High preoperative modified frailty index has a negative impact on short- and long-term outcomes of octogenarians with gastric cancer after laparoscopic gastrectomy

The concept of dynamic frailty: an exploratory study of the trajectory to postoperative mortality

BACKGROUND

Frailty is a heightened vulnerability to stress due to decreased physical and mental abilities. Preoperative frailty has been associated with poorer outcomes. However, frailty is not static, and those patients who eventually die appear to become more frail. Our hypothesis is in-patient, postoperative changes in frailty after major operations predicts the trajectory to postoperative discharge alive or in-hospital mortality.

STUDY DESIGN

The accumulating deficit model of frailty was used. Data from the medical records of patients who have undergone major operations were used to determine the mFI preoperatively, postoperative day 1, and day before discharge or death. Of the 1063 patients who met inclusion criteria, 50 patients with in-hospital postoperative death and 50 patients discharged alive were randomly selected.

RESULTS

Patients in the in-hospital mortality group had significantly greater median preoperative mFI scores than those in the discharged alive (0.178 vs. 0.115 p = 0.00009). This significant difference was present on postoperative day 1, while also increasing in margin (0.240 vs. 0.143, p < 0.00001). Median Pre-Post mFI differences were also significant between the two groups, with operations leading to in-hospital mortality experiencing a greater increase in mFI (0.06 vs. 0.01 p = 0.00019), and the day before death or discharge (0.276 vs. 0.014, p < 0.00001).

CONCLUSION

Preoperative mFI is a useful predictor of postoperative mortality. Moreover, worsening mFI score as early as day 1 and continued worsening scores throughout hospitalization are associated with a postoperative trajectory toward mortality. Recognition of worsening frailty may be helpful in identifying patients in need of early intervention.

The Prediction of Postoperative Delirium Using the Preoperative Assessments of Frailty and Cognitive Impairment in Aged Patients

Purpose

Frailty and cognitive impairment are closely associated with postoperative delirium. The purpose of this study was to compare the ability of screening tools assessing preoperative frailty and cognitive impairment to predict Postoperative delirium (POD) and the association with prevalence of postoperative complications, Intensive Care Unit (ICU) admission, and the hospital length of stay.

Patients and Methods

Two hundred and ninety-nine patients aged ≥60 years presenting for elective major thoracic or abdominal surgery were divided into preoperative frailty and no frailty groups or cognitive impairment and no cognitive impairment groups. The primary outcome was the incidence of postoperative delirium. The secondary outcomes included postoperative complications, ICU admission, and hospital lengths of stay.

Results

Frailty (25.6% VS 14.6%, P = 0.017) and cognitive impairment (32.7% VS 13.4%, P < 0.001) were associated with POD. However, the area under the receiver operating characteristic curve (AUC-ROC) between frailty (0.657 [95% CI 0.60-0.71]) and cognitive impairment (0.661 [95% CI 0.60-0.71]) for POD was not different (P = 0.9) and both lower than the integrated predictive model of age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, duration of surgery, morphine equivalent, surgical risk, frailty and cognitive impairment (0.814 [95% CI 0.77-0.86], P < 0.0001, P < 0.0001). Besides, frailty (15.6% vs 6.3%, P = 0.010) and cognitive impairment (16.3% vs 8.0%, P = 0.029) was associated with the incidence of postoperative complications.

Conclusion

Preoperative frailty and cognitive impairment were associated with POD. However, preoperative frailty or cognitive impairment by themselves were comparably poor predictors of POD. A comprehensive predictive model including age, BMI, ASA status, duration of surgery, morphine equivalent, surgical risk, frailty and cognitive impairment was more useful to predict POD.

Prognostic impact of a 3-week multimodal prehabilitation program on frail elderly patients undergoing elective gastric cancer surgery: a randomized trial

BACKGROUND

Research indicates that prehabilitation is effective in optimizing physical status before surgery, although this method may be considered "aggressive" for frail elderly patients. This study aimed to evaluate whether multimodal prehabilitation decreases postoperative complications and improves functional recovery in frail elderly patients undergoing gastric cancer surgery, in comparison to usual clinical care.

