Preoperative Frailty Evaluation: A Promising Risk-stratification Tool in Older Adults Undergoing General Surgery

Impact of frailty on postoperative outcomes after hepatectomy: A systematic review and meta-analysis

BACKGROUND

The impact of frailty on postoperative outcomes in patients undergoing hepatectomy is still unclear.

AIM

To study the influence of frailty on postoperative outcomes, such as mortality, rate of complications, and length of hospitalization, following hepatectomy.

METHODS

PubMed, EMBASE, and Scopus databases were searched for observational studies with adult (≥ 18 years) patients after planned/elective hepatectomy. A random-effects model was used for all analyses, and the results are expressed as weighted mean difference (WMD), relative risk (RR), or hazards ratio (HR) with 95% confidence interval (CI).

RESULTS

Analysis of the 13 included studies showed a significant association of frailty with elevated risk of in-hospital mortality (RR = 2.76, 95%CI: 2.10-3.64), mortality at 30 d (RR = 4.60, 95%CI: 1.85-11.40), and mortality at 90 d (RR = 2.52, 95%CI: 1.70-3.75) in the postoperative period. Frail patients had a poorer long-term survival (HR = 2.89, 95%CI: 1.84-4.53) and higher incidence of "any" complications (RR = 1.69, 95%CI: 1.40-2.03) and major (grade III or higher on the Clavien-Dindo scale) complications (RR = 2.69, 95%CI: 1.85-3.92). Frailty was correlated with markedly lengthier hospital stay (WMD = 3.65, 95%CI: 1.45-5.85).

CONCLUSION

Frailty correlates with elevated risks of mortality, complications, and prolonged hospitalization, which need to be considered in surgical management. Further research is essential to formulate strategies for improved outcomes in this vulnerable cohort.

Impact of frailty on perioperative outcomes following percutaneous nephrolithotomy in older persons: evidence from the US Nationwide Inpatient Sample

To evaluate the impact of frailty on perioperative outcomes of older patients undergoing PCNL, utilizing the US Nationwide Inpatient Sample (NIS) database. Data of hospitalized patients ≥ 60 years who received PCNL were extracted from the 2010 to 2020 NIS database, and included demographics, clinical, and hospital-related information. Patients were assigned to low (< 5), medium (5-15), and high frailty risk (> 15) groups based on the hospital frailty risk score (HFRS). Associations between frailty risk and perioperative outcomes including total hospital cost were determined using population-weighted linear and logistic regression analyses. Data of 30,829 hospitalized patients were analyzed (mean age 72.5 years; 55% male; 78% white). Multivariable analyses revealed that compared to low frailty risk, increased frailty risk was significantly associated with elevated in-hospital mortality (adjusted odds ratio (aOR) = 10.70, 95% confidence interval (CI): 6.38-18.62), higher incidence of unfavorable discharge (aOR = 5.09, 95% CI: 4.43-5.86), prolonged hospital length of stay (LOS; aOR = 7.67, 95% CI: 6.38-9.22), increased transfusion risk (aOR = 8.05, 95% CI: 6.55-9.90), increased total hospital costs (adjusted Beta = 37.61, 95% CI: 36.39-38.83), and greater risk of complications (aOR = 8.52, 95% CI: 7.69-9.45). Frailty is a significant prognostic indicator of adverse perioperative outcomes in older patients undergoing PCNL, underscoring importance of recognizing and managing frailty in older patients.

Factors associated with one-year mortality after curative surgery for primary clinical T4 and locally recurrent rectal cancer in elderly patients

INTRODUCTION

Despite advancements in colorectal cancer care, one-year post-operative mortality rates remain high for elderly patients who have undergone curative surgery for primary clinical T4 rectal cancer (cT4RC) or locally recurrent rectal cancer (LRRC). This study aimed to identify factors associated with one-year mortality and to evaluate the causes of death.

MATERIALS & METHODS

This retrospective cohort study included patients aged ≥70 years who underwent surgery with curative intent for cT4RC or LRRC between January 2013 and December 2020. Clinical and follow-up data were collected and analyzed to determine survival rates and investigate factors associated with mortality within one year after surgery.

RESULTS

A total of 183 patients (94 cT4RC, 89 LRRC) were included. One-year mortality rates were 16.0% for cT4RC and 28.1% for LRRC (P = 0.064). In cT4RC patients, factors associated with one-year mortality were preoperative anemia (OR 3.83, P = 0.032), total pelvic exenteration (TPE) (OR 7.18, P = 0.018), multivisceral resections (OR 5.73, P = 0.028), pulmonary complications (OR 13.31, P < 0.001) and Clavien-Dindo grade ≥ III complications (OR 5.19, P = 0.025). In LRRC patients, factors associated with one-year mortality were TPE (OR 27.00, P = 0.008), the need for supported care after discharge (OR 3.93, P = 0.041) and Clavien-Dindo grade ≥ III complications (OR 3.95, P = 0.006). The main causes of death in cT4RC and LRRC patients were failure to recover (cT4RC 26.6%, LRRC 28.0%) and disease recurrence (cT4RC 26.6%, LRRC 60.0%).

CONCLUSION

In order to tailor treatment in elderly with cT4RC and LRRC, factors associated with increased one-year mortality (e.g. pre-operative anemia, TPE) should be incorporated in the decision-making process.

CLINICAL TRIAL REGISTRATION

Not applicable.

The significance of G8 and other geriatric assessments in urologic cancer management: A comprehensive review

In urologic oncology, which often involves older patients, it is important to consider how to manage their care appropriately. Geriatric assessment (GA) is a method that can address the specific needs of older cancer patients. The GA encompasses various assessment domains, but these domains exhibit variations across the literature. Some of the common items include functional ability, nutrition, comorbidities, cognitive ability, psychosocial disorders, polypharmacy, social and financial support, falls/imbalance, and vision/hearing. Despite the diversity of domains, there is limited consensus on reliable measurement methods. This review discusses the role of GA in managing urologic cancer in unique scenarios, such as those necessitating temporary or permanent urinary catheters or stomas due to urinary diversion. A comprehensive GA is time and human-resource-intensive in real-world clinical practice. Hence, simpler tools such as the Geriatric-8 (G8), capable of identifying high-risk patients requiring a detailed GA, are also under investigation in various contexts. Therefore, we conducted a systematic literature review on the G8. Our findings indicate that patients with low G8 scores encounter difficulties with stoma self-care after urinary diversion and have higher risks of urinary tract infections and ileus after radical cystectomy. The utilization of G8 as a screening tool for urologic cancer patients may facilitate the delivery of appropriate and personalized treatment and care.

Comparison of frailty indexes as predictors of clinical outcomes after major thoracic surgery

Background

Despite greater appreciation for the importance of frailty in surgical patients, due to improved understanding that frailty is often linked to poor outcomes, the optimal method of assessment remains unknown. In this study, we sought to evaluate the prevalence of frailty in patients considered for elective thoracic surgery and to test the ability of several frailty measurements to predict postoperative outcomes.

Methods

Patients included were candidates for major elective thoracic surgery. Preoperative assessment of frailty included the Fried frailty phenotype, the Edmonton Frail Scale (EFS), the modified frailty index (mFI), the Clinical Frailty Scale (CFS), and additional components of frailty. Outcome data include days with chest drain, length of hospital stay, and postoperative adverse events.

Results

According to the Fried frailty phenotype, 53% of 94 patients included were prefrail or frail. A significant association between frailty and postoperative complications was found (odds ratio 7.65; P=0.001). No association between CFS, mFI, EFS, and complications was observed. The Frailty Phenotype seemed the most accurate in predicting postoperative complications, with an area under the curve (AUC) of 0.77. Twenty-seven percent of patients meet the criteria for depression according to the Geriatric Depression Scale and they showed a higher risk of postoperative complications (OR 2.47; P=0.03). A lower psoas muscle index was associated with a higher risk of complications (OR 3.40; P=0.04).

Conclusions

According to our results, the Fried frailty phenotype seems the most accurate tool to test frailty in patients undergoing thoracic resections. Surgeons should be aware that, although these aspects are not routinely tested, they are potential targets to improve clinical outcomes. Studies on additional interventions specifically targeting frail people in the setting of elective thoracic surgery are required.

The risk analysis index is an independent predictor of outcomes after lung cancer resection

BACKGROUND

The Risk Analysis Index (RAI) is a frailty assessment tool based on an accumulation of deficits model. We mapped RAI to data from the Society of Thoracic Surgeons (STS) Database to determine whether RAI correlates with postoperative outcomes following lung cancer resection.

METHODOLOGY/PRINCIPAL FINDINGS

This was a national database retrospective observational study based on data from the STS Database. Study patients underwent surgery 2018 to 2020. RAI was divided into four increasing risk categories. The associations between RAI and each of postoperative complications and administrative outcomes were examined using logistic regression models. We also compared the performance of RAI to established risk indices (American Society of Anesthesiology (ASA) and Charlson Comorbidity Index (CCI)) using areas under the Receiver Operating Characteristic (ROC) curves (AUC). Results: Of 29,420 candidate patients identified in the STS Database, RAI could be calculated for 22,848 (78%). Almost all outcome categories exhibited a progressive increase in marginal probability as RAI increased. On multivariable analyses, RAI was significantly associated with an incremental pattern with almost all outcomes. ROC analyses for RAI demonstrated "good" AUC values for mortality (0.785; 0.748) and discharge location (0.791), but only "fair" values for all other outcome categories (0.618 to 0.690). RAI performed similarly to ASA and CCI in terms of AUC score categories.

CONCLUSIONS/SIGNIFICANCE

RAI is associated with clinical and administrative outcomes following lung cancer resection. However, its overall accuracy as a surgical risk predictor is only moderate and similar to ASA and CCI. We do not recommend routine use of RAI for assessment of individual patient risk for major lung resection.

