{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T14:08:26Z","timestamp":1792850906034,"version":"4.5.0"},"reference-count":41,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2025,7,9]],"date-time":"2025-07-09T00:00:00Z","timestamp":1752019200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background: Prehabilitation programs improve postoperative outcomes in vulnerable patients undergoing major surgery. However, current screening tools such as the Malnutrition Universal Screening Tool (MUST) may lack the sensitivity needed to identify those who would benefit most. Muscle quality assessed by Computed Tomography (CT), specifically muscle radiodensity in Hounsfield Units (HUs), has emerged as a promising alternative for risk stratification. Objective: To evaluate the prognostic performance of CT-derived muscle radiodensity in predicting adverse postoperative outcomes in colorectal cancer patients, and to compare it with the performance of the MUST score. Methods: This single-center cross-sectional study included 201 patients with non-metastatic colon cancer undergoing elective laparoscopic resection. Patients were stratified based on enrollment in a multimodal prehabilitation program, either within an Enhanced Recovery After Surgery (ERAS) protocol or a non-ERAS pathway. Nutritional status was assessed using MUST, SARC-F questionnaire (strength, assistance with walking, rise from a chair, climb stairs, and falls), and the Global Leadership Initiative on Malnutrition (GLIM) criteria. CT scans at the L3 level were analyzed using automated segmentation to extract muscle area and radiodensity. Postoperative complications and hospital stay were compared across nutritional screening tools and CT-derived metrics. Results: MUST shows limited sensitivity (&lt;27%) for predicting complications and prolonged hospitalization. In contrast, CT-derived muscle radiodensity demonstrates higher discriminative power (AUC 0.62\u20130.69), especially using a 37 HU threshold. In the non-ERAS group, patients with HU \u2264 37 had significantly more complications (33% vs. 15%, p = 0.036), longer surgeries, and more severe events (Clavien\u2013Dindo \u2265 3). Conclusions: Opportunistic CT-based assessment of muscle radiodensity outperforms traditional screening tools in identifying patients at risk of poor postoperative outcomes, and may enhance patient selection for prehabilitation strategies like the ERAS program.<\/jats:p>","DOI":"10.3390\/nu17142264","type":"journal-article","created":{"date-parts":[[2025,7,10]],"date-time":"2025-07-10T09:38:27Z","timestamp":1752140307000},"page":"2264","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Prognostic Value of Computed Tomography-Derived Muscle Density for Postoperative Complications in Enhanced Recovery After Surgery (ERAS) and Non-ERAS Patients"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9941-1816","authenticated-orcid":false,"given":"Fiorella X.","family":"Palmas","sequence":"first","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"},{"name":"Diabetes and Metabolism Research Unit, Vall d\u2019Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain"},{"name":"Department of Medicine, Universitat Aut\u00f2noma de Barcelona, 08193 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marta","family":"Ricart","sequence":"additional","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amador","family":"Lluch","sequence":"additional","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-7517-5265","authenticated-orcid":false,"given":"Fernanda","family":"Mucarzel","sequence":"additional","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raul","family":"Cartiel","sequence":"additional","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alba","family":"Zabalegui","sequence":"additional","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-4384-079X","authenticated-orcid":false,"given":"Elena","family":"Barrera","sequence":"additional","affiliation":[{"name":"ARTIS Development, 35017 Las Palmas de Gran Canaria, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6751-7491","authenticated-orcid":false,"given":"Nuria","family":"Roson","sequence":"additional","affiliation":[{"name":"Department of Radiology, Institut De Diagn\u00f2stic Per La Imatge (IDI), University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4838-781X","authenticated-orcid":false,"given":"Aitor","family":"Rodriguez","sequence":"additional","affiliation":[{"name":"Department