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

Frailty assessment and postoperative outcomes among patients undergoing general surgery

BACKGROUND

Frailty is an emerging concept in modern general surgery because of its correlation with adverse outcomes. More frail older patients are undergoing general surgery due to the rapid aging of the population and the effect of the "baby boom" generation. However, there is no consensus on the definition of frailty and on ways to assess its severity and effect.

PURPOSE

To describe the definition and epidemiology, measurement tools, and the effect of frailty on postoperative outcomes after general surgery.

METHODS

PubMed and Google Scholar databases were comprehensively searched.

RESULTS

Frailty is a syndrome defined as increased vulnerability to stressors due to a decline in physiological function and reserve among organ systems, resulting in adverse outcomes. Numerous tools have been described and tested for frailty measurement, but the ideal clinical tool has not been found yet. The evidence from cohort studies and meta-analyses shows associations between preoperative frailty and adverse perioperative outcomes after general surgery.

CONCLUSION

Frailty is an essential concept in general surgery. However, further studies have to identify the optimal way to preoperatively assess frailty and risk-stratify older patients.

The Accumulating Deficits Model for Postoperative Mortality and Readmissions: Comparison of four Methods Over Multiple Calendar Year Cohorts: Brief Title: Stability of the Modified Frailty Index

OBJECTIVE

To assess four measures of the accumulating deficits model of frailty for postoperative mortality and readmissions including their stability over time.

BACKGROUND

Frailty has been assessed by multiple methods. It is unclear whether variation in how frailty is measured is important and would be stable over time.

METHODS

Rockwood's 57-item frailty index (FI) was mapped onto 14,568 ICD9 diagnosis codes from Healthcare Cost and Utilization Project State Inpatient Database for the state of Florida (HCUP-SID-FL) for calendar years 2011-2015, inclusive, with 962 ICD9 codes matching onto 42 items. This became the modified frailty index (mFI) used. Three measures of the mFI were differentiated: the number of admission diagnoses, number of chronic conditions upon admission, and number of increased deficits accumulated during the admission. The Charlson Co-Morbidity Index was a fourth measure of frailty. The mFI of patients who survived or died and were readmitted or not were compared.

RESULTS

Across all years, 4,796,006 patient observations were compared to the number of diagnoses matched on the 42 items of the mFI. The median mFI scores for each method was statistically significantly higher for patients who died compared those that survived and for patients readmitted compared to patients not re-admitted for all years. There was little-to-no variation in the year to year median mFI scores.

CONCLUSIONS

The four methods of calculating frailty performed similarly and were stable. The actual method of determining the accumulated deficits may not be as important as enumerating their number.

Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery

Background

Postoperative outcome prediction in elderly is based on preoperative physical status but its predictive value is uncertain. The goal was to evaluate the value of risk assessment performed perioperatively in predicting outcome in case of admission to an intensive care unit (ICU).

Methods

A total of 108 postsurgical patients were retrospectively selected from a prospectively recorded database of 144 elderly septic patients (>70 years) admitted to the ICU department after elective or emergency abdominal surgery between 2012 and 2017. Perioperative risk assessment scores including Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM) and American Society of Anaesthesiologists Physical Status classification (ASA) were determined. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) was obtained at ICU admission.

Results

In-hospital mortality was 48.9% in elderly requiring ICU admission after elective surgery (n = 45), compared to 49.2% after emergency surgery (n = 63). APACHE IV significantly predicted in-hospital mortality after complicated elective surgery [area under the curve 0.935 (p < 0.001)] where outpatient ASA physical status and P-POSSUM did not. In contrast, P-POSSUM and APACHE IV significantly predicted in-hospital mortality when based on current physical state in elderly requiring emergency surgery (AUC 0.769 (p = 0.002) and 0.736 (p = 0.006), respectively).

Conclusions

Perioperative risk assessment reflecting premorbid physical status of elderly loses its value when complications occur requiring unplanned ICU admission. Risks in elderly should be re-assessed based on current clinical condition prior to ICU admission, because outcome prediction is more reliable then.

Splenectomy for benign and malignant hematologic pathology: Modern morbidity, mortality, and long-term outcomes

Background

The role of splenectomy to diagnose and treat hematologic disease continues to evolve. In this single-center retrospective review, we describe modern morbidity, mortality, and long-term outcomes associated with splenectomy for benign and malignant hematologic disorders.