[Prevalence of frailty in a population aged 70 and older who pay a visit to health center and its detection in primary care]

INTRODUCTION

The detection of frailty in the elderly is key to preventing disability. The main objective of this study is to find out the proportion of frail people in subjects aged 70 and over who attend a health center in A Coruña (Spain).

METHODS

Cross-sectional study, carried out from August 2020 to April 2021. Consecutive selection of patients ≥70 years, with Barthel ≥90, who accessed the health center.

DEPENDENT VARIABLES

Short Physical Performance Battery (SPPB), Get Up and Go (TUG) and Gait Speed (MV); independent: gender, age, number of falls in the last year, number of drugs used chronically, and Charlson index.

RESULTS

The sample was 114 people. The proportion of frail people is 16.7% (95% CI 10.94-24.57) with the SPPB, 28.6% in those aged 80 and over; and 36.8% using VM. The risk of frailty increases by at least 4.1% for each year of age after 70. Being a woman multiplies the risk by at least 1.5. The concordance between frailty according to the SPPB and MV is 46.8% (95% CI 30.85-62.77).

CONCLUSIONS

The prevalence of frailty in independent people for basic ADL who attend a health center is at least 10.94%. Both the SPPB and the MV are feasible and useful methods in primary care.

Preoperative diagnosis of frailty

The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years there has been an increase in the application of frailty indices. Multiple scales have emerged that can be applied in the perioperative setting. Each one has demonstrated some utility, either by way of establishing postoperative prognosis or as a method for the clinical optimization of patient care. Anaesthesiologists are offered a wide choice of scales, the characteristics and appropriate management of which they are often unaware. This narrative review aims to clarify the concept of frailty, describe its importance in the perioperative setting and evaluate the different scales that are most applicable to the perioperative setting. It will also establish paths for the future optimization of patient care.

Frailty as a predictor of postoperative outcomes in neurosurgery: a systematic review

INTRODUCTION

Baseline frailty status has been utilized to predict a wide range of outcomes and guide preoperative decision making in neurosurgery. This systematic review aims to analyze existing literature on the utilization of frailty as a predictor of neurosurgical outcomes.

EVIDENCE ACQUISITION

We conducted a systematic review following PRISMA guidelines. Studies that utilized baseline frailty status to predict outcomes after a neurosurgical intervention were included in this systematic review. Studies that utilized sarcopenia as the sole measure of frailty were excluded. PubMed, EMBASE, and Cochrane library was searched from inception to March 1st, 2023, to identify relevant articles.

EVIDENCE SYNTHESIS

Overall, 244 studies met the inclusion criteria. The 11-factor modified frailty index (mFI-11) was the most utilized frailty measure (N.=91, 37.2%) followed by the five-factor modified Frailty Index (mFI-5) (N.=80, 32.7%). Spine surgery was the most common subspecialty (N.=131, 53.7%), followed by intracranial tumor resection (N.=57, 23.3%), and post-operative complications were the most reported outcome (N.=130, 53.2%) in neurosurgical frailty studies. The USA and the Bowers author group published the greatest number of articles within the study period (N.=176, 72.1% and N.=37, 15.2%, respectively).

CONCLUSIONS

Frailty literature has grown exponentially over the years and has been incorporated into neurosurgical decision making. Although a wide range of frailty indices exist, their utility may vary according to their ability to be incorporated in the outpatient clinical setting.

Treatment Options for Early Stage Inoperable Breast Cancer: Cryoablation or Radiotherapy?

Background

Surgical removal of the tumour is the gold standard treatment for early stage invasive breast cancer. However, with a global ageing population, a larger number of diagnoses are occurring in women with comorbidities that render them unsuitable for surgery. Hence, it is of interest to explore alternative treatment strategies for this group of women.

Summary

Our narrative review aims to explore two such techniques, cryoablation and external beam radiotherapy, providing a brief summary of the evidence behind each technique. Following this, we discuss which groups of patients would gain the most benefit from each technique. Factors favouring the use of radiotherapy include patients with larger tumours, more superficial tumours, and those with less well-demarcated tumours where there is uncertainty regarding tumour extent. Meanwhile, patients who may benefit more from cryoablation include those who desire a smaller number of treatment sessions, have concerns regarding cosmesis and skin pigmentation, or who have relative contraindications to radiotherapy such as scleroderma, systemic lupus erythematosus, reduced lung function, or cardiac comorbidities.

Key Messages

Continued advancements in both cryoablation and radiotherapy technologies are taking place, in tandem with imaging technologies enabling greater certainty in tumour detection and delineation. These factors will help increase local control rates in this group of non-operable early stage breast cancer patients. Through this review, we hope to aid in the clinical decision-making process regarding the selection and referral of patients for each treatment.

Relation between frailty and adverse outcomes in elderly patients with gastric cancer: a scoping review

Background

Playing an exemplary role, frailty have crucial effect on the preoperative evaluation of elderly patients. Previous studies have shown that frailty is associated with complications and mortality in patients with gastric cancer (GC). However, with the development of the concept of "patient-centered", the range of health-related outcomes is broad. The differences in relation between frailty and various adverse outcomes will be further explored.

Method

The PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases were searched for keywords, including frailty (such as frail) and gastric cancer (such as stomach neoplasms or stomach cancer or gastrectomy or gastric surgery). The search period is until August 2023. The included studies were observational or cohort studies with postoperative related adverse outcomes as primary or secondary outcome measures. Valid assessment tools were used. The Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess methodological quality in the included literature.

Result

Fifteen studies were included, including 4 cross-sectional studies, 8 retrospective cohort studies, and 3 prospective cohort studies. Among them, 6 studies were rated as "Good" and 9 studies were rated as "Fair," indicating that the quality of the literature was high. Then, 10 frailty assessment tools were summarized and classified into two broad categories in accordance with frailty models. Results of the included studies indicated that frailty in elderly patients with GC was associated with postoperative complications, mortality, hospital days, readmissions, quality of life, non-home discharge, and admission to the intensive care unit.

Conclusion

This scoping review concludes that high levels of preoperative frailty increase the risk of adverse outcomes in elderly patients with GC. Frailty will be widely used in the future clinical evaluation of elderly gastric cancer patients, precise risk stratification should be implemented for patients, and frailty management should be implemented well to reduce the occurrence of adverse treatment outcomes.

A new risk calculation model for complications of hepatectomy in adults over 75

BACKGROUND

Owing to poor organ function reserve, older adults have a high risk of postoperative complications. However, there is no well-established system for assessing the risk of complications after hepatectomy in older adults.

METHODS

This study aimed to design a risk assessment tool to predict the risk of complications after hepatectomy in adults older than 75 years. A total of 326 patients were identified. A logistic regression equation was used to create the Risk Assessment System of Hepatectomy in Adults (RASHA) for the prediction of complications (Clavien‒Dindo classification ≥ II).

RESULTS

Multivariate correlation analysis revealed that comorbidity (≥ 5 kinds of disease or < 5 kinds of disease, odds ratio [OR] = 5.552, P < 0.001), fatigue (yes or no, OR = 4.630, P = 0.009), Child‒Pugh (B or A, OR = 4.211, P = 0.004), number of liver segments to be removed (≥ 3 or ≤ 2, OR = 4.101, P = 0.001), and adjacent organ resection (yes or no, OR = 1.523, P = 0.010) were independent risk factors for postoperative complications after hepatectomy in older persons (aged ≥ 75 years). A binomial logistic regression model was established to evaluate the RASHA score (including the RASHA scale and RASHA formula). The area under the curve (AUC) for the RASHA scale was 0.916, and the cut-off value was 12.5. The AUC for the RASHA formula was 0.801, and the cut-off value was 0.2106.

CONCLUSION

RASHA can be used to effectively predict the postoperative complications of hepatectomy through perioperative variables in adults older than 75 years.

TRIAL REGISTRATION

The Research Registry: researchregistry8531. https://www.researchregistry.com/browse-the-registry#home/registrationdetails/63901824ae49230021a5a0cf/ .

Association between frailty and clinical outcomes in patients undergoing craniotomy-systematic review and meta-analysis of observational studies

BACKGROUND

Frailty in patients undergoing craniotomy may affect perioperative outcomes. There have been a number of studies published in this field; however, evidence is yet to be summarized in a quantitative review format. We conducted a systematic review and meta-analysis to examine the effects of frailty on perioperative outcomes in patients undergoing craniotomy surgery.

METHODS

Our eligibility criteria included adult patients undergoing open cranial surgery. We searched MEDLINE via Ovid SP, EMBASE via Ovid SP, Cochrane Library, and grey literature. We included retrospective and prospective observational studies. Our primary outcome was a composite of complications as per the Clavien-Dindo classification system. We utilized a random-effects model of meta-analysis. We conducted three preplanned subgroup analyses: patients undergoing cranial surgery for tumor surgery only, patients undergoing non-tumor surgery, and patients older than 65 undergoing cranial surgery. We explored sources of heterogeneity through a sensitivity analysis and post hoc analysis.

RESULTS

In this review of 63,159 patients, the pooled prevalence of frailty was 46%. The odds ratio of any Clavien-Dindo grade 1-4 complication developing in frail patients compared to non-frail patients was 2.01 [1.90-2.14], with no identifiable heterogeneity and a moderate level of evidence. As per GradePro evidence grading methods, there was low-quality evidence for patients being discharged to a location other than home, length of stay, and increased mortality in frail patients.

CONCLUSION

Increased frailty was associated with increased odds of any Clavien-Dindo 1-4 complication. Frailty measurements may be used as an integral component of risk-assessment strategies to improve the quality and value of neurosurgical care for patients undergoing craniotomy surgery.

ETHICS AND DISSEMINATION

Formal ethical approval is not needed, as primary data were not collected.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO identification number: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405240.

Impact of frailty on complications and length of stay after minimally invasive adrenalectomy surgery

BACKGROUND

Adrenal disease requiring surgery incidence increases with age, and minimally invasive adrenalectomy procedures have improved the safety of adrenal surgery. This study evaluates the perioperative outcomes of elective adrenalectomies when performed in older patients and how frailty affects such outcomes.

