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Abstract

Background

Cholinesterase is a classical nutritional and inflammatory marker. The aim of the present study was to evaluate the value of cholinesterase as a predictive marker for postoperative skeletal muscle loss after gastrectomy for gastric cancer.

Methods

The study comprised 68 patients who had undergone gastrectomy for gastric cancer. Skeletal muscle mass was evaluated using skeletal mass index, and major skeletal muscle loss was defined as less than or equal to the median change rate (1-year postoperative/preoperative) of skeletal mass index in all patients. We explored the relationship between postoperative major skeletal muscle loss and disease-free survival and overall survival. Then we investigated the relationship between change rate of skeletal muscle index and serum cholinesterase levels after gastrectomy.

Results

The median value of change rate of skeletal mass index was 0.93. Postoperative major skeletal muscle loss was significantly associated with disease-free survival after gastrectomy (P = 0.003). Although major skeletal muscle loss had worse overall survival, it was not significant (P = 0.058). The change rate of skeletal mass index and cholinesterase had a stronger positive correlation compared with other nutritional indices according to Spearman's rank correlation coefficient (r = 0.438, P ≤ 0.001).

Conclusion

Evaluation of serum cholinesterase levels may be valuable for predicting postoperative skeletal muscle loss after gastrectomy, suggesting the importance of cholinesterase in postoperative nutritional management of patients with gastric cancer.

cholinesterase, gastric cancer, prognosis, skeletal mass index, skeletal muscle loss

Introduction

Gastric cancer is one of the most commonly diagnosed cancers in the world (1). Advance of surgical techniques has made gastrectomy more curative and safety treatment in patients with gastric cancer (2). However, previous reports have shown that patients with advanced gastric cancer experience recurrence and have a poor prognosis even after curative resection (3). Therefore, postoperative follow-up should be performed using diagnostic imaging and blood tests carefully in patients after gastrectomy for gastric cancer.

Skeletal muscle mass assessment is performed using computer tomography (CT) to assess health problem, malnutrition and frailty in patients with cancers (4). Most patients after gastrectomy suffer skeletal muscle loss due to malnutrition caused by reduction of gastric capacity and function (5, 6). Recently, postoperative skeletal muscle loss has been reported to be associated with poor prognosis in patients with gastric cancer (6). Although an auxiliary marker for predicting skeletal muscle loss would be useful in patients after gastrectomy, it has not been well-investigated.

Cholinesterase (ChE) is a sensitive nutritional and inflammatory marker (7). Recent evidence has suggested that low serum ChE levels have been associated with poor prognosis in patients with gastric cancer (8). We hypothesized that serum ChE levels could be a useful marker for predicting postoperative skeletal muscle loss in patients with gastric cancer. The aim of the present study was to evaluate the significance of ChE as a predictor for skeletal muscle loss 1 year after gastrectomy in patients with gastric cancer.

Material and methods

Study population

Between July 2014 and May 2022, 84 patients underwent curative surgery for gastric cancer. Of these, 16 patients were excluded (seven for death within one year and nine for insufficient data), leaving 68 patients for the present study. The present study was approved by the ethics committee of Tokyo General Hospital (No.23-9), and was conducted in accordance with the tenets of the Declaration of Helsinki. Informed consent was obtained in the form of opt-out on the web-site.

Patients date

The demographic and clinical data included age, sex, body mass index, American Society of Anesthesiologists Physical Status (ASA-PS) (9), comorbidities, laboratory data, tumor stage, operative methods, lymph node dissection and postoperative complications occurrence. Laboratory data included hemoglobin, albumin, ChE and neutrophil to lymphocyte ratio (NLR), and prognostic nutritional index (PNI) and their changes were calculated as 1-year postoperative/preoperative (10,11). Postoperative complications were defined as those occurring within 30 days after primary surgery. Patients with Clavien−Dindo grade II or higher complications were included in the complication group (12).

Assessment of skeletal muscle mass

Skeletal muscle mass was evaluated as skeletal muscle index (SMI) preoperatively and one-year postoperatively, as previously described (13). All included patients underwent abdominal CT scans and SMI was calculated by measuring the cross-sectional area (cm2) of skeletal muscle in the third lumbar vertebra (L3) region, followed by normalizing it by height (cm2/m2). The change rate of SMI was calculated as 1-year postoperative/preoperative, and major loss of SMI was defined as less than or equal to the median change rate of SMI of all patients.

