The role of sarcopenia in the development of early complications in patients with Advanced Epithelial Ovarian Carcinoma undergoing Cytoreductive Surgery

The role of sarcopenia in the development of early complications in patients with Advanced Epithelial Ovarian Carcinoma undergoing Cytoreductive Surgery | 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 Research Article The role of sarcopenia in the development of early complications in patients with Advanced Epithelial Ovarian Carcinoma undergoing Cytoreductive Surgery Gökhan Coşkun, Ufuk Karabacak, Halil Türkan, Murat Can Mollaoğlu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4726769/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jun, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Sarcopenia has been identified as a prognostic factor in various cancers. The aim of the study is to investigate the role of sarcopenia in the development of early complications following Primary Cytoreductive Surgery in advanced stage ovarian cancer patients. Methods A total of 57 patients who underwent Cytoreductive Surgery due to advanced stage ovarian cancer at the Surgical Oncology Clinic of ………….. University Hospital between January 2013 and June 2021 were retrospectively analyzed. Routine preoperative Computed Tomography(CT) images were used to measure the cross-sectional areas of the paraspinal muscles, abdominal wall muscles at the L3 level in cm2. The Skeletal Muscle Index (SMI) and Psoas Muscle Index (PMI) values were calculated. Postoperative early complications were classified as Clavien-Dindo grade 3 and above major complications. Results Based on SMI measurements, 23 patients with SMI < 38.5 were classified as sarcopenic, while 34 patients with SMI ≥ 38.5 were classified as nonsarcopenic; based on PMI measurements, 19 patients with PMI < 4.3 were classified as sarcopenic, while 38 patients with PMI ≥ 4.3 were classified as nonsarcopenic. Major complications occurring in the early postoperative period were significantly more common in the sarcopenic group. High Peritoneal Carcinomatosis Index (PCI) score and FIGO 3C stage were associated with a significantly higher incidence of early complications. High PCI score and SMI < 38.5 value were identified as risk factors for postoperative early complications. Conclusions The quantitative measurements of sarcopenia using routine CT imaging for preoperative staging are a useful and cost-effective method. Determining the sarcopenic status of patients before treatment offers an advantage in predicting treatment complications. Sarcopenia Ovarian cancer Primary cytoreductive surgery Postoperative complications Figures Figure 1 Figure 2 Introduction Epithelial origin gynecologic cancers are among the most common types of cancer in women. Globally, they rank fifth among the causes of death in women. Although survival rates have increased over the past decade, ovarian cancer still holds the highest mortality rate among gynecologic malignancies[ 1 ]. The majority of ovarian cancer patients present with peritoneal metastasis at the time of diagnosis[ 2 ]. Treatment of ovarian cancer is based on the Fédération Internationale de Gynécologie et d’Obstétrique(FIGO) classification. Surgical intervention remains the gold standard in the management of advanced-stage Epithelial Ovarian Cancers with peritoneal spread. Primary Cytoreductive Surgery (PCS), aimed at achieving either no residual tumor or minimal residual tumor, is the primary treatment method contributing to overall survival in these cancers[ 3 – 5 ]. IntervalCytoreductive Surgery (ICS) following Neoadjuvant Chemotherapy is preferred when achieving R0 or R1 status seems unlikely. Some studies have shown no significant difference in terms of survival and early complications between PCS and ICS[ 6 ]. Various factors contribute to the development of early postoperative complications, including tumor-related factors and patients' characteristic features[ 7 ]. Sarcopenia, one of the characteristic features of patients, refers to the progressive loss of muscle mass, muscle strength, and function over time. First described by Rosenberg in 1989, its clinical definition was established by Baumgartner et al[ 8 ].Sarcopenia is a multifactorial condition whose prevalence increases with age[ 9 ]. It is also associated with conditions such as heart failure, chronic kidney disease, malnutrition, and various cancers[ 10 , 11 ].Sarcopenia has been identified as a prognostic factor in several cancers, including pancreatic, hepatic, biliary tract, gastrointestinal, and urothelial cancers [ 12 – 15 ].However, relatively fewer studies have focused on sarcopenia in gynecologic cancers. Cancer-associated sarcopenia is part of the cancer cachexia syndrome, whose diagnosis is based on either weight loss alone or a combination of muscle and weight loss. In advanced-stage ovarian cancers, weight loss may be masked due to the formation of intraperitoneal ascites. Therefore, quantitative measurement of skeletal muscle mass provides more accurate information regarding cancer cachexia. Magnetic Resonance Imaging and Computed Tomography (CT)imaging can be utilized for quantitative measurement of skeletal muscle mass[ 10 – 16 ]. In this study, we investigated the role of sarcopenia in the development of early postoperative complications following Primary Cytoreductive Surgery in advanced-stage ovarian cancer patients. Materials and methods This study was approved by the Ethics Committee of Sivas Cumhuriyet University. (Approval number:2021-05/38, date:26.05.2021). Study population A retrospective analysis was conducted on 72 patients who underwent Primary Cytoreductive Surgery for advanced-stage serous ovarian cancer at the Surgical Oncology Clinic of ……………University Hospital between January 2013 and June 2021. Abdominal CT images taken within 50 days prior to surgery were screened. Eight patients were excluded from the study due to either unavailability or inadequate quality of CT images. Five patients who received neoadjuvant chemotherapy were also excluded. Additionally, two patients with a second primary (metachronous) malignancy were excluded. CT images of the abdomen of 57 included patients were reviewed. Calculation of Skeletal Muscle Area, Skeletal Muscle Index, Psoas major muscles, and Psoas Muscle Index Axial sections at the L3 level were used to measure the cross-sectional areas (in cm 2 ) of the right and left paraspinal muscles (Quadratus lumborum, Erector spinae, Psoas major), abdominal wall muscles (External oblique, Internal oblique, Transversus abdominis), and Rectus abdominis muscles. Measurements were performed using OsiriXsoftware 5.0. The Skeletal Muscle Index (SMI) was calculated by normalizing the Skeletal Muscle Area (SMA) value to the square of the patient's height. Additionally, the total cross-sectional area of the right and left Psoas major muscles (Psoas Muscle Area, PMA) was measured separately, and the Psoas Muscle Index (PMI) was calculated by normalizing it to the square of the patient's height. In the control group, consisting of 26 women without malignancy who underwent abdominal CT for reasons other than major abdominal surgery during the same period and in a similar age group, SMA, SMI, PMA, and PMI values were measured, and cut-off values were determined for SMI and PMI. Cut-off values of 38.5 cm2/m2 for SMI and 4.3 cm2/m2 for PMI were established. These measurements, although subject to variations based on race, environmental factors, and societal differences, are consistent with international consensus values (OECD 2020). Among the patient group, 23 patients with SMI = 38.5 were classified as nonsarcopenic. According to PMI measurements, 19 patients with PMI = 4.3 were categorized as nonsarcopenic. The clinicopathological characteristics of patients The clinicopathological characteristics of patients, including age, Body Mass Index (BMI), preoperative albumin, Hb, WBC, Plt, ASA score, FIGO stage, tumor grade, presence of ascites, operative time, intraoperative hemorrhage, Residual tumor status, length of hospital stay, Peritoneal Carcinomatosis Index (PCI) score, and intraperitoneal chemotherapy status, were examined. Early postoperative complications (within the first 30 days) were classified according to the Clavien-Dindo scale. Complications graded as Clavien-Dindo 3 and above were considered major complications. Statistical analysis Statistical analysis of the study was performed using SPSS software (Version 20, SPSS Inc., Chicago,IL, USA). Mann-Whitney U test and Logrank (Mantel-Cox) testiwas used to analyze variables. Survival curves wereprepared according to the Kaplan–Meier method and statistical differences were persuadedusing the log-rank test. Univariate and multivariate Cox-proportional hazard models wereused to evaluate risk factors. P value < 0.05was considered to indicate statistical significance. Results The statystical analyses of the clinicopathological characteristics of the patients The demographic, clinical and histopathologic characteristics, laboratory results, surgery time, intraoperative hemorrhagiae, intraperitoneal chemotherapy, hospitalization time of all patients are shown in Table 1 . Table 1 The clinicopathological