Impact of sarcopenia on early surgical outcomes in elderly patients following lung cancer surgery: a prospective cohort study

Introduction

Background

Sarcopenia was initially described as an age-related decline in muscle mass; however, contemporary interpretations now encompass a reduction in muscle strength and a decline in physical performance (1). According to the Asian Working Group for Sarcopenia (AWGS) guidelines, the prevalence of sarcopenia is estimated to be approximately 7.3–12.0% in individuals aged ≥60 years, with the prevalence increasing to 25.7% in those aged ≥75 years (1,2). In elderly patients, sarcopenia triggers various metabolic syndromes and increases the incidence of cognitive impairment and depression (3). Moreover, the presence of sarcopenia in hospitalized patients is associated with increased mortality, overall severe complications, elevated postoperative infection risk, and extended hospitalization periods (3).

Rationale and knowledge gap

Sarcopenia has adverse effects on prognosis post-cancer surgery. Specifically, several prospective cohort studies have reported associations between sarcopenia and detrimental postoperative clinical outcomes and poor long-term prognosis (4,5). In the field of thoracic oncology, retrospective studies have explored correlations among sarcopenia, postoperative complications, and long-term prognosis (6-8). Many of these studies define sarcopenia as muscle mass or area measured from imaging studies, which is not aligned with the current definition by international guidelines (1,9). According to the AWGS and the European Working Group on Sarcopenia in Older People guidelines, sarcopenia should be defined by a combination of muscle mass, muscle strength, and physical activity; thus, sarcopenia should not solely be defined by low muscle mass. Moreover, they recommend that muscle should be measured using dual-energy X-ray absorptiometry or bioelectrical impedance analysis (BIA) and that imaging studies should not serve as the measurement algorithms, as imaging acquisition protocols are not standardized across the centers and countries (1,9). Additionally, most studies have included patients of all ages and were retrospective in nature (6-8).

Objective

We designed a large prospective cohort study to investigate associations between sarcopenia and early and long-term outcomes of lung cancer surgery in elderly patients. In contrast to previous relevant studies, we prospectively recruited elderly patients with lung cancer, and sarcopenia was diagnosed according to international standard definitions. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1375/rc) (10).

Methods

The LUng CAncer Surgery in sarcoPENia patients with old age (LUCAS-PEN) study was conducted at Seoul National University Hospital, located in Seoul, South Korea. The study was approved by the Institutional Review Board of Seoul National University Hospital (IRB No. H2103-037-1203; approval date: March 11, 2021). Informed consent was obtained from all individual participants prior to their inclusion in the study. This study and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was registered on ClinicalTrials.gov (No. NCT05346185). The primary endpoint of the LUCAS-PEN study was overall survival; secondary endpoints included recurrence-free survival, non-cancer deaths, postoperative pulmonary function change, postoperative changes in the Geriatric Depression Scale (GDS), quality of life, cognitive function, and early postoperative clinical outcomes, including in-hospital mortality, complication rate, and hospital-stay length.

Patients

From April 2021 to July 2023, this study prospectively enrolled patients aged ≥70 years intending to undergo curative surgery for confirmed lung cancer or pulmonary nodules suspected of lung cancer. Exclusion criteria included prior treatment for lung cancer or other solid cancers within the past 5 years (except adenocarcinoma in situ), the need for concurrent surgery for other diseases, or investigator-determined ineligibility (Figure 1).

Figure 1 Overall study flow.

Definitions of sarcopenia

Sarcopenia was assessed according to AWGS guidelines (1). The diagnosis of sarcopenia involved the evaluation of three factors: muscle mass, muscle strength, and physical performance. Muscle mass was measured by BIA (BWA 2.0; InBody Co., Seoul, Korea) and expressed as appendicular skeletal muscle mass index (ASMI; kg/m²), with low mass defined as ASMI <7.0 for men and <5.7 for women. Muscle strength was assessed by handgrip dynamometry (Takei Scientific Instruments, Tokyo, Japan), with cut-offs of <28 kg for men and <18 kg for women. Physical performance was measured by 6-m gait speed using motion sensors (Dyphi, Daejeon, Korea), with <1.0 m/s indicating low performance. Sarcopenia was diagnosed when criteria for low muscle mass plus either low strength or low performance were met, in accordance with AWGS (Figure S1).