METHODS

This study was a single-center, single-blind, randomized controlled trial. Patients over 65 years old with a Fried Frailty Index of 2 or higher, scheduled for gastric cancer surgery, were considered for inclusion. Eligible participants were randomized in a 1:1 ratio to either the intervention or control group. The intervention group underwent a 3-week multimodal prehabilitation program prior to surgery, in addition to perioperative care guided by ERAS protocols. The control group received only the latter. The primary outcome was the comprehensive complications index (CCI) measured at 30 days after surgery. Secondary outcomes included 30-day overall complications, functional walking capacity as assessed by 6-minute walking distance (6MWD) at 4 weeks postoperatively, and 3-month postoperative quality of life. This study was registered at ClinicalTrials.gov (No. NCT06510088).

RESULTS

Among the 112 eligible patients, the median age was 74 years, with 58 (52.7%) being female. No between-group difference was found in the primary outcome measure, 30-day CCI. The Median (Q1-Q3) CCI for the intervention and control groups was 0 (0-12.2) and 0 (0-22.6) (P = 0.082), while the mean (SD) CCI was 6.1 (15.8) and 9.8 (12.7), respectively (P = 0.291). Notably, the incidence of severe complications (CCI > 20) was significantly lower in the intervention group compared to the control group (11.1% vs. 25.9%, P = 0.046), particularly in terms of medical complications (12.3% vs. 29.3%, P = 0.025). Preoperatively, 27 patients (47.4%) in the intervention group exhibited an increase in the 6MWD of at least 20 m, compared to 16 patients (27.6%) in the control group (P = 0.028). At 4 weeks postoperatively, more patients in the intervention group returned to their baseline 6MWD levels (63.2% vs. 43.1%, P = 0.031). Secondary parameters of functional capacity in the postoperative period generally favored the multimodal prehabilitation approach.

CONCLUSIONS

In frail elderly patients undergoing elective gastric cancer surgery, a prehabilitation program did not affect the 30-day postoperative complication rate or CCI but reduced severe complications and improved perioperative functional capacity.

TRIAL REGISTRATION

[ClinicalTrials.gov], [NCT06510088], [07/15/2024], [Retrospectively registered].

Risk factors for infectious complications after gastrectomy in older patients

The present study aimed to identify preoperative and perioperative risk factors for postoperative infectious complications in older patients with gastric cancer. The present retrospective study included 504 patients with gastric cancer aged >65 years who underwent radical gastrectomy. After determining the cutoff values for various perioperative factors in the receiver operating characteristic curve analysis, preoperative and perioperative risk factors for the development of infectious complications after gastrectomy were examined using logistic regression analysis. Of the 504 patients who underwent gastrectomy, 95 (18.8%) developed infectious complications of grade II-V based on the Clavien-Dindo classification. In an analysis restricted to preoperative factors, male sex, low prognostic nutritional index, high visceral fat area and total gastrectomy were independent risk factors for infectious complications after gastrectomy. Among all perioperative factors, a low prognostic nutritional index and long operative duration were identified as independent risk factors for infectious complications after gastrectomy. The patients were divided into five groups according to the number of positive preoperative risk factors for infectious complications, and the incidence of infectious complications differed among the five groups (0 factors, 6.7%; 1 factor, 10.4%; 2 factors, 18.9%; 3 factors, 27.8%; and 4 factors, 47.6%; P<0.001). Older patients with gastric cancer who have a number of preoperative risk factors require careful consideration of the indication for gastrectomy and a shorter operative time to reduce infectious complications.

