frequency limits were 0 to 1000 kHz, half-semi-circular Cole-Cole plots, adjusting the standard error of the estimate (SEE) to \u0026lt;\u0026thinsp;1, extracellular resistance (Re) was approximately half of intracellular resistance (Ri), and fat-free mass (FFM) was within physiological limits. Exclusion occurred when test conditions were unmet and the extracellular to intracellular body water ratio (ECW: IBW) approached 1. FFM was normalised for height to obtain fat-free mass index (FFMI, kg/m\u003csup\u003e2\u003c/sup\u003e). Low FFMI was males\u0026thinsp;\u0026lt;\u0026thinsp;17kg/m\u003csup\u003e2\u003c/sup\u003e and females\u0026thinsp;\u0026lt;\u0026thinsp;15kg/m\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eStatistical analysis was undertaken using SPSS Statistics Version 23 (IBM Corp., New York, USA) or SAS version 9.4 (SAS Institute, Cary, USA). Continuous variables were summarised using means, standard deviations (SD), medians, and interquartile ranges (IQR) according to data type and distribution. Categorical variables were expressed as frequency counts and percentages. Group comparisons were performed using Student\u0026rsquo;s t-tests or Wilcoxon rank-sum tests as appropriate for continuous variables and chi-square or Fisher\u0026rsquo;s exact tests (where numbers were small) for categorical variables. Changes in body composition measures over time were assessed using the PROC MIXED procedure in SAS, with each patient treated as a random effect. Models were fitted using main effects for time, group (obese vs non-obese) and an interaction between group and time to ascertain if the groups behaved differently over time. Post-hoc comparisons were performed using Bonferroni adjustment for multiple comparisons. All calculated p values were two-tailed; a p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistical significance. The study was powered to detect a mean difference in CT-derived SMI of 10.5cm/m\u003csup\u003e2\u003c/sup\u003e (SD 11.9) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) between low SMI and normal SMI groups with 80% power at a significance level of 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eThere were 50 patients; 45 (90%) had accessible measures at diagnosis, and 36 (72%) at 12 months. Patients were predominantly male (n\u0026thinsp;=\u0026thinsp;31, 62%), mean age of 64 \u0026plusmn; 10.3 years, had tumours located at the oesophagogastric junction (n\u0026thinsp;=\u0026thinsp;30, 60%), and oesophagectomy was most common (n\u0026thinsp;=\u0026thinsp;34, 68%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics and postoperative outcomes in oesophagogastric cancer surgery patients (n\u0026thinsp;=\u0026thinsp;50).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjuvant therapy, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo adjuvant therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39 (78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResection type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDistal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubtotal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal Gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal extended gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 stage oesophagectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIvor Lewis oesophagectomy - open\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary tumour site, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIvor Lewis oesophagectomy - hybrid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFeeding jejunostomy tube, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophageal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePostoperative complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOesophago-gastric junction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease pathology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAtelectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBacteraemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignet ring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCardiac arrythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant therapy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChyle leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePleural effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemoradiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo neoadjuvant therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePneumothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological TNM stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSevere complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePostoperative outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLOS (days), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReadmitted\u0026thinsp;\u0026le;\u0026thinsp;90 days, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisease recurrence at 1 year, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverall survival at 1 year, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 4b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eLOS: length of stay; SD: standard deviation; TNM: tumour, node, metastasis.