Data collection

Baseline demographic, clinical, and preoperative evaluation data were collected, including standard lung cancer workup with imaging and pulmonary function testing. Operative data and postoperative outcome data were also collected. Respiratory complications were defined as atelectasis requiring bronchoscopy, pneumonia, reintubation for respiratory failure, tracheostomy, or acute respiratory distress syndrome. All complications were classified using the extended Clavien-Dindo system, with grade ≥3 considered major (18). Pulmonary function tests are planned to be conducted 1 year postoperatively, with surveys at 1, 3, and 5 years postoperatively. As of September 2024, the median follow-up period is 26 months. The LUCAS-PEN study is planned to have a follow-up duration of approximately 5 years and is expected to be completed in mid-2028. After completion, we plan to analyze the associations between sarcopenia and survival outcomes (overall and recurrence-free survival), as well as longitudinal changes in mental health indicators.

Questionnaires for psychiatric factors

To evaluate whether sarcopenia affects the perioperative mood, quality of life, and cognitive function in elderly patients, we planned several surveys. The Korean version of the GDS (GDS-K), which is appropriately standardized for screening depression in the elderly with 30 simple questions, was employed (11,12). The higher the score on the GDS-K, the more severe the depressive mood; a score of >15 is associated with depressive disorder (12). Health-related quality of life was evaluated using the Korean version of the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) and EuroQoL Visual Analog Scale (EQ-VAS) (13-15). Cognitive function was appraised utilizing the Korean version of the Montreal Cognitive Assessment (K-MoCA) for mild cognitive impairment screening, with a cutoff score of 17 for individuals aged ≥70 years (16,17). Currently, the 1-year follow-up data for GDS-K, EQ-5D-5L, and EQ-VAS have been obtained, and analyses were conducted accordingly.

Perioperative management and surgical strategies

In our center, all patients undergoing lung surgery are managed according to our institution’s enhanced recovery-after-surgery (ERAS) protocol, based on European ERAS guidelines (19). Preoperatively, patients were encouraged to quit smoking for at least 4 weeks, sedatives were avoided, and mechanical prophylaxis for venous thromboembolism was provided. Before surgery, intravenous antibiotics were administered, and the skin was prepared using chlorhexidine alcohol. Intraoperatively, forced air-warming blankets, lung-protective ventilation during one-lung ventilation, and euvolemic fluid management were used to minimize complications. Regional anesthesia, such as preemptive analgesia, was combined with general anesthesia to enable early emergence and optimize pain control. Minimally invasive approaches (video-assisted thoracoscopic or robotic surgery) were preferred, while thoracotomy cases employed muscle-sparing techniques and additional local anesthesia. Postoperatively, early mobilization and physiotherapy (incentive spirometry, cough encouragement) were encouraged.

Outcomes

This analysis focused on postoperative complication rate as the primary outcome, with respiratory complications and mental health changes as secondary outcomes. Long-term endpoints will be reported separately.

Statistical analysis

Statistical analysis was conducted using R software (version 4.3.2). Variable distribution was assessed using the Shapiro-Wilk test. Normally distributed continuous variables are presented as mean ± standard deviation (SD) and compared using Student’s t-test; non-normally distributed variables are reported as median [interquartile range (IQR)] and compared using the Mann-Whitney U-test. Categorical data are expressed as numbers (percentages) and compared using the Chi-squared or Fisher’s exact test. For the geriatric mental health data, changes from baseline to 1 year were compared between groups using the Mann-Whitney U-test. Variables with P<0.1 in univariable analysis were entered into multivariable logistic regression; statistical significance was set at P<0.05 (two-sided).

Because the sarcopenia group comprised a relatively small subset of our study cohort, propensity score matching (PSM) was used to enhance the comparability of patients. Scores were estimated through a logistic regression model that included age, sex, body mass index, smoking history, preoperative pulmonary function, clinical tumor (T) and node (N) stage, surgical approach (minimally invasive vs. open), and extent of surgery as covariates. Because the prevalence of sarcopenia among individuals aged over 70 is approximately 25%, each sarcopenic patient was matched to four non-sarcopenic patients (1:4 ratio) using the ‘optimal’ method in the R package MatchIt, with a caliper of 0.20 to minimize poor matches. Balance was assessed by examining standardized mean differences before and after matching. Post-matching, baseline characteristics and postoperative outcomes (overall complications, major complications, respiratory complications, and length of hospital stay) were compared between the matched sarcopenia and non-sarcopenia groups. Statistical significance for the matched analysis remained at P<0.05.