Short- and Long-Term Advantages of Laparoscopic Gastrectomy for Elderly Patients with Locally Advanced Cancer

Minimally invasive surgery has provided several clinical advantages in locally advanced gastric cancer (LAGC) care, although a consensus on its application criteria remains unclear. Surgery remains a careful choice in elderly patients, who frequently present with frailty, comorbidities, and other disabling diseases. This study aims to assess the possible advantages of laparoscopic gastric resections in elderly patients presenting with LAGC. This retrospective study analyzed a single-center series of elderly patients (≥75 years) undergoing curative resections for LAGC between 2015 and 2020. A comparative analysis of open versus laparoscopic approaches was conducted, focusing on postoperative complications, length of hospital stay (LOS), and long-term survival. A total of 62 patients underwent gastrectomy through an open or a laparoscopic approach (31 pts each). The study population did not show statistically significant differences in demographics, operative risk, and neoadjuvant chemotherapy. The laparoscopic group reported significantly minimized overall complications (45.2 vs. 71%, p = 0.039) and pulmonary complications (0 vs. 9.7%, p = 0.038) as well as a shorter LOS (8 vs. 12 days, p = 0.007). Lymph node harvest was equal between the groups, although long-term overall survival presented significantly better after laparoscopic gastrectomy (p = 0.048), without a relevant difference in terms of disease-free and disease-specific survivals. Laparoscopic gastrectomy proves effective in elderly LAGC patients, offering substantial short- and long-term postoperative benefits.

Risk factors for preoperative frailty in older patients with gastric cancer: a systematic review and meta-analysis

PURPOSE

To summarize the available evidence on risk factors for preoperative frailty in older gastric cancer patients.

METHODS

We comprehensively searched the CNKI, Wanfang, VIP, CBM, PubMed, Embase, The Cochrane Library, Web of Science, and CINAHL databases for preoperative articles on risk factors for frailty in older gastric cancer patients. The search was conducted from the time of construction of the library to January 27, 2024, with no language restrictions. The quality of the included studies was rated by the Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality tool.

RESULTS

A total of 20 studies were included, including 16 cohort studies and 4 cross-sectional studies, with a total sample size of 51,717 individuals. The results of the meta-analysis showed that age, albumin, hemoglobin, cancer stage III-IV, Charlson Comorbidity Index score ≥ 3, Eastern Cooperative Oncology Group score > 2, American Society of Anesthesiologists score > 2, smoking, nutritional risk, high school degree or above, and sleep disorders are the main influencing factors for the occurrence of preoperative frailty in older gastric cancer patients. Among them, high school degree or above was a protective factor.

CONCLUSIONS

Our study provides valid evidence of risk factors for preoperative frailty in older patients with gastric cancer and informs clinical healthcare professionals to make targeted interventions.

Evaluation and Application of Frailty Index in Colorectal Cancer: A Comprehensive Review

Colorectal cancer (CRC) is a common malignant tumor that primarily affects the elderly population. Surgery is one of the main treatment modalities for CRC. Frailty is a prevalent characteristic among the elderly and a leading cause of mortality. The frailty index (FI) is a comprehensive tool for assessing patients' frailty status, quantifying indicators such as weight loss, fatigue, and nutritional status, to reflect the degree of frailty. In recent years, the FI has undergone modifications to more accurately evaluate the risk of surgical complications and prognosis in CRC patients. This review summarizes the methods for frailty assessment, the development and modifications of the FI, and compiles the research findings and applications of the FI in predicting surgical complications, postoperative recovery, and survival rates in CRC patients. Furthermore, limitations in the current modified frailty index (mFI) and future research directions are discussed. This review provides essential references for further understanding the role of frailty in CRC patients and the clinical application of the mFI.

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.

Prevalence and unfavorable outcome of frailty in older adults with gastric cancer: a systematic review and meta-analysis

BACKGROUND AND AIM

Previous studies reported inconsistent results on the prevalence and prognostic implications of frailty among older adults with gastric cancer. This systematic review synthesized available literature pertaining on this topic to establish the prevalence and unfavorable outcomes of frailty in older adults with gastric cancer.

METHODS

A comprehensive search was conducted across multiple English databases including PubMed, Cochrane Library, CINAHL, Embase, and Web of Science as well as Chinese databases, namely, CNKI, Wan Fang, and CBM, from inception to July 4, 2023, to identify potential studies. Data related to the incidence of frailty and its unfavorable outcomes in older adults with gastric cancer were extracted. RevMan5.3 and R 4.2.2 were used to evaluate pooled prevalence, hazard ratios (HR), and 95% confidence interval (CI).