Methods

We analyzed all nontrauma splenectomies performed for benign or malignant hematologic disorders from January 2009 to September 2018. Variables collected included demographics, preexisting comorbidities, laboratory results, intra- and postoperative features, and long-term follow-up. Outcomes of interest included postoperative complications, 30-day mortality, and overall mortality.

Results

We identified 161 patients who underwent splenectomy for hematologic disorders. Median age was 54 years (range 19–94), and 83 (52%) were female. Splenectomy was performed for 95 (59%) patients with benign hematologic disorders and for 66 (41%) with malignant conditions. Most splenectomies were laparoscopic (76%), followed by laparoscopic hand assisted (11%), open (8%), and laparoscopic converted to open (6%). Median follow-up was 761 days (interquartile range: 179–2025 days). Major complications occurred in 21 (13%) patients. Three (2%) patients died within 30 days; 16 (9%) died more than 30 days after operation, none from surgical complications, with median time to death of 438 days (interquartile range: 231–1497 days). Among malignant cases, only preoperative thrombocytopenia predicted death (odds ratio = 5.8, 95% confidence interval = 1.1–31.8, P = .04). For benign cases, increasing age was associated with inferior survival (odds ratio = 2.3, 95% confidence interval = 1.0–5.1, P = .05).

Conclusion

Splenectomy remains an important diagnostic and therapeutic option for patients with benign and malignant hematologic disorders and can be performed with a low complication rate. Despite considerable burden of comorbid disease in these patients, early postoperative mortality was uncommon.

Impact of frailty on inpatient outcomes in thyroid cancer surgery: 10-year results from the U.S. national inpatient sample

Background

Frailty is linked to perioperative morbidity and mortality. We evaluated the impact of preoperative frailty on inpatient outcomes of patients undergoing surgery for thyroid malignancy.

Methods

This population-based, retrospective observational study extracted data of hospitalized patients who were 18 years and older with a primary diagnosis of thyroid cancer undergoing thyroidectomy from the US Nationwide Inpatient Sample (NIS) database (2005–2014). Participants were stratified into frail and non-frail using the Johns Hopkins (ACG) frailty-defining diagnosis indicator. Study endpoints were in-hospital mortality, incidence of surgical and medical complications and prolonged length of stay. Univariate and multivariate analysis were performed to determine associations between the endpoints and frailty.

Results

Data of 38,202 patients were included. After adjusting for possible confounders, frailty remained significantly associated with higher odds of in-hospital mortality (OR: 3.839, 95% CI: 1.738–8.480), prolonged length of stay (OR: 5.420, 95% CI: 3.799–7.733), surgical complications (OR: 3.144, 95% CI: 2.443–4.045) and medical complications (OR: 6.734, 95% CI: 5.099–8.893) compared with non-frailty. In patients > age 65 years, adjusted odds ratio for frailty was 4.099 (95% CI: 1.736–9.679) for in-hospital mortality, 6.164 (95% CI: 3.514–10.812) for prolonged length of stay, 3.736 (95% CI: 2.620–5.328) for surgical complications, and 5.970, 95% CI: 4.088–8.720 for medical complications, all with significance.

Conclusion

Frailty is associated with increased risk for adverse inpatient outcomes, including prolonged hospital stay, surgical and medical complications and mortality independent of age and comorbidities in thyroid cancer patients undergoing surgery. Study findings may provide valuable information for preoperative risk stratification.

Laparoscopic Repair of Perforated Peptic Ulcer in the Elderly: An Interim Analysis of the FRAILESEL Italian Multicenter Prospective Cohort Study

INTRODUCTION

The number of elderly patients requiring emergency surgical intervention has increased dramatically. Perforated peptic ulcer (PPU) complications, such as perforation, have remained relatively stable and associated morbidity remains between 10% and 20%. Advances in perioperative care have greatly improved the outcomes of laparoscopic emergency surgery, allowing increasing numbers of patients, even the elderly, to undergo safe repair. The aim of this study was to evaluate the feasibility, safety, and outcome of laparoscopic gastric repair in the elderly using the database of the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study.