of Radiology, Institut De Diagn\u00f2stic Per La Imatge (IDI), University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eloy","family":"Espin-Basany","sequence":"additional","affiliation":[{"name":"Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d\u2019Hebron, Universitat Aut\u00f2noma de Barcelona, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosa M.","family":"Burgos","sequence":"additional","affiliation":[{"name":"Nutrition Support Unit, Endocrinology and Nutrition Department, University Hospital Vall d\u2019Hebron, 08035 Barcelona, Spain"},{"name":"Diabetes and Metabolism Research Unit, Vall d\u2019Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain"},{"name":"Department of Medicine, Universitat Aut\u00f2noma de Barcelona, 08193 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,7,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1016\/j.bja.2021.12.007","article-title":"Prehabilitation, enhanced recovery after surgery, or both? A narrative review","volume":"128","author":"Gillis","year":"2022","journal-title":"Br. J. Anaesth."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1139\/apnm-2021-0299","article-title":"Malnutrition modifies the response to multimodal prehabilitation: A pooled analysis of prehabilitation trials","volume":"47","author":"Gillis","year":"2022","journal-title":"Appl. Physiol. Nutr. Metab.=Physiol. Appl. Nutr. Metab."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1245\/s10434-022-12623-9","article-title":"Improved Postoperative Outcomes after Prehabilitation for Colorectal Cancer Surgery in Older Patients: An Emulated Target Trial","volume":"30","author":"Heil","year":"2023","journal-title":"Ann. Surg. Oncol."},{"key":"ref_4","first-page":"Doc10","article-title":"Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery","volume":"17","author":"Schwenk","year":"2022","journal-title":"GMS Hyg. Infect. Control"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1016\/j.clnu.2017.02.013","article-title":"ESPEN guideline: Clinical nutrition in surgery","volume":"36","author":"Weimann","year":"2017","journal-title":"Clin. Nutr."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1002\/ncp.10844","article-title":"Ability of malnutrition screening and assessment tools to identify computed tomography defined low muscle mass in colorectal cancer surgery","volume":"37","author":"Djordjevic","year":"2022","journal-title":"Nutr. Clin. Pract."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"van Dronkelaar, C., Tieland, M., Cederholm, T., Reijnierse, E.M., Weijs, P.J.M., and Kruizenga, H. (2023). Malnutrition Screening Tools Are Not Sensitive Enough to Identify Older Hospital Patients with Malnutrition. Nutrients, 15.","DOI":"10.3390\/nu15245126"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Ser\u00f3n-Arbeloa, C., Labarta-Monz\u00f3n, L., Puzo-Foncillas, J., Mallor-Bonet, T., Lafita-L\u00f3pez, A., Bueno-Vidales, N., and Montoro-Huguet, M. (2022). Malnutrition Screening and Assessment. Nutrients, 14.","DOI":"10.20944\/preprints202205.0071.v1"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Meza-Valderrama, D., Marco, E., D\u00e1valos-Yerovi, V., Muns, M.D., Tejero-S\u00e1nchez, M., Duarte, E., and S\u00e1nchez-Rodr\u00edguez, D. (2021). Sarcopenia, Malnutrition, and Cachexia: Adapting Definitions and Terminology of Nutritional Disorders in Older People with Cancer. Nutrients, 13.","DOI":"10.3390\/nu13030761"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1001\/jamasurg.2020.2497","article-title":"Association of Low Muscle Mass and Low Muscle Radiodensity with Morbidity and Mortality for Colon Cancer Surgery","volume":"155","author":"Xiao","year":"2020","journal-title":"JAMA Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1007\/s11912-016-0546-5","article-title":"Clinical Implications of Sarcopenic Obesity in Cancer","volume":"18","author":"Carneiro","year":"2016","journal-title":"Curr. Oncol. Rep."