Results

From April 2021 to July 2023, we screened patients aged ≥70 years who met the inclusion and exclusion criteria. Of 650 screened patients, 400 were enrolled herein. A total of 29 patients were excluded from the analysis, including 16 whose final pathological results did not confirm lung cancer, 5 who did not undergo lung resection due to pleural seeding, 5 whose surgeries were cancelled, and 3 for other reasons (Figure 1). Among 371 patients, 357 were included in the final analysis after excluding those who could not undergo or refused the handgrip strength test, 6-meter walk test, or BIA for the diagnosis of sarcopenia.

Patient characteristics

Twenty-four patients (6.7%) were diagnosed with sarcopenia according to the AWGS criteria. The study population was divided into two groups (normal vs. sarcopenia) for further analysis. Preoperative and operative data are shown in Table 1. The median age of the normal group was 74.0 (IQR, 72.0–77.0) years, while the sarcopenia group had a median age of 76.0 (IQR, 73.0–80.3) years (P=0.03). The body mass index (BMI) was significantly lower in the sarcopenia group (22.4±2.27 kg/m²) than in the control group (24.4±3.10 kg/m², P<0.001). When classifying ASMI, handgrip strength, and gait speed based on the AWGS sarcopenia diagnostic criteria, a notable disparity emerged in the prevalence of low ASMI and low handgrip strength between the two groups (both P<0.001). The proportion of low gait speed did not show a significant difference between the two groups (P=0.20); however, when analyzed solely based on gait speed, a significant difference was observed (1.02±0.23 vs. 0.93±0.18; P=0.02). Regarding the clinical stage, a significantly higher proportion of higher stages was observed in the sarcopenia group than in the normal group (P<0.01). The clinical T stage did not differ significantly between the two groups (P=0.30), whereas for the N stage, there were more cases of node positivity in the sarcopenia group (P=0.045). Minimally invasive surgery and the extent of surgery did not differ significantly between the two groups (Table 1).

Postoperative outcomes

Postoperative outcomes are shown in Table 2. Complication rates were 21.6% in the normal group and 25.0% in the sarcopenia group, respectively, with no significant difference (P=0.80). Although rates of atrial fibrillation and pneumonia were higher in the sarcopenia group, differences were not statistically significant (2.4% vs. 8.3%, P=0.14; and 4.8% vs. 8.3%, P=0.34, respectively). Major complications (3.6% vs. 8.3%; P=0.24) and respiratory complications (1.2% vs. 8.3%; P=0.055) were not significantly different. There were no in-hospital mortalities in both groups; hospital-stay lengths did not show a significant difference between the two groups [4.0 (IQR, 3.0–7.0) vs. 5.0 (IQR, 3.75–9.25) days; P=0.11].

Geriatric mental health

Results of the preoperative and 1-year follow-up mental health screening for geriatric patients are shown in Table 3. As some patients refused to complete certain questionnaires, 341 participants completed the GDS-K, 346 the EQ-5D-5L, 344 the EQ-VAS, and 282 the K-MoCA during the preoperative assessment. The GDS-K showed higher scores in the sarcopenia group, indicating a higher level of depression [3.0 (IQR 1.0–5.0) vs. 6.5 (IQR 3.8–11.2); P<0.001] (12). Furthermore, when divided based on a GDS-K score of 15, which is associated with depressive disorders, a higher proportion of geriatric depression was observed in the sarcopenia group (3.1% vs. 16.7%; P=0.01). Both the EQ-5D-5L index and EQ-VAS scores were significantly lower in the sarcopenia group [0.829 (IQR, 0.740–1.000) vs. 0.728 (IQR, 0.688–0.763), P<0.001; 80 (IQR, 70–90) vs. 70 (IQR, 60–80), P=0.002]. When screening mild cognitive impairment based on a score of 17 or higher on the K-MoCA, the sarcopenia group showed a significantly higher proportion of patients with cognitive impairment than the normal group (7.2% vs. 27.8%; P=0.01) (17). Furthermore, none of the mental health measures showed a significant association with the complication rate [GDS-K: odds ratio (OR) =1.04, 95% confidence interval (CI): 0.98–1.09, P=0.17; EQ-5D-5L index: OR =0.72, 95% CI: 0.10–5.10, P=0.75; EQ-VAS: OR =0.99, 95% CI: 0.97–1.01, P=0.18; K-MoCA (≤17): OR =0.45, 95% CI: 0.10–1.37, P=0.21] (Table 2).

