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Lv YJ, Xu GX, Lan JR. Impact of frailty on postoperative outcomes after hepatectomy: A systematic review and meta-analysis. World J Gastrointest Surg 2024; 16:2319-2328. [DOI: 10.4240/wjgs.v16.i7.2319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/28/2024] [Accepted: 05/27/2024] [Indexed: 07/22/2024] Open
Abstract
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.
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Affiliation(s)
- Yao-Jia Lv
- Day Surgery Ward, Huzhou Central Hospital, The Affiliated Central Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
| | - Guang-Xing Xu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jia-Rong Lan
- Department of Medicine, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou 313000, Zhejiang Province, China
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Al Abbas AI, Kuchta K, Talamonti MS, Hogg ME. The minimally invasive approach confers improved outcomes in frail cancer patients undergoing hepatectomy: an American College of Surgeons National Surgical Quality Improvement Program analysis. J Gastrointest Surg 2024; 28:1017-1026. [PMID: 38574963 DOI: 10.1016/j.gassur.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/30/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Morbidity for liver resection has decreased, and frail patients are undergoing surgery. The effect of minimally invasive liver resection (MILR) is unknown. This study aimed to evaluate the effect of MILR on the outcomes in frail patients. METHODS Elective hepatectomies from the 2014-2020 American College of Surgeons National Surgical Quality Improvement Program hepatectomy-specific Participant User File were reviewed. The 5-factor modified frailty index (mFI-5) was used. It includes diabetes mellitus, hypertension, functional status, heart failure, and dyspnea. Patients were considered frail if their mFI-5 score was ≥2. RESULTS A total of 3116 patients were included: 2117 (67.9%) in the minor hepatectomy group and 999 (32%) in the major hepatectomy group. There were 2254 open cases and 862 MILRs. Postoperatively, patients in the minor hepatectomy group who underwent MILR had lower rates of prolonged length of stay (LOS), nonhome discharge, transfusion, major complications, and minor complications (P < .05). Postoperatively, patients in the major hepatectomy group who underwent MILR had lower rates of prolonged LOS and any complication (P < .05). In the minor hepatectomy group, MILR remained independently predictive of lower rates of prolonged LOS (odds ratio [OR], 0.34; 95% CI, 0.28-0.42), nonhome discharge (OR, 0.58; 95% CI, 0.41-0.84), transfusion (OR, 0.72; 95% CI, 0.54-0.96), major complication (OR, 0.78; 95% CI, 0.62-1.00), and any complication (OR, 0.73; 95% CI, 0.58-0.92). In the major hepatectomy group, MILR remained independently predictive of prolonged LOS (OR, 0.60; 95% CI, 0.40-0.89). CONCLUSION MILR resulted in lower rates of complications in the minor hepatectomy group and shorter LOS in the major hepatectomy group. The minimally invasive approach to hepatectomy may benefit frail patients with cancer.
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Affiliation(s)
- Amr I Al Abbas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States.
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, North Shore, Illinois, United States
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, North Shore, Illinois, United States; Department of Surgery, University of Chicago, Chicago, Illinois, United States
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, North Shore, Illinois, United States; Department of Surgery, University of Chicago, Chicago, Illinois, United States
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Lunca S, Morarasu S, Rouet K, Ivanov AA, Morarasu BC, Roata CE, Clancy C, Dimofte GM. Frailty Increases Morbidity and Mortality in Patients Undergoing Oncological Liver Resections: A Systematic Review and Meta-analysis. Ann Surg Oncol 2024:10.1245/s10434-024-15571-8. [PMID: 38856830 DOI: 10.1245/s10434-024-15571-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/21/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Considered to reflect a patients' biological age, frailty is a new syndrome shown to predict surgical outcomes in elderly patients. In view of the increasing age at which patients are proposed oncological liver surgery and the morbidity associated with it, we attempted to perform a systematic review and meta-analysis to compare morbidity and mortality between frail and nonfrail patients after liver resections. METHODS The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining surgical outcomes after liver resections between frail and nonfrail patients. RESULTS Ten studies were included based on the selection criteria with a total of 71,102 patients, split into two groups: frail (n = 17,167) and the control group (n = 53,928). There were more elderly patients with a lower preoperative albumin level in the frail group (p = 0.02, p = 0.001). Frail patients showed higher rates of morbidity with more major complications and a higher incidence of postoperative liver failure (p < 0.001). Mortality (p < 0.001) and readmission rate (p = 0.021) also was higher in frail patients. CONCLUSIONS Frailty seems to be a solid predictive risk factor of morbidity and mortality after liver surgery and should be considered a selection criterion for liver surgery in at-risk patients.