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1017\/S0029665115004279","article-title":"Sarcopenia and cachexia in the era of obesity: Clinical and nutritional impact","volume":"75","author":"Prado","year":"2016","journal-title":"Proc. Nutr. Soc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.clnu.2018.08.002","article-title":"GLIM criteria for the diagnosis of malnutrition\u2014A consensus report from the global clinical nutrition community","volume":"38","author":"Cederholm","year":"2019","journal-title":"Clin. Nutr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1425","DOI":"10.1016\/j.clnu.2022.02.001","article-title":"Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition (GLIM) diagnosis of malnutrition","volume":"41","author":"Barazzoni","year":"2022","journal-title":"Clin. Nutr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1200","DOI":"10.1002\/jcsm.12379","article-title":"The evolution of body composition in oncology\u2014Epidemiology, clinical trials, and the future of patient care: Facts and numbers","volume":"9","author":"Brown","year":"2018","journal-title":"J. Cachexia Sarcopenia Muscle"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"3","DOI":"10.3393\/ac.2022.01207.0172","article-title":"Multimodal prerehabilitation for elderly patients with sarcopenia in colorectal surgery","volume":"40","author":"Wu","year":"2023","journal-title":"Ann. Coloproctol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"afae052","DOI":"10.1093\/ageing\/afae052","article-title":"The Conceptual Definition of Sarcopenia: Delphi Consensus from the Global Leadership Initiative in Sarcopenia (GLIS)","volume":"53","author":"Kirk","year":"2024","journal-title":"Age Ageing"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1002\/jcsm.12673","article-title":"Nutrition in the spotlight in cachexia, sarcopenia and muscle: Avoiding the wildfire","volume":"12","author":"Prado","year":"2021","journal-title":"J. Cachexia Sarcopenia Muscle"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"S54","DOI":"10.1002\/jpen.2420","article-title":"Nascent to novel methods to evaluate malnutrition and frailty in the surgical patient","volume":"47","author":"Prado","year":"2023","journal-title":"JPEN J. Parenter. Enter. Nutr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1139\/H08-075","article-title":"A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care","volume":"33","author":"Mourtzakis","year":"2008","journal-title":"Appl. Physiol. Nutr. Metab."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Tolonen, A., Pakarinen, T., Sassi, A., Kytt\u00e4, J., Cancino, W., Rinta-Kiikka, I., Pertuz, S., and Arponen, O. (2021). Methodology, clinical applications, and future directions of body composition analysis using computed tomography (CT) images: A review. Eur. J. Radiol., 145.","DOI":"10.1016\/j.ejrad.2021.109943"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"458","DOI":"10.3892\/ol.2024.14591","article-title":"Prognostic value of computed tomography-derived skeletal muscle index and radiodensity in patients with gastric cancer after curative gastrectomy","volume":"28","author":"Hashimoto","year":"2024","journal-title":"Oncol. Lett."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"102839","DOI":"10.1016\/j.critrevonc.2019.102839","article-title":"Myosteatosis and prognosis in cancer: Systematic review and meta-analysis","volume":"145","author":"Aleixo","year":"2020","journal-title":"Crit. Rev. Oncol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Chang, Y.Y., and Cheng, B. (2024). Prognostic impact of myosteatosis in patients with colorectal cancer undergoing curative surgery: An updated systematic review and meta-analysis. Front. Oncol., 14.","DOI":"10.3389\/fonc.2024.1388001"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1136\/gutjnl-2022-327736","article-title":"Global burden of colorectal cancer in 2020 and 2040: Incidence and mortality estimates from GLOBOCAN","volume":"72","author":"Morgan","year":"2023","journal-title":"Gut"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Bossi, P., Delrio, P., Mascheroni, A., and Zanetti, M. (2021). The Spectrum of Malnutrition\/Cachexia\/Sarcopenia in Oncology According to Different Cancer Types and Settings: A Narrative Review. Nutrients, 13.","DOI":"10.3390\/nu13061980"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1111\/apt.17045","article-title":"Review article: Obesity and colorectal cancer","volume":"56","author":"Bardou","year":"2022","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1590\/1806-9282.20220339","article-title":"Preoperative evaluation of sarcopenia in patients with colorectal cancer: A prospective study","volume":"69","author":"Nunes","year":"2023","journal-title":"Rev. Assoc. M\u00e9dica Bras."