characteristics of the patients. Characteristics of patients n (%) Sarcopenic(SMI = 38,5) P value Age average 55,4 (32–79) 55,8 55,2 0,846 BMI (kg/m2) 27,2 (20,2–34,3) 25,9 28,1 0,092 Obesity(BMI > 30) 16 (%28,0) 5 (%21,7) 11 (%32,3) ResidualtumorafterPCS 0–2,5 mm 2,5 mm-2 cm > 2 cm 46 (%80,7) 8 (%14,0) 3 (%5,3) 18 (%78,2) 3 (%13,0) 1 (%4,3) 28 (%82,3) 5 (%14,7) 2 (%5,8) 0,229 Histologicalgrade 1 2 3 1 (%1,7) 4 (%7,0) 52 (%91,3) PeritonealCarcinomatosisindex 24,1 (14–30) 24,3 23,9 0,938 Ascit Positive Negative 50 (%87,7) 7 (%12,3) 20 (%87,0) 3 (%13,0) 30 (%88,2) 4 (%11,8) 0,421 0,138 FIGO 3A 3B 3C 25 (%43,9) 5 (%8,7) 27 (%47,4) 10 (%43,5) 2 (%8,7) 11 (%47,8) 15 (%44,1) 3 (%8,8) 16 (%47,1) 0,731 Albumingr/dl 37,2 (24,1–51,2) 35,3 (24,1–46,2) 38,4 (27,2–51,2) 0,398 WBC 7,8 (3,1–15) 7,9 (3,1–13,8) 7,7 (3,8–15) 0,483 PLT 217(122–526) 230 (132–526) 210 (122–486) 0,232 ASA 1 2 3 6 (%11,5) 12 (%21,0) 39 (%68,5) Surgery time (min) 226,5 (110–300) 231 (130–280) 214,7 (110–300) 0,156 Intraoperativhemorajıa(ml) 440 (200–900) 497 (290–900) 425 (200–750) 0,094 Intraperı̇tonealChemotherapy (HIPEC+/- EPIC) 57 (%100) Length of hospitalization (days) 16,3 (5–88) 16,9 (5–49) 16,0 (7–88) 0,186 BMI : Body mass index PCS : Primary Cytoreductive Surgery Comparision of Skeletal Muscle Area, Skeletal Muscle Index, Psoas major muscles, and Psoas Muscle Index with hospital length, operation time, intraoperative hemorrhage, and survival time No statistically significant difference was observed in the median values of hospital length, operation time, intraoperative hemorrhage, and survival time among sarcopenia and nonsarcopenia patients across different SMI cutoff values (p > 0.05).(Table 2 ) Table 2 Comparison of hospitalization time, operation time, intraop hemorrhage and survival time according to SMI cut-off value. SMI Cutoff P value* ≥ 38,5 < 38,5 Ort. ± s. Sapma Ort. (min. - maks.) Ort. ± s. Sapma Ort. (min. - maks.) Length of hospitalization 16,0 ± 13,6 13,0 (7,0–88,0) 16,9 ± 8,7 15,0 (5,0–49,0) 0,186 Operation time 214,7 ± 50,3 217,5 (110,0–300,0) 231,7 ± 33,3 240,0 (130,0–280,0) 0,156 Intraoperativehemorrhage 425,0 ± 155,8 400,0 (200,0–750,0) 497,8 ± 163,4 500,0 (250,0–900,0) 0,094 Survival time (months) 22,2 ± 14,5 19,5 (0,0–60,0) 18,1 ± 14,6 18,0 (0,0–51,0) 0,321 * Mann-Whitney U testwasusedforcomparision There was no statistically significant difference observed in the median values of hospital length, operation time, intraoperative hemorrhage, and survival time between patients with sarcopenia and those without sarcopenia across various PMI cutoff values (p > 0.05).(Table 3 ) Table 3 Comparison of hospitalization time, operation time, intraop hemorrhage and survival time according to PMI cut-off value PMI cutoff Pvalue* ≥ 4,3 < 4,3 Mean ± Standard deviation Mean(min. - maks.) Mean ± Standard deviation Mean(min. - maks.) Length of hospitalization 15,9 ± 12,9 13,5 (7,0–88,0) 17,2 ± 9,6 15,0 (5,0–49,0) 0,212 Operation time 218,2 ± 49,9 230,0 (110,0–300,0) 228,4 ± 32,0 220,0 (170,0–280,0) 0,418 Intraoperativehemorrhage 436,8 ± 164,3 400,0 (200,0–900,0) 489,5 ± 154,2 450,0 (250,0–750,0) 0,250 Survival time (months) 22,3 ± 15,1 19,0 (0,0–60,0) 17,1 ± 12,9 18,0 (0,0–44,0) 0,318 * Mann-Whitney U test was used for comparision Association with Clavien-Dindo classifications and Skeletal Muscle Index and Psoas Muscle Index However, a statistically significant difference was found in the distribution of Clavien-Dindo classifications based on SMI cutoff values (p = 0.015). Specifically, 17.6% of patients with an SMI value of 38.5 and above and 47.8% of those with an SMI value below 38.5 were classified as Clavien-Dindo grade 3 or above. Regarding the distribution of survival statuses based on SMI cutoff values, no statistically significant difference was found (p = 0.127). (Table 4 ) Table 4 Comparison of Clavien-Dindo and survival according to SMI cut-off value. SMI Cut-off Toplam P value ≥ 38,5 < 38,5 Clavien-Dindo 2 andbelow 28 (82,4) 12 (52,2) 40 (70,2) 0,015 3 andabove 6 (17,6) 11 (47,8) 17 (29,8) Survival Dead 20 (58,8) 18 (78,3) 38 (66,7) 0,127 Alive 14 (41,2) 5 (21,7) 19 (33,3) Similarly, a statistically significant difference was found in the distribution of Clavien-Dindo classifications based on PMI cutoff values (p = 0.008). Specifically, 18.4% of patients with a PMI value of 4.3 and above and 52.6% of those with a PMI value below 4.3 were classified as Clavien-Dindo grade 3 or above. However, no statistically significant difference was observed in the distribution of survival statuses based on PMI cutoff values (p = 0.164).(Table 5 ) There was no statistically significant difference in median survival times based on SMI (p = 0.093)and PMI (p = 0.063) (Table 6 ). A statistically significant weak positive correlation was observed between Body Mass Index (BMI) and SMI values (p = 0.024). Table 5 Comparison of Clavien-Dindo and survival according to PMI cut-off value. PMI cut-off Total P value ≥ 4,3 < 4,3 Clavien-Dindo 2 ve aşağısı 31 (81,6) 9 (47,4) 40 (70,2) 0,008 3 ve üzeri 7 (18,4) 10 (52,6) 17 (29,8) Survival Dead 23 (60,5) 15 (78,9) 38 (66,7) 0,164 Alive 15 (39,5) 4 (21,1) 19 (33,3) Table 6 Comparison of survival time according to SMI and PMI cut-off values. Mediansurvival (%95 CI) Pvalue SMI cut-off ≥ 38,5 26 (18,052 − 33,948) 0,093* < 38,5 21 (13,676 − 28,324) PMI cut-off ≥ 4,3 26 (14,707 − 37,293) 0,063* < 4,3 21 (13,667 − 28,333) *Logrank (Mantel-Cox) testi Association with Clavien-Dindo classifications and risk factors Factors affecting survival were examined using univariate and multivariate Cox regression analysis. The analysis results indicated Clavien-Dindo classification as a risk factor in both univariate and multivariate models. After excluding four patients who died in the early postoperative period (Clavien-Dindo 5), the univariate model showed that the long-term mortality risk for patients with Clavien-Dindo 3 and above was 2.791 times higher compared to those with two or below. Similarly, in the multivariate model, after excluding Clavien-Dindo five patients, the mortality risk for patients with Clavien-Dindo 3 and above was 4.748 times higher compared to those with two or below. Other risk factors did not reach statistical significance (p > 0.05) (Table 7 ). Table 7 Investigation of risk factors affecting survival time by Cox regression analysis. Univariate Multivariate HR (%95 CI) P HR (%95 CI) p SMI Cutoff 1,741 (0,895–3,386) 0,102 1,193 (0,443–3,21) 0,727 PMI cutoff 1,866 (0,946–3,683) 0,072 1,38 (0,458–4,158) 0,567 FIGO 1,081 (0,768–1,522) 0,654 0,739 (0,407–1,341) 0,320 PeritonealCarcinomatosisindex 1,03 (0,951–1,114) 0,471 1,04 (0,904–1,196) 0,583 Residualtumor 1,085 (0,708–1,664) 0,708 1,04 (0,546–1,979) 0,906 Albumin 1,003 (0,997–1,008) 0,335 0,999 (0,994–1,004) 0,705 Chemotherapystatus 0,938 (0,55 − 1,601) 0,815 0,469 (0,213–1,03) 0,059 Clavien-DindoIndex 2,791 (1,377–5,657) 0,004 4,748 (1,645 − 13,707) 0,004 *Reference category Discussion Sarcopenia, initially a condition that received relatively little attention when clinically defined, has become increasingly studied in recent years. Numerous studies have investigated its prognostic significance, particularly in pancreatic, hepatic, gastrointestinal, and urothelial cancers, but relatively fewer studies have focused on epithelial ovarian cancers[ 13 – 15 ]. In the study by Rutten et al. sarcopenic patients with advanced-stage ovarian cancer were reported to have significantly lower overall survival rates compared to non-sarcopenic patients. However, sarcopenia was not found to be decisive in overall survival and major complications in multivariate analysis[ 2 ].Conversely, in the study by Kumar et al. no differences were observed in overall survival and disease-free survival between sarcopenic and non-sarcopenic groups of patients with advanced-stage ovarian cancer[ 18 ].In our study, no significant difference in overall survival was observed between sarcopenic and non-sarcopenic groups. Similarly, Conrad et al. found no significant impact of sarcopenia on early postoperative morbidity in patients with advanced-stage ovarian cancer, but combined sarcopenia with hypoalbuminemia negatively affected overall survival[ 19 ].However, in our study, no significant relationship was found between albumin levels and overall survival or postoperative early complications. In contrast to these studies, Bronger et al. reported significantly lower overall survival and disease-free survival rates in sarcopenic patients with advanced-stage ovarian cancer[ 20 ].Baseline sarcopenia was identified as a prognostic factor in advanced-stage ovarian cancer. Similarly, Huang et al. reported the effectiveness of sarcopenia in 5-year overall survival and disease-free survival rates in patients with advanced-stage ovarian cancer[ 21 ]. In the study by Ataseven et al. patients with advanced-stage ovarian cancer were classified based on quantitative SMI measurements using three different cut-off values. No association with overall survival was observed for any of the three cut-off values. However, qualitative assessment of sarcopenia based on muscle density measurement (Hounsfield Unit, HU) showed a significant association between low values and poor prognosis[ 22 ].Silva de Paula et al. identified sarcopenic patients using quantitative SMI measurements and further categorized them qualitatively based on muscle density into High-Radiodensity and Low-Radiodensity SMI groups. Qualitative skeletal muscle status was reported as the most significant predictive factor for surgical complications. High-Radiodensity SMI was found to be an independent determinant of early surgical complications and associated with early mortality[ 7 ]. In the study by Kim et al. patients with advanced-stage ovarian cancer were grouped based on quantitative SMI measurements. No difference was found in overall survival and progression-free survival rates. Additionally, when patients were subgrouped based on Fat-to-Muscle Ratio (FMR), high FMR in sarcopenic patients was found to be unfavorable for overall survival, but no difference was observed in disease-free survival[ 23 ].A meta-analysis conducted in 2020, which included most of these studies, found no significant relationship between the increase in treatment complications and sarcopenia based on data from five studies, but indicated an increased risk associated with sarcopenia. However, among the data from ten studies, a relationship was found between low overall survival and progression-free survival rates and sarcopenia, although the heterogeneity of data in these study groups was noted to be high [ 24 ]. In our study, patients were classified as sarcopenic and non-sarcopenic based on quantitative measurements. No differences were found in the characteristics of patients between the two groups. No statistically significant difference was observed in overall survival between sarcopenic and non-sarcopenic groups of patients who underwent PCS. However, major complications (Clavien-Dindo 3 and above) in the early postoperative period (first 30 days) were significantly more common in the sarcopenic group. Additionally, high PCI score and FIGO 3C stage were associated with more early complications compared to low PCI score and FIGO 3A-3B stage. The higher incidence of major complications in patients with high PCI score and FIGO 3C stage is thought to be due to the higher rates of procedures such as diaphragmatic peritonectomy, diaphragm resection, splenectomy, extensive bowel resection, and liver resection. High PCI score and SMI < 38.5 were identified as risk factors for early postoperative complications in both univariate and multivariate analyses. However, no significant difference was found in overall survival. Furthermore, when examining the factors affecting overall survival, the development of early major complications in the postoperative period was identified as a risk factor in both univariate and multivariate models. The mortality risk for patients with Clavien-Dindo 3 and above was found to be 2.791 times higher compared to those with 2 or below in the univariate model after excluding four patients who had died (Clavien-Dindo 5) in the early postoperative period. In the multivariate model, the mortality risk for patients with Clavien-Dindo 3 and above was 4.748 times higher compared to those with two or below. Delay or absence of adjuvant treatment in patients with major complications developing early postoperatively is considered to be the cause of this. Our study has some limitations, such as being a retrospective review and having a small number of scanned patients. However, the patient group studied is quite homogeneous, and patients who underwent surgery at a single center were included in the study. Conclusion Diagnosis of sarcopenia, measurement methods, and its effects on overall and disease-free survival in advanced-stage ovarian cancer are still areas of no consensus. Therefore, there is a need for prospective randomized studies with larger patient series. However, determining patients' sarcopenic status from routine preoperative CT images using quantitative measurements is a useful and cost-effective method. Determining a patient's sarcopenic status before treatment is advantageous for predicting treatment complications. Declarations AUTHORS’ CONTRIBUTIONS: Study conception and design: GC. Acquisition of data: UK, HT, MCM, MEB, KK. Analysis and interpretation of data: GC, UK, KK.Drafting of manuscript: GC. Critical revision ofmanuscript: GC, UK Ethical Approval This study was approved by the Ethics Committee of Sivas Cumhuriyet University. (Approval number:2021-05/38, date:26.05.2021). Acknowledgments We thank Prof. Dr. İsmail Şalk for his help in obtaining radiological images. Declaration of conflicting interests The authors declared there is no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. The authors declared there is no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Data availability No datasets were generated or analysed during thecurrent study References Bray F, Ferlay J, Soerjomataram I, et al (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 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Cite Share Download PDF Status: Published Journal Publication published 13 Jun, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 25 Mar, 2025 Reviews received at journal 11 Mar, 2025 Reviewers agreed at journal 31 Jan, 2025 Reviewers invited by journal 14 Aug, 2024 Editor assigned by journal 13 Jul, 2024 Submission checks completed at journal 12 Jul, 2024 First submitted to journal 11 Jul, 2024 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-4726769","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":329647752,"identity":"0f3453b1-0afb-4843-b2bf-8db4f387f031","order_by":0,"name":"Gökhan Coşkun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDCCAzCCvQfM5+EjXgvPGTDNw0a8FokcCE1QC9/tww8f/jhzOE8+8u3Bxx9z7GTYGJgfPrqBR4vkuTRjY54bh4sNb+clGxzclgx0GJuxcQ4eLQZneNikGT4cTtw4O8dM4uA2ZqAWoAghLZI/QFpmngFpqSdOiwTQYYnzJXhAWg4T1iJ5BuhynjPpiRt4cowNzm47zsPGTMAvfGeYgSF2zDpxfvsZwweV26rt+dmbHz7GpwXhwgMwFjMxykFAvoFYlaNgFIyCUTDiAAAMZ0w+FDaYGwAAAABJRU5ErkJggg==","orcid":"","institution":"Ministry of Health Tokat State Hospital, Clinic of Surgical Oncology","correspondingAuthor":true,"prefix":"","firstName":"Gökhan","middleName":"","lastName":"Coşkun","suffix":""},{"id":329647754,"identity":"be61bc5d-9b4a-4fe3-af19-3d5b59028d2f","order_by":1,"name":"Ufuk Karabacak","email":"","orcid":"","institution":"Ondokuz Mayıs University Faculty of Medicine, Department of General Surgery, and Surgical Oncology","correspondingAuthor":false,"prefix":"","firstName":"Ufuk","middleName":"","lastName":"Karabacak","suffix":""},{"id":329647756,"identity":"d2f674ca-83b8-47a0-87da-866726592aed","order_by":2,"name":"Halil Türkan","email":"","orcid":"","institution":"Mehmet Akif İnan Education and Research Hospital, Clinic of Surgical Oncology","correspondingAuthor":false,"prefix":"","firstName":"Halil","middleName":"","lastName":"Türkan","suffix":""},{"id":329647757,"identity":"dfd253a2-f534-4aa2-81a5-c1c8b1e8ca66","order_by":3,"name":"Murat Can Mollaoğlu","email":"","orcid":"","institution":"İstinye University Gaziosmanpaşa Medikalpark Hospital, Clinic of General Surgery and Surgical Oncology","correspondingAuthor":false,"prefix":"","firstName":"Murat","middleName":"Can","lastName":"Mollaoğlu","suffix":""},{"id":329647759,"identity":"fb1beac2-732f-40f2-8537-d0a0daad2892","order_by":4,"name":"Meriç Emre Bostancı","email":"","orcid":"","institution":"Ministry of Health Sivas Numune State Hospital, Clinic of Surgical Oncology","correspondingAuthor":false,"prefix":"","firstName":"Meriç","middleName":"Emre","lastName":"Bostancı","suffix":""},{"id":329647760,"identity":"15d31aca-1d4d-494c-8e13-214f2d57a3b6","order_by":5,"name":"Kürşat Karadayı","email":"","orcid":"","institution":"İstinye University Gaziosmanpaşa Medikalpark Hospital, Clinic of General Surgery and Surgical Oncology","correspondingAuthor":false,"prefix":"","firstName":"Kürşat","middleName":"","lastName":"Karadayı","suffix":""}],"badges":[],"createdAt":"2024-07-11 21:06:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4726769/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4726769/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-025-03761-1","type":"published","date":"2025-06-13T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62217905,"identity":"e67bfe82-6a82-47b7-a924-118509bd78b1","added_by":"auto","created_at":"2024-08-11 11:57:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":380154,"visible":true,"origin":"","legend":"\u003cp\u003eTotal skeletal muscle area\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4726769/v1/911f498532076652b2757542.png"},{"id":62217906,"identity":"d33afbe9-6c4b-4a2b-bdee-a263850eb063","added_by":"auto","created_at":"2024-08-11 11:57:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":300643,"visible":true,"origin":"","legend":"\u003cp\u003ePsoas muscle area\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4726769/v1/1668a2ba89df48992d5ada53.png"},{"id":84726744,"identity":"d702d952-2e1e-4c3e-bcb2-f038f2538028","added_by":"auto","created_at":"2025-06-16 16:08:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2581066,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4726769/v1/20841a6d-d7a6-4a5c-b67b-215a75df4f00.