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Affiliation(s)
- Sorinel Lunca
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Stefan Morarasu
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania.
| | - Kevin Rouet
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Andreea Antonina Ivanov
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Bianca Codrina Morarasu
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
- Department of Internal Medicine and Toxicology, Saint Spiridon University Regional Emergency Hospital, Iasi, Romania
| | - Cristian Ene Roata
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Cillian Clancy
- Department of Colorectal Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Gabriel-Mihail Dimofte
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
- Grigore T Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
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Talwar G, McKechnie T, Patel J, Qiu R, Wu K, Lee Y, Hong D, Doumouras A, Bogach J, Eskicioglu C. Assessing the Modified Frailty Index and Post-Operative Outcomes in Adhesive Small Bowel Obstruction: A Retrospective Cohort Study. J Surg Res 2024; 297:71-82. [PMID: 38447338 DOI: 10.1016/j.jss.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/18/2023] [Accepted: 12/16/2023] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Studies identifying predictors of postoperative outcomes in adhesive small bowel obstruction are limited. This study investigates the efficacy of the modified frailty index (mFI)to predict postoperative morbidity and mortality among patients undergoing surgery for adhesive small bowel obstruction. METHODS A multicentre retrospective cohort study including patients undergoing surgery for adhesive small bowel obstruction after failed trial of nonoperative management between January 2015 and December 2020 was performed. Impact of frailty status using the mFI, stratified as frail (≥0.27) and robust (<0.27), on postoperative morbidity, mortality, length of stay, and discharge destination was evaluated using multiple logistic regression. RESULTS Ninety-two robust patients (mean age 62.4 y, 68% female) and 41 frail patients (mean age 81.7 y, 63% female) were included. On simple stratification, frail patients had significantly increased 30-d morbidity (overall morbidity 80% versus 49%) and need for higher level of care on discharge (41% versus 9%). However, on multiple regression, functional dependence but not the mFI, was independently associated with worse 30-d overall morbidity (odds ratio [OR] 3.97, confidence interval [CI] 1.29-12.19) and lower likelihood of returning to preoperative disposition (OR 0.21, CI 0.05-0.91). The delay in operation beyond 5 d was independently associated with worse 30-d outcomes including overall morbidity and mortality (OR 7.54, CI 2.13-26.73) and decreased return to preoperative disposition (OR 0.14, CI 0.04-0.56). CONCLUSIONS The mFI, although promising, was not independently predictive of outcomes following surgery for adhesive small bowel obstruction. Further adequately powered studies are required.
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Affiliation(s)
- Gaurav Talwar
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Janhavi Patel
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Reva Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kathy Wu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jessica Bogach
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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Talwar G, McKechnie T, Lee Y, Kazi T, El-Sayes A, Bogach J, Hong D, Eskicioglu C. Modified frailty index predicts postoperative morbidity in adhesive small bowel obstruction: analyzing the National Inpatient Sample 2015-2019. J Gastrointest Surg 2024; 28:205-214. [PMID: 38445910 DOI: 10.1016/j.gassur.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/08/2023] [Accepted: 10/25/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND There are limited data identifying predictors of postoperative outcomes in adhesive small bowel obstruction (ASBO). This study used the National Inpatient Sample (NIS) to assess the efficacy of the modified frailty index (mFI) to predict postoperative morbidity among patients undergoing an operation for ASBO. METHODS A retrospective analysis of the NIS between September 1, 2015, and December 31, 2019, was performed to identify adult patients who underwent nonelective operative intervention for ASBO. The mFI was used to stratify patients as either frail (mFI value ≥ 0.27) or robust (mFI value < 0.27). The primary outcomes were overall in-hospital postoperative morbidity and mortality. The secondary outcomes were system-specific morbidity, length of stay (LOS), total in-hospital healthcare cost, and discharge disposition. Univariable and multivariable regressions were used. RESULTS Overall, 23251 robust patients and 6122 frail patients were included. Adjusted analyses demonstrated that frail patients had increased in-hospital mortality (adjusted odds ratio [aOR], 2.16; 95% CI, 1.80-2.60), postoperative morbidity (aOR, 1.63; 95% CI, 1.52-1.74), postoperative LOS (adjusted mean difference [aMD], 0.97 days; 95% CI, 0.73-1.21), and total in-hospital healthcare costs (aMD, $18,921; 95% CI, $14,608-$23,235) and were less likely to be discharged home (aOR, 0.59; 95% CI, 0.55-0.63). The findings were unchanged on subgroup analysis of patients undergoing open operation and those older than 65 years of age. CONCLUSION The mFI may predict postoperative outcomes for ASBO. Stratifying patients based on frailty may assist clinicians and patients in making informed decisions, setting realistic expectations, and proactively planning postoperative disposition.