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Chung, E., Lee, H.S., Cho, E.S., Park, E.J., Baik, S.H., Lee, K.Y., and Kang, J. (2019). Changes in Body Composition during Adjuvant FOLFOX Chemotherapy and Overall Survival in Non-Metastatic Colon Cancer. Cancers, 12.","DOI":"10.3390\/cancers12010060"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Zhang, L., Guan, J., Ding, C., Feng, M., Gong, L., and Guan, W. (2022). Muscle loss 6 months after surgery predicts poor survival of patients with non-metastatic colorectal cancer. Front. Nutr., 9.","DOI":"10.3389\/fnut.2022.1047029"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1016\/j.clnu.2014.07.010","article-title":"Assessing appendicular skeletal muscle mass with bioelectrical impedance analysis in free-living Caucasian older adults","volume":"34","author":"Sergi","year":"2015","journal-title":"Clin. Nutr."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/S0261-5614(03)00048-7","article-title":"Validation of a bioelectrical impedance analysis equation to predict appendicular skeletal muscle mass (ASMM)","volume":"22","author":"Kyle","year":"2003","journal-title":"Clin. Nutr."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Palmas, F., Mucarzel, F., Ricart, M., Lluch, A., Zabalegui, A., Melian, J., Guerra, R., Rodriguez, A., Roson, N., and Ciudin, A. (2024). Body composition assessment with ultrasound muscle measurement: Optimization through the use of semi-automated tools in colorectal cancer. Front. Nutr., 11.","DOI":"10.3389\/fnut.2024.1372816"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"524","DOI":"10.1148\/rg.2021200056","article-title":"Opportunistic screening at abdominal CT: Use of automated body composition biomarkers for added cardiometabolic value","volume":"41","author":"Pickhardt","year":"2021","journal-title":"Radiographics"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"371","DOI":"10.2214\/AJR.22.28043","article-title":"Utility of fully automated body composition measures on pretreatment abdominal CT for predicting survival in patients with colorectal cancer","volume":"220","author":"Lee","year":"2023","journal-title":"Am. J. Roentgenol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Salam, B., Al Zaidi, M., Sprinkart, A.M., Nowak, S., Theis, M., Kuetting, D., Aksoy, A., Nickenig, G., Attenberger, U., and Zimmer, S. (2023). Opportunistic CT-derived analysis of fat and muscle tissue composition predicts mortality in patients with cardiogenic shock. Sci. Rep., 13.","DOI":"10.1038\/s41598-023-49454-x"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"671","DOI":"10.2214\/AJR.22.27749","article-title":"CT-derived body composition assessment as a prognostic tool in oncologic patients: From opportunistic research to artificial intelligence\u2013based clinical implementation","volume":"219","author":"Bates","year":"2022","journal-title":"Am. J. Roentgenol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1016\/j.clnu.2021.12.024","article-title":"Agreement between GLIM and PG-SGA for diagnosis of malnutrition depends on the screening tool used in GLIM","volume":"41","author":"Henriksen","year":"2022","journal-title":"Clin. Nutr."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.clnu.2021.11.008","article-title":"Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool","volume":"41","author":"Santos","year":"2022","journal-title":"Clin. Nutr."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Carvalho, A.L.M.d., Gonzalez, M.C., Sousa, I.M.d., das Virgens, I.P.A., Medeiros, G.O.C.d., Oliveira, M.N., Dantas, J.C.A.d.S., and Trussardi Fayh, A.P. (2021). Low skeletal muscle radiodensity is the best predictor for short-term major surgical complications in gastrointestinal surgical cancer: A cohort study. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0247322"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1091","DOI":"10.1007\/s10151-023-02769-3","article-title":"CT-derived measures of muscle quantity and quality predict poorer outcomes from elective colorectal surgery: A UK multicentre retrospective cohort study","volume":"27","author":"Blackwell","year":"2023","journal-title":"Tech. Coloproctol."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/17\/14\/2264\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:06:56Z","timestamp":1760033216000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/17\/14\/2264"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,9]]},"references-count":41,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["nu17142264"],"URL":"https:\/\/doi.org\/10.3390\/nu17142264","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,9]]}}}