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of sarcopenia in the development of early complications in patients with Advanced Epithelial Ovarian Carcinoma undergoing Cytoreductive Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEpithelial origin gynecologic cancers are among the most common types of cancer in women. Globally, they rank fifth among the causes of death in women. Although survival rates have increased over the past decade, ovarian cancer still holds the highest mortality rate among gynecologic malignancies[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The majority of ovarian cancer patients present with peritoneal metastasis at the time of diagnosis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Treatment of ovarian cancer is based on the F\u0026eacute;d\u0026eacute;ration Internationale de Gyn\u0026eacute;cologie et d\u0026rsquo;Obst\u0026eacute;trique(FIGO) classification. Surgical intervention remains the gold standard in the management of advanced-stage Epithelial Ovarian Cancers with peritoneal spread. Primary Cytoreductive Surgery (PCS), aimed at achieving either no residual tumor or minimal residual tumor, is the primary treatment method contributing to overall survival in these cancers[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIntervalCytoreductive Surgery (ICS) following Neoadjuvant Chemotherapy is preferred when achieving R0 or R1 status seems unlikely. Some studies have shown no significant difference in terms of survival and early complications between PCS and ICS[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Various factors contribute to the development of early postoperative complications, including tumor-related factors and patients' characteristic features[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSarcopenia, one of the characteristic features of patients, refers to the progressive loss of muscle mass, muscle strength, and function over time. First described by Rosenberg in 1989, its clinical definition was established by Baumgartner et al[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].Sarcopenia is a multifactorial condition whose prevalence increases with age[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It is also associated with conditions such as heart failure, chronic kidney disease, malnutrition, and various cancers[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].Sarcopenia has been identified as a prognostic factor in several cancers, including pancreatic, hepatic, biliary tract, gastrointestinal, and urothelial cancers [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].However, relatively fewer studies have focused on sarcopenia in gynecologic cancers.\u003c/p\u003e \u003cp\u003eCancer-associated sarcopenia is part of the cancer cachexia syndrome, whose diagnosis is based on either weight loss alone or a combination of muscle and weight loss. In advanced-stage ovarian cancers, weight loss may be masked due to the formation of intraperitoneal ascites. Therefore, quantitative measurement of skeletal muscle mass provides more accurate information regarding cancer cachexia. Magnetic Resonance Imaging and Computed Tomography (CT)imaging can be utilized for quantitative measurement of skeletal muscle mass[\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we investigated the role of sarcopenia in the development of early postoperative complications following Primary Cytoreductive Surgery in advanced-stage ovarian cancer patients.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study was approved by the Ethics Committee of Sivas Cumhuriyet University. (Approval number:2021-05/38, date:26.05.2021).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 72 patients who underwent Primary Cytoreductive Surgery for advanced-stage serous ovarian cancer at the Surgical Oncology Clinic of \u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;University Hospital between January 2013 and June 2021. Abdominal CT images taken within 50 days prior to surgery were screened. Eight patients were excluded from the study due to either unavailability or inadequate quality of CT images. Five patients who received neoadjuvant chemotherapy were also excluded. Additionally, two patients with a second primary (metachronous) malignancy were excluded. CT images of the abdomen of 57 included patients were reviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCalculation of Skeletal Muscle Area, Skeletal Muscle Index, Psoas major muscles, and Psoas Muscle Index\u003c/h2\u003e \u003cp\u003eAxial sections at the L3 level were used to measure the cross-sectional areas (in cm\u003csup\u003e2\u003c/sup\u003e) of the right and left paraspinal muscles (Quadratus lumborum, Erector spinae, Psoas major), abdominal wall muscles (External oblique, Internal oblique, Transversus abdominis), and Rectus abdominis muscles. Measurements were performed using OsiriXsoftware 5.0. The Skeletal Muscle Index (SMI) was calculated by normalizing the Skeletal Muscle Area (SMA) value to the square of the patient's height. Additionally, the total cross-sectional area of the right and left Psoas major muscles (Psoas Muscle Area, PMA) was measured separately, and the Psoas Muscle Index (PMI) was calculated by normalizing it to the square of the patient's height.\u003c/p\u003e \u003cp\u003eIn the control group, consisting of 26 women without malignancy who underwent abdominal CT for reasons other than major abdominal surgery during the same period and in a similar age group, SMA, SMI, PMA, and PMI values were measured, and cut-off values were determined for SMI and PMI. Cut-off values of 38.5 cm2/m2 for SMI and 4.3 cm2/m2 for PMI were established. These measurements, although subject to variations based on race, environmental factors, and societal differences, are consistent with international consensus values (OECD 2020).\u003c/p\u003e \u003cp\u003eAmong the patient group, 23 patients with SMI\u0026thinsp;\u0026lt;\u0026thinsp;38.5 were categorized as sarcopenic, while 34 patients with SMI\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;38.5 were classified as nonsarcopenic. According to PMI measurements, 19 patients with PMI\u0026thinsp;\u0026lt;\u0026thinsp;4.3 were considered sarcopenic, while 38 patients with PMI\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;4.3 were categorized as nonsarcopenic.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eThe clinicopathological characteristics of patients\u003c/h2\u003e \u003cp\u003eThe clinicopathological characteristics of patients, including age, Body Mass Index (BMI), preoperative albumin, Hb, WBC, Plt, ASA score, FIGO stage, tumor grade, presence of ascites, operative time, intraoperative hemorrhage, Residual tumor status, length of hospital stay, Peritoneal Carcinomatosis Index (PCI) score, and intraperitoneal chemotherapy status, were examined.\u003c/p\u003e \u003cp\u003eEarly postoperative complications (within the first 30 days) were classified according to the Clavien-Dindo scale. Complications graded as Clavien-Dindo 3 and above were considered major complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis of the study was performed using SPSS software (Version 20, SPSS Inc., Chicago,IL, USA). Mann-Whitney U test and Logrank (Mantel-Cox) testiwas used to analyze variables. Survival curves wereprepared according to the Kaplan\u0026ndash;Meier method and statistical differences were persuadedusing the log-rank test. Univariate and multivariate Cox-proportional hazard models wereused to evaluate risk factors. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThe statystical analyses of the clinicopathological characteristics of the patients\u003c/h2\u003e \u003cp\u003eThe demographic, clinical and histopathologic characteristics, laboratory results, surgery time, intraoperative hemorrhagiae, intraperitoneal chemotherapy, hospitalization time of all patients are shown in 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\u003eThe clinicopathological characteristics of the patients.