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Affiliation(s)
- Gaurav Talwar
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Faculty of Health Sciences Undergraduate Medical Education, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Abdullah El-Sayes
- Faculty of Health Sciences Undergraduate Medical Education, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Bogach
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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Asai M, Dobesh KD. Combined Resection Approaches: Decision Making for Synchronous Resection, Timing of Staged Intervention to Optimize Outcome. Clin Colon Rectal Surg 2024; 37:96-101. [PMID: 38322604 PMCID: PMC10843888 DOI: 10.1055/s-0043-1761475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Advancement in systemic and regional radiation therapy, surgical technique, and anesthesia has provided a path for increased long-term survival and potential cure for more patients with stage IV rectal cancer in recent years. When patients have resectable disease, the sequence for surgical resection is classified in three strategies: classic, simultaneous, or combined, and reversed. The classic approach consists of rectal cancer resection followed by metastatic disease at a subsequent operation. Simultaneous resection addresses both rectal and metastatic disease in a single surgery. The reversed approach treats metastatic disease first, followed by the primary tumor in several months. Simultaneous resection is appropriate for selected patients to avoid delay of definitive surgery, and reduce number of surgeries, hospital stay, and cost to the health care system. It may also improve patients' psychological effect. Multidisciplinary discussions including colorectal and liver surgeons to review patients' baseline medical conditions, tumor biology and behavior, and disease burden and distribution is imperative to guide proper patient selection for simultaneous resection and perioperative treatments.
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Affiliation(s)
- Megumi Asai
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kaitlyn D. Dobesh
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
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Impact of Frailty on Short-Term Outcomes After Laparoscopic and Open Hepatectomy. World J Surg 2022; 46:2444-2453. [PMID: 35810214 PMCID: PMC9436876 DOI: 10.1007/s00268-022-06648-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/27/2022]
Abstract
Background Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on post-operative outcomes after LH and OH. Patients and methods Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail. Results Of 1826 patients, 34.7% (N = 634) were frail and 18.6% (N = 340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p < 0.001) and post-operative complications (36.3% vs. 26.1%, p < 0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients. Conclusions Frailty is independently associated with inferior post-operative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.
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Hosoda K, Shimizu A, Kubota K, Notake T, Masuo H, Yoshizawa T, Sakai H, Hayashi H, Yasukawa K, Soejima Y. Usefulness of frailty to predict short‐ and long‐term outcomes in patients who have undergone major hepatectomy for perihilar cholangiocarcinoma. Ann Gastroenterol Surg 2022; 6:833-841. [PMID: 36338592 PMCID: PMC9628246 DOI: 10.1002/ags3.12596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/16/2022] [Indexed: 11/08/2022] Open
Abstract
Aim The influence of frailty on outcomes after hepatectomy for perihilar cholangiocarcinoma (PHCC) remains unclear. This study aimed to investigate the impact of frailty on the incidence of postoperative complications and survival after major hepatectomy for PHCC. Methods A total of 87 patients who had undergone surgery for PHCC between 2007 and 2020 were enrolled in this study. Frailty was scored retrospectively using the Clinical Frailty Scale (CFS). The survival and incidence of postoperative complications were compared based on the degree of frailty, and their risk factors were analyzed. Results The overall survival of the CFS score 1‐2 group was significantly higher than that of the CFS score 3‐7 group (P = .01). The survival benefit was especially observed in stage I or II PHCC. Furthermore, there were significant differences between the CFS score 1‐3 group and the CFS score 4‐7 group in the incidence of Clavien–Dindo classification grade ≥ IIIa (39.4% vs 70.6%; P = .03). Frailty was an independent risk factor for severe postoperative complications (odds ratio, 4.11; 95% confidence interval, 1.18‐15.20; P = .03) and the incidence of systemic complications (P < .01). Conclusion Frailty is a predictive factor for short‐ and long‐term outcomes in patients who have undergone major hepatectomy for PHCC.