At the 1-year postoperative follow-up, some degree of dropout occurred in the questionnaire responses, with 261 patients completing the GDS-K and 262 completing the EQ-5D-5L index and EQ-VAS. The median GDS-K score in the sarcopenia group was 5.0 (IQR, 4.0–7.0), which was significantly higher than that of the normal group, 2.0 (IQR, 0.0–4.0) (P<0.001). Regarding the proportion of patients scoring above 15 on the GDS-K, three patients (1.2%) were identified in the normal group, whereas none (0.0%) were observed in the sarcopenia group. The sarcopenia group also showed significantly lower scores on the EQ-5D-5L index and EQ-VAS, with median values of 0.73 (IQR, 0.70–0.75) and 70 (IQR, 60–80), respectively, compared to 0.83 (IQR, 0.74–1.00) and 80 (IQR, 70–85) in the normal group (P=0.002 and P=0.008, respectively). When comparing the change in scores from preoperative baseline to 1-year follow-up within each group, no significant differences were observed between the groups for GDS-K, EQ-5D-5L index, or EQ-VAS (P=0.24, 0.64, and 0.78, respectively), suggesting no significant intergroup difference in change over time. The trends in changes within each group can be visually assessed in Figure 2.

Figure 2 Comparison of preoperative and 1-year postoperative geriatric mental health scores between sarcopenia and normal groups. (A) GDS-K scores; (B) EQ-5D-5L index; (C) EQ-VAS scores. EQ-5D-5L, EuroQoL 5-Dimension 5-Level; EQ-VAS, EuroQoL Visual Analogue Scale; GDS-K, Korean version of the Geriatric Depression Scale.

Multivariable analysis for complications

To identify the factors associated with complications, we first conducted an univariable analysis; subsequently, a multivariable analysis was performed for relevant factors (Table 4). In the univariable analysis, sarcopenia and its subcomponents were not significantly associated with complications. In the multivariable analysis, male sex and minimally invasive surgery were identified as factors related to complications (OR =3.75, 95% CI: 1.41–9.87, P=0.008; OR =0.41, 95% CI: 0.19–0.91, P=0.02). A similar approach was used for respiratory complications (Table 5). Except for low gait speed, sarcopenia and its subcomponents did not show significant associations in the univariable analysis. Low gait speed and minimally invasive surgery were not associated with respiratory complications in the multivariable analysis, while male gender and BMI were associated (OR =4.48, 95% CI: 1.50–13.44, P=0.006; OR =0.85, 95% CI: 0.76–0.95, P=0.006).

Propensity matched score analysis

PSM in a 1:4 ratio yielded a matched cohort of 24 sarcopenic and 96 non-sarcopenic patients with well-balanced baseline characteristics (Table 6). Overall complication rates were comparable between the sarcopenia and non-sarcopenia groups (25.0% vs. 24.0%, P>0.99), as were major complications (8.3% vs. 4.2%, P=0.75) and major respiratory complications (8.3% vs. 1.0%, P=0.19) (Table 7). The median length of hospital stays also did not differ significantly between matched groups (5 vs. 6 days, P=0.75). These findings suggest that, after accounting for potential confounders, sarcopenia does not adversely affect early postoperative outcomes in elderly patients undergoing lung cancer surgery.

Discussion

We conducted a large prospective cohort study to evaluate sarcopenia according to international guidelines and analyzed associations between sarcopenia and lung cancer in patients aged ≥70 years (1). In our cohort, sarcopenia prevalence was 6.7%. No significant differences were observed between sarcopenia and non-sarcopenia groups in overall complications, respiratory complications, or length of hospital stay. Multivariable logistic regression analysis of complications, respiratory complications, sarcopenia, and its subcomponents showed no significant associations. Male sex and thoracotomy surgery were associated with an overall higher rate of complications, whereas male sex and low BMI were associated with respiratory complications. PSM analysis yielded similar results. Preoperatively, patients with sarcopenia had higher rates of depression, lower quality of life, and more frequent cognitive impairment.