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSarcopenic(SMI\u0026thinsp;\u0026lt;\u0026thinsp;38,5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNonsarcopenic\u003c/p\u003e \u003cp\u003e(SMI\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;38,5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\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\u003e\u003cb\u003eAge average\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55,4 (32\u0026ndash;79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,846\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27,2 (20,2\u0026ndash;34,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObesity(BMI\u0026thinsp;\u0026gt;\u0026thinsp;30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (%28,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (%21,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (%32,3)\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\u003e\u003cb\u003eResidualtumorafterPCS\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;2,5 mm\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e2,5 mm-2 cm\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;2 cm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (%80,7)\u003c/p\u003e \u003cp\u003e8 (%14,0)\u003c/p\u003e \u003cp\u003e3 (%5,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (%78,2)\u003c/p\u003e \u003cp\u003e3 (%13,0)\u003c/p\u003e \u003cp\u003e1 (%4,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (%82,3)\u003c/p\u003e \u003cp\u003e5 (%14,7)\u003c/p\u003e \u003cp\u003e2 (%5,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,229\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistologicalgrade\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (%1,7)\u003c/p\u003e \u003cp\u003e4 (%7,0)\u003c/p\u003e \u003cp\u003e52 (%91,3)\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 \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeritonealCarcinomatosisindex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24,1 (14\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAscit\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (%87,7)\u003c/p\u003e \u003cp\u003e7 (%12,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (%87,0)\u003c/p\u003e \u003cp\u003e3 (%13,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (%88,2)\u003c/p\u003e \u003cp\u003e4 (%11,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,421\u003c/p\u003e \u003cp\u003e0,138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFIGO\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3A\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3B\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3C\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (%43,9)\u003c/p\u003e \u003cp\u003e5 (%8,7)\u003c/p\u003e \u003cp\u003e27 (%47,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (%43,5)\u003c/p\u003e \u003cp\u003e2 (%8,7)\u003c/p\u003e \u003cp\u003e11 (%47,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (%44,1)\u003c/p\u003e \u003cp\u003e3 (%8,8)\u003c/p\u003e \u003cp\u003e16 (%47,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,731\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumingr/dl\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37,2 (24,1\u0026ndash;51,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35,3 (24,1\u0026ndash;46,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38,4 (27,2\u0026ndash;51,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,398\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,8 (3,1\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,9 (3,1\u0026ndash;13,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7,7 (3,8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,483\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePLT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217(122\u0026ndash;526)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e230 (132\u0026ndash;526)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e210 (122\u0026ndash;486)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,232\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (%11,5)\u003c/p\u003e \u003cp\u003e12 (%21,0)\u003c/p\u003e \u003cp\u003e39 (%68,5)\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 \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226,5 (110\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e231 (130\u0026ndash;280)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e214,7 (110\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperativhemorajıa(ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e440 (200\u0026ndash;900)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e497 (290\u0026ndash;900)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e425 (200\u0026ndash;750)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraperı̇tonealChemotherapy\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(HIPEC+/- EPIC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (%100)\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 \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospitalization (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16,3 (5\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16,9 (5\u0026ndash;49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16,0 (7\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eBMI\u003c/b\u003e: Body mass index \u003cb\u003ePCS\u003c/b\u003e: Primary Cytoreductive Surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eComparision of Skeletal Muscle Area, Skeletal Muscle Index, Psoas major muscles, and Psoas Muscle Index with hospital length, operation time, intraoperative hemorrhage, and survival time\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNo statistically significant difference was observed in the median values of hospital length, operation time, intraoperative hemorrhage, and survival time among sarcopenia and nonsarcopenia patients across different SMI cutoff values (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).(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\u003eComparison of hospitalization time, operation time, intraop hemorrhage and survival time according to SMI cut-off value.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" 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=\"char\" char=\"\u0026plusmn;\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eSMI Cutoff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;38,5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;38,5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrt. \u0026plusmn; s. Sapma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOrt. (min. - maks.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrt. \u0026plusmn; s. Sapma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOrt. (min. - maks.)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospitalization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16,0\u0026thinsp;\u0026plusmn;\u0026thinsp;13,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13,0 (7,0\u0026ndash;88,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16,9\u0026thinsp;\u0026plusmn;\u0026thinsp;8,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15,0 (5,0\u0026ndash;49,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperation time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e214,7\u0026thinsp;\u0026plusmn;\u0026thinsp;50,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e217,5 (110,0\u0026ndash;300,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e231,7\u0026thinsp;\u0026plusmn;\u0026thinsp;33,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e240,0 (130,0\u0026ndash;280,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperativehemorrhage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e425,0\u0026thinsp;\u0026plusmn;\u0026thinsp;155,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e400,0 (200,0\u0026ndash;750,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e497,8\u0026thinsp;\u0026plusmn;\u0026thinsp;163,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e500,0 (250,0\u0026ndash;900,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival time (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e22,2\u0026thinsp;\u0026plusmn;\u0026thinsp;14,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19,5 (0,0\u0026ndash;60,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e18,1\u0026thinsp;\u0026plusmn;\u0026thinsp;14,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18,0 (0,0\u0026ndash;51,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Mann-Whitney U testwasusedforcomparision\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was no statistically significant difference observed in the median values of hospital length, operation time, intraoperative hemorrhage, and survival time between patients with sarcopenia and those without sarcopenia across various PMI cutoff values (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\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\u003eComparison of hospitalization time, operation time, intraop hemorrhage and survival time according to PMI cut-off value\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" 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=\"char\" char=\"\u0026plusmn;\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003ePMI cutoff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePvalue*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4,3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4,3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean(min. - maks.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean(min. - maks.)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospitalization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15,9\u0026thinsp;\u0026plusmn;\u0026thinsp;12,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13,5 (7,0\u0026ndash;88,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e17,2\u0026thinsp;\u0026plusmn;\u0026thinsp;9,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15,0 (5,0\u0026ndash;49,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperation time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e218,2\u0026thinsp;\u0026plusmn;\u0026thinsp;49,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e230,0 (110,0\u0026ndash;300,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e228,4\u0026thinsp;\u0026plusmn;\u0026thinsp;32,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e220,0 (170,0\u0026ndash;280,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperativehemorrhage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e436,8\u0026thinsp;\u0026plusmn;\u0026thinsp;164,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e400,0 (200,0\u0026ndash;900,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e489,5\u0026thinsp;\u0026plusmn;\u0026thinsp;154,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e450,0 (250,0\u0026ndash;750,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival time (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e22,3\u0026thinsp;\u0026plusmn;\u0026thinsp;15,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19,0 (0,0\u0026ndash;60,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e17,1\u0026thinsp;\u0026plusmn;\u0026thinsp;12,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18,0 (0,0\u0026ndash;44,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Mann-Whitney U test was used for comparision\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAssociation with Clavien-Dindo classifications and Skeletal Muscle Index and Psoas Muscle Index\u003c/h2\u003e \u003cp\u003eHowever, a statistically significant difference was found in the distribution of Clavien-Dindo classifications based on SMI cutoff values (p\u0026thinsp;=\u0026thinsp;0.015). Specifically, 17.6% of patients with an SMI value of 38.5 and above and 47.8% of those with an SMI value below 38.5 were classified as Clavien-Dindo grade 3 or above. Regarding the distribution of survival statuses based on SMI cutoff values, no statistically significant difference was found (p\u0026thinsp;=\u0026thinsp;0.127). (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Clavien-Dindo and survival according to SMI cut-off value.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSMI Cut-off\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eToplam\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;38,5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;38,5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien-Dindo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003e\u003cb\u003e2 andbelow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (82,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (52,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (70,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0,015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 andabove\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (17,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (47,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (29,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival\u003c/b\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (58,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (78,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (66,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (41,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (21,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (33,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSimilarly, a statistically significant difference was found in the distribution of Clavien-Dindo classifications based on PMI cutoff values (p\u0026thinsp;=\u0026thinsp;0.008). Specifically, 18.4% of patients with a PMI value of 4.3 and above and 52.6% of those with a PMI value below 4.3 were classified as Clavien-Dindo grade 3 or above. However, no statistically significant difference was observed in the distribution of survival statuses based on PMI cutoff values (p\u0026thinsp;=\u0026thinsp;0.164).(Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) There was no statistically significant difference in median survival times based on SMI (p\u0026thinsp;=\u0026thinsp;0.093)and PMI (p\u0026thinsp;=\u0026thinsp;0.063) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). A statistically significant weak positive correlation was observed between Body Mass Index (BMI) and SMI values (p\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Clavien-Dindo and survival according to PMI cut-off value.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePMI cut-off\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4,3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4,3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien-Dindo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003e\u003cb\u003e2 ve aşağısı\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (81,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (47,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (70,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0,008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 ve \u0026uuml;zeri\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (18,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (52,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (29,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival\u003c/b\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDead\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (60,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (78,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (66,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (39,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (21,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (33,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of survival time according to SMI and PMI cut-off values.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediansurvival (%95 CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePvalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMI cut-off\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;38,5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e26 (18,052\u0026thinsp;\u0026minus;\u0026thinsp;33,948)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,093*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;38,5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e21 (13,676\u0026thinsp;\u0026minus;\u0026thinsp;28,324)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePMI cut-off\u003c/b\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;4,3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e26 (14,707\u0026thinsp;\u0026minus;\u0026thinsp;37,293)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,063*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;4,3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e21 (13,667\u0026thinsp;\u0026minus;\u0026thinsp;28,333)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Logrank (Mantel-Cox) testi\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAssociation with Clavien-Dindo classifications and risk factors\u003c/h3\u003e\n\u003cp\u003eFactors affecting survival were examined using univariate and multivariate Cox regression analysis. The analysis results indicated Clavien-Dindo classification as a risk factor in both univariate and multivariate models. After excluding four patients who died in the early postoperative period (Clavien-Dindo 5), the univariate model showed that the long-term mortality risk for patients with Clavien-Dindo 3 and above was 2.791 times higher compared to those with two or below. Similarly, in the multivariate model, after excluding Clavien-Dindo five patients, the mortality risk for patients with Clavien-Dindo 3 and above was 4.748 times higher compared to those with two or below. Other risk factors did not reach statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInvestigation of risk factors affecting survival time by Cox regression analysis.\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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR (%95 CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHR (%95 CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSMI Cutoff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,741 (0,895\u0026ndash;3,386)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,193 (0,443\u0026ndash;3,21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,727\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePMI cutoff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,866 (0,946\u0026ndash;3,683)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,38 (0,458\u0026ndash;4,158)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,567\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFIGO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,081 (0,768\u0026ndash;1,522)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,739 (0,407\u0026ndash;1,341)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeritonealCarcinomatosisindex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,03 (0,951\u0026ndash;1,114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,04 (0,904\u0026ndash;1,196)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,583\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidualtumor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,085 (0,708\u0026ndash;1,664)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,708\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,04 (0,546\u0026ndash;1,979)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,906\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,003 (0,997\u0026ndash;1,008)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,999 (0,994\u0026ndash;1,004)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,705\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChemotherapystatus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0,938 (0,55\u0026thinsp;\u0026minus;\u0026thinsp;1,601)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,469 (0,213\u0026ndash;1,03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClavien-DindoIndex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,791 (1,377\u0026ndash;5,657)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,748 (1,645\u0026thinsp;\u0026minus;\u0026thinsp;13,707)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0,004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Reference category\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSarcopenia, initially a condition that received relatively little attention when clinically defined, has become increasingly studied in recent years. Numerous studies have investigated its prognostic significance, particularly in pancreatic, hepatic, gastrointestinal, and urothelial cancers, but relatively fewer studies have focused on epithelial ovarian cancers[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the study by Rutten et al. sarcopenic patients with advanced-stage ovarian cancer were reported to have significantly lower overall survival rates compared to non-sarcopenic patients. However, sarcopenia was not found to be decisive in overall survival and major complications in multivariate analysis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].Conversely, in the study by Kumar et al. no differences were observed in overall survival and disease-free survival between sarcopenic and non-sarcopenic groups of patients with advanced-stage ovarian cancer[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].In our study, no significant difference in overall survival was observed between sarcopenic and non-sarcopenic groups. Similarly, Conrad et al. found no significant impact of sarcopenia on early postoperative morbidity in patients with advanced-stage ovarian cancer, but combined sarcopenia with hypoalbuminemia negatively affected overall survival[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].However, in our study, no significant relationship was found between albumin levels and overall survival or postoperative early complications.\u003c/p\u003e \u003cp\u003eIn contrast to these studies, Bronger et al. reported significantly lower overall survival and disease-free survival rates in sarcopenic patients with advanced-stage ovarian cancer[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].Baseline sarcopenia was identified as a prognostic factor in advanced-stage ovarian cancer. Similarly, Huang et al. reported the effectiveness of sarcopenia in 5-year overall survival and disease-free survival rates in patients with advanced-stage ovarian cancer[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the study by Ataseven et al. patients with advanced-stage ovarian cancer were classified based on quantitative SMI measurements using three different cut-off values. No association with overall survival was observed for any of the three cut-off values. However, qualitative assessment of sarcopenia based on muscle density measurement (Hounsfield Unit, HU) showed a significant association between low values and poor prognosis[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].Silva de Paula et al. identified sarcopenic patients using quantitative SMI measurements and further categorized them qualitatively based on muscle density into High-Radiodensity and Low-Radiodensity SMI groups. Qualitative skeletal muscle status was reported as the most significant predictive factor for surgical complications. High-Radiodensity SMI was found to be an independent determinant of early surgical complications and associated with early mortality[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the study by Kim et al. patients with advanced-stage ovarian cancer were grouped based on quantitative SMI measurements. No difference was found in overall survival and progression-free survival rates. Additionally, when patients were subgrouped based on Fat-to-Muscle Ratio (FMR), high FMR in sarcopenic patients was found to be unfavorable for overall survival, but no difference was observed in disease-free survival[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].A meta-analysis conducted in 2020, which included most of these studies, found no significant relationship between the increase in treatment complications and sarcopenia based on data from five studies, but indicated an increased risk associated with sarcopenia. However, among the data from ten studies, a relationship was found between low overall survival and progression-free survival rates and sarcopenia, although the heterogeneity of data in these study groups was noted to be high [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, patients were classified as sarcopenic and non-sarcopenic based on quantitative measurements. No differences were found in the characteristics of patients between the two groups. No statistically significant difference was observed in overall survival between sarcopenic and non-sarcopenic groups of patients who underwent PCS. However, major complications (Clavien-Dindo 3 and above) in the early postoperative period (first 30 days) were significantly more common in the sarcopenic group. Additionally, high PCI score and FIGO 3C stage were associated with more early complications compared to low PCI score and FIGO 3A-3B stage. The higher incidence of major complications in patients with high PCI score and FIGO 3C stage is thought to be due to the higher rates of procedures such as diaphragmatic peritonectomy, diaphragm resection, splenectomy, extensive bowel resection, and liver resection. High PCI score and SMI\u0026thinsp;\u0026lt;\u0026thinsp;38.5 were identified as risk factors for early postoperative complications in both univariate and multivariate analyses. However, no significant difference was found in overall survival.\u003c/p\u003e \u003cp\u003eFurthermore, when examining the factors affecting overall survival, the development of early major complications in the postoperative period was identified as a risk factor in both univariate and multivariate models. The mortality risk for patients with Clavien-Dindo 3 and above was found to be 2.791 times higher compared to those with 2 or below in the univariate model after excluding four patients who had died (Clavien-Dindo 5) in the early postoperative period. In the multivariate model, the mortality risk for patients with Clavien-Dindo 3 and above was 4.748 times higher compared to those with two or below. Delay or absence of adjuvant treatment in patients with major complications developing early postoperatively is considered to be the cause of this.\u003c/p\u003e \u003cp\u003eOur study has some limitations, such as being a retrospective review and having a small number of scanned patients. However, the patient group studied is quite homogeneous, and patients who underwent surgery at a single center were included in the study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDiagnosis of sarcopenia, measurement methods, and its effects on overall and disease-free survival in advanced-stage ovarian cancer are still areas of no consensus. Therefore, there is a need for prospective randomized studies with larger patient series. However, determining patients' sarcopenic status from routine preoperative CT images using quantitative measurements is a useful and cost-effective method. Determining a patient's sarcopenic status before treatment is advantageous for predicting treatment complications.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAUTHORS\u0026rsquo; CONTRIBUTIONS:\u0026nbsp;\u003c/strong\u003eStudy conception and design: GC. Acquisition of data: UK, HT, MCM, MEB, KK. Analysis and interpretation of data: GC, UK, KK.Drafting of manuscript: GC. Critical revision ofmanuscript: GC, UK\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Sivas Cumhuriyet University. (Approval number:2021-05/38, date:26.05.2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Prof. Dr. İsmail Şalk for his help in obtaining radiological images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared there is no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eThe authors declared there is no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e No datasets were generated or analysed during thecurrent study\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, et al (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin68(6):394-424. doi: 10.3322/caac.21492.\u003c/li\u003e\n\u003cli\u003eRutten IJ, Ubachs J, Kruitwagen RFet al (2017)The influence of sarcopenia on survival and surgical complications in ovarian cancer patients undergoing primary debulking surgery. Eur J Surg Oncol43(4):717-724. doi: 10.1016/j.ejso.2016.12.016.\u003c/li\u003e\n\u003cli\u003eKehoe S, Hook J, Nankivell M, et al (2015)Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet386(9990):249-257. doi: 10.1016/S0140-6736(14)62223-6.