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Affiliation(s)
- Kiyotaka Hosoda
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Akira Shimizu
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Koji Kubota
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Tsuyoshi Notake
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Hitoshi Masuo
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Takahiro Yoshizawa
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Hiroki Sakai
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Hikaru Hayashi
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Koya Yasukawa
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan
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Ida M, Naito Y, Tanaka Y, Inoue S, Kawaguchi M. Factors associated with functional disability or mortality after elective noncardiac surgery: a prospective cohort study. Can J Anaesth 2022; 69:704-714. [PMID: 35396651 DOI: 10.1007/s12630-022-02247-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Preoperative prediction of functional status after surgery is essential when practicing patient-centered medicine. We aimed to evaluate the incidence and factors associated with postoperative functional disability or all-cause mortality. Secondarily, we sought to describe the trajectory of disability in this population. METHODS Adults aged ≥ 55 yr who underwent elective noncardiac surgery under general anesthesia in a tertiary care hospital were followed up one year after surgery. Pre- and intraoperative factors associated with a composite outcome of postoperative functional disability or all-cause mortality were assessed using a multiple logistic regression. The sequential changes in the 12-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 score were described and stratified by surgical invasiveness. RESULTS Of the 2,921 patients included, 293 experienced postoperative functional disability (10.0%; 95% confidence interval [CI], 8.9 to 11.1) and 124 died (4.2%; 95% CI, 3.5 to 5.0). In a multiple regression model, the potentially modifiable risk factors, body mass index ≥ 30 kg·m-2 and poor preoperative nutritional status, were significantly associated with the primary composite outcome, as well as nonmodifiable factors such as age, preoperative comorbidities, and blood loss volume. Changes in the 12-item WHODAS 2.0 disability score varied between different levels of surgical invasiveness and types of surgery. CONCLUSION Within one year after surgery, one in ten patients experienced postoperative functional disability and one in 20 died. We identified potentially modifiable factors (obesity, poor nutritional status) associated with these adverse outcomes. STUDY REGISTRATION University Hospital Medical Information Network (UMIN000021671); registered 31 December 2015.
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Affiliation(s)
- Mitsuru Ida
- Department of Anaesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Yusuke Naito
- Department of Anaesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yuu Tanaka
- Department of Anaesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoki Inoue
- Department of Anaesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anaesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Leigh N, Williams GA, Strasberg SM, Fields RC, Hawkins WG, Hammill CW, Sanford DE. Increased Morbidity and Mortality After Hepatectomy for Colorectal Liver Metastases in Frail Patients is Largely Driven by Worse Outcomes After Minor Hepatectomy: It's Not "Just a Wedge". Ann Surg Oncol 2022; 29:5476-5485. [PMID: 35595939 DOI: 10.1245/s10434-022-11830-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/11/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Frailty is associated with postoperative mortality, but its significance after hepatectomy for colorectal liver metastases (CRLM) is poorly defined. This study evaluated the impact of frailty after hepatectomy for CRLM. METHODS The study identified 8477 patients in National Surgical Quality Improvement Program databases from 2014 to 2019 and stratified them by frailty score using the risk analysis index as very frail (>90th percentile), frail (75th-90th percentile), or non-frail (< 75th percentile). Multivariate regression models determined the impact of frailty on perioperative outcomes, including by the extent of hepatectomy. RESULTS The procedures performed were 2752 major hepatectomies (left hepatectomy, right hepatectomy, trisectionectomy) and 5725 minor hepatectomies (≤2 segments) for 870 (10.3%) very frail, 1680 (19.8%) frail, and 5927 (69.9%) non-frail patients. Postoperatively, the very