Statistical analysis

All statistical analyses were conducted using EZR software version 1.51 (Saitama Medical Center, Jichi Medical University, Japan) and GraphPad Prism (version 9). All P-values were two-sided with α level of 0.05.

Data are expressed as a median value. The Kaplan–Meier method was used to estimate cumulative survival probabilities, and the differences between groups were compared using the log-rank test. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify the variables affecting the disease-free and overall survival. To compare the two groups, we used the Mann–Whitney U or chi-square tests, as appropriate. The cutoff value of change rate of nutritional markers for predicting skeletal muscle loss was calculated through the Youden’s index obtained from the receiver operating characteristic curve. The correlation analysis was performed using Spearman's rank correlation coefficient test.

Results

Patient characteristics

Table 1 shows the demographic and characteristics of patients. Of all patients, the median age was 75 (54–91) years and 43 patients were male. The median values of preoperative hemoglobin, albumin, ChE levels, NLR and PNI were 12.5 g/dl, 3.9 g/dL, 248 U/L, 3.02 and 47.7, respectively. The median values of change ratio of hemoglobin, albumin, ChE levels, NLR and PNI were 0.97, 0.97, 0.92, 0.71 and 0.97, respectively. Preoperative SMI was 41.6 cm2/m2 and the median value of change rate of SMI was 0.93.

Table 1
Open in new tab

Patient characteristics

VariablesAll patients
(n = 68)
Age (y)77 (54–91)
Sex (Male)43 (63%)
BMI (kg/m2)21.5 (16.2–35.6)
ASA-PS ≥ 37 (10%)
Diabetes mellitus12 (18%)
Cardiovascular comorbidities13 (19%)
Preoperative data
 Hemoglobin (g/dl)12.5 (7.4–15.6)
 Albumin (g/dL)4.0 (2.2–4.8)
 ChE (U/L)264 (91–514)
 NLR3.02 (1.05–12.7)
 PNI47.7 (28.2–56.3)
 SMI41.6 (29.9–65.7)
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.97 (0.67–2.09)
 Albumin0.97 (0.66–2.33)
 ChE0.92 (0.37–2.81)
 NLR0.71 (0.15–4.16)
 PNI0.97 (0.65–1.51)
 SMI0.93 (0.62–1.33)
T stage ≥ 49 (13%)
N stage ≥ 1–328 (41%)
Stage I/II/III35/17/16
Total gastrectomy18 (26%)
Lymph node dissection D225 (37%)
Postoperative complications15 (22%)
VariablesAll patients
(n = 68)
Age (y)77 (54–91)
Sex (Male)43 (63%)
BMI (kg/m2)21.5 (16.2–35.6)
ASA-PS ≥ 37 (10%)
Diabetes mellitus12 (18%)
Cardiovascular comorbidities13 (19%)
Preoperative data
 Hemoglobin (g/dl)12.5 (7.4–15.6)
 Albumin (g/dL)4.0 (2.2–4.8)
 ChE (U/L)264 (91–514)
 NLR3.02 (1.05–12.7)
 PNI47.7 (28.2–56.3)
 SMI41.6 (29.9–65.7)
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.97 (0.67–2.09)
 Albumin0.97 (0.66–2.33)
 ChE0.92 (0.37–2.81)
 NLR0.71 (0.15–4.16)
 PNI0.97 (0.65–1.51)
 SMI0.93 (0.62–1.33)
T stage ≥ 49 (13%)
N stage ≥ 1–328 (41%)
Stage I/II/III35/17/16
Total gastrectomy18 (26%)
Lymph node dissection D225 (37%)
Postoperative complications15 (22%)

ASA-PS, American Society of Anesthesiologists physical status;

BMI, body mass index; ChE, cholinesterase, NLR, neutrophil to lymphocyte ratio; PNI, prognostic nutritional index;