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAnthropometry\u003c/h2\u003e \u003cp\u003eAt diagnosis, mean body weight was 85.2kg (\u0026plusmn;\u0026thinsp;27.3), BMI 29.0 kg/m\u003csup\u003e2\u003c/sup\u003e (\u0026plusmn;\u0026thinsp;9.2), and 47% (n\u0026thinsp;=\u0026thinsp;21) were overweight or obese (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Weight loss was most prominent from surgery to week two post-discharge and continued for 12 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). The proportion of underweight patients increased with a marked reduction in obesity, and the incidence of severe weight loss (\u0026ge;\u0026thinsp;10%) increased from 13% (n\u0026thinsp;=\u0026thinsp;6) at diagnosis to 66% (n\u0026thinsp;=\u0026thinsp;24) at 12 months (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBody mass index (BMI) and weight loss from diagnosis to 12 months postoperatively. Percentage weight loss was recorded as total weight lost from premorbid weight.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeek 2\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;42\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeek 6\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeek 12\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e) mean (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.0 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.0 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.3 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.9 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24.4 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24.5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBMI categories n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight (\u0026le;\u0026thinsp;18.5 kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthy weight (18.5\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight (25-29.9 kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese (\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOW (%) mean (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.8 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.0 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWeight loss categories n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-9.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10-14.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15-19.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eBMI: body mass index (kg/m\u003csup\u003e2\u003c/sup\u003e); LOW: loss of weight; SE: standard error\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e* p value indicates a significant overall time effect (Linear mixed model)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBody composition assessment\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eComputed Tomography (CT)\u003c/h2\u003e \u003cp\u003eDuring neoadjuvant treatment, skeletal muscle CSA (p\u0026thinsp;=\u0026thinsp;0.0004) and skeletal muscle index (SMI) (50.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38 cm/m\u003csup\u003e2\u003c/sup\u003e diagnosis vs 47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36 restaging, p\u0026thinsp;=\u0026thinsp;0.002) reduced significantly without change in total adipose tissue (p\u0026thinsp;=\u0026thinsp;0.919) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). Postoperatively, changes in skeletal muscle were not statistically significant (p\u0026thinsp;=\u0026thinsp;0.064), and SMI (47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e vs 45.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44 12 months, p\u0026thinsp;=\u0026thinsp;0.047) and total adipose tissue (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) reduced with greater VAT loss (-93.5 cm\u003csup\u003e2\u003c/sup\u003e) compared to SAT (-38.36 cm\u003csup\u003e2\u003c/sup\u003e). Skeletal muscle attenuation remained stable during neoadjuvant treatment (37.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40 HU at diagnosis vs 36.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38 HU, p\u0026thinsp;=\u0026thinsp;0.786) and increased at 12 months (40.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48 HU, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003eb describes the proportion of patients with low SMI, myosteatosis, and visceral obesity. The prevalence of low SMI and obesity was 6.7% (n\u0026thinsp;=\u0026thinsp;3) at diagnosis, 6% (n\u0026thinsp;=\u0026thinsp;3) preoperatively, and 3.2% (n\u0026thinsp;=\u0026thinsp;1) at 12 months.\u003c/p\u003e \u003cp\u003eFemales had lower skeletal muscle CSA than males (127.18\u0026thinsp;\u0026plusmn;\u0026thinsp;8.07 cm\u003csup\u003e2\u003c/sup\u003e vs 153.36\u0026thinsp;\u0026plusmn;\u0026thinsp;6.29 cm\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.013) but no difference in SMI (44.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e females vs 49.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63 cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.084). Males and females had similar VAT (p\u0026thinsp;=\u0026thinsp;0.531), SAT (p\u0026thinsp;=\u0026thinsp;0.731) and muscle attenuation (p\u0026thinsp;=\u0026thinsp;0.396). There were no gender differences in skeletal muscle or total adipose tissue CSA change over time (p\u0026thinsp;=\u0026thinsp;0.892 and p\u0026thinsp;=\u0026thinsp;0.533, respectively). There were no differences between age groups (\u0026lt;\u0026thinsp;or \u0026ge;\u0026thinsp;65 years) for skeletal muscle (p\u0026thinsp;=\u0026thinsp;0.727), total adipose tissue (p\u0026thinsp;=\u0026thinsp;0.515) and skeletal muscle attenuation (p\u0026thinsp;=\u0026thinsp;0.625).