frail and frail patients experienced more complications (very frail [41.8%], frail [35.1%], non-frail [31.0%]), which resulted in a longer hospital stay (very-frail [5.7 days], frail [5.8 days], non-frail [5.1 days]), a higher 30-day mortality (very-frail [2.2%], frail [1.3%], non-frail [0.5%]), and more discharges to a facility (very frail [6.8%], frail [3.7%], non-frail [2.6%]) (p < 0.05) although they underwent similarly extensive (major vs. minor) hepatectomies. In the multivariate analysis, frailty was independently associated with complications (very-frail [odds ratio {OR}, 1.70], frail [OR, 1.25]) and 30-day mortality (very-frail [OR, 4.24], frail [OR, 2.41]) (p < 0.05). After minor hepatectomy, the very frail and frail patients had significantly higher rates of complications and 30-day mortality than the non-frail patients, and in the multivariate analysis, frailty was independently associated with complications (very frail [OR, 1.97], frail [OR, 1.27]) and 30-day mortality (very frail [OR, 6.76], frail [OR, 3.47]) (p < 0.05) after minor hepatectomy. CONCLUSIONS Frailty predicted significantly poorer outcomes after hepatectomy for CRLM, even after only a minor hepatectomy.
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Affiliation(s)
- Natasha Leigh
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven M Strasberg
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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11
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Li V, Awan A, Serrano PE. Frailty Predicts Postoperative Complications following Pancreaticoduodenectomy. Eur Surg Res 2022; 63:232-240. [PMID: 35172304 DOI: 10.1159/000522576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/08/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Frailty is a clinically recognizable state of decreased reserve and function across physiologic systems, characterized by an inability to cope with acute stressors. A validated modified frailty index (mFI) was used to evaluate the impact of frailty on postoperative complications following pancreaticoduodenectomy. METHODS Data from consecutive patients undergoing pancreaticoduodenectomy from 2011 to 2020 were collected retrospectively at a high-volume tertiary care hepatopancreatobiliary hospital. Based on an 11-item mFI, patients were grouped by high (≥0.27) and low mFI. The main outcome was postoperative complications (Clavien-Dindo classification). The impact of frailty on complications was analyzed by evaluating baseline and operative characteristics using multivariable logistic regression. Secondary outcomes included postoperative mortality, length of hospital stay, and intensive care unit (ICU) admission, which were analyzed using univariable logistic regression. RESULTS There were 64/554 patients (12%) with high mFI. Low and high mFI had similar characteristics, including proportion of pancreatic adenocarcinoma (low mFI = 247/490 [50%] vs. high mFI = 31/64 [48%], p = 0.767), intermediate or hard pancreatic texture (low mFI = 75/191 [39%] vs. high mFI = 6/19 [32%], p = 0.512), operative room time (low mFI = 370 min vs. high mFI = 368 min, p = 0.630), and drain placement (low mFI = 355/490 [72%] vs. high mFI = 48/64 [75%], p = 0.642). The mFI score was an independent predictor for the development of any type of postoperative complications (OR 1.44, 95% CI 1.02-2.10) and major postoperative complications (OR 1.44, 95% CI 1.05-1.98) by multivariable analysis. High mFI patients had a higher 90-day mortality rate (high mFI = 7/64 [11%] vs. low mFI = 20/490 [4.1%], p = 0.017), a longer median length of hospital stay (high mFI = 11 days vs. low mFI = 8 days, p = 0.016), and a higher rate of ICU admission (high mFI = 47/64 [73%] vs. low mFI = 211/490 [43%], p < 0.001). CONCLUSION Among patients who are considered surgical candidates, the mFI can identify those at high risk of developing postoperative complications. This tool can be used to accurately discuss postoperative risk with patients undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Vivian Li
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Amen Awan
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Pablo E Serrano