METHODS

Patients undergoing elective minimally invasive adrenalectomy were identified using the American College of Surgeon's National Surgical Quality Improvement Program Participant Use Targeted File years 2005 to 2020. The surgical indication was categorized as a benign disease, an endocrine disorder, or a malignant disease. Frailty was defined using the 5-item modified frailty index. Multivariable regressions were used to model the relationship of age and frailty with surgical outcomes.

RESULTS

In 8,693 minimally invasive adrenalectomy patients, 5,281 (61%) were female, 5,026 (58%) were White, and 1,924 (22%) were aged 65 years or older. Surgical indications were benign disease 5,487 (63%), endocrinopathy 2,850 (33%), and malignancy 356 (4%). Patients aged <65 years (compared to those aged ≥65) were more likely to have a 5-item modified frailty index = 0 (26% vs 14%, respectively) and less likely to have a 5-item modified frailty index = ≥3 (2% vs 4%, respectively; P < .001).

OUTCOMES

30-day mortality 20 (0.2%), complications 459 (5%), return to operating room 73 (0.8%), and median length of stay 2 days. Thirty-day mortality was associated with a 5-item modified frailty index ≥3 (P = .009) and endocrine disease (P = .005) but not with age. Complications were associated with a 5-item modified frailty index ≥2 (≤P < .001) and malignant disease (P = .002), but not with age.

CONCLUSION

Minimally invasive adrenalectomy has low 30-day mortality and complication rates that increase with frailty and not age. Frailty is a better predictor than the age of most adverse outcomes after elective minimally invasive adrenalectomy.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation

INTRODUCTION

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking.

METHODS

This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator.

RESULTS

Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge.

CONCLUSIONS

Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

The role of geriatric nutritional risk index as a predictor for postoperative outcomes in gastrointestinal emergencies

BACKGROUND

The geriatric nutritional risk index (GNRI) is a simple nutritional and inflammatory marker for older adults. The aim of the present study was to investigate the usefulness of the GNRI in older adults who underwent emergency gastrointestinal surgery.

METHODS

This study included 206 older adults who had undergone emergency gastrointestinal surgery. We retrospectively investigated the relationship between the GNRI and postoperative complications. Univariate and multivariate analyses were performed to evaluate risk factors for postoperative complications. We then evaluated the association between GNRI and clinical variables among older adults undergoing emergency gastrointestinal surgery.

RESULTS

Postoperatively, all complications occurred in 89 (43%) older adults, infectious in 53 (26%), and non-infectious in 36 (17%). In the multivariate analysis, age (p = 0.016), GNRI (p = 0.012), operative severity (p = 0.003), and operation time (p = 0.003) were independent risk factors for all postoperative complications. While the GNRI (p = 0.049) was an independent risk factor for infectious complications, age (p = 0.035) and bleeding volume (p = 0.035) were independent risk factors for postoperative non-infectious complications. In the low GNRI group, age (p = 0.029), serum C-reactive protein levels (p < 0.001), and proportion of sarcopenia (p < 0.001) were significantly higher, and the length of hospital stay (p < 0.001) was significantly longer than that in the high GNRI group. In Spearman's rank correlation coefficient, the skeletal mass index and the GNRI had a positive correlation (r = 0.415 and p < 0.001).

CONCLUSION

The GNRI may be a predictor of postoperative infectious complications in older adults after emergency gastrointestinal surgery, suggesting the usefulness of the GNRI as a nutritional marker and sarcopenia-related parameter.

TRIAL REGISTRATION NUMBER

No. 22-16.

Chart-Derived Frailty Index and 90-Day Mortality After Burn Surgery

INTRODUCTION

Frailty is a reduced physiological reserve condition associated with postoperative morbidity and mortality. The chart-derived frailty index (CFI) can measure frailty using demographic and laboratory values. We evaluated the association of preoperative CFI with 90-d mortality after burn surgery.

METHODS

This large retrospective study included burn intensive care unit (ICU) patients between 2012 and 2021 and calculated CFI using the sum of the following five variables: age >70 y, body mass index <18.5 kg/m2, hematocrit <35%, albumin <3.4 g/dL, and creatinine >2.0 mg/dL; high CFI was a score of 3-5. Postoperative 90-d mortality rate, major adverse cardiac events (MACE), pneumonia, continuous renal replacement therapy (CRRT) requirement, and prolonged ICU stay (>60 d) were evaluated.

RESULTS

Of 1118 patients, 147 (13.1%) had high CFI. High CFI patients had a higher 90-d mortality rate than did low CFI patients (38.8% versus 22.6%, P < 0.001). A high CFI was significantly associated with postoperative 90-d mortality (hazard ratio = 4.124, 95% confidence interval = 2.980-5.707, P < 0.001) in multivariate Cox regression analysis. Kaplan-Meier analysis revealed significantly different postoperative 90-d mortality rates between patients with high and low CFIs (log-rank test, P < 0.001). Incidences of postoperative MACE, pneumonia, the need for CRRT, and prolonged ICU stay were significantly higher in patients with high CFIs than in those with low CFIs.

CONCLUSIONS

Preoperative high CFI was associated with increased 90-d mortality, MACE, pneumonia, CRRT requirement, and ICU stay following burn surgery.

Optimization of Care for the Elderly Surgical Emergency Patient

Geriatric patients undergoing emergency surgery are at significantly higher risk for complications and death when compared with younger patients. Optimizing care for these patients requires a multidisciplinary team, special attention to physiologic changes and medication use, as well as targeted intervention to mitigate complications such as delirium, which can worsen overall outcomes. Frailty can be assessed preoperatively to identify patients at the highest risk for complications. Shared decision-making with both the family and patient during the consent process is integral to defining patient's goals of care in these high-risk situations.

Frailty and Adverse Outcomes After SARS-CoV-2 Infection in Elderly Patients on Maintenance Hemodialysis: A Cohort Study

Purpose

Frailty is an important geriatric syndrome associated with aging and adverse events, especially in patients with severe infection. To help guide prognosis for elderly patients undergoing maintenance hemodialysis (MHD) who experience acute infection, this study investigated whether baseline (pre-infection) frailty may be associated with adverse outcomes in elderly patients undergoing MHD who suffer SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection.

Patients and Methods

Patients (aged ≥60 y) receiving MHD had been assessed for overall frailty and the 5 frailty components based on the Fried Frailty Phenotype scale within 3 months prior to SARS-CoV-2 infection.

Results

There were 59 and 98 patients in the frail and non-frail groups, respectively. Three months after SARS-CoV-2 infection, 21 (13.4%) and 45 (28.7%) patients had died or were in hospital. The multivariate COX proportional risk model suggested that the all-cause mortality rate in patients judged overall frail or with low activity was significantly higher compared with that of the non-frail (P = 0.049; 0.003). The multivariate logistic regression analysis showed that hospitalization 3 months after SARS-CoV-2 infection was associated with both overall frailty and low activity (OR 2.276, 95% CI: 1.034-5.010, P = 0.041; OR 2.809, 95% CI: 1.311-6.020, P = 0.008, respectively).

Conclusion

Overall frailty and specifically low activity were significantly associated with all-cause mortality and hospitalization in this elderly MHD population after SARS-CoV-2 infection. Early assessment of frailty and effective interventions are recommended to improve the prognosis of patients receiving MHD who are at higher risk of acute infection.

Efficacy of a modified FRAIL scale in predicting the peri-operative outcome of hepatectomy in older adults (aged ≥ 75 years): a model development study

BACKGROUND

The FRAIL scale for evaluating frailty consists of five items: fatigue, resistance, aerobic, illness, and loss of weight. However, it is difficult to obtain a specific weight loss value. Since the Timed Up and Go Test (TUGT) is simple, accurate, and easy to perform, we replaced weight loss with the TUGT in the FRAIL scale, with the remaining four items unchanged, and named it the FRAIT scale. The aim of this study was to determine the value of the FRAIT scale in predicting the peri-operative outcome of hepatectomy.

METHODS

This model development study was conducted between January 2017 and December 2021. The reliability, validity and area under the curve (AUC) of the FRAIL/FRAIT scales were calculated. The frailty status of patients aged ≥ 75 years who underwent hepatectomy was measured using the FRAIL/FRAIT scales. Logistic regression was used to compare the relationship between FRAIL/FRAIT scores/grades and perioperative outcomes.

RESULTS

The AUCs for predicting operation duration, intraoperative bleeding, complications, and death based on the FRAIL score were 0.692, 0.740, 0.709, and 0.733, respectively, and those based on the FRAIT score were 0.700, 0.745, 0.708, and 0.724, respectively. The AUCs for predicting operation duration, intraoperative bleeding, complications, and death based on the FRAIL grade were 0.693, 0.735, 0.695, and 0.755, respectively, and those based on the FRAIT grades were 0.700, 0.758, 0.699, and 0.750, respectively. The FRAIL score has three effective predictors (intraoperative bleeding, complications, and death), while the FRAIT score has four effective predictors (operation duration, intraoperative bleeding, complications, and death). The FRAIL grade has two effective predictors (intraoperative bleeding and death), while the FRAIT grade has three effective predictors (operation duration, intraoperative bleeding, and death).

CONCLUSIONS

This study describes a new and more effective tool for the assessment of preoperative frailty in older adults undergoing hepatectomy. The items of the FRAIT scale are easier to obtain than those of the FRAIL scale, and the predictive effect of the FRAIT scale is stronger than that of the FRAIL scale.