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eBioimpedance Spectroscopy (BIS)\u003c/h2\u003e \u003cp\u003eFat-free mass (FFM) reduced significantly from surgery to week two (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with no significant changes after (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). FM loss was not significant until six months postoperatively (p\u0026thinsp;=\u0026thinsp;0.0004) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). The proportion with low FFMI increased from surgery to week two (n\u0026thinsp;=\u0026thinsp;4, 8% vs n\u0026thinsp;=\u0026thinsp;9, 18% p\u0026thinsp;=\u0026thinsp;0.031), with no significant change at week 6 (n\u0026thinsp;=\u0026thinsp;6, 12%), week 12 (n\u0026thinsp;=\u0026thinsp;8, 16%), six months (n\u0026thinsp;=\u0026thinsp;7, 14%) or 12 months (n\u0026thinsp;=\u0026thinsp;6, 12%).\u003c/p\u003e \u003cp\u003eOverall, males had higher FFM than females (59.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 kg vs 51.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 kg, p\u0026thinsp;=\u0026thinsp;0.037) and similar FM (17.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 kg vs 21.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 kg, p\u0026thinsp;=\u0026thinsp;0.195), but there was significant time effect (p\u0026thinsp;=\u0026thinsp;0.992 and p\u0026thinsp;=\u0026thinsp;0.083, respectively). Age groups had comparable FFM (p\u0026thinsp;=\u0026thinsp;0.855) and FM (p\u0026thinsp;=\u0026thinsp;0.959), with similar postoperative changes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBMI group differences\u003c/h2\u003e \u003cp\u003eThere were no differences in baseline, oncological and surgical characteristics of patients with obesity and those without (data not shown). Anthropometric and CT body composition variables are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Preoperatively, both groups had 5% LOW, whereas patients with obesity had a higher percentage LOW than those without at 12 months (18.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3% vs 11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3%, p\u0026thinsp;=\u0026thinsp;0.048).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe absolute values for anthropometric and CT body composition variables at diagnosis, preoperatively and 12 months postoperatively, comparing patients who were in obese (BMI\u0026thinsp;\u0026le;\u0026thinsp;30kg/m\u003csup\u003e2\u003c/sup\u003e) and non-obese (BMI\u0026thinsp;\u0026lt;\u0026thinsp;30kg/m\u003csup\u003e2\u003c/sup\u003e) groups before surgery. Linear mixed models assessed overall within-group (time effect) and between-group (obese vs non-obese) differences for 32 patients with CT body composition analysis at each time point. Post-hoc analyses compared differences at each time point.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003ePostoperative (12 months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOverall group effect\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-obese\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObese\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-obese\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eObese\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNon-obese\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eObese\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAnthropometrics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.7 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118.2 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.7 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e113.1 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e66.8 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e92.2 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% LOW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.2 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.1 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.4 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18.4 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCT body composition\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkeletal muscle (cm\u003csup\u003e2\u003c/sup\u003e)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135.3 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e191.8 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e127.5 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e178.1 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e124.6 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e160.5 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.006\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisceral AT (cm\u003csup\u003e2\u003c/sup\u003e)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116.2 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e415.8 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114.5 (18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e380.7 (46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e63.6 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e140.8 (32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous AT (cm\u003csup\u003e2\u003c/sup\u003e)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145.7 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e302.8 (57.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e138.5 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e301.4 (59.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e117.4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e179.0 (47.