MATERIALS AND METHODS

This is a retrospective analysis carried out on data of the FRAILESEL study. Data on all the elderly patients who underwent emergency abdominal surgery for PPU from January 2017 to December 2017 at 36 Italian surgical departments were analyzed. Patients who underwent PPU repair were further divided into a laparoscopic gastroduodenal repair (LGR) cohort and an open gastroduodenal repair (OGR) cohort, and the clinicopathologic features of the patients in both the groups were compared.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria. Thirty-three patients (47.8%) underwent LGR. The LGR patients had less blood loss and shorter postoperative stay, even if the difference was not statistically significant. The mean operative time was significantively higher in the OGR (OGR 96.5±27.7 vs. LGR 78.6±16.3 P=0.000). The rate of death after laparoscopic surgery was similar to the rate of the open surgery. Multivariate analysis indicated that only age (P=0.018), admission haemoblogbin (Hb) level (P=0.006), platelet count (P=0.16), lactate level (P=0.47), and Mannheim Peritonitis Index (P=0.18) were independent variables associated with the risk of overall mortality.

CONCLUSIONS

LGR is safe and feasible in elderly patients with PPU and it is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieving better outcomes.

Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes

Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.

Loss of Independence in Older Patients after Operation for Colorectal Cancer

BACKGROUND

Disease-free survival is the cornerstone for colorectal cancer outcomes. Maintenance of independence may represent the preferred cancer outcome in older patients. Frailty and cognitive impairment are associated with adverse clinical outcomes after operation in patients ≥65 years. The aim of this study was to determine the impact of frailty and cognitive impairment on loss of independence (LOI) among colorectal cancer patients.

STUDY DESIGN

From 2016 to 2018, patients undergoing operation for colorectal cancer and having geriatric-specific American College of Surgeons NSQIP variables recorded were included. Frailty was assessed using the modified frailty index. Loss of independence was defined by the need for assistance with activities of daily living. Complications were assessed using the Clavien-Dindo (CD) scoring system. Multivariable analyses examining LOI, length of stay (LOS), and 30-day postoperative complication and readmission were performed.

RESULTS

There were 1,676 patients included. Preoperatively, 118 (7%) patients reported cognitive impairment, 388 (23%) patients used a mobility aid, and 82 (5%) patients were partially or totally dependent. Loss of independence upon discharge was seen in 344 (20.5%) patients and was independently associated with an increase in LOS (incidence rate ratio [IRR] 1.44, 95% CI 1.30 to 1.59) and major complication (odds ratio [OR] 1.86, 95% CI 1.36 to 2.53). Risk factors predictive of LOI upon discharge were increasing age, cognitive impairment, use of mobility aid, and postoperative delirium. In patients ≥80 years old, 93 (18%) had LOI at 30 days. Risk factors predictive of LOI at 30 days included a preoperative mobility aid, postoperative delirium, and the need for a new mobility aid.

CONCLUSIONS

One of 5 older patients undergoing operation for colorectal cancer experience LOI, and risk factors include a decline in cognition and mobility. Future studies should evaluate risks for long-term LOI and explore interventions to optimize this patient population.

Standardized measures of frailty predict hospital length of stay following orthotopic liver transplantation for hepatocellular carcinoma

Frailty in liver transplant (LT) waitlisted patients has been shown to predict waitlist mortality. While not currently used to allocate organs, the relationship between preoperative frailty and postoperative outcomes following orthotopic LT needs further elucidation. We determined the frailty status of 50 OLT candidates listed for hepatocellular carcinoma (HCC) and examined relationships between frailty and outcomes on the waitlist and, if transplanted, 30-day mortality, hospital length of stay (LOS), ICU LOS, and several other secondary outcomes. The overall prevalence of frailty was 30%, and the median natural MELD score for patients was 13. The overall hospital LOS for the frail group was longer (14.5 days [IQR 12-19]) as compared to the non-frail group (8 days [IQR 7-13]); P = .015. Groups also differed in the time to their first PT session (6 days [IQR 4-15] for the frail vs 4 days [IQR 3-7] for the non-frail patients; P = .042). There was no statistically significant difference in other outcomes measures, including ICU LOS and 30-day mortality. Frailty in OLT patients with diagnosed HCC is a predictor of longer hospital stay and longer time to the first completed PT session independent of preoperative MELD scores.

Anesthetic management of geriatric patients

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.