RESULTS

This review comprehensively selected 13 studies, comprising 9 cohort studies and 4 cross-sectional studies, on 44,117 older adults diagnosed with gastric cancer. The incidence of frailty among older adults with gastric cancer ranged from 10 to 71%. The pooled prevalence of frailty was 29% (95% CI 0.21-0.39). Frailty was found to be associated with an elevated risk of postoperative complications (HR = 1.99, 95% CI 1.45-2.73), prolonged postoperative hospital stay (HR = 2.68, 95% CI 2.38-3.02), likelihood of readmission (HR = 3.28, 95% CI 1.77-6.08), and an increased mortality risk (HR = 1.60, 95% CI 1.36-1.90).

CONCLUSIONS

Frailty was associated with a poor prognosis in older adults with gastric cancer. Clinical medical staff should focus on the frailty of older adults with gastric cancer, conduct large-scale, multicenter, and prospective studies and early screening of patients, and provide guidance for the implementation of prevention and treatment strategies.

The effect of frailty and age on outcomes in elective paraesophageal hernia repair

INTRODUCTION

Paraesophageal hernia repair (PEHR) is a safe and effective operation. Previous studies have described risk factors for poor peri-operative outcomes such as emergent operations or advanced patient age, and pre-operative frailty is a known risk factor in other major surgery. The goal of this retrospective cohort study was to determine if markers of frailty were predictive of poor peri-operative outcomes in elective paraesophageal hernia repair.

METHODS

Patients who underwent elective PEHR between 1/2011 and 6/2022 at a single university-based institution were identified. Patient demographics, modified frailty index (mFI), and post-operative outcomes were recorded. A composite peri-operative morbidity outcome indicating the incidence of any of the following: prolonged length of stay (≥ 3 days), increased discharge level of care, and 30-day complications or readmissions was utilized for statistical analysis. Descriptive statistics and logistic regression were used to analyze the data.

RESULTS

Of 547 patients who underwent elective PEHR, the mean age was 66.0 ± 12.3, and 77.1% (n = 422) were female. Median length of stay was 1 [IQR 1, 2]. ASA was 3-4 in 65.8% (n = 360) of patients. The composite outcome occurred in 32.4% (n = 177) of patients. On multivariate analysis, increasing age (OR 1.021, p = 0.02), high frailty (OR 2.02, p < 0.01), ASA 3-4 (OR 1.544, p = 0.05), and redo-PEHR (OR 1.72, p = 0.02) were each independently associated with the incidence of the composite outcome. On a regression of age for the composite outcome, a cutoff point of increased risk is identified at age 72 years old (OR 2.25, p < 0.01).

CONCLUSION

High frailty and age over 72 years old each independently confer double the odds of a composite morbidity outcome that includes prolonged post-operative stay, peri-operative complications, the need for a higher level of care after elective paraesophageal hernia repair, and 30-day readmission. This provides additional information to counsel patients pre-operatively, as well as a potential opportunity for targeted pre-habilitation.

Impact of Frailty and Sarcopenia on Short- and Long-Term Outcomes in Elderly Patients Undergoing Radical Gastrectomy for Gastric Cancer

BACKGROUND

The impact of frailty and sarcopenia in patients with gastric cancer is unclear. This study aimed to comprehensively examine the impact of frailty and sarcopenia on the short- and long-term outcomes in elderly patients undergoing radical gastrectomy for gastric cancer.

METHODS

We retrospectively assessed 246 patients aged ≥ 65 years who underwent radical gastrectomy. Frailty and sarcopenia were assessed using the modified frailty index (mFI) and psoas muscle mass index (PMI), respectively.