Previous retrospective studies on sarcopenia in solid cancers, including lung cancer, often relied on preoperative computed tomography with variable algorithms and cut-off values, leading to inconsistent prevalence estimates (22.4–55.8%), which are relatively high (median age, 68–71 years) (6,7). According to AWGS guidelines, the prevalence of sarcopenia is approximately 7.3–12.0% in individuals aged ≥60 years and 27.2% in those aged ≥70 years (1,20). In contrast, our study applied the AWGS diagnostic criteria, which require assessment of both muscle mass and function, yielding a lower prevalence (6.7%) than prior reports. This difference likely reflects the more stringent criteria and the relatively healthy surgical population, as all participants were deemed fit for curative surgery. We believe that the adoption of standardized criteria is essential to improving diagnostic consistency and cross-study comparability in sarcopenia research.

Several studies have reported that sarcopenia is associated with poor postoperative outcomes in various cancer surgeries (5). Particularly in digestive tract cancer surgery, sarcopenia has been linked to worse postoperative outcomes, with higher rates of total complications (37.4% vs. 12.9%), pulmonary complications (3.1% vs. 2.1%), and 30-day readmission (1.1% vs. 0.4%) and longer hospital stays (9.4 vs. 8.5 days). In our study, sarcopenia was not identified as a risk factor for postoperative complications, nor were ASMI, muscle strength, or physical performance. This can be attributed to several factors. First, it is possible that sarcopenia has a minimal impact on early postoperative outcomes because of the widespread adoption of minimally invasive surgery and appropriate ERAS protocols (21). In our study, minimally invasive surgery was performed in approximately 90% of cases, leading to reduced pain and faster recovery. Moreover, well-established institutional ERAS protocols appear to contribute to reducing complication rates. The postoperative complication rate of 21.8% in our study is lower than the reported complication rate of approximately 30% for lung cancer surgery (22) and lower than the complication rate for other elderly lung cancer patients aged ≥70 years (47%) (23). Second, the difference in outcomes compared with digestive tract cancer surgery may be attributed to differences in patient pathophysiology, surgical techniques, and surgical sites. One study reported that the rate of severe malnutrition increased from 2.3% before gastrointestinal cancer surgery to 26.3% after surgery, with no significant impact (24). For lung cancer, it has been reported that while malnutrition is evident in 33.9% of cases at an advanced stage, it only comprises 1.8% at an early stage (25). Concerning gastrointestinal cancer, disease-specific symptoms can lead to poor oral intake, and it takes time to recover sufficient oral intake even after surgery, making it relatively easy to develop malnutrition. Malnutrition is a significant factor influencing complication rates (26), suggesting that the disparity between lung cancer surgery and gastrointestinal cancer may arise from malnutrition rather than sarcopenia.

The correlation between preoperative geriatric mental health and sarcopenia has been highlighted in previous studies. In those with sarcopenia, the odds ratio for depression was 1.57 (95% CI: 1.32–1.86), indicating a significant association (27). Additionally, health-related quality of life was significantly reduced in sarcopenic patients (28), and cognitive impairment showed a high correlation with sarcopenia, with an odds ratio of 2.25 (95% CI: 1.70–2.97) (29). The resulting physical limitations and reduced physical activity due to decreased muscle strength and mass can lead not only to depressive symptoms but also to impaired cognitive function and reduced quality of life (27-29). Conversely, poor mental health—such as depression or cognitive decline—may diminish motivation and social engagement, ultimately contributing to the development or progression of sarcopenia. This bidirectional relationship suggests a potential vicious cycle between sarcopenia and mental health deterioration. In line with these findings, our study also found an association between sarcopenia and each of these three aspects: depression, quality of life, and cognitive function. This highlights the importance of addressing mental health concerns in patients with sarcopenia, especially in the context of cancer, where such interrelated vulnerabilities may further exacerbate patient outcomes. Meanwhile, these mental health measures were not associated with complication rates, which may be explained by the potential benefits of ERAS protocol components—such as meticulous pain control and prevention of analgesic side effects, early ambulation, and minimally invasive surgery—in preserving quality of life and cognitive function, as well as perioperative exercise for pulmonary rehabilitation, which is known to help alleviate depressive symptoms and improve quality of life (19,30,31).