SMI, skeletal muscle index; Y, year

Table 1
Open in new tab

Patient characteristics

VariablesAll patients
(n = 68)
Age (y)77 (54–91)
Sex (Male)43 (63%)
BMI (kg/m2)21.5 (16.2–35.6)
ASA-PS ≥ 37 (10%)
Diabetes mellitus12 (18%)
Cardiovascular comorbidities13 (19%)
Preoperative data
 Hemoglobin (g/dl)12.5 (7.4–15.6)
 Albumin (g/dL)4.0 (2.2–4.8)
 ChE (U/L)264 (91–514)
 NLR3.02 (1.05–12.7)
 PNI47.7 (28.2–56.3)
 SMI41.6 (29.9–65.7)
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.97 (0.67–2.09)
 Albumin0.97 (0.66–2.33)
 ChE0.92 (0.37–2.81)
 NLR0.71 (0.15–4.16)
 PNI0.97 (0.65–1.51)
 SMI0.93 (0.62–1.33)
T stage ≥ 49 (13%)
N stage ≥ 1–328 (41%)
Stage I/II/III35/17/16
Total gastrectomy18 (26%)
Lymph node dissection D225 (37%)
Postoperative complications15 (22%)
VariablesAll patients
(n = 68)
Age (y)77 (54–91)
Sex (Male)43 (63%)
BMI (kg/m2)21.5 (16.2–35.6)
ASA-PS ≥ 37 (10%)
Diabetes mellitus12 (18%)
Cardiovascular comorbidities13 (19%)
Preoperative data
 Hemoglobin (g/dl)12.5 (7.4–15.6)
 Albumin (g/dL)4.0 (2.2–4.8)
 ChE (U/L)264 (91–514)
 NLR3.02 (1.05–12.7)
 PNI47.7 (28.2–56.3)
 SMI41.6 (29.9–65.7)
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.97 (0.67–2.09)
 Albumin0.97 (0.66–2.33)
 ChE0.92 (0.37–2.81)
 NLR0.71 (0.15–4.16)
 PNI0.97 (0.65–1.51)
 SMI0.93 (0.62–1.33)
T stage ≥ 49 (13%)
N stage ≥ 1–328 (41%)
Stage I/II/III35/17/16
Total gastrectomy18 (26%)
Lymph node dissection D225 (37%)
Postoperative complications15 (22%)

ASA-PS, American Society of Anesthesiologists physical status;

BMI, body mass index; ChE, cholinesterase, NLR, neutrophil to lymphocyte ratio; PNI, prognostic nutritional index;

SMI, skeletal muscle index; Y, year

Survival curve in patients after gastrectomy for gastric cancer according to postoperative skeletal muscle loss

Postoperative major skeletal muscle loss was significantly associated with disease-free survival after gastrectomy (Fig. 1a, Log-rank test, P = 0.003). Also, we have shown disease-free survivals in each stage of gastric cancer (Supplementary Fig. 1). In the subgroup of Stage I, II and III patients, major skeletal muscle loss group had worse disease-free survivals than minor skeletal muscle loss group. Although major skeletal muscle loss had worse overall survival, it was not significant (Fig. 1b, Log-rank test, P = 0.058).

Kaplan–Meier curves according to postoperative skeletal muscle loss for disease-free survival (a) and overall survival (b) after gastrectomy for gastric cancer.
Figure 1

Kaplan–Meier curves according to postoperative skeletal muscle loss for disease-free survival (a) and overall survival (b) after gastrectomy for gastric cancer.

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Clinicopathological variables associated with skeletal muscle loss

Table 2 lists the relationship between the clinical variables and postoperative major skeletal muscle loss after gastrectomy for gastric cancer. Change ratios of hemoglobin (P = 0.013), albumin (P = 0.004), ChE (P = 0.002) and PNI (P = 0.018) were significantly associated with postoperative major skeletal muscle loss. On the other hand, preoperative values of these nutritional indices were not associated with postoperative major skeletal muscle loss.