RESULTS

There were 30 (12.2%) and 60 (24.4%) patients with High-mFI and Low-PMI, respectively. As the age increased, both sexes showed significant correlations with PMI and mFI (r = - 0.238, 0.322, P = 0.003 and 0.002, respectively). High-mFI and Low-PMI did not affect the short-term outcomes. However, High-mFI was an independent risk factor for non-home discharge (P = 0.004) and was a significant predictor of 3- and 5-year overall survival (OS) (HR = 2.76 and 2.26; P = 0.002 and 0.005, respectively) and 1-, 3- and 5-year non-cancer-specific survival (non-CSS) (HR = 4.88, 8.05, and 4.01; P = 0.017, < 0.001, < 0.001, respectively). Low-PMI was a significant predictor of only 5-year OS (HR = 2.03, P = 0.003) and non-CSS (HR = 2.10, P = 0.020).

CONCLUSIONS

Frailty is significant predictor of non-home discharge and 1-, 3-, 5-year OS and 3- and 5-year non-CSS. Sarcopenia is a significant predictor of 5-year OS and non-CSS. Preoperative assessment of both frailty and sarcopenia can help surgeons to select adequate treatment strategies for the elderly population.

Frailty and long-term survival of patients with gastric cancer: a meta-analysis

Background

The relationship between frailty and the long-term clinical outcome of gastric cancer (GC) patients has not yet been established, although frailty is associated with a poor short-term outcome. The impact of frailty on long-term survival of GC patients was investigated through a systematic review and meta-analysis.

Methods

Observational studies with longitudinal follow-ups for a minimum of one year were identified through a search of the PubMed, Embase, Cochrane Library, and Web of Science databases, in accordance with the objective of the meta-analysis. Combining the findings was achieved using a random-effects model, which accounted for inter-study heterogeneity.

Results

Ten datasets from nine cohort studies were included, which involved 7613 patients with GC. A total of 2074 patients (27.2%) were with frailty at baseline, and the mean follow-up duration was 48.1 months. A pooled analysis of the results showed that frailty was linked to a poor long-term overall survival in GC patients (risk ratio [RR]: 1.65, 95% confidence interval [CI]: 1.27 to 2.13, p < 0.001; I2 = 80%). Sensitivity analysis showed consistent results in older patients (≥ 65 years, RR: 1.51, p = 0.002) and the oldest old (≥ 80 years, RR: 1.41, p = 0.01). In addition, frailty was also associated with poor long-term progression-free survival (RR: 1.65, 95% CI: 1.39 to 1.96, p < 0.001; I2 = 0%) and disease-specific survival (RR: 1.71, 95% CI: 1.23 to 2.37, p = 0.001; I2 = 4%).

Conclusion

Frailty is associated with poor long-term survival of patients with GC.

Modified Frailty Index and Albumin-Fibrinogen Ratio Predicts Postoperative Seroma After Laparoscopic TAPP

Background

Postoperative seroma is the most common minor complication after inguinal hernia repair surgery and can have negative consequences. The objective of this study was to identify potential risk factors for postoperative seroma.

Methods

This study consecutively included 354 elderly patients with inguinal hernia who underwent laparoscopic Transabdominal preperitoneal Patch Plasty (TAPP). Seroma diagnosis was conducted by the same experienced surgeon based on the physical examinations combined with ultrasound. Risk factors for seroma were identified through univariate analysis and subsequently included in the binary multivariate logistic regression model.

Results

A total of 40 patients experienced postoperative complications of seroma, with an incidence rate of 11.3% (40/354). The binary logistic regression analysis revealed that obesity (OR: 2.98, 95% CI: 1.20-7.41, P = 0.018), disease duration ≥ 4.5 years (OR: 4.88, 95% CI: 2.14-11.18, P < 0.001), albumin-fibrinogen ratio (AFR) level < 9.25 (OR: 6.13, 95% CI: 2.00-18.76, P = 0.001), and modified frailty index (mFI) score ≥ 0.225 (OR: 6.38, 95% CI: 2.69-15.10, P < 0.001) were four independent risk factors for postoperative seroma.

Conclusion

Obesity, prolonged disease duration, decreased AFR level, and increased mFI score independently predict postoperative seroma after laparoscopic TAPP.