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

Neuraxial anesthesia for abdominal surgery, beyond the pandemic: a feasibility pilot study of 70 patients in a suburban hospital

The aim of this study is to establish the feasibility of awake laparotomy under neuraxial anesthesia (NA) in a suburban hospital. A retrospective analysis of the results of a consecutive series of 70 patients undergoing awake abdominal surgery under NA at the Department of Surgery of our Hospital from February 11th, 2020 to October 20th, 2021 was conducted. The series includes 43 cases of urgent surgical care (2020) and 27 cases of elective abdominal surgery on frail patients (2021). Seventeen procedures (24.3%) required sedation to better control patient discomfort. Only in 4/70 (5.7%) cases, conversion to general anesthesia (GA) was necessary. Conversion to GA was not related to American Society of Anesthesiology (ASA) score or operative time. Only one of the four cases requiring conversion to GA was admitted to the Intensive Care Unit (ICU) postoperatively. Fifteen patients (21.4%) required postoperative ICU support. A statistically non-significant association was observed between conversion to GA and postoperative ICU admission. The mortality rate was 8.5% (6 patients). Five out of six deaths occurred while in the ICU. All six were frail patients. None of these deaths was related to a complication of NA. Awake laparotomy under NA has confirmed its feasibility and safety in times of scarcity of resources and therapeutic restrictions, even in the most frail patients. We believe that this approach should be considered as an useful asset, especially for suburban hospitals.

Efficacy of breast reconstruction in elderly women (>60 years) using deep inferior epigastric perforator flaps: A comparative study

BACKGROUND

The indications for microsurgical breast reconstruction remain debated, particularly concerning the safety of deep inferior epigastric perforator (DIEP) flaps in elderly women. Free tissue transfer still carries a risk of perioperative morbidity and mortality in elderly patients. We conducted this comparative study to clarify this issue.

METHODS

This retrospective cohort study included all unilateral DIEP breast reconstructions performed at a single institution. Patients were divided into two groups based on age: an elderly (60 years or older) and a non-elderly cohort (younger than 60 years). Demographic and comorbidity data were secondary predictor variables. The primary outcomes were complete flap loss, partial flap loss, and the need for flap re-exploration. The secondary outcomes included surgical site occurrences, such as wound healing-related complications, seroma, and others.

RESULTS

We included 214 flaps, 177 in the non-elderly and 37 in the elderly cohort. Elderly women had slightly higher comorbidity rates than those of non-elderly women, although these differences were not statistically significant. BMI was significantly lower in elderly women than in non-elderly women. The incidence of total or partial flap loss did not differ significantly between the two cohorts (2.7% vs 1.1%, p = 0.459% and 0.0% vs 5.1%, p = 0.161), nor did the flap re-exploration (8.1% vs 10.1%, p = 0.937). Similarly, postoperative complication rates did not differ significantly between the two groups (45.9% vs 61.8%, p = 0.074). On logistic regression, being elderly was not a risk factor for complete flap loss, nor for any complications. The overall success rate for the non-elderly cohort was 98.7%, whereas that for the elderly cohort was 97.3%.

CONCLUSIONS

Microsurgical breast reconstruction using DIEP is safe in elderly patients, as it achieves outcomes and complications rates comparable to those observed in a younger population. Patients should not be denied DIEP flaps because of their age alone.

The five-item modified frailty index predicts long-term outcomes in elderly patients undergoing colorectal cancer surgery

BACKGROUND

Frailty has been globally recognized as a predictor of adverse postoperative outcomes. Frailty assessment using the five-factor modified frailty index (5-mFI) has recently gained traction; however, long-term outcomes are unknown in colorectal cancer (CRC) surgery. This study aimed to investigate whether the 5-mFI predicted long-term survival and cause of death on the basis of frailty severity in elderly patients who underwent CRC surgery and to determine the risk factors for mortality.

METHODS

A total of 299 patients underwent CRC surgery with curative intent between January 2013 and December 2017. Patients were divided into three groups by the 5-mFI score: group 1 (5-mFI: 0 or 1; n = 164): no frailty; group 2 (5-mFI: 2; n = 91): moderate frailty; and group 3 (5-mFI: ≥ 3; n = 44): severe frailty. Clinicopathological variables, namely comorbidities, 5-mFI, prognostic nutrition index, operative/postoperative data, and outcome, including cause of death, were compared between the three groups. To identify factors associated with death from CRC- and non-CRC-related causes, univariate and multivariate analyses using a Cox regression model were performed.

RESULTS

The immediate postoperative morbidity of patients with Clavien-Dindo grade ≥ III complications (9.1%) in group 3 was not significantly different from that in group 1 (9.1%) or group 2 (14.3%); however, the 30-day mortality rate (4.5%) in group 3 was significantly higher. Long-term disease-free survival was similar between frailty groups, suggesting that CRC surgery provides oncological benefit to patients irrespective of frailty. The 5-year survival rates in groups 1, 2, and 3 were 83.5%, 71.2%, and 47.9%, respectively, showing a significantly lower survival rate as frailty advanced. Sixty percent of the deaths in frail patients were due to respiratory failure and cardiovascular diseases. Multivariate analysis demonstrated that advanced age, higher 5-mFI score, and longer postoperative hospital stay were risk factors for mortality unrelated to CRC. Multivariate analysis also revealed that advanced tumor stage, carcinoembryonic antigen ≥ 5 ng/ml, undifferentiated tumor, and R1 resection were risk factors for CRC-related mortality.

CONCLUSIONS

The 5-mFI score can predict postoperative short- and long-term outcomes and risk factors for mortality unrelated to CRC. Additionally, long-term survival was negatively associated with the 5-mFI score.

The Burden of Streptococcus pneumoniae-Related Admissions and In-Hospital Mortality: A Retrospective Observational Study between the Years 2015 and 2022 from a Southern Italian Province

Streptococcus pneumoniae (SP) has high worldwide incidence and related morbidity and mortality, particularly among children and geriatric patients. SP infection could manifest with pneumonia, bacteremia, sepsis, meningitis, and osteomyelitis. This was a retrospective study aimed at evaluating the incidence, comorbidities, and factors associated with in-hospital mortality of pneumococcal disease-related hospitalization in a province in southern Italy from the years 2015 to 2022. This study was performed in the Local Health Authority (LHA) of Pescara. Data were collected from hospital discharge records (HDRs): this database is composed of 288,110 discharge records from LHA Pescara's hospitals from 2015 to 2022. Streptococcus Pneumoniae-related hospitalizations were about 5% of the hospitalizations; 67% of these were without comorbidities; 21% were with one comorbidity; and 13% were with two or more comorbidities. Regarding mortality of SP infection, the most affected age group was older people, with the percentage of cases among the over-65s being more than 50% compared to the other age groups. HDRs represent a valid and useful epidemiological tool for evaluating the direct impact of pneumococcal disease on the population and also indirectly for evaluating the effectiveness of vaccination strategies and directing them.

A Novel Mobile App to Identify Patients With Multimorbidity in the Emergency Setting: Development of an App and Feasibility Trial

BACKGROUND

Multimorbidity is associated with an increased risk of poor surgical outcomes among older adults; however, identifying multimorbidity in the clinical setting can be a challenge.

OBJECTIVE

We created the Multimorbid Patient Identifier App (MMApp) to easily identify patients with multimorbidity identified by the presence of a Qualifying Comorbidity Set and tested its feasibility for use in future clinical research, validation, and eventually to guide clinical decision-making.

METHODS

We adapted the Qualifying Comorbidity Sets' claims-based definition of multimorbidity for clinical use through a modified Delphi approach and developed MMApp. A total of 10 residents input 5 hypothetical emergency general surgery patient scenarios, common among older adults, into the MMApp and examined MMApp test characteristics for a total of 50 trials. For MMApp, comorbidities selected for each scenario were recorded, along with the number of comorbidities correctly chosen, incorrectly chosen, and missed for each scenario. The sensitivity and specificity of identifying a patient as multimorbid using MMApp were calculated using composite data from all scenarios. To assess model feasibility, we compared the mean task completion by scenario to that of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS-NSQIP-SRC) using paired t tests. Usability and satisfaction with MMApp were assessed using an 18-item questionnaire administered immediately after completing all 5 scenarios.

RESULTS

There was no significant difference in the task completion time between the MMApp and the ACS-NSQIP-SRC for scenarios A (86.3 seconds vs 74.3 seconds, P=.85) or C (58.4 seconds vs 68.9 seconds,P=.064), MMapp took less time for scenarios B (76.1 seconds vs 87.4 seconds, P=.03) and E (20.7 seconds vs 73 seconds, P<.001), and more time for scenario D (78.8 seconds vs 58.5 seconds, P=.02). The MMApp identified multimorbidity with 96.7% (29/30) sensitivity and 95% (19/20) specificity. User feedback was positive regarding MMApp's usability, efficiency, and usefulness.

CONCLUSIONS

The MMApp identified multimorbidity with high sensitivity and specificity and did not require significantly more time to complete than a commonly used web-based risk-stratification tool for most scenarios. Mean user times were well under 2 minutes. Feedback was overall positive from residents regarding the usability and usefulness of this app, even in the emergency general surgery setting. It would be feasible to use MMApp to identify patients with multimorbidity in the emergency general surgery setting for validation, research, and eventual clinical use. This type of mobile app could serve as a template for other research teams to create a tool to easily screen participants for potential enrollment.

Clinicopathological characteristics and prognostic factors in axial chondroblastomas: a retrospective analysis of 61 cases and comparison with extra-axial chondroblastomas

BACKGROUND

A comprehensive understanding of the clinical characteristics and prognostic factors associated with axial chondroblastoma (ACB) is still lacking. This study aimed to understand the clinical characteristics and prognostic factors of axial chondroblastoma (ACB) and compare them with extra-axial chondroblastoma (EACB).

METHODS

A retrospective review of our institution's local database was conducted, encompassing a total of 132 CB patients, of which 61 were diagnosed with ACB and 71 with EACB. Immunohistochemistry was employed to evaluate the expression levels of vimentin, S100, and cytokeratin.