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Shcherbakov A, Bisharat N. Associations between different measures of intra-operative tachycardia during noncardiac surgery and adverse postoperative outcomes: A retrospective cohort analysis. Eur J Anaesthesiol 2022; 39:145-151. [PMID: 34690273 DOI: 10.1097/eja.0000000000001618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intra-operative tachycardia during noncardiac surgery has been associated with adverse postoperative outcomes. However, harm thresholds for tachycardia have not been uniformly defined. The definition of intra-operative tachycardia that best correlates with adverse postoperative outcomes remains unclear. OBJECTIVE We aimed to identify the definition of intra-operative tachycardia during noncardiac surgery that is associated with the best predictive ability for adverse postoperative outcomes. DESIGN A single-centre retrospective cohort analysis. SETTING Secondary care hospital, Afula, Israel. PATIENTS AND METHODS Adults who underwent elective or nonelective noncardiac surgery during 2015 to 2019. Five intra-operative heart rate (HR) cut-off values and durations were applied with penalised logistic regression modelling for the outcome measures. MAIN OUTCOME MEASURES The primary outcome was all-cause 30-day mortality; the secondary outcome was myocardial ischaemia or infarction (MI) within 30 days after noncardiac surgery. RESULTS The derivation and validation datasets included 6490 and 4553 patients, respectively. Altogether, all-cause 30-day mortality and MI rates averaged 2.1% and 3.2%, respectively. Only two definitions of intra-operative tachycardia were significantly associated with the outcome measures: HR ≥ 100 bpm for ≥ 30 min and HR ≥ 120 bpm for ≥ 5 min. The C-statistics of the base models without tachycardia exposure for all-cause 30-day mortality and MI were 0.75 (95% confidence interval, CI, 0.74 to 0.78) and 0.73 (95% CI, 0.72 to 0.76), respectively. The addition of intra-operative tachycardia exposure to the base models significantly improved their predictive performance. The highest area under the curve (AUC) was achieved when tachycardia was defined as an intra-operative HR ≥ 100 bpm for at least 30 min: AUC 0.81 (95% CI, 0.80 to 0.84) and AUC 0.80 (95% CI, 0.79 to 0.82) for all-cause 30-day mortality and MI, respectively. CONCLUSION Intra-operative tachycardia, defined as an intra-operative HR ≥ 100 bpm for at least 30 min, was associated with the highest predictive power for adverse postoperative outcomes.
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Affiliation(s)
- Anna Shcherbakov
- From the Department of Anaesthesiology, Emek Medical Center, Afula, Israel (AS), Department of Medicine, Emek Medical Center, Afula, Israel (NB) and Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (NB)
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Nishikawa H, Fukunishi S, Asai A, Nishiguchi S, Higuchi K. Sarcopenia and Frailty in Liver Cirrhosis. Life (Basel) 2021; 11:life11050399. [PMID: 33925660 PMCID: PMC8146021 DOI: 10.3390/life11050399] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 02/06/2023] Open
Abstract
Skeletal muscle is the largest organ in the body, and skeletal muscle atrophy results from a shift in the balance of protein synthesis and degradation toward protein breakdown. Primary sarcopenia is defined as a loss of skeletal muscle mass and strength or physical function due to aging, and secondary sarcopenia is defined as a loss of skeletal muscle mass and strength or physical function due to underlying diseases. Liver cirrhosis (LC) is one of the representative diseases which can be complicated with secondary sarcopenia. Muscle mass loss becomes more pronounced with worsening liver reserve in LC patients. While frailty encompasses a state of increased vulnerability to environmental factors, there is also the reversibility of returning to a healthy state with appropriate intervention. Several assessment criteria for sarcopenia and frailty were proposed in recent years. In 2016, the Japan Society of Hepatology created assessment criteria for sarcopenia in liver disease. In Japan, health checkups for frailty in the elderly aged 75 years or more started in April 2020. Both sarcopenia and frailty can be adverse predictors for cirrhotic patients. In this review article, we will summarize the current knowledge of sarcopenia and frailty in LC patients.
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Affiliation(s)
- Hiroki Nishikawa
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka 569-8686, Japan; (S.F.); (A.A.); (K.H.)
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
- Correspondence: or ; Tel.: +81-726-83-1221
| | - Shinya Fukunishi
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka 569-8686, Japan; (S.F.); (A.A.); (K.H.)
| | - Akira Asai
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka 569-8686, Japan; (S.F.); (A.A.); (K.H.)
| | | | - Kazuhide Higuchi
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka 569-8686, Japan; (S.F.); (A.A.); (K.H.)
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