Significance of Preoperative Pulmonary Function on Short- and Long-Term Outcomes Following Gastrectomy for Gastric Cancer

BACKGROUND

Preoperative pulmonary function assessment is useful for selecting surgical candidates and operative methods and assessing the risk of postoperative pulmonary complications. However, few studies have investigated the relationship between preoperative pulmonary function and short- and long-term outcomes in patients who underwent gastrectomy for gastric cancer.

METHODS

Of the 1040 patients with gastric cancer (stages I-III) who had undergone R0 gastrectomy between 2009 and 2020, 750 who underwent preoperative spirometry were included. Restrictive ventilatory impairment was defined as a vital capacity of the predicted value (%VC) < 80%, while obstructive ventilatory impairment was defined as forced expiratory volume in one second (FEV1%) < 70%. Postoperative complications were assessed using the Clavien-Dindo (CD) classification. The relationship between clinical factors, including %VC, FEV1%, severe postoperative complications (CD ≥ 3b), overall survival (OS), and relapse-free survival, were assessed.

RESULTS

The mean age of the 750 patients was 68 ± 10.5 years. Severe postoperative complications were observed in 25 (3.3%) patients and were significantly associated with FEV1% < 70% in the univariate analysis. The 5-year OS was 72.5%. Multivariate analysis showed that the cancer stage, age > 75 years, preoperative comorbidities, %VC < 80%, total gastrectomy, severe postoperative complications, and postoperative adjuvant chemotherapy were the significant independent factors affecting OS. Pneumonia was significantly associated with %VC < 80%.

CONCLUSIONS

FEV1% < 70%was associated with the development of severe postoperative complications, while %VC < 80% was associated with poor OS independent of the cancer stage because of death from pneumonia. Spirometry helps surgeons and patients discuss the risks and benefits of surgery.

Risk factors for non-gastric-cancer-related death after gastrectomy in elderly patients

Aim

To identify preoperative factors, especially other diseases that cause death, that are associated with the prognosis of gastrectomy in elderly patients with gastric cancer.

Methods

This retrospective study included a total of 211 consecutive patients aged ≥75 years who underwent radical gastrectomy due to gastric cancer. Time-dependent receiver operating characteristic curve analysis was performed to determine the optimal cutoff values for various perioperative factors. Risk factors for the overall survival and death from other diseases were analyzed using the Cox proportional hazards model.

Results

Among the all perioperative factors, sex, neutrophil-to-lymphocyte ratio, skeletal muscle mass index, and lymph node dissection in accordance with guidelines or not extracted as independent risk factors for death from other diseases. In an analysis restricted to the preoperative factors, sex, neutrophil-to-lymphocyte ratio, and skeletal muscle mass index of the patients were extracted as independent risk factors for death from other diseases and overall survival. We divided the patients into four groups according to the number of preoperative risk factors for death from other diseases and found that the 5-year non-gastric-cancer-related survival was different among the four groups (risk factor 0, 91.7%; risk factor 1, 83.3%; risk factor 2, 56.3%; risk factor 3, 27.2%; P < 0.001).

Conclusion

Male sex, low skeletal muscle mass index, and high neutrophil-to-lymphocyte ratio are risk factors for non-gastric-cancer-related death and the overall survival of elderly patients undergoing gastrectomy. Cautious treatment strategies are needed for elderly gastric cancer patients with many risk factors.

Impact of frailty on survival and readmission in patients with gastric cancer undergoing gastrectomy: A meta-analysis

Background

Frailty as a common geriatric syndrome can affect the clinical outcomes in patients with gastric cancer. However, the impact of frailty on survival and readmission patients with gastric cancer has not been well-characterised.

Objectives

To investigate the impact of frailty on survival and readmission in patients with gastric cancer undergoing gastrectomy by conducting a meta-analysis.