RESULTS

ACB and EACB shared similar characteristics, with the exception of advanced age, tumor size, elevated Vim expression, incidence of surrounding tissue invasion, and postoperative sensory or motor dysfunction. While wide resection and absence of surrounding tissue invasion consistently showed a favorable association with survival in both ACB and EACB cohorts during univariate analysis, most parameters exhibited differential prognostic significance between the two groups. Notably, the significant prognostic factors for local recurrence-free survival in the ACB cohort included the type of resection and the presence of chicken-wire calcification. In the multivariate analysis of overall survival, the type of resection emerged as a significant predictor in the ACB cohort, whereas in the EACB group, the type of resection and the occurrence of postoperative sensory or motor dysfunction were predictive of overall survival.

CONCLUSION

There may exist distinct biological behaviors between ACB and EACB, thereby providing valuable insights into the prognostic characteristics of ACB patients and contributing to enhanced outcome prediction in this particular patient population.

Retrospective In-Hospital Mortality Analysis of GeriatricPatients Treated in a Level 1 Trauma Center

The aim of this study is to determine the critical time intervals and influencing covariates for in-hospital mortality in geriatric trauma and orthopedic patients. During a period of five years, we retrospectively review patients aged > 60 years who were hospitalized at the Department of Trauma, Orthopedic, and Plastic Surgery. The primary outcome is the mean time to death. Survival analysis is performed using an accelerated failure time model. A total of 5388 patients are included in the analysis. Two-thirds underwent surgery (n = 3497, 65%) and one-third were conservatively treated (n = 1891, 35%). The in-hospital mortality rate is 3.1% (n = 168; surgery, n = 112; conservative, n = 56). The mean time to death is 23.3 days (±18.8) after admission in the surgery group and 11.3 days (±12.5) in the conservative treatment group. The greatest accelerating effect on mortality is found in the intensive care unit (16.52, p < 0.001). We are able to identify a critical time interval for in-hospital mortality between days 11 and 23. The day of death on weekend days/holidays, hospitalization for conservative treatment, and treatment at the intensive care unit significantly increase the risk of in-hospital mortality. Early mobilization and a short hospitalization duration seem to be of major importance in fragile patients.

Risk factors for postoperative complications in patients with Parkinson disease: A single center retrospective cohort study

Surgical treatment for patients with Parkinson disease (PD) under general anesthesia has become frequent. PD is a significant predictor of postoperative complications. However, the factors that predict complications in patients with PD remain unknown. We retrospectively recruited patients with PD who underwent surgery between April 2015 and March 2019. The prevalence of postoperative complications was analyzed. We compared the patient characteristics, medical data, and surgical data between patients with and without postoperative complications. We also estimated the odds ratios (OR) for postoperative complications in patients with PD who underwent surgery. Sixty-five patients were enrolled. Eighteen patients presented with 22 complications, including urinary tract infections (UTI) (n = 3; 5%), pneumonia (n = 1; 2%), surgical site infections (SSI) (n = 3; 5%), postoperative delirium (POD) (n = 7; 10%), and others (n = 8; 12%). Four patients presented with 2 complications each. The operation time, the red blood cell transfusion and the rate of rotigotine usage were higher in patients with complications than those without (314 ± 197 min vs 173 ± 145 min, P = .006; 0 [0-560] mL vs 0 [0-0] mL, P = .02; 39% vs 6%, P = .003, respectively) (mean ± standard deviation or median [interquartile range]). Preoperative rotigotine usage (OR: 9.33; 95% confidential interval [CI]: 2.07-42.07; P = .004) was an independent risk factors for postoperative complications. The findings indicate that clinicians should closely monitor postoperative complications when patients with PD who have received transdermal dopamine agonists undergone longer time surgery.

The modified 5-item frailty index determines the length of hospital stay and accompanies with mortality rate in patients with bone and implant-associated infections after trauma and orthopedic surgery

BACKGROUND

Bone and implant-associated infections are severe complications after trauma and orthopedic surgery. The modified 5-item frailty index (mFI-5) is an easily applicable score to predict adverse outcome after surgery. The current literature regarding mFI-5 is focused on a period of 30-days postoperative.

PURPOSE

This study aims to assess the impact of frailty in orthopedic trauma patients with bone and implant-associated infections. mFI-5 was calculated from a database, which prospectively collects data about factors potentially correlated with peri- and postoperative complications since 2014.

METHODS

In a level I trauma center a total of 345 patients with surgical site infections were enrolled in this study. Hereof, patients with fracture-related infections after osteosynthesis, periprosthetic joint infections of the hip and knee and post-operative osteomyelitis were included. Extensive medical baseline examination was performed in 2013/14, a three-year follow-up was organized as a telephone interview. The mFI-5 score was calculated based on the 5 factor-principle as established by Subramaniam. The nutritional status was assessed using the Nutritional Risk Screening (NRS-2002).

RESULTS

130 patients were included, whereof seven had died, resulting in 123 patients. A grouping of our patients was performed in mFI-5 = 0 (n = 46; 36,4%), mFI-5 = 1 (n = 41; 33,3%) or mFI-5 ≥ 2 (n = 36; 29,3%). Sex distribution showed 69,1% male and 30,9% female patients. Frailty did neither impact on the re-admission (p = 0,433) nor the reoperation (p = 0,327) rate in our cohort. The mortality risk nearly doubled (1,7 times) in frail patients, but did not reach significance. In hospital stay was prolonged due to frailty (12,1 ± 11,8; p = 0,004) compared to those with a mFI-5 = 0 (5,9 ± 5,1) or mFI-5 = 1 (6,9 ± 5,9). Frailty goes along with a risk of malnutrition and increases with age.

CONCLUSION

The modified 5-item frailty index is not a suitable screening tool for predicting revision rate, re-admission rate, and mortality in our orthopedic trauma patient population with bone and implant-associated infections. Nevertheless, frailty is associated with an increased risk of malnutrition and increases with age.

The Predictive Value of a Modified Frailty Index on Perioperative Morbidity and Mortality Following Otologic Surgery

Objectives

Recently, determinants of frailty have become an increasingly recognized perioperative risk stratification tool. This study examines the predictive value of a 5-factor modified frailty index (mFI-5) on perioperative morbidity and mortality in patients undergoing otologic surgery, with a subgroup analysis based on surgery site.

Study Design

Cross-sectional analysis.

Setting

National surgical quality improvement program dataset 2005-2019.

Patients

Current procedural terminology (CPT) codes were used to identify patients undergoing all otologic surgeries.

Interventions

Otologic surgeries as indicated by CPT codes, including external ear, middle ear/mastoid, implants, and inner ear/facial nerve subgroups.

Main Outcome Measures

Primary outcomes examined in this study included rates of overall complications and life-threatening complications within 30 days after surgery. Overall complications included superficial surgical site infections (SSI), deep incisional SSI, readmission, deep vein thrombosis, life-threatening complications, and mortality. Life-threatening complications included those classified as Clavien-Dindo grade IV: cerebrovascular accident, mechanical ventilation for more than 48 hours, reintubation, pulmonary embolism, acute renal failure, cardiac arrest, and myocardial infarction.

Results

A total of 16,859 patients who underwent otologic surgery were identified, resulting in a cohort that was 47.5% male with an average age of 47.6 years (17.1 SD). Multivariable regression analysis of the entire cohort demonstrated a score of 3 or more on the mFI-5 was independently predictive of all postoperative complications (odds ratio (OR): 2.02, P < 0.0001). However, subgroup analysis showed that only "external ear" surgery correlated with mFi-5 (OR 8.03, P = 0.013).

Conclusions

Higher frailty scores as measured by the mFI-5 correlate with postoperative morbidity and mortality after otologic surgery, though subgroup analysis reveals an association only with cases performed on the external ear. These findings suggest that for most otologic surgery, the mFI-5 frailty score is not predictive of postoperative complications.

The modified 5-item frailty index as a predictor of complications in burn patients

The modified 5-item frailty index (mFI-5), as a measure of frailty and biological age, has been shown to be a reliable predictor of complications and mortality in a variety of surgical specialties. However, its role in burn care remains to be fully elucidated. We, therefore, correlated frailty with in-hospital mortality and complications after burn injury. The medical charts of all burn patients admitted between 2007 and 2020 who had ≥ 10 % of their total body surface area affected were retrospectively reviewed. Data on clinical, demographic, and outcome parameters were collected and evaluated, and mFI-5 was calculated on the basis of the data obtained. Univariate and multivariate regression analyses were used to investigate the association between mFI-5 and medical complications and in-hospital mortality. A total of 617 burn patients were included in this study. Increasing mFI-5 scores were significantly associated with increased in-hospital mortality (p < 0.0001), myocardial infarction (p = 0.03), sepsis (p = 0.005), urinary tract infections (p = 0.006), and perioperative blood transfusions (p = 0.0004). They were also associated with an increase in the length of hospital stay and the number of surgical procedures, albeit without statistical significance. An mFI-5 score of ≥ 2 was a significant predictor of sepsis (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.03 to 3.95; p = 0.04), urinary tract infection (OR = 2.82; 95% CI: 1.47 to 5.19; p = 0.002), and perioperative blood transfusions (OR = 2.61; 95% CI: 1.61 to 4.25; p = 0.0001). Multivariate logistic regression analysis revealed that an mFI-5 score of ≥ 2 was not an independent risk factor for in-hospital mortality (OR = 1.44; 95% CI: 0.61 to 3.37; p = 0.40). mFI-5 is a significant risk factor for only a few select complications in the burn population. It is not a reliable predictor of in-hospital mortality. Therefore, its utility as a risk stratification tool in the burn unit may be limited.

Prehabilitation in Cardiovascular Surgery: The Effect of Neuromuscular Electrical Stimulation (Randomized Clinical Trial)

OBJECTIVE

We aimed to determine the effects of prehabilitation with neuromuscular electrical stimulation (NMES) on muscle status and exercise capacity in patients before cardiac surgery.