Table 2
Open in new tab

Patient characteristics associated with major skeletal muscle loss

CharacteristicPostoperative skeletal muscle lossP-value
Major (n = 34)Minor (n = 34)
Age (y)77 (54–87)78 (57–91)0.768
Sex (Male)21 (62%)22 (65%)1.000
BMI (kg/m2)21.3 (16.9–31.2)21.9 (16.2–35.6)0.783
ASA-PS ≥ 34 (12%)3 (8.8%)1.000
Diabetes mellitus7 (21%)5 (15%)0.752
Cardiovascular comorbidities7 (21%)6 (18%)1.000
Preoperative data
 Hemoglobin (g/dl)12.4 (9.7–15.4)12.5 (7.4–15.6)0.677
 Albumin (g/dL)4.0 (2.2–4.8)4.1 (2.5–4.8)0.735
 ChE (U/L)266 (106–387)258 (91–514)0.377
 NLR2.81 (1.09–8.56)3.22 (1.05–12.7)0.216
 PNI47.7 (28.2–55.9)47.9 (30.3–56.3)0.747
 SMI40.9 (29.5–65.7)41.8 (30.0–61.4)0.446
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.92 (0.67–1.25)0.98 (0.69–2.09)0.013
 Albumin0.93 (0.66–1.59)0.98 (0.84–2.33)0.004
 ChE0.85 (0.37–1.40)1.00 (0.65–2.81)0.002
 NLR0.70 (0.27–4.16)0.72 (0.15–2.20)0.851
 PNI0.94 (0.65–1.51)0.99 (0.80–1.44)0.018
 SMI0.81 (0.62–0.93)1.02 (0.93–1.33)<0.001
T stage ≥ 44 (12%)5 (15%)1.000
N stage ≥ 1–314 (41%)14 (41%)1.000
Stage I/II/III15/10/920/7/70.534
Total gastrectomy12 (35%)6 (18%)0.168
Lymph node dissection D216 (47%)9 (26%)0.131
Postoperative complications6 (18%)9 (26%)0.560
CharacteristicPostoperative skeletal muscle lossP-value
Major (n = 34)Minor (n = 34)
Age (y)77 (54–87)78 (57–91)0.768
Sex (Male)21 (62%)22 (65%)1.000
BMI (kg/m2)21.3 (16.9–31.2)21.9 (16.2–35.6)0.783
ASA-PS ≥ 34 (12%)3 (8.8%)1.000
Diabetes mellitus7 (21%)5 (15%)0.752
Cardiovascular comorbidities7 (21%)6 (18%)1.000
Preoperative data
 Hemoglobin (g/dl)12.4 (9.7–15.4)12.5 (7.4–15.6)0.677
 Albumin (g/dL)4.0 (2.2–4.8)4.1 (2.5–4.8)0.735
 ChE (U/L)266 (106–387)258 (91–514)0.377
 NLR2.81 (1.09–8.56)3.22 (1.05–12.7)0.216
 PNI47.7 (28.2–55.9)47.9 (30.3–56.3)0.747
 SMI40.9 (29.5–65.7)41.8 (30.0–61.4)0.446
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.92 (0.67–1.25)0.98 (0.69–2.09)0.013
 Albumin0.93 (0.66–1.59)0.98 (0.84–2.33)0.004
 ChE0.85 (0.37–1.40)1.00 (0.65–2.81)0.002
 NLR0.70 (0.27–4.16)0.72 (0.15–2.20)0.851
 PNI0.94 (0.65–1.51)0.99 (0.80–1.44)0.018
 SMI0.81 (0.62–0.93)1.02 (0.93–1.33)<0.001
T stage ≥ 44 (12%)5 (15%)1.000
N stage ≥ 1–314 (41%)14 (41%)1.000
Stage I/II/III15/10/920/7/70.534
Total gastrectomy12 (35%)6 (18%)0.168
Lymph node dissection D216 (47%)9 (26%)0.131
Postoperative complications6 (18%)9 (26%)0.560

ASA-PS, American Society of Anesthesiologists physical status;

BMI, body mass index; ChE, cholinesterase, NLR, neutrophil to lymphocyte ratio; PNI, prognostic nutritional index;