Methods

Eligible studies were identified by searching the PubMed, Web of Science, Cochrane Library, and Embase databases until 2 September 2022. Observational studies that evaluated the value of frailty in predicting adverse outcomes in gastric cancer patients undergoing gastrectomy were included. The outcomes of interest were overall survival, disease-specific survival (death from gastric cancer), and readmission. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were pooled to calculate the association of frailty with adverse outcomes.

Results

Eight studies reported on nine articles with 2,792 patients with gastric cancer were included. A fixed-effect meta-analysis indicated that frailty was associated with a reduced in-hospital overall survival (HR 2.08; 95% CI 1.46–2.95), long-term overall survival (HR 1.84; 95% CI 1.37–2.47), and disease-specific survival (HR 1.94; 95% CI 1.34–2.83). In addition, frailty was associated with increased risk of readmission within 1 year (HR 3.63; 95% CI 1.87–7.06).

Conclusions

Frailty was associated with a reduced overall survival and disease-specific survival and an increased risk of readmission in patients with gastric cancer undergoing gastrectomy. Frail status may play an important role in the risk stratification of gastric cancer after gastrectomy.

Short- and Long-term Outcome After Gastric Cancer Resection in Patients Aged 80 Years and Older

BACKGROUND/AIM

We aimed to assess the risk factors for postoperative complications and long-term outcome of patients aged ≥80 years after curative resection for gastric cancer (GC).

PATIENTS AND METHODS

Patients aged ≥80 years who underwent curative gastrectomy for stage I-III GC between 2013 and 2020 were included. Clinical factors were retrospectively analyzed.

RESULTS

Of all 109 patients, 29 (26.6%) had 33 postoperative complications (Clavien-Dindo grade ≥2). The rate of postoperative complications was higher in those with greater blood loss (≥170 ml, p<0.001). In multivariate analysis, greater blood loss was confirmed as an independent predictor of postoperative complications (p<0.001). The 30-day, 180-day, 1-year, and 3-year cumulative overall survival rates were 100%, 97.0%, 91.6%, and 74.7%, respectively. Multivariate analysis showed postoperative complications (p=0.014) and low prognostic nutritional index (PNI, p=0.044) were independent prognostic factors for poor overall survival.

CONCLUSION

Performing operations with less bleeding is important to reduce postoperative complications. According to the analysis of long-term survival, patients who experience postoperative complications and patients with a low preoperative PNI require special attention in the follow-up period. Nutritional support should be considered in patients with malnutrition.

Modified Frailty Index Independently Predicts Postoperative Pulmonary Infection in Elderly Patients Undergoing Radical Gastrectomy for Gastric Cancer

Background

Pulmonary infection is one of the most common postoperative complications after radical gastrectomy for gastric cancer (GC) and is associated with a poorer prognosis. This study aimed to investigate potential predictive factors for pulmonary infection in elderly GC patients.

Methods

This study retrospectively enrolled 346 elderly GC patients undergoing elective radical gastrectomy between January 2017 and December 2020. Pulmonary infection within postoperative 30 days was set as the primary observational endpoint. The baseline demographic, clinicopathological, and laboratory data were compared between patients with or without pulmonary infection. ROC curves were plotted to evaluate the cut-off and predictive values of factors. Binary univariate and multivariate logistic regression analyses were employed to determine risk factors for postoperative pulmonary infection.

Results

Of the enrolled 346 patients, pulmonary infection was observed in 51 patients within postoperative 30 days, with an incidence of 14.7%. mFI was a significant predictor for pulmonary infection by ROC curve analysis (AUC: 0.770, P < 0.001). Moreover, preoperative mFI was the only independent risk factor for pulmonary infection (OR: 2.72, 95% CI: 2.02–3.31, P = 0.011) by univariate and multivariate logistic regression analyses.

Conclusion

Our study indicates that mFI independently predicts pulmonary infection in elderly GC patients.