METHODS

Preoperative elective cardiac surgery patients were randomly assigned to the NMES group or control group. Intervention in the NMES group was 7-10 sessions, whereas the control group carried out breathing exercises and an educational program. The outcome measures included a six-minute walk test (6MWT) and a muscle status assessment (knee extensor strength (KES), knee flexor strength (KFS), and handgrip strength (HS)) after the course of prehabilitation.

RESULTS

A total of 122 patients (NMES, n = 62; control, n = 60) completed the study. During the NMES course, no complications occurred. After the course prehabilitation KES, KFS, and 6MWT distance were significantly increased (all p < 0.001) in the NMES group compared to the control. There was no significant difference in HS before surgery.

CONCLUSIONS

A short-term NMES course before cardiac surgery is feasible, safe, and effective to improve preoperative functional capacity (six-minute walk distance) and the strength of stimulated muscles.

Is pancreatic head surgery safe in the elderly?

BACKGROUND

During the last century, life expectancy has doubled. As a result, senior patients with cancer are more frequently referred for possible surgery. Pancreatic surgery is a complex surgery associated with significant postoperative morbidity. Surgical decision-making in the elderly population can be difficult because outcomes in the elderly are poorly defined. Our objective is to characterize differences in mortality and morbidity for pancreatic surgery in the elderly population.

METHODS

A retrospective review of all patients undergoing pancreatic head surgery in our tertiary referral center from 2015 to 2021 was conducted. Analysis was performed for the entire cohort, classifying patients into three age groups: <70 years, 70-79 years, and ≥80 years. Data from these three groups were compared, including comorbidity, oncologic outcomes and postoperative complications.

RESULTS

A total of 326 patients underwent pancreatic head resection. The 90-day mortality increased from 2.9% to 5.3% to 15.4% with increasing age (p = 0,015). There were no differences among the three groups in terms of postoperative morbidity. There was no difference in disease-free survival (DFS), but overall survival was better in patients under 70 years (p = 0,046).

CONCLUSION

Compared to younger patients, patients over 80 years old have a higher risk of mortality despite similar postoperative morbidity.

Development and validation of a patient-specific model to predict postoperative SIRS in older patients: A two-center study

Introduction

Postoperative systemic inflammatory response syndrome (SIRS) is common in surgical patients especially in older patients, and the geriatric population with SIRS is more susceptible to sepsis, MODS, and even death. We aimed to develop and validate a model for predicting postoperative SIRS in older patients.

Methods

Patients aged ≥65 years who underwent general anesthesia in two centers of Third Affiliated Hospital of Sun Yat-sen University from January 2015 to September 2020 were included. The cohort was divided into training and validation cohorts. A simple nomogram was developed to predict the postoperative SIRS in the training cohort using two logistic regression models and the brute force algorithm. The discriminative performance of this model was determined by area under the receiver operating characteristics curve (AUC). The external validity of the nomogram was assessed in the validation cohort.

Results

A total of 5,904 patients spanning from January 2015 to December 2019 were enrolled in the training cohort and 1,105 patients from January 2020 to September 2020 comprised the temporal validation cohort, in which incidence rates of postoperative SIRS were 24.6 and 20.2%, respectively. Six feature variables were identified as valuable predictors to construct the nomogram, with high AUCs (0.800 [0.787, 0.813] and 0.822 [0.790, 0.854]) and relatively balanced sensitivity (0.718 and 0.739) as well as specificity (0.718 and 0.729) in both training and validation cohorts. An online risk calculator was established for clinical application.

Conclusion

We developed a patient-specific model that may assist in predicting postoperative SIRS among the aged patients.

[Older patients in abdominal surgery]

BACKGROUND

The aging society imposes special challenges on operative medicine.

OBJECTIVE

Characteristics in the perioperative treatment of older patients. Consequences for the daily practice.

MATERIAL AND METHODS

Evaluation and summary of existing literature including recommendations for the (peri)operative management of older patients.

RESULTS

Despite the growing relevance there are only few studies focusing on older patients. The altered (patho)physiology and comorbidities are challenging and can lead to complications.

CONCLUSION

The evaluation of the indications for surgery should meticulously take the improvement to be expected into account by weighing up the individual wishes of patients and special risks. The adequate perioperative care including early mobilization and sufficient analgesia are decisive.

External Validation of the American College of Surgeons Surgical Risk Calculator in Elderly Patients Undergoing General Surgery Operations

Preoperative risk stratification in the elderly surgical patient is an essential part of contemporary perioperative care and can be done with the use of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). However, data on the generalizability of the ACS-SRC in the elderly is scarce. In this study, we report an external validation of the ACS-RC in a geriatric cohort. A retrospective analysis of a prospectively maintained database was performed including patients aged > 65 who underwent general surgery procedures during 2012−2017 in a Greek academic centre. The predictive ability of the ACS-SRC for post-operative outcomes was tested with the use of Brier scores, discrimination, and calibration metrics. 471 patients were included in the analysis. 30-day postoperative mortality was 3.2%. Overall, Brier scores were lower than cut-off values for almost all outcomes. Discrimination was good for serious complications (c-statistic: 0.816; 95% CI: 0.762−0.869) and death (c-statistic: 0.824; 95% CI: 0.719−0.929). The Hosmer-Lemeshow test showed good calibration for all outcomes examined. Predicted and observed length of stay (LOS) presented significant differences for emergency and for elective cases. The ACS-SRC demonstrated good predictive performance in our sample and can aid preoperative estimation of multiple outcomes except for the prediction of post-operative LOS.

Association of frailty with outcomes of resection for colonic volvulus: A national analysis

Background

With limited national studies available, we characterized the association of frailty with outcomes of surgical resection for colonic volvulus.

Methods

Adults with sigmoid or cecal volvulus undergoing non-elective colectomy were identified in the 2010–2019 Nationwide Readmissions Database. Frailty was identified using the Johns Hopkins indicator which utilizes administrative codes. Multivariable models were developed to examine the association of frailty with in-hospital mortality, perioperative complications, stoma use, length of stay, hospitalization costs, non-home discharge, and 30-day non-elective readmissions.

Results

An estimated 66,767 patients underwent resection for colonic volvulus (Sigmoid: 39.6%; Cecal: 60.4%). Using the Johns Hopkins indicator, 30.3% of patients with sigmoid volvulus and 15.9% of those with cecal volvulus were considered frail. After adjustment, frail patients had higher risk of mortality compared to non-frail in both sigmoid (10.6% [95% CI 9.47–11.7] vs 5.7% [95% CI 5.2–6.2]) and cecal (10.4% [95% CI 9.2–11.6] vs 3.5% [95% CI 3.2–3.8]) volvulus cohorts. Frailty was associated with greater odds of acute venous thromboembolism occurrences (Sigmoid: AOR 1.50 [95% CI 1.18–1.94]; Cecal: AOR 2.0 [95% CI 1.50–2.72]), colostomy formation (Sigmoid: AOR 1.73 [95% CI 1.57–1.91]; Cecal: AOR 1.48 [95% CI 1.10–2.00]), non-home discharge (Sigmoid: AOR 1.97 [95% CI 1.77–2.20]; Cecal: AOR 2.56 [95% CI 2.27–2.89]), and 30-day readmission (Sigmoid: AOR 1.15 [95% CI 1.01–1.30]; Cecal: AOR 1.26 [95% CI 1.10–1.45]). Frailty was associated with incremental increase in length of stay (Sigmoid: +3.4 days [95% CI 2.8–3.9]; Cecal: +3.8 days [95% CI 3.3–4.4]) and costs (Sigmoid: +$7.5k [95% CI 5.9–9.1]; Cecal: +$12.1k [95% CI 10.1–14.1]).

Conclusion

Frailty, measured using a simplified administrative tool, is associated with significantly worse clinical and financial outcomes following non-elective resections for colonic volvulus. Standard assessment of frailty may aid risk-stratification, better inform shared-decision making, and guide healthcare teams in targeted resource allocation in this vulnerable patient population.

Prognostic Significance of Baseline Frailty Status in Traumatic Spinal Cord Injury

BACKGROUND

Literature evaluating frailty in traumatic spinal cord injury (tSCI) is limited.

OBJECTIVE

To evaluate the prognostic significance of baseline frailty status in tSCI.

METHODS

Patients with tSCI were identified in the National Inpatient Sample from 2015 to 2018 and stratified according to frailty status, which was quantified using the 11-point modified frailty index (mFI).

RESULTS

Among 8825 operatively managed patients with tSCI identified (mean age 57.9 years, 27.6% female), 3125 (35.4%) were robust (mFI = 0), 2530 (28.7%) were prefrail (mFI = 1), 1670 (18.9%) were frail (mFI = 2), and 1500 (17.0%) were severely frail (mFI ≥ 3). One thousand four-hundred forty-five patients (16.4%) were routinely discharged (to home), and 320 (3.6%) died during hospitalization, while 2050 (23.3%) developed a severe complication, and 2175 (24.6%) experienced an extended length of stay. After multivariable analysis adjusting for age, illness severity, trauma burden, and other baseline covariates, frailty (by mFI-11) was independently associated with lower likelihood of routine discharge [adjusted odds ratio (aOR) 0.82, 95% CI 0.77-0.87; P &lt; .001] and development of a severe complication (aOR 1.17, 95% CI 1.12-1.23; P &lt; .001), but not with in-hospital mortality or extended length of stay. Subgroup analysis by age demonstrated robust associations of frailty with routine discharge in advanced age groups (aOR 0.71 in patients 60-80 years and aOR 0.69 in those older than 80 years), which was not present in younger age groups.

CONCLUSION

Frailty is an independent predictor of clinical outcomes after tSCI, especially among patients of advanced age. Our large-scale analysis contributes novel insights into limited existing literature on this topic.