SMI, skeletal muscle index; Y, year

Table 2
Open in new tab

Patient characteristics associated with major skeletal muscle loss

CharacteristicPostoperative skeletal muscle lossP-value
Major (n = 34)Minor (n = 34)
Age (y)77 (54–87)78 (57–91)0.768
Sex (Male)21 (62%)22 (65%)1.000
BMI (kg/m2)21.3 (16.9–31.2)21.9 (16.2–35.6)0.783
ASA-PS ≥ 34 (12%)3 (8.8%)1.000
Diabetes mellitus7 (21%)5 (15%)0.752
Cardiovascular comorbidities7 (21%)6 (18%)1.000
Preoperative data
 Hemoglobin (g/dl)12.4 (9.7–15.4)12.5 (7.4–15.6)0.677
 Albumin (g/dL)4.0 (2.2–4.8)4.1 (2.5–4.8)0.735
 ChE (U/L)266 (106–387)258 (91–514)0.377
 NLR2.81 (1.09–8.56)3.22 (1.05–12.7)0.216
 PNI47.7 (28.2–55.9)47.9 (30.3–56.3)0.747
 SMI40.9 (29.5–65.7)41.8 (30.0–61.4)0.446
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.92 (0.67–1.25)0.98 (0.69–2.09)0.013
 Albumin0.93 (0.66–1.59)0.98 (0.84–2.33)0.004
 ChE0.85 (0.37–1.40)1.00 (0.65–2.81)0.002
 NLR0.70 (0.27–4.16)0.72 (0.15–2.20)0.851
 PNI0.94 (0.65–1.51)0.99 (0.80–1.44)0.018
 SMI0.81 (0.62–0.93)1.02 (0.93–1.33)<0.001
T stage ≥ 44 (12%)5 (15%)1.000
N stage ≥ 1–314 (41%)14 (41%)1.000
Stage I/II/III15/10/920/7/70.534
Total gastrectomy12 (35%)6 (18%)0.168
Lymph node dissection D216 (47%)9 (26%)0.131
Postoperative complications6 (18%)9 (26%)0.560
CharacteristicPostoperative skeletal muscle lossP-value
Major (n = 34)Minor (n = 34)
Age (y)77 (54–87)78 (57–91)0.768
Sex (Male)21 (62%)22 (65%)1.000
BMI (kg/m2)21.3 (16.9–31.2)21.9 (16.2–35.6)0.783
ASA-PS ≥ 34 (12%)3 (8.8%)1.000
Diabetes mellitus7 (21%)5 (15%)0.752
Cardiovascular comorbidities7 (21%)6 (18%)1.000
Preoperative data
 Hemoglobin (g/dl)12.4 (9.7–15.4)12.5 (7.4–15.6)0.677
 Albumin (g/dL)4.0 (2.2–4.8)4.1 (2.5–4.8)0.735
 ChE (U/L)266 (106–387)258 (91–514)0.377
 NLR2.81 (1.09–8.56)3.22 (1.05–12.7)0.216
 PNI47.7 (28.2–55.9)47.9 (30.3–56.3)0.747
 SMI40.9 (29.5–65.7)41.8 (30.0–61.4)0.446
Change ratio (postoperative 1Y/preoperative)
 Hemoglobin0.92 (0.67–1.25)0.98 (0.69–2.09)0.013
 Albumin0.93 (0.66–1.59)0.98 (0.84–2.33)0.004
 ChE0.85 (0.37–1.40)1.00 (0.65–2.81)0.002
 NLR0.70 (0.27–4.16)0.72 (0.15–2.20)0.851
 PNI0.94 (0.65–1.51)0.99 (0.80–1.44)0.018
 SMI0.81 (0.62–0.93)1.02 (0.93–1.33)<0.001
T stage ≥ 44 (12%)5 (15%)1.000
N stage ≥ 1–314 (41%)14 (41%)1.000
Stage I/II/III15/10/920/7/70.534
Total gastrectomy12 (35%)6 (18%)0.168
Lymph node dissection D216 (47%)9 (26%)0.131
Postoperative complications6 (18%)9 (26%)0.560

ASA-PS, American Society of Anesthesiologists physical status;

BMI, body mass index; ChE, cholinesterase, NLR, neutrophil to lymphocyte ratio; PNI, prognostic nutritional index;

SMI, skeletal muscle index; Y, year

Association between nutritional change and postoperative skeletal muscle loss

The change rate of SMI and hemoglobin (r = 0.281, P = 0.021), albumin (r = 0.391, P = 0.001) and PNI (r = 0.316, P = 0.015) had a weak positive correlation according to Spearman's rank correlation coefficient (Fig. 2a, b, d). While, the change rate of SMI and ChE had a strong positive correlation according to Spearman's rank correlation coefficient (r = 0.438, P < 0.001) (Fig. 2c). The cutoff value of change rate of serum ChE levels for postoperative major skeletal muscle loss was 0.73 (sensitivity = 41.2%, specificity = 97.1%), with the AUC of 0.720 (95% CI: 0.599–0.840) (Fig. 3).

The correlation between change ratio of SMI and (a) hemoglobin, (b) albumin, (c) ChE and (d) PNI in the Spearman’s rank correlation coefficient test.
Figure 2

The correlation between change ratio of SMI and (a) hemoglobin, (b) albumin, (c) ChE and (d) PNI in the Spearman’s rank correlation coefficient test.