At the 1-year follow-up, both groups showed overall improvement in depressive symptoms, as reflected by decreased GDS-K scores. However, the difference between the sarcopenia and normal groups remained largely unchanged. While the proportion of patients with clinically significant depressive symptoms (GDS-K >15) was initially higher in the sarcopenia group, this number markedly decreased at the 1-year follow-up, with no new cases observed. All 14 patients who had GDS-K scores above 15 at baseline showed improvement, with reduced scores at follow-up. These findings suggest that preoperative depressive symptoms may gradually improve during the postoperative recovery period, particularly in vulnerable patients with sarcopenia. Meanwhile, for the quality-of-life measures, EQ-5D-5L index and EQ-VAS, no substantial changes were observed in either group between the preoperative period and the 1-year follow-up. Further longitudinal analysis is warranted to clarify the long-term clinical implications and potential association with cancer recurrence. We also plan to explore various potential contributing factors that may underlie the differences in mental health outcomes between the sarcopenia and non-sarcopenia groups in our future long-term follow-up analysis of this cohort.

This study has some limitations. The lower average BMI of the Korean patient population compared with Western populations may limit the generalizability of our findings. In addition, surgeons typically select candidates who are generally fit for surgery, resulting in a lower-than-expected sarcopenia prevalence (6.7% instead of the anticipated ~20% in adults ≥70 years), and consequently limiting statistical power. During study planning, we did not estimate the number of sarcopenic patients based on an assumed prevalence or conduct a sample size calculation accordingly. Instead, we adopted an all-comer design, enrolling consecutive surgical candidates without selecting for sarcopenia status. This approach allowed us to observe the actual prevalence of sarcopenia in the surgical population and to explore its clinical impact under real-world conditions. To address this, we prospectively enrolled all consenting surgical patients and conducted a 1:4 PSM to approximate the general population’s sarcopenia prevalence.

To supplement the limited statistical power and further validate our findings, we conducted a Bayesian logistic regression analysis to assess the association between sarcopenia and postoperative complications. Bayesian inference, which incorporates prior knowledge with observed data, is particularly advantageous in small-sample settings by yielding more stable and robust estimates. Unlike frequentist approaches such as PSM, Bayesian methods offer a different inferential framework that can strengthen interpretation from an alternative perspective. In our Bayesian logistic regression model, a non-informative prior was initially applied for sarcopenia. This analysis revealed no significant association between sarcopenia and postoperative complications [OR =0.76; 95% credible interval (CrI): 0.23–2.29; P_{(OR >1)}=0.32] (Table S1). In contrast, male sex and minimally invasive surgery were significantly associated with increased and decreased complication risk, respectively. To further test the robustness of our findings, we repeated the analysis using a strongly informative prior for sarcopenia (OR ≈2.0, SD =0.5), which assumes a strong positive association. The results remained consistent, with no meaningful association observed [OR =1.31; 95% CrI: 0.64–2.68; P_{(OR >1)}=0.77]. The persistence of a lack of association under both prior settings supports the stability of our conclusion. Through a series of sensitivity analyses, including unadjusted logistic regression, PSM, and Bayesian analyses with both non-informative and informative priors, we consistently observed no significant association between sarcopenia and postoperative complication risk. These findings are summarized in Table S2 and provide robust evidence that sarcopenia, as defined by AWGS criteria, may not be a significant predictor of early postoperative complications in elderly patients undergoing lung cancer surgery. Although this strategy strengthened our analysis, a larger cohort of sarcopenic patients is necessary to confirm our findings conclusively. Future studies with longer-term follow-up are warranted to validate our results and explore potential long-term outcomes.

Conclusions

This is the first large prospective study to investigate the relevance of sarcopenia diagnosis according to international guidelines for lung cancer surgery. Postoperative outcomes in the sarcopenia group were comparable to those in the normal group. Multivariable analysis showed that complications were associated with male sex and minimally invasive surgery, while respiratory complications were associated with male sex and BMI, neither of which involved sarcopenia. The PSM analysis further reinforced these findings by demonstrating no significant impact of sarcopenia on early postoperative outcomes in elderly patients. Notably, geriatric mental health was poorer among patients with sarcopenia. Therefore, although minimally invasive surgery and enhanced recovery protocols appear to enable safe surgery in elderly patients with sarcopenia, heightened attention to mental healthcare is warranted. The long-term implications of sarcopenia merit ongoing investigation.

Acknowledgments

The authors are grateful to the clinical coordinator, Suji Kim, who supported the study management and conductance.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1375/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1375/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1375/prf

Funding: This work was supported by the Research Program 2021 of the Seoul National University College of Medicine Research Foundation (No. 800-20210011).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1375/coif). K.J.N. is a co-founder of Portrai, Inc., which is not related to this article. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Seoul National University Hospital (IRB No. H2103-037-1203; approval date: March 11, 2021). Informed consent was obtained from all individual participants prior to their inclusion in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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