Emergency General Surgery: Predicting Morbidity and Mortality in the Geriatric Population

Introduction  Numerous scoring systems have been created to predict the risk of morbidity and mortality in patients undergoing emergency general surgery (EGS). In this article, we compared the different scoring systems utilized at Humanitas Research Hospital and analyzed which one performed the best when assessing geriatric patients (>65 years of age). The scoring systems that were utilized were the APACHE II (Acute Physiology and Chronic Health Evaluation II), ASA (American Society of Anesthesiologists), ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program), Clinical Frailty Score, and the Clavien-Dindo classification as control. Materials and Methods  We compiled a database consisting of all patients over the age of 65 who underwent EGS in a consecutive 24-month period between January 1, 2017 and December 31, 2018. We used the biostatistical program "Stata Version 15" to analyze our results. Results  We found 213 patients who matched our inclusion criteria. Regarding death, we found that the ACS-NSQIP death calculator performed the best with an area under the curve of 0.9017 (odds ratio: 1.09; 95% confidence interval: 1.06-1.12). The APACHE II score had the lowest discriminator when predicting death. Considering short-term complications, the Clavien-Dindo classification scored highly, while both the APACHE II score and Clinical Frailty Score produced the lowest results. Conclusion  The results obtained from our research showed that scoring systems and classifications produced different results depending on whether they were used to predict deaths or short-term complications among geriatric patients undergoing EGS.

Frailty Is Superior to Age for Predicting Readmission, Prolonged Length of Stay, and Wound Infection in Elective Otology Procedures

OBJECTIVE

To determine the predictive ability of the 5-point modified frailty index relative to age in elective otology patients.

STUDY DESIGN

Retrospective database analysis.

SETTING

Multicenter, national database of surgical patients.

PATIENTS

We selected all elective surgical patients who received tympanoplasty, tympanomastoidectomy, mastoidectomy, revision mastoidectomy, and cochlear implant procedures from 2016 to 2019 from the National Surgical Quality Improvement database.

INTERVENTIONS

Therapeutic.

MAIN OUTCOME MEASURES

Readmission rates, discharge disposition, reoperation rates, and extended length of hospital stay.

RESULTS

Utilizing receiver operating characteristics with area under the curve (AUC) analysis, nonrobust status was determined to be a superior predictor relative to age of readmission (AUC = 0.628 [p < 0.001] versus AUC = 0.567 [p = 0.047], respectively) and open wound infection relative to age (AUC = 0.636 [p = 0.024] versus AUC = 0.619 [p = 0.048], respectively). Nonrobust otology patients were more likely to have dyspnea at rest and an American Society of Anesthesiology score higher than 2 before surgery (odds ratios, 13.304 [95% confidence interval, 2.947-60.056; p < 0.001] and 7.841 [95% confidence interval, 7.064-8.704; p < 0.001], respectively).

CONCLUSION

Nonrobust status was found to be a useful predictor of readmission and prolonged length of stay in patients undergoing elective otology procedures, which generally have low complication rate. Given the aging population and corresponding increase in otology disease, it is important to use age-independent risk stratification measures. Frailty may provide a useful risk stratification tool to select surgical candidates within the aging population.

Frailty and Potentially Inappropriate Prescribing in Older People with Polypharmacy: A Bi-Directional Relationship?

Frail older adults commonly experience multiple co-morbid illnesses and other risk factors for potentially inappropriate prescribing. However, determination of frailty varies depending on the frailty instrument used. Older people’s degree of frailty often influences their care and treatment priorities. Research investigating the association between frailty and potentially inappropriate prescribing is hindered by a wide variety of frailty definitions and measurement tools. We undertook a narrative review of selected articles of PubMed and Google Scholar databases. Articles were selected on the basis of relevance to the core themes of frailty and potentially inappropriate prescribing. We identified observational studies that clearly link potentially inappropriate prescribing, potential prescribing omissions, and adverse drug reactions with frailty in older adults. Equally, the literature illustrates that measured frailty in older adults predisposes to inappropriate polypharmacy and associated adverse drug reactions and events. In essence, there is a bi-directional relationship between frailty and potentially inappropriate prescribing, the underlying substrates being multimorbidity and inappropriate polypharmacy. We conclude that there is a need for consensus on rapid and accurate identification of frailty in older people using appropriate and user-friendly methods for routine clinical practice as a means of identifying older multimorbid patients at risk of potentially inappropriate prescribing. Detection of frailty should, we contend, lead to structured screening for inappropriate prescribing in this high-risk population. Of equal importance, detection of potentially inappropriate prescribing in older people should trigger screening for frailty. All clinicians undertaking a medication review of multimorbid patients with associated polypharmacy should take account of the important interaction between frailty and potentially inappropriate prescribing in the interest of minimizing patient harm.

Effect of sarcopenia in predicting postoperative mortality in emergency laparotomy: a systematic review and meta-analysis

Background

While emergency laparotomy has been associated with high rates of postoperative mortality and adverse events, preoperative systematic evaluation of patients may improve perioperative outcomes. However, due to the critical condition of the patient and the limited operation time, it is challenging to conduct a comprehensive evaluation. In recent years, sarcopenia is considered a health problem associated with an increased incidence of poor prognosis. This study aimed to investigate the effect of sarcopenia on 30-day mortality and postoperative adverse events in patients undergoing emergency laparotomy.

Methods

We systematically searched databases including PubMed, Embase, and Cochrane for all studies comparing emergency laparotomy in patients with and without sarcopenia up to March 1, 2022. The primary outcome was of 30-day postoperative mortality. Secondary outcomes were the length of hospital stay, the incidence of adverse events, number of postoperative intensive care unit (ICU) admissions, and ICU length of stay. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) tool. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Result

A total of 11 eligible studies were included in this study. The results showed that patients with sarcopenia had a higher risk of death 30 days after surgery (OR = 2.42, 95% CI = 1.93–3.05, P < 0.00001). More patients were admitted to ICU after surgery (OR = 1.58, 95% CI = 1.11–2.25, P = 0.01). Both the ICU length of stay (MD = 0.55, 95% CI = 0.05–1.06, P = 0.03) and hospital length of stay (MD = 2.33, 95% CI = 1.33–3.32, P < 0.00001) were longer in the sarcopenia group. The incidence of postoperative complications was also significantly higher in patients with sarcopenia (OR = 1.78, 95% CI = 1.41–2.26, P < 0.00001).

Conclusion

In emergency laparotomy, sarcopenia was associated with increased 30-day postoperative mortality. Both the lengths of stay in the ICU and the total length of hospital stay were significantly higher than those in non-sarcopenic patients. Therefore, we concluded that sarcopenia can be used as a tool to identify preoperative high-risk patients, which can be considered to develop new postoperative risk prediction models.

Registration number Registered on Prospero with the registration number of CRD42022300132.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00440-0.

Effects of frailty on postoperative clinical outcomes of aneurysmal subarachnoid hemorrhage: results from the National Inpatient Sample database

Background

This study aimed to investigate the potential effect of preoperative frailty on postoperative clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH).

Methods

Data of patients aged 18 years and older who were diagnosed with subarachnoid hemorrhage or intracerebral hemorrhage, underwent aneurysm repair surgical intervention from 2005 to 2014. A retrospective database analysis was performed based on U.S. National Inpatient Sample (NIS) from 2005 to 2014. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Patients were stratified into frail and non-frail groups and the study endpoints were incidence of postoperative complications and related adverse clinical outcomes.

Results

Among 20,527 included aSAH patients, 2303 (11.2%) were frail and 18,224 (88.8%) were non-frail. Significant differences were found between frailty and non-frailty groups in the four clinical outcomes (all p < 0.05). Multivariate analysis showed that frailty was associated with significant higher risks of discharge to institutional care (aOR: 2.50, 95%CI: 2.10–2.97), tracheostomy or gastrostomy tube replacement (aOR: 4.41, 95%CI: 3.81–5.10) and postoperative complications (aOR: 3.29, 95%CI: 2.55–4.25) but a lower risk of death in hospital (aOR: 0.40, 95%CI: 0.33–0.49) as compared with non-frailty. Stratified analysis showed the impact of frailty on some of the outcomes were greater among patients younger than 65 years than their older counterparts.

Conclusions

Frailty is significantly correlated with the increased risk of discharge to institutional care, tracheostomy or gastrostomy tube placement, and postoperative complications but with the reduced risk of in-hospital mortality outcomes after aneurysm repair. Frailty seems to have greater impact among younger adults than older ones. Baseline frailty evaluation could be applied to risk stratification for aSAH patients who were undergoing surgery.

Is Laparoscopic Common Bile Duct Exploration Safe For The Oldest old patients?

Background

This study aimed to identify the risk factors for postoperative complications of laparoscopic common bile duct exploration (LCBDE) in the oldest old patients aged 80 years or older.

Methods

From March 2001 to October 2020, 363 patients underwent LCBDE with stone removal. Based on their ages, they were divided into two groups, those younger than 80 years (n=240) and those 80 years old or older (n=123). We compared patient demographics, disease characteristics, surgical outcomes, and postoperative complications based on these groups.

Results

The older group had a higher proportion of patients with a Charlson Comorbidity Index ≥5 (p<0.001) and the American Society of Anesthesiologist (ASA) physical status classification ≥3 (p<0.001). In addition, the older group had longer postoperative hospital stays than younger group (7.5±6.1 days vs. 6.2±3.9 days, p=0.013). However, there were no significant differences between groups according to the postoperative complications (13.8% vs. 20.3%, p=0.130). According to multivariate analysis, the risk factors for postoperative complications were Charlson Comorbidity Index ≥5 (odds ratio [OR]=2.307; 95% confidence interval [CI], 1.162–4.579; p=0.017) and operative time >2 hours (OR=3.204; 95% CI, 1.802–5.695; p<0.001).

Conclusion

In patients with Charlson Comorbidity Index <5 and operation time <2 hours, LCDBE with stone removal can be considered safe for the oldest old patients.