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The optimal cutoff value of change ratio of serum ChE levels for postoperative skeletal muscle loss after gastrectomy for gastric cancer.
Figure 3

The optimal cutoff value of change ratio of serum ChE levels for postoperative skeletal muscle loss after gastrectomy for gastric cancer.

Open in new tabDownload slide

Clinicopathological variables associated with disease-free and overall survival

Supplementary Table 1 shows the relationship between clinicopathological variables and disease-free survival after gastrectomy. In the univariate analysis, the change ratio of ChE (P = 0.026), PNI (P = 0.040), SMI (P = 0.009) and T stage ≥4 (P = 0.016) were significantly associated with disease-free survival. In the multivariate analysis, T stage ≥4 (P = 0.010) was an independent predictor of disease-free survival, but the change ratio of ChE was not (P = 0.096).

Supplementary Table 2 shows the relationship between clinicopathological variables and overall survival after gastrectomy. In the univariate analysis, the change ratio of albumin (P = 0.036), ChE (P = 0.002), PNI (P ≤ 0.001) and T stage ≥4 (P = 0.015) were significantly associated with overall survival. In the multivariate analysis, T stage ≥4 (P = 0.035) was an independent predictor of overall survival, but the change ratio of ChE was not (P = 0.060).

Discussion

In the present study, we revealed the significant association between major skeletal muscle loss and poor prognosis after gastrectomy for gastric cancer. As a novelty, postoperative change rate of serum ChE levels were associated strongly with skeletal muscle loss after gastrectomy for gastric cancer. These findings suggest that perioperative serum ChE levels can be one of the valuable markers for predicting nutritional status and identifying patients at risk for skeletal muscle loss after gastrectomy.

Skeletal muscle loss has been reported as a nutritional and prognostic marker in patients with gastric cancer (14). Although several nutritional markers such as hemoglobin and albumin have been correlated with skeletal muscle loss (15), ChE had higher correlation with skeletal muscle loss than other nutritional indices in the present study. Also, although the change rate of serum ChE levels were not associated with worsen survival in multivariate analysis, it was close to significant. These results may suggest the value of ChE for assessing the nutritional status of gastric cancer patients consistently in the perioperative periods.

Inflammation is an important contributor to skeletal muscle loss and dysfunction (16). Inflammatory cytokines such as tumor necrosis factor-α and interleukin-6 activate inflammation pathway and induce skeletal muscle loss progress (17,18). These inflammatory cascades have promoted to block the synthesis of ChE and albumin in favor of acute-phase protein synthesis (19). Furthermore, the half-life of serum ChE is shorter than that of serum albumin (7). Thus, this evidence line may support our findings that the impact of serum ChE levels in skeletal muscle loss after gastrectomy.

Postoperative nutritional intervention can improve nutritional status, resulting skeletal muscle maintenance in patients with gastric cancer (20). Given our results that postoperative ChE change rate was most associated with skeletal muscle loss, assessment of serum ChE levels may be useful in perioperative nutritional intervention period. We defined the cutoff value of change rate of ChE (0.73), which had high specificity (97.1%) for predicting postoperative skeletal muscle loss after gastrectomy. Thus, nutritional management and guidance should be performed to keep postoperative serum ChE levels above at least 70% of preoperative levels. ChE assessment may enable surgeons to evaluate the change in nutritional status and effect of nutritional intervention, and predict postoperative poor prognosis in patients with gastric cancer.

In the present study, there are some limitations. First, this was the retrospective study in the single-center single with the limited sample size. Second, ChE is associated with several factors such as age, inflammatory status and cancer stage. Thus, the influence of the confounding factors may not be fully excluded. Third, the change ratio of ChE may be influenced by the value of preoperative serum ChE levels. Fourth, although the median value was used as the definition of major skeletal muscle loss in the present study, the definition of skeletal muscle loss remains controversial. Further large-scale studies with measurement of serum ChE levels and SMI are required to validate our results.

In conclusion, we found that change ratio of serum ChE levels were associated with postoperative skeletal muscle loss after gastrectomy for gastric cancer. This novel aspect of our study underscores the importance of ChE in the postoperative nutritional management in patients with gastric cancer, offering a potentially valuable tool for clinicians to optimize patient outcomes.

Acknowledgements

Not applicable.

Funding

Not applicable.

Conflict of interests statement

None declared.

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