Preoperative Fall Risk Assessment Score as a Prognostic Factor in Esophageal Cancer Patients after Esophagectomy

The current study investigated the impact of preoperative fall risk assessment score (FRAS) on long-term prognoses in patients with esophageal cancer (EC). A total of 161 patients with EC who underwent curative surgery were classified into a high-risk (95, 41.0%) and low-risk (66, 41.0%) groups according to their FRAS. This study investigated the relationships between the FRAS and clinicopathological findings and prognoses. Accordingly, patients in the high-risk group were significantly older and had a significantly higher Charlson comorbidity index than those in the low-risk group. No significant difference was found in pathological findings between both groups. The high-risk group had significantly lower overall survival (OS) and relapse-free survival (RFS) rates than the low-risk group (p = 0.004 and 0.001, respectively). Multivariate analysis identified high FRAS as an independent prognostic factor for poor OS, with a hazard ratio of 1.75 (p = 0.033). Moreover, re-analysis of the data after excluding age as a category showed that the high-risk group had significantly worse OS (p = 0.004) and RFS (p = 0.003) than the low-risk group. The FRAS can, therefore, be considered a useful method for assessing frailty and a potential prognostic factor for EC.

Effects of preoperative frailty on outcomes following surgery among patients with digestive system tumors: A systematic review and meta-analysis

BACKGROUND

Frailty is common in patients who undergo digestive system tumor surgery. This review aimed to explore the effects of preoperative frailty on multiple outcomes following surgery among patients with digestive system tumors.

METHODS

PubMed (Medline), Embase, Web of Science, and other databases were searched from the inception of each database to April 2021. Meta-analysis or qualitative synthesis was performed to examine the relationship between preoperative frailty and adverse postoperative outcomes.

RESULTS

A total of 29 studies encompassing 122,548 patients were included. Through meta-analysis, frailty was associated with an increased risk of total complications (risk ratio [RR] 1.44; 95 % confidence interval [CI] 1.39 to 1.50), major complications (RR 1.72; 95 % CI 1.51 to 1.95), 30-d mortality (RR 2.40; 95 % CI 2.14 to 2.70), and 5-year mortality (RR 1.74; 95 % CI 1.35 to 2.24). Through qualitative synthesis, compared with non-frail patients, two studies found that frail patients had a worse quality of life, and three studies reported that frail patients experienced greater rates of non-home discharge. However, two studies demonstrated inconsistent conclusions regarding the relationship between frailty and functional status.

CONCLUSIONS

Preoperative frailty was an important risk factor for multiple adverse postoperative outcomes of patients with digestive system tumors, including objective clinical outcomes and patient-centered outcomes. Future studies focusing on the effects of frailty on patient-centered outcomes such as quality of life and functional status are needed.

Preoperative fall risk assessment score as a prognostic factor in gastric cancer patients after gastrectomy

OBJECTIVE

Falls are related to frailty, which is known as an unfavorable prognosticator of gastric cancer. In this study, we investigated the influence of the fall risk assessment score on short- and long-term prognoses in patients with gastric cancer after gastrectomy.

METHODS

A total of 430 patients who underwent gastrectomy for gastric cancer were included in this retrospective study. The fall risk assessment score was scored by nursing staffs on admission. We investigated the relationships between the fall risk assessment score and clinicopathological findings, postoperative outcomes and prognoses. We assigned patients with a fall risk assessment score ≥7 to the high-risk group (92 cases, 21.4%) and those with a fall risk assessment score <6 to the low-risk group (338 cases, 78.6%).

RESULTS

There were no significant differences between the two groups in pathological stage of gastric cancer and postoperative complications, but the high-risk group had significantly longer postoperative hospital stays than the low-risk group (P < 0.001). The overall and the relapse-free survival rates in the high-risk group were significantly lower than those in the low-risk group. The high-risk group was one of the independent poor prognostic factors for overall survival, with a hazard ratio of 2.91 (P ≤ 0.001) in univariate analysis and a hazard ratio of 2.74 (P = 0.008) in multivariate analysis.

CONCLUSIONS

While the fall risk assessment score is an objective and easy-to-use method to assess fall risk and frailty, it may present a prognostic factor in gastric cancer.

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.

Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery

Background

A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice.

Methods

The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed.

Results

Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility.

Conclusions

Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility.

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