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal AT (cm\u003csup\u003e2\u003c/sup\u003e)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e237.7 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e808.8 (149.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e264.2 (26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e742.6 (135.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e192.0 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e315.0 (91.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle density (HU)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.6 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.1 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.7 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.6 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e41.5 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e36.0 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.006\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLean muscle mass (kg)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.7 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.6 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.3 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.5 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e43.4 (2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e54.2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.006\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat mass (kg)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.2 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.3 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.4 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0 .001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19.3 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e24.4 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eAT: adipose tissue; HU: Hounsfield Units; LOW: loss of weight.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e#mean (SE); *median (IQR);\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003ea\u003c/sup\u003e p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 within-group time effect difference between diagnosis and preoperative.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003eb\u003c/sup\u003e p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 within-group time effect difference between preoperative and postoperative.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAt surgery, the absolute change in skeletal muscle CSA (-13.69\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27 cm\u003csup\u003e2\u003c/sup\u003e obese vs -7.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63 cm\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.077) and muscle attenuation (-1.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08 HU obese vs 1.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13 HU, p\u0026thinsp;=\u0026thinsp;0.601) between groups was not significant, but the obese group had lost more TAT than the non-obese group (-66.21\u0026thinsp;\u0026plusmn;\u0026thinsp;66.43 cm\u003csup\u003e2\u003c/sup\u003e vs -8.80\u0026thinsp;\u0026plusmn;\u0026thinsp;10.27 cm\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.045). At 12 months, patients with obesity at diagnosis had greater absolute muscle loss (-31.36\u0026thinsp;\u0026plusmn;\u0026thinsp;9.95 cm\u003csup\u003e2\u003c/sup\u003e obese vs 10.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.36 cm\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.006), improved muscle attenuation (8.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75 HU obese vs 0.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03 HU, p\u0026thinsp;=\u0026thinsp;0.002) and higher TAT (-493.80\u0026thinsp;\u0026plusmn;\u0026thinsp;131.60 cm\u003csup\u003e2\u003c/sup\u003e obese vs -81.75\u0026thinsp;\u0026plusmn;\u0026thinsp;20.61 cm\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.001) than patients without obesity. The percentage change in muscle quantity, TAT and muscle attenuation from diagnosis stratified by baseline obesity are shown in Fig.\u0026nbsp;4.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis prospective longitudinal study found that patients undergoing oesophagogastric cancer surgery experience substantial weight loss, predominantly muscle loss during neoadjuvant treatment and adipose tissue after surgery. Body composition changes were not influenced by the presence of obesity at diagnosis.\u003c/p\u003e \u003cp\u003eMean weight loss of 13% at 12 months was consistent with studies reporting weight loss rates of 8.8\u0026ndash;10.1% one-year post-oesophagectomy (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and 16% after total gastrectomy (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Weight loss was rapid in the early postoperative period, with 46% of patients losing\u0026thinsp;\u0026ge;\u0026thinsp;10% of weight at 12 weeks. Early and severe weight loss, defined as 14\u0026ndash;17% LOW within 1.5-3 months, predicts reduced survival after oesophagectomy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), poorer adjuvant chemotherapy tolerance, and disease-free survival after gastrectomy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSkeletal muscle loss was observed throughout treatment, with the most significant reduction during neoadjuvant treatment. Skeletal muscle loss resulted in almost half of patients having CT-derived low SMI before surgery. Adipose tissue stores remained stable during the same period. Studies have shown muscle atrophy with the preservation of adipose tissue during neoadjuvant chemoradiation (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and chemotherapy (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Anecdotally, weight regain may occur after obstructive symptoms subside or neoadjuvant treatment completion. Frequent anthropometric and body composition assessments are required to determine whether weight regain is attributable to increased adipose tissue or skeletal muscle.\u003c/p\u003e \u003cp\u003eAlthough CT-muscle loss continues, changes from surgery to 12 months were not significant. Contradictory data show a significant decline in skeletal muscle within one year postoperatively (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Regardless, 36% of patients had low SMI at 12 months, aligning with 35% reported by Elliott et al (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Boshier et al. demonstrated that one year after oesophagectomy, a greater than 10% decrease in SMI and low SMI was associated with poorer 5-year survival, whereas low SMI at diagnosis was not (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The marked reduction in total and visceral fat is consistent with retrospective reports (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAssessing longitudinal fat and fat-free mass using BIS provides unique insight into body composition variability within one year of surgery. Like weight loss, significant skeletal muscle loss occurred within one month after surgery without subsequent muscle mass recovery. In contrast, ongoing weight loss at 6 and 12 months coincided with a significant reduction in fat mass. There are limited studies utilising prospective bioimpedance measurements. Yoshida et al. showed muscle mass recovered from six months post-oesophagectomy, whereas fat mass was at the lowest point and remained stable (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Contrasting results may be attributable to fewer patients with BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e (17% vs 46%), the predominance of squamous cell carcinoma, and different preoperative treatments; overall, a vastly different population to OG adenocarcinomas in the present study and Western centres.\u003c/p\u003e \u003cp\u003ePatients with obesity had significantly more weight loss at 12 months compared to the non-obese group (18% vs 11.4%). Although patients with obesity had higher baseline skeletal muscle and adipose tissue compared to patients without obesity, experiencing a greater absolute loss of both, the percentage change in muscle and adipose tissue was comparable between groups. These findings are relevant during neoadjuvant treatment when muscle loss is predominant and fat mass is maintained.\u003c/p\u003e \u003cp\u003eThe negative implications of preoperative myosteatosis have been identified (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), but changes in muscle attenuation throughout treatment have not been described. Muscle attenuation was stable at surgery but increased postoperatively, indicating an overall improvement in muscle quality. However, the percentage increase in muscle attenuation after surgery for patients with obesity (55%) was significantly greater than in the non-obese group (3.3%). Muscle attenuation increases with reduced fat infiltration (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), explaining muscle quality improvement with adipose tissue loss.\u003c/p\u003e \u003cp\u003eThe mechanisms for body composition changes are likely multifactorial and may differ depending on the phase of treatment. Muscle loss during neoadjuvant treatment and early postoperatively corresponds with inflammatory processes associated with chemotherapy-induced muscle wasting and the surgical stress response driving catabolism (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Negative energy balance in the absence of inflammation leads to the mobilisation of adipose tissue while preserving skeletal muscle (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and may explain ongoing weight and fat mass loss observed 6 to 12 months after surgery.\u003c/p\u003e \u003cp\u003eClinical oncology nutrition guidelines recommend body composition analysis forms part of a comprehensive nutrition assessment to provide individualised interventions (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Yet, measuring weight alone, without knowledge of body composition changes, remains common. Weight loss experienced by patients with obesity during neoadjuvant treatment may be viewed favourably. Yet, our results demonstrate that weight loss during this period results from muscle wasting rather than fat loss, irrespective of BMI. Conversely, the negative implications of excess central adiposity may not be considered if weight maintenance is the primary focus before surgery.\u003c/p\u003e \u003cp\u003eThe preoperative period presents an opportunity to improve body composition. Halliday et al. showed that a multimodal prehabilitation program attenuated skeletal muscle loss and reduced visceral adiposity (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The marked reduction in weight at 12 months in patients with premorbid obesity, predominantly due to adipose tissue loss, is less concerning if muscle mass is preserved. Interventions to minimise muscle loss after surgery include individualised nutrition counselling for 12 months post-gastrectomy (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) and perioperative multi-disciplinary management (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first study to prospectively measure weight and body composition change, using multiple methods, throughout the curative treatment of oesophagogastric cancer and stratify changes based on premorbid BMI. A key strength is CT body composition analysis, which segments skeletal muscle and adipose tissue, delineating changes between compartments. Less comprehensive techniques that measure muscle circumference may misinterpret changes in muscle size with fluctuations in fat deposition. The study\u0026rsquo;s generalisability may be limited by challenges in achieving reproducible conditions for valid BIS measures in clinical practice. Finally, obtaining detailed perioperative dietary intake data linked with body composition changes may provide a focus for future nutrition intervention studies.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWeight loss during neoadjuvant treatment is primarily attributable to skeletal muscle loss. Despite continued muscle decline, adipose tissue loss is more substantial postoperatively, an important consideration for patients with obesity. CT body composition analysis provides a precise and validated method accessible to the surgical oncology population. In clinical practice, body composition should be assessed rather than focusing solely on body weight. Future research requires exploring interventions to preserve muscle, particularly during neoadjuvant therapy, and understanding the clinical impact of preoperative adipose tissue loss.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the support and contributions of Dr Kate Lambell, Senior Dietitian at Alfred Health, Melbourne, Australia, for validating CT image analysis methodology, and Julie Playfair, research nurse at Monash University Department of Surgery, for assistance with study coordination and data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLisa C. Murnane, Paul R. Burton, Audrey C. Tierney, and Adrienne K. Forsyth contributed to the conception and design of the research. Lisa C. Murnane, Kalai Shaw, Paul R. Burton, Wendy A Brown, and Jim Koukounaras contributed to data acquisition. Lisa C. Murnane and Eldho Paul conducted the statistical analysis of data. Lisa C. Murnane, Audrey C. Tierney, and Adrienne K. Forsyth contributed to data interpretation. Lisa C. Murnane drafted the manuscript. All authors provided a critical appraisal of the manuscript and provided approval for publication of the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to conduct this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFull ethics approval was obtained from the Alfred\u0026nbsp;Human Research and Ethics Committee (HREC number 104/18).\u0026nbsp;Informed consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLisa Murnane has received a speaker honorarium from Fresenius-Kabi and Nestle Health Science outside of the submitted work. Prof. Wendy Brown has received grants from Johnson and Johnson, Medtronic, GORE and Novo Nordisc, and personal fees from GORE, Novo Nordisc, Merck Sharpe and Dohme, outside of the submitted work. For the remaining authors, no conflicts of interest were declared.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamamoto K, Tanaka K, Yamasaki M, Yamashita K, Makino T, Saito T, et al. Early postoperative weight loss is associated with poor prognosis in patients with esophageal cancer. Esophagus. 2022;19(4):596\u0026ndash;603.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubo Y, Miyata H, Sugimura K, Shinno N, Asukai K, Hasegawa S, et al. Prognostic Implication of Postoperative Weight Loss After Esophagectomy for Esophageal Squamous Cell Cancer. 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European Radiology. 2016;26(5):1359\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy CF, Fanning M, Raftery N, Elliott JA, Docherty NG, Donohoe CL, et al. Early experience with a nutrition and survivorship clinic in esophageal cancer. Dis Esophagus. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Journo XB, Ouattara M, Loundou A, Trousse D, Dahan L, Nathalie T, et al. Prognostic impact of weight loss in 1-year survivors after transthoracic esophagectomy for cancer. Dis Esophagus. 2012;25(6):527\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsaoka R, Irino T, Makuuchi R, Tanizawa Y, Bando E, Kawamura T, et al. Changes in body weight, skeletal muscle and adipose tissue after gastrectomy: a comparison between proximal gastrectomy and total gastrectomy. ANZ J Surg. 2019;89(1\u0026ndash;2):79\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoterazawa Y, Oshikiri T, Takiguchi G, Urakawa N, Hasegawa H, Yamamoto M, et al. Severe weight loss after minimally invasive oesophagectomy is associated with poor survival in patients with oesophageal cancer at 5 years. BMC Gastroenterol. 2020;20(1):407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElliott JA, Doyle SL, Murphy CF, King S, Guinan EM, Beddy P, et al. Sarcopenia: Prevalence, and Impact on Operative and Oncologic Outcomes in the Multimodal Management of Locally Advanced Esophageal Cancer. Ann Surg. 2017;266(5):822\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRinninella E, Strippoli A, Cintoni M, Raoul P, Vivolo R, Di Salvatore M, et al. Body Composition Changes in Gastric Cancer Patients during Preoperative FLOT Therapy: Preliminary Results of an Italian Cohort Study. Nutrients. 2021;13(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoshier PR, Klevebro F, Jenq W, Puccetti F, Muthuswamy K, Hanna GB, et al. Long-term variation in skeletal muscle and adiposity in patients undergoing esophagectomy. Dis Esophagus. 2021;34(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshida S, Nishigori T, Tsunoda S, Tanaka E, Okabe H, Kobayashi A, et al. Chronological Changes in Skeletal Muscle Mass Two Years after Minimally Invasive Esophagectomy: A Prospective Cohort Study. Surg Endosc. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirnstein E, Schattner M. Nutritional Support in Esophagogastric Cancers. Surg Oncol Clin N Am. 2017;26(2):325\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrpcic M, Jordan T, Popuri K, Sok M. Sarcopenia and myosteatosis at presentation adversely affect survival after esophagectomy for esophageal cancer. Radiol Oncol. 2020;54(2):237\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang CL, Shen X, Huang YY, Zhang FM, Chen XY, Ma LL, et al. Myosteatosis predicts prognosis after radical gastrectomy for gastric cancer: A propensity score-matched analysis from a large-scale cohort. Surgery. 2019;166(3):297\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodpaster BH, Kelley DE, Thaete FL, He J, Ross R. Skeletal muscle attenuation determined by computed tomography is associated with skeletal muscle lipid content. Journal of applied physiology. 2000;89(1):104\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia: an international consensus. 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Dis Esophagus. 2023;36(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakata N, Kikuchi S, Kuroda S, Tanabe S, Maeda N, Noma K, et al. Effect of Patient-Participation Continuous Nutritional Counseling in Gastric Cancer Patients who Underwent Gastrectomy. Ann Surg Oncol. 2023;30(2):1110\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawata S, Hiramatsu Y, Shirai Y, Watanabe K, Nagafusa T, Matsumoto T, et al. Multidisciplinary team management for prevention of pneumonia and long-term weight loss after esophagectomy: a single-center retrospective study. Esophagus. 2020;17(3):270\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4704469/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4704469/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLow muscle mass, myosteatosis, and excess adiposity are associated with adverse outcomes after oesophagogastric (OG) cancer surgery. There is limited prospective data to evaluate body composition throughout treatment. We aimed to measure longitudinal changes in skeletal muscle and adipose tissue and describe variations according to baseline BMI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective longitudinal study included patients having OG cancer surgery at Alfred Health, Melbourne, Australia. CT images and bioimpedance spectroscopy (BIS) were used to assess body composition at multiple time points up to 12 months postoperatively. Low skeletal muscle, myosteatosis and visceral obesity were defined using published thresholds. BMI groups were defined as ≥ 30kg/m\u003csup\u003e2\u003c/sup\u003e (obese) and \u0026lt; 30kg/m\u003csup\u003e2\u003c/sup\u003e (non-obese). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 50 patients. During neoadjuvant treatment, CT-muscle declined (152.7 vs 142.4cm\u003csup\u003e2\u003c/sup\u003e, p\u0026lt;0.001) and adipose tissue was stable. Postoperatively, total adipose tissue reduced (357.7 vs 224.4cm\u003csup\u003e2\u003c/sup\u003e, p\u0026lt;0.001), but muscle did not (142.4 vs 133.6cm\u003csup\u003e2\u003c/sup\u003e, p=0.064). Low CT-muscle prevalence increased during neoadjuvant treatment (diagnosis 33%, restaging 49%, p=0.02) but not at 12 months (54%, p=0.21). Visceral obesity was common and stable between diagnosis and restaging (58% vs 54%, p=1.00) with a marked reduction at 12 months (19%, p\u0026lt;0.001). BIS-muscle declined rapidly early after surgery and did not recover. The proportion of muscle and adipose tissue loss between BMI groups was comparable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWeight loss during OG cancer treatment is significant. Skeletal muscle loss occurs during neoadjuvant treatment, while adipose tissue loss is predominant postoperatively. Anticipated changes in body composition should be considered throughout treatment, focusing on early muscle loss.\u003c/p\u003e","manuscriptTitle":"Longitudinal changes in skeletal muscle and adipose tissue during surgical treatment of oesophagogastric cancer: a prospective study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-08 00:56:05","doi":"10.21203/rs.3.rs-4704469/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13f11c23-9265-4972-b631-69cb33e8382b","owner":[],"postedDate":"October 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":35899346,"name":"Health sciences/Health care/Diagnosis/Physical examination"},{"id":35899347,"name":"Health sciences/Medical research/Translational research"}],"tags":[],"updatedAt":"2025-04-14T14:25:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-08 00:56:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4704469","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4704469","identity":"rs-4704469","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}