\u003c/li\u003e\n\u003cli\u003eOnda T, Satoh T, Ogawa G, et al; Japan Clinical Oncology Group (2020) Comparison of survival between primary debulking surgery and neoadjuvant chemotherapy for stage III/IV ovarian, tubal and peritoneal cancers in phase III randomised trial. Eur J Cancer130:114-1125. doi: 10.1016/j.ejca.2020.02.020.\u003c/li\u003e\n\u003cli\u003eFagotti A, Ferrandina G, Vizzielli G, et al. Phase III randomised clinical trial comparing primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load (SCORPION trial): Final analysis of peri-operative outcome. Eur J Cancer59:22-33. doi: 10.1016/j.ejca.2016.01.017.\u003c/li\u003e\n\u003cli\u003eYao SE, Tripcony L, Sanday K, et al (2020) Survival outcomes after delayed cytoreduction surgery following neoadjuvant chemotherapy in advanced epithelial ovarian cancer. Int J Gynecol Cancer30(12):1935-1942. doi: 10.1136/ijgc-2020-001658.\u003c/li\u003e\n\u003cli\u003eSilva de Paula N, de Aguiar Bruno K, Azevedo Aredes M, et al (2018)Sarcopenia and Skeletal Muscle Quality as Predictors of Postoperative Complication and Early Mortality in Gynecologic Cancer. Int J Gynecol Cancer28(2):412-420. doi: 10.1097/IGC.0000000000001157.\u003c/li\u003e\n\u003cli\u003eBaumgartner RN, Koehler KM, Gallagher D, et al (1998) Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol147(8):755-763. doi: 10.1093/oxfordjournals.aje.a009520.\u003c/li\u003e\n\u003cli\u003eWalston JD. Sarcopenia in older adults (2012) Curr Opin Rheumatol24(6):623-27. doi: 10.1097/BOR.0b013e328358d59b.\u003c/li\u003e\n\u003cli\u003eCruz-Jentoft AJ, Bahat G, Bauer J, et al; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2 (2019) Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing48(1):16-31. doi: 10.1093/ageing/afy169.\u003c/li\u003e\n\u003cli\u003eMuscaritoli M, Anker SD, Argil\u0026eacute;s J, et al (2010) Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) \u0026quot;cachexia-anorexia in chronic wasting diseases\u0026quot; and \u0026quot;nutrition in geriatrics\u0026quot;. Clin Nutr29(2):154-159. doi: 10.1016/j.clnu.2009.12.004.\u003c/li\u003e\n\u003cli\u003eShachar SS, Williams GR, Muss HB, et al (2016)Prognostic value of sarcopenia in adults with solid tumours: A meta-analysis and systematic review. \u003cem\u003eEur J Cancer\u003c/em\u003e57:58-67. doi: 10.1016/j.ejca.2015.12.030.\u003c/li\u003e\n\u003cli\u003eFukushima H, Nakanishi Y, Kataoka M, et al (2016)Prognostic significance of sarcopenia in upper tract urothelial carcinoma patients treated with radical nephroureterectomy. Cancer Med5(9):2213-2220. doi: 10.1002/cam4.795.\u003c/li\u003e\n\u003cli\u003eLevolger S, van Vugt JL, de Bruin RW, et al (2015)Systematic review of sarcopenia in patients operated on for gastrointestinal and hepatopancreatobiliary malignancies. \u003cem\u003eBr J Surg\u003c/em\u003e102(12):1448-1458. doi: 10.1002/bjs.9893. \u003c/li\u003e\n\u003cli\u003eChoi Y, Oh DY, Kim TY, et al (2015) Skeletal Muscle Depletion Predicts the Prognosis of Patients with Advanced Pancreatic Cancer Undergoing Palliative Chemotherapy, Independent of Body Mass Index. PLoS One10(10):e0139749. doi: 10.1371/journal.pone.0139749\u003c/li\u003e\n\u003cli\u003eCesari M, Fielding RA, Pahor M, et al; International Working Group on Sarcopenia (2012) Biomarkers of sarcopenia in clinical trials-recommendations from the International Working Group on Sarcopenia. J Cachexia Sarcopenia Muscle3(3):181-190. doi: 10.1007/s13539-012-0078-2.\u003c/li\u003e\n\u003cli\u003eOECD Health Statistics 2020 Definitions, Sources and Methods. Available online: https://www.oecd.org/els/health-systems/Table-of-Content-Metadata-OECD-Health-Statistics-2020.pdf\u003c/li\u003e\n\u003cli\u003eKumar A, Moynagh MR, Multinu F, et al (2016) Muscle composition measured by CT scan is a measurable predictor of overall survival in advanced ovarian cancer. Gynecol Oncol142(2):311-316. doi: 10.1016/j.ygyno.2016.05.027.\u003c/li\u003e\n\u003cli\u003eConrad LB, Awdeh H, Acosta-Torres S, et al (2018)Pre-operative core muscle index in combination with hypoalbuminemia is associated with poor prognosis in advanced ovarian cancer. J Surg Oncol117(5):1020-1028. doi: 10.1002/jso.24990.\u003c/li\u003e\n\u003cli\u003eBronger H, Hederich P, Hapfelmeier A, et al (2017)Sarcopenia in Advanced Serous Ovarian Cancer. Int J Gynecol Cancer27(2):223-232. doi: 10.1097/IGC.0000000000000867.\u003c/li\u003e\n\u003cli\u003eHuang CY, Yang YC, Chen TC, et al (2020)Muscle loss during primary debulking surgery and chemotherapy predicts poor survival in advanced-stage ovarian cancer. J Cachexia Sarcopenia Muscle11(2):534-546. doi: 10.1002/jcsm.12524.\u003c/li\u003e\n\u003cli\u003eAtaseven B, Luengo TG, du Bois A, et al (2018)Skeletal Muscle Attenuation (Sarcopenia) Predicts Reduced Overall Survival in Patients with Advanced Epithelial Ovarian Cancer Undergoing Primary Debulking Surgery. Ann Surg Oncol 25(11):3372-3379. doi: 10.1245/s10434-018-6683-3.\u003c/li\u003e\n\u003cli\u003eKim SI, Kim TM, Lee M, et al (2020)Impact of CT-Determined Sarcopenia and Body Composition on Survival Outcome in Patients with Advanced-Stage High-Grade Serous Ovarian Carcinoma. Cancers (Basel)12(3):559. doi: 10.3390/cancers12030559. \u003c/li\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, et al (2021)Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin71(3):209-249. doi: 10.3322/caac.21660. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sarcopenia, Ovarian cancer, Primary cytoreductive surgery, Postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-4726769/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4726769/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSarcopenia has been identified as a prognostic factor in various cancers. The aim of the study is to investigate the role of sarcopenia in the development of early complications following Primary Cytoreductive Surgery in advanced stage ovarian cancer patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 57 patients who underwent Cytoreductive Surgery due to advanced stage ovarian cancer at the Surgical Oncology Clinic of \u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;.. University Hospital between January 2013 and June 2021 were retrospectively analyzed. Routine preoperative Computed Tomography(CT) images were used to measure the cross-sectional areas of the paraspinal muscles, abdominal wall muscles at the L3 level in cm2. The Skeletal Muscle Index (SMI) and Psoas Muscle Index (PMI) values were calculated. Postoperative early complications were classified as Clavien-Dindo grade 3 and above major complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBased on SMI measurements, 23 patients with SMI\u0026thinsp;\u0026lt;\u0026thinsp;38.5 were classified as sarcopenic, while 34 patients with SMI\u0026thinsp;\u0026ge;\u0026thinsp;38.5 were classified as nonsarcopenic; based on PMI measurements, 19 patients with PMI\u0026thinsp;\u0026lt;\u0026thinsp;4.3 were classified as sarcopenic, while 38 patients with PMI\u0026thinsp;\u0026ge;\u0026thinsp;4.3 were classified as nonsarcopenic. Major complications occurring in the early postoperative period were significantly more common in the sarcopenic group. High Peritoneal Carcinomatosis Index (PCI) score and FIGO 3C stage were associated with a significantly higher incidence of early complications. High PCI score and SMI\u0026thinsp;\u0026lt;\u0026thinsp;38.5 value were identified as risk factors for postoperative early complications.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe quantitative measurements of sarcopenia using routine CT imaging for preoperative staging are a useful and cost-effective method. Determining the sarcopenic status of patients before treatment offers an advantage in predicting treatment complications.\u003c/p\u003e","manuscriptTitle":"The role of sarcopenia in the development of early complications in patients with Advanced Epithelial Ovarian Carcinoma undergoing Cytoreductive Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-11 11:57:43","doi":"10.21203/rs.3.rs-4726769/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-25T12:35:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-11T16:25:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146900280237956449061765590997278327276","date":"2025-01-31T20:57:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-14T10:25:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-13T05:34:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-12T09:57:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-07-11T21:04:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7e3205c9-2059-465f-a80c-995b32301809","owner":[],"postedDate":"August 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-16T16:05:19+00:00","versionOfRecord":{"articleIdentity":"rs-4726769","link":"https://doi.org/10.1007/s00423-025-03761-1","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2025-06-13 15:57:16","publishedOnDateReadable":"June 13th, 2025"},"versionCreatedAt":"2024-08-11 11:57:43","video":"","vorDoi":"10.1007/s00423-025-03761-1","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03761-1","workflowStages":[]},"version":"v1","identity":"rs-4726769","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4726769","identity":"rs-4726769","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}