The impact of frailty on postoperative complications in geriatric patients undergoing multi-level lumbar fusion surgery

STUDY DESIGN

Retrospective Cohort Study.

PURPOSE

This study evaluates the impact of patient frailty status on postoperative complications in those undergoing multi-level lumbar fusion surgery.

METHODS

The Nationwide Readmission Database (NRD) was retrospectively queried between 2016 and 2017 for patients receiving multi-level lumbar fusion surgery. Demographics, frailty status, and relevant complications were queried at index admission and readmission intervals. Primary outcome measures included perioperative complications and 30-, 90-, and 180-day complication and readmission rates. Perioperative complications of interest were infection, urinary tract infection (UTI), and posthemorrhagic anemia. Secondary outcome measures included inpatient length of stay (LOS), adjusted all-payer costs, and discharge disposition. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail patients with similar diagnoses and procedures. Subgroup analysis of minimally invasive surgery (MIS) versus open surgery within frail and non-frail cohorts was conducted to evaluate differences in surgical and medical complication rates. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Frail patients encountered higher rates perioperative complications including posthemorrhagic anemia (OR: 1.73, 95%CI 1.50-2.00, p < 0.0001), infection (OR: 2.94, 95%CI 2.04-4.36, p < 0.0001), UTI (OR: 2.57, 95%CI 2.04-3.26, p < 0.0001), and higher rates of non-routine discharge (OR: 2.07, 95%CI 1.80-2.38, p < 0.0001). Frail patients had significantly greater LOS and total all-payer inpatient costs compared to non-frail patients (p < 0.0001). Frailty was associated with significantly higher rates of 90- (OR: 1.43, 95%CI 1.18-1.74, p = 0.0003) and 180-day (OR: 1.28, 95%CI 1.03-1.60, p = 0.02) readmissions along with higher rates of wound dehiscence (OR: 2.21, 95%CI 1.17-4.44, p = 0.02) at 90 days. Subgroup analysis revealed that frail patients were at significantly higher risk for surgical complications with open surgery (16%) compared to MIS (0%, p < 0.0001). No significant differences were found between surgical approaches with respect to medical complications in both cohorts, nor surgical complications in non-frail patients.

CONCLUSIONS

Frailty was associated with higher odds of all perioperative complications, LOS, and all-payer costs following multi-level lumbar fusion. Frail patients had significantly higher rates of 90 and 180-day readmission and higher rates of wound disruption at 90-days. On subgroup analysis, MIS was associated with significantly reduced rates of surgical complications specifically in frail patients. Our results suggest frailty status to be an important predictor of perioperative complications and long-term readmissions in geriatric patients receiving multi-level lumbar fusions. Frail patients should undergo surgery utilizing minimally invasive techniques to minimize risk of surgical complications. Future studies should explore the utility of implementing frailty in risk stratification assessments for patients undergoing spine surgery.

Exploring red cell distribution width as a potential risk factor in emergency bowel surgery—A retrospective cohort study

Increased preoperative red cell distribution width (RDW) is associated with higher mortality following non-cardiac surgery in patients older than 65 years. Little is known if this association holds for all adult emergency laparotomy patients and whether it affects 30-day or long-term mortality. Thus, we examined the relationship between increased RDW and postoperative mortality. Furthermore, we investigated the prognostic worth of anisocytosis and explored a possible association between increased RDW and frailty in this cohort. We conducted a retrospective, single centre National Emergency Laparotomy Audit (NELA) database study at St Mary’s Hospital Imperial NHS Trust between January 2014 and April 2018. A total of 356 patients were included. Survival models were developed using Cox regression analysis, whereas RDW and frailty were analysed using multivariable logistic regression. Underlying model assumptions were checked, including discrimination and calibration. We internally validated our models using bootstrap resampling. There were 33 (9.3%) deaths within 30-days and 72 (20.2%) overall. Median RDW values for 30-day mortality were 13.8% (IQR 13.1%-15%) in survivors and 14.9% (IQR 13.7%-16.1%) in non-survivors, p = 0.007. Similarly, median RDW values were lower in overall survivors (13.7% (IQR 13%-14.7%) versus 14.9% (IQR 13.9%-15.9%) (p<0.001)). Mortality increased across quartiles of RDW, as did the proportion of frail patients. Anisocytosis was not associated with 30-day mortality but demonstrated a link with overall death rates. Increasing RDW was associated with a higher probability of frailty for 30-day (Odds ratio (OR) 4.3, 95% CI 1.22–14.43, (p = 0.01)) and overall mortality (OR 4.9, 95% CI 1.68–14.09, (p = 0.001)). We were able to show that preoperative anisocytosis is associated with greater long-term mortality after emergency laparotomy. Increasing RDW demonstrates a relationship with frailty. Given that RDW is readily available at no additional cost, future studies should prospectively validate the role of RDW in the NELA cohort nationally.

Association of Complex Multimorbidity and Long-term Survival After Emergency General Surgery in Older Patients With Medicare

Importance

Although nearly 1 million older patients are admitted for emergency general surgery (EGS) conditions yearly, long-term survival after these acute diseases is not well characterized. Many older patients with EGS conditions have preexisting complex multimorbidity defined as the co-occurrence of at least 2 of 3 key domains: chronic conditions, functional limitations, and geriatric syndromes. The hypothesis was that specific multimorbidity domain combinations are associated with differential long-term mortality after patient admission with EGS conditions.

Objective

To examine multimorbidity domain combinations associated with increased long-term mortality after patient admission with EGS conditions.

Design, Setting, and Participants

This cohort study included community-dwelling participants aged 65 years and older from the Medicare Current Beneficiary Survey with linked Medicare data (January 1992 through December 2013) and admissions for diagnoses consistent with EGS conditions. Surveys on health and function from the year before EGS conditions were used to extract the 3 domains: chronic conditions, functional limitations, and geriatric syndromes. The number of domains present were summed to calculate a categorical rank: no multimorbidity (0 or 1), multimorbidity 2 (2 of the 3 domains present), and multimorbidity 3 (all 3 domains present). Whether operative treatment was provided during the admission was also identified. Data were cleaned and analyzed between January 16, 2020, and April 29, 2021.

Exposures

Mutually exclusive multimorbidity domain combinations (functional limitations and geriatric syndromes; functional limitations and chronic conditions; chronic conditions and geriatric syndromes; or functional limitations, geriatric syndromes, and chronic conditions).

Main Outcomes and Measures

Time to death (up to 3 years from EGS conditions admission) in patients with multimorbidity combinations was analyzed using a Cox proportional hazards model and compared with those without multimorbidity; hazard ratios (HRs) and 95% CIs are presented. Models were adjusted for age, sex, and operative treatment.

Results

Of 1960 patients (median [IQR] age, 79 [73-85] years; 1166 [59.5%] women), 383 (19.5%) had no multimorbidity, 829 (42.3%) had 2 multimorbidity domains, and 748 (38.2%) had all 3 domains present. A total of 376 (19.2%) were known to have died in the follow-up period, with a median (IQR) follow-up of 377 (138-621) days. Patients with chronic conditions and geriatric syndromes had a mortality risk similar to those without multimorbidity. However, all domain combinations with functional limitations were associated with significantly increased risk of death: functional limitations and chronic conditions (HR, 1.83; 95% CI, 1.03-3.23); functional limitations and geriatric syndromes (HR, 2.91; 95% CI, 1.37-6.18); and functional limitations, geriatric syndromes, and chronic conditions (HR, 2.08; 95% CI, 1.49-2.89).

Conclusions and Relevance

Findings of this study suggest that a patient's baseline complex multimorbidity level efficiently identifies risk stratification groups for long-term survival. Functional limitations are rarely considered in risk stratification paradigms for older patients with EGS conditions compared with chronic conditions and geriatric syndromes. However, functional limitations may be the most important risk factor for long-term survival.

Delirium and long-term psychopathology following surgery in older adults

OBJECTIVE

To describe the risk of postoperative delirium and long-term psychopathology (depression, anxiety or post-traumatic stress syndrome (PTSS)) in older adults.

METHODS

255 elderly patients (≥ 65 years) undergoing major surgery (planned surgical time > 60 min) in a tertiary hospital were compared to 76 non-surgical controls from general practice. Patients were assessed twice daily for postoperative delirium using the Confusion Assessment Method (CAM(-ICU)), nursing delirium screening scale (NuDESC) and validated chart review. Before surgery and 3 and 12 months thereafter, the participants filled in the Hospital Anxiety and Depression Scale (HADS), the Geriatric Depression Scale (GDS-15) and the Post-Traumatic Stress Syndrome-14-Questions Inventory (PTSS-14). Non-surgical controls filled in the same questionnaires with similar follow-up.

RESULTS

Patients were more often male, had higher American Society of Anesthesiologists scores and more often had a spouse compared to controls (p < 0.005). Forty-three patients (18%) developed postoperative delirium, who were significantly older, had higher ASA scores and lower estimated IQ scores compared to the patients who did not develop delirium (p < 0.05). There were no differences in psychopathology at baseline and 3-month follow-up between patients and controls. At 12-months, surgical patients less frequently scored positive for depression (7% versus 16%) and anxiety (2% versus 10%) compared to nonsurgical controls (p < 0.05). We did not observe differences in occurrence of psychopathology between patients who had and had not developed postoperative delirium.

CONCLUSION

Our results suggest that the older surgical population, with or without postoperative delirium, does not appear to be at greater risk of developing psychopathology. WHY DOES THIS PAPER MATTER?: The older surgical population does not appear to be at greater risk of developing psychopathology, neither seems this risk influenced by the occurrence of postoperative delirium.

The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine

BACKGROUND CONTEXT

The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden.

PURPOSE

The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease.

STUDY DESIGN/SETTING

Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease.

PATIENT SAMPLE

A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients.

OUTCOME MEASURES

Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs.

METHODS

A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI).

RESULTS

7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups.

CONCLUSIONS

A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty.