The impact of frailty on ventral hernia repair outcomes in a statewide database

Impact of preoperative frailty status on decision regret following elective hernia repair

PURPOSE

Decision regret following hernia repair is common, particularly for patients who experience complications. Frailty is a risk factor for complications, but whether frailty is independently associated with regret remains unknown.

METHODS

We retrospectively reviewed the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry, a representative sample of adult patients from > 70 hospitals across Michigan. We included patients who underwent elective ventral and incisional hernia repair (VIHR) or groin hernia repair (GHR) from 2020 to 2021 and completed a survey measuring regret. Frailty was quantified using validated 5-factor modified frailty index (mFI5): no (mFI5 = 0), moderate (mFI5 = 1), or severe frailty (mFI5 ≥ 2). Primary outcome was regret at 90-days. Multivariable regression models evaluated the association of frailty with regret.

RESULTS

795 patients underwent VIHR: 294 (37.0%) were moderately frail, and 127 (16.0%) were severely frail. Severely frail patients were older, more often male, more comorbid, had higher BMI, and had larger hernias (all p < 0.05). Regret was demonstrated in 88 patients (11.1%). 2502 patients underwent GHR: 966 (38.6%) moderately frail, and 213 (8.5%) severely frail. Severely frail patients were older, had higher BMI, and more comorbidities (all p < 0.001). 271 persons (10.8%) expressed regret. For both VIHR and GHR, frailty was not associated with regret (p > 0.05). There were no differences in complications by frailty status (p = 0.10 and p = 0.22).

CONCLUSION

Despite their higher risk, persons with frailty are not more likely to express regret following hernia repair. Decision regret is important for evaluating quality-of-life operations, but frailty status should not be used alone to predict risk of decision regret.

Minimally Invasive Surgery Benefits Frail Patients Undergoing Emergency Hernia Repairs

Background

Compared to elective surgery, emergent hernia repairs carry higher morbidity. Additionally, frailty is independently associated with worse postoperative outcomes. This study aimed to assess if the surgical approach, minimally invasive surgery versus open, confers improved outcomes for frail patients who underwent emergent hernia repairs.

Methods

The National Surgical Quality Improvement Program database (2018-2020) was queried for patients who underwent emergency hernia repair by Current Procedural Terminology (CPT) codes (49505-49659). A modified frailty index-5 score was calculated; only frail patients with a score of ≥2 were included. The impact of surgical approach on length of stay, discharge destination, and mortality was determined by multivariate analysis.

Results

A total of 1,893 patients met the inclusion criteria. Most patients (56.5%) were female, and 61.4% of patients were age ≥65. Most patients (83.62%) underwent open repair. After adjusting for covariates, patients who underwent minimally invasive surgery had a shorter length of stay compared to open surgery (hazard ratio = 1.22; 95% confidence interval [1.06,1.41]; P = .006). Surgical approach was not associated with a difference in 30-day mortality (P =.28) or discharge destination (P = .97).

Conclusion

Minimally invasive emergent hernia repairs in frail patients in the National Surgical Quality Improvement Program database cohort are associated with a shorter length of stay compared to open surgery, without increased 30-day mortality or change in discharge destination. Prospective studies are needed to validate best-practices in treating frail surgical patients.

Variation in surgical approach and postoperative complication among older adults undergoing ventral hernia repair

BACKGROUND

Surgical decision-making for preference-sensitive operations among older adults is understudied. Ventral hernia repair (VHR) is one operation where granular data are limited to guide preoperative decision-making. We aimed to determine risk for VHR in older adults given clinically nuanced data including surgical and hernia characteristics.

METHODS

We performed a retrospective analysis of the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry from January 2020 to March 2023. The primary outcome was postoperative complication across age groups: 18-64, 65-74, and ≥ 75 years, with secondary outcome of surgical approach. Mixed-effects logistic regression evaluated association between minimally invasive surgery (MIS) and 30-day complications, controlling for patient and hernia characteristics.

RESULTS

Among 8,659 patients, only 7% were 75 or older. MIS rates varied across hospitals [Median = 31.4%, IQR: (14.8-51.6%)]. The overall complication rate was 2.2%. Complication risk for undergoing open versus MIS approach did not vary between age groups; however, patients over age 75 undergoing laparoscopic repair had increased risk (aOR = 4.58, 95% CI 1.13-18.67). Other factors associated with risk included female sex (aOR = 2.10, 95% CI 1.51-2.93), higher BMI (aOR = 1.18, 95% CI 1.03-1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96-5.04), previous repair (aOR = 1.44, 95% CI 1.02-2.05), and component separation (aOR = 1.98, 95% CI 1.28-3.05). Patients most likely to undergo MIS were female (aOR = 1.21, 95% CI 1.09-1.34), black (aOR = 1.30, 95% CI 1.12-1.52), with larger hernias: 2-5.9 cm (aOR = 1.76, 95% CI 1.57-1.97), or intraoperative mesh placement (aOR = 14.4, 95% CI 11.68-17.79). There was no difference in likelihood to receive MIS across ages when accounting for hospital (SD of baseline likelihood = 1.53, 95% CI 1.14-2.05) and surgeon (SD of baseline likelihood = 2.77, 95% CI 2.46-3.11) variation.

CONCLUSIONS

Our findings demonstrate that hernia, intraoperative, and patient characteristics other than age increase probability for complication following VHR. These findings can empower surgeons and older patients considering preoperative risk for VHR.

Classifying frailty in the ventral hernia population

INTRODUCTION

Frailty is increasingly recognized as a preoperative predictor of adverse outcomes following various surgical procedures. Our study aims to compare validated frailty measures in the ventral hernia population, as this is a common elective procedure with a paucity of data regarding frailty prevalence.

METHODS

Patients aged 18 years or older with planned ventral hernia repairs were prospectively enrolled in our single-institution study from January 2023 through June 2023. After obtaining informed consent, patients completed the Fried Frailty Index (FFI), the FRAIL Scale, and the Strength, Assistance walking, Rising from a chair, Climbing stairs, and Falls (SARC-F) questionnaires, as well as the standard completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) measures at their preoperative clinic appointment. Chart review was performed for baseline demographics and comorbidities. The Modified Frailty Index (mFI-11) and the Charleston Comorbidity Index (CCI) were calculated.

RESULTS

A total of 63 patients were enrolled in our study. On average, the population was 60 years old, with a BMI of 32.4 kg/m2, a CCI of 3, and on 10.5 medications preoperatively. Overall, 12 patients (19%) screened positive for frailty by the mFI-11, 17 patients (27%) by the FFI, 15 patients (23.8%) by the FRAIL Scale, and 15 patients (23.8%) screened positive for sarcopenia by SARC-F. The FFI and the FRAIL Scale were strongly correlated with the other measures by Spearman's rank-order correlation (p < 0.05). On multivariate regression analysis, a longer Timed Up and Go test was associated with screening positive for frailty or sarcopenia (OR 1.896, p = 0.016).

CONCLUSION

In this study, we find that frailty is more prevalent than previously reported in the literature by any measure used. Both the FRAIL Scale and FFI strongly correlate with the other tools investigated. Surgeons should consider using these assessments preoperatively to estimate frailty and guide operative planning as well as shared decision-making.

Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review

OBJECTIVE

Many tools have been used to assess frailty in the perioperative setting. However, no single scale has been shown to be the most effective in predicting postoperative complications. We evaluated the relationship between several frailty scales and the occurrence of complications following different non-cardiac surgeries.

METHODS

This systematic review was registered in PROSPERO (CRD42023473401). The search strategy included PubMed, Google Scholar, and Embase, covering manuscripts published from January 2000 to July 2023. We included prospective and retrospective studies that evaluated frailty using specific scales and tracked patients postoperatively. Studies on cardiac, neurosurgical, and thoracic surgery were excluded because of the impact of underlying diseases on patients' functional status. Narrative reviews, conference abstracts, and articles lacking a comprehensive definition of frailty were excluded.

RESULTS

Of the 2204 articles identified, 145 were included in the review: 7 on non-cardiac surgery, 36 on general and digestive surgery, 19 on urology, 22 on vascular surgery, 36 on spinal surgery, and 25 on orthopedic/trauma surgery. The reviewed manuscripts confirmed that various frailty scales had been used to predict postoperative complications, mortality, and hospital stay across these surgical disciplines.

CONCLUSION

Despite differences among surgical populations, preoperative frailty assessment consistently predicts postoperative outcomes in non-cardiac surgeries.

Outcomes and quality of life of frail patients following elective ventral hernia repair: Retrospective review of a national hernia collaborative

BACKGROUND

Ventral hernia repair (VHR) is one of the most common general surgery procedures among older adults but is often deferred due to a higher risk of complications. This study compares postoperative quality of life (QOL) and complications between frail and non-frail patients undergoing elective VHR. We hypothesized that frail patients would have higher complication rates and smaller gains in quality of life compared to non-frail patients.

STUDY DESIGN

Patients 65 years of age and older, undergoing elective VHR between 2018 and 2022 were selected from the ACHQC (Abdominal Core Health Quality Collaborative) and grouped based on frailty scores obtained using the Modified Frailty Index (mFI-5). Logistic regression adjusting for hernia characteristics (size, recurrent, parastomal, incisional) were performed for 30-day outcomes including surgical site infections (SSI), surgical site occurrences (SSO), surgical site infections/occurrences requiring procedural intervention (SSOPI), and readmission. Multivariable analyses controlling for patient and procedure characteristics were performed comparing QOL scores (HerQLes scale, 0-100) at baseline, 30 days, 6 months and 1 year postoperatively.

RESULTS

A total of 4888 patients were included, 29.17% non-frail, 47.87% frail, and 22.95% severely frail. On adjusted analysis, severely frail patients had higher odds of SSO (most commonly seroma formation) but no evidence of a difference in SSI, SSOPI, readmission or mortality. Severely frail patients had lower median QOL scores at baseline (48.3/100, IQR 26.1-71.7, p ​= ​0.001) but reported higher QOL scores at both 30-days (68.3/100, IQR 41.7-88.3, p ​= ​0.01) and 6-months (86.7/100, IQR 65.0-93.3, p ​= ​0.005).

CONCLUSION

Severely frail patients reported similar increases in QOL and similar complications to their not frail counterparts. Our results demonstrate that appropriately selected older patients, even those who are severely frail, may benefit from elective VHR in the appropriate clinical circumstance.

The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis

BACKGROUND

Many surgical risk assessment tools emphasize patient-specific risk factors. Our objective was to use a hernia-specific database to assess risk factors of complications in ventral hernia repair (VHR) focusing on hernia-specific and procedural factors.

METHODS

The ACHQC database was queried for elective VHR in adults from 2012 to 2023. Primary outcome was overall 30-day complications. Multivariable logistic regression was used for analysis.

RESULTS

41,526 VHR were included. The rate of 30-day complications was 18%, surgical site infection 3%, surgical site occurrence requiring procedural intervention 4%, readmission 4%, reoperation 2%, and mortality 0.2%. Multivariable analysis demonstrated that BMI, ASA, frailty, COPD, anticoagulants, defect width, incisional and recurrent hernias, presence of stoma or prior mesh, prior abdominal wall infection, non-clean wound, operative time, open approach and myofascial release were associated with 30-day complications (OR ​= ​1.01-1.66). Preoperative chlorhexidine, bowel preparation and fascial closure were associated with lower complication risk (OR ​= ​0.70-0.89).

CONCLUSION

Hernia and procedural risk factors are associated with early complications following elective VHR. These factors need to be included in surgical risk assessment tools, to supplement patient-specific factors.

Quality of life among older patients after elective ventral hernia repair: A retrospective review

BACKGROUND

Ventral hernia repair is a common elective general surgery procedure among older patients, a population at greater risk of complications. Prior research has demonstrated improved quality of life in this population despite increased risk of complications. This study sought to assess the relationship between post-ventral hernia repair quality of life and patient frailty. We hypothesized that frail patients would report smaller gains in quality of life compared to the non-frail group.

METHODS

The Abdominal Core Health Quality Collaborative was used to identify a cohort of patients 65 years of age or older undergoing elective ventral hernia repair from 2018 to 2022. Patients were categorized based on their modified frailty index scores as not frail/prefrail, frail, and severely frail. Quality of life was assessed using a patient-reported 12-item scale preoperatively, 30 days, 6 months, and 1 year postoperatively.

RESULTS

A total of 3,479 patients were included: 30.93% non-frail, 47.17% frail, and 21.90% severely frail. Severely frail patients had lower quality of life scores at baseline (P = .001) but reported higher quality of life at both 30 days (1.24 points higher, 95% confidence interval (-1.51, 2.52), P = .010) and 6 months (0.92 points higher, 95% confidence interval (-2.29, 4.13), P = .005). Severely frail patients had higher rates of surgical site complications (P < .001) but no difference in 30-day readmissions.

CONCLUSION

Our results found that frail patients reported the greatest increase in quality of life 1 year from baseline, showing that they, when selected appropriately, can gain equal benefits and have similar surgical outcomes as their non-frail counterparts.

The modified frailty index predicts postoperative morbidity in elective hernia repair patients: analysis of the national inpatient sample 2015-2019

PURPOSE

Frailty has shown promise in predicting postoperative morbidity and mortality following hernia surgery. This study aims to evaluate the predictive capacity of the 11-item modified frailty index (mFI) in estimating postoperative outcomes following elective hernia surgery using the National Inpatient Sample (NIS) database.

METHODS

A retrospective analysis of the NIS from 2015 to 2019 was performed including adult patients who underwent elective hernia repair. The mFI was used to stratify patients as either frail (mFI ≥ 0.27) or robust (mFI < 0.27). The primary outcomes were 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 utilized.

RESULTS

In total, 14,125 robust patients and 1704 frail patients were included. Frailty was associated with an increased age (mean age 66.4 years vs. 52.6 years, p < 0.001) and prevalence of ventral hernias (51.9% vs. 44.4%, p < 0.001). Adjusted analyses demonstrated that frail patients had increased in-hospital mortality (adjusted odds ratio (aOR) 3.89, 95% CI 1.50, 10.11, p = 0.005), postoperative overall morbidity (aOR 1.98, 95% CI 1.72, 2.29, p < 0.001), postoperative LOS (adjusted mean difference (aMD) 0.78 days, 95% CI 0.51, 1.06, p < 0.001), total in-hospital healthcare costs (aMD $7562 95% CI 3292, 11,832, p = 0.001), and were less likely to be discharged home (aOR 0.61, 95% CI 0.53, 0.69, p < 0.001).

CONCLUSION

The mFI may be a reliable predictor of postoperative morbidity and mortality in elective hernia surgery. Utilizing this tool can aid in patient education and identifying high-risk patients who may benefit from tailored prehabilitation.

Minimally invasive pancreaticoduodenectomy: A favorable approach for frail patients with pancreatic cancer

BACKGROUND

Within the past decade, minimally invasive pancreaticoduodenectomy has been increasingly adopted in high-volume cancer centers. Amid broader trends of a growing older population, the numbers of frail patients with cancer are expected to increase. In this study, we compared the postoperative outcomes of open pancreaticoduodenectomy and minimally invasive pancreaticoduodenectomy in frail patients with pancreatic ductal adenocarcinoma.

METHODS

Using the pancreatectomy-targeted American College of Surgeons-National Surgical Quality Improvement Program database (2014-2021), we identified pancreaticoduodenectomy cases for pancreatic ductal adenocarcinoma. Patients with a modified frailty index ≥2 were considered frail. We performed 2:1 (open pancreaticoduodenectomy to minimally invasive pancreaticoduodenectomy) optimal pair propensity score matching for both patient- and disease-specific characteristics. We evaluated baseline covariate balance for homogeneity and assessed 30-day postoperative outcomes: complications, discharge destination, major morbidity, and mortality.

RESULTS

We identified 3,143 frail patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Of those, 275 (9%) underwent minimally invasive pancreaticoduodenectomy. Minimally invasive pancreaticoduodenectomy was associated with a lower rate of any complications compared with open pancreaticoduodenectomy (43% vs 54%; P < .001), major morbidity (29% vs 35%; P = .042), and nonhome discharge (12% vs 17%; P = .022). When comparing the 2 minimally invasive pancreaticoduodenectomy approaches, robotic surgery was associated with fewer complications compared with laparoscopy (39% vs 51%; P = .040) and a lower mortality rate (1% vs 4%; P = .041) CONCLUSION: In frail patients with pancreatic cancer, minimally invasive pancreaticoduodenectomy was associated with better postoperative outcomes than open pancreaticoduodenectomy. This study builds on growing literature reporting that, when properly implemented, minimally invasive pancreaticoduodenectomy is associated with more favorable postoperative outcomes. Given the particularly high risk of complication in frail patients, implementing a preoperative frailty assessment can provide valuable insights to inform patient counseling.

УЛУЧШЕНИЕ РЕЗУЛЬТАТОВ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ГРЫЖ ПЕРЕДНЕЙ БРЮШНОЙ СТЕНКИ У ПАЦИЕНТОВ ПОЖИЛОГО ВОЗРАСТА

Tədqiqatın məqsədi qarnın ön divarının yırtığı olan, yüksək zəriflik indeksli yaşlı xəstələrin cərrahi müalicəsinin yaxşılaşdırılması məqsədilə yeni müalicə taktikasının effektivliynin öyrənilməsi olmuşdur. Kontrol qrupunda olan (n=43) xəstə ənənəvi qaydada əməliyyatdan sonrakı müalicə almışdır. Əsas qrup xəstələrdə (n=49) müəllifin təklif etdiyi üsulla müalicə aparılmışdır: bütün xəstələrə nazoqastral zond qoyulmuş, mərkəzi vena kateterizasiya edilmiş, genişspektrli antibiotik infuziyası, mərkəzi venoz təzyiqi və arterial təzyiqi stabilləşdirmək şərtilə vena daxilinə kolloid və kristalloid məhlulların infuziyası aparılmış və xəstələr 6 saat ərzində əməliyyata götürülmüşdür. Əməliyyatdan sonrakı erkən dövrdə intensiv terapiya şöbəsində tənəffüs gimnastikası, erkən per os qidalanma, ağrının idarə edilməsi üçün epidural kateter vasitəsilə ağrıkəsicilərin istifadəsi, erkən hərəkətə başlama və beynin funksional aktivliyinin artırılması üçün kognitiv məşqlər icra edilmişdir. Əsas və kontrol qruplarında alınmış nəticələrin müqayisəsi göstərmişdir ki, Clavien-Dindo klassifikasiyasına görə II və III sinif ağırlaşmalara kontrol qrupunda daha çox rast gəlinmişdir. Xəstələrin əməliyyatdan sonrakı hospitaldaxili vəziyyətləri əsas qrupda daha yaxşı olması ilə seçilmişdir. Təklif etdiyimiz yeni metodun effektivliyi qanda iltihab əlamətlərinin daha mülayim olması ilə öz təsdiqini tapmışdır.

Представлены результаты исследования, проведенного с целью изучения эффективности новой тактики лечения, предложенного автором для улучшения хирургического лечения больных пожилого возраста с грыжами передней брюшной стенки с высоким индексом хрупкости. Больные контрольной группы (n=43) получали традиционное послеоперационное лечение. Основная группа больных (n=49) получили лечение предлагаемым автором способом, в которое входили: установление всем пациентам назогастрального зонда, катетеризация центральной вены, инфузия антибиотиков широкого спектра действия, внутривенное введение коллоидных и кристаллоидных растворов при условии стабилизации центрального венозного давления и артериального давления, а также 6 часов, в течение которых больного доставляют на операцию. В раннем послеоперационном периоде в отделении интенсивной терапии проводили дыхательную гимнастику, раннее пероральное питание, применение обезболивающих средств через эпидуральный катетер для купирования боли, раннюю двигательную и когнитивную гимнастику для повышения функциональной активности головного мозга. Сравнение результатов, полученных в основной (n=49) и контрольной (n=43) группах, показало, что по классификации Clavien-Dindo в контрольной группе чаще встречались осложнения II и III классов. Течение послеоперационого периода было лучше в основной группе. Эффективность предложенного нового метода подтверждена более хорошими показателями воспаления в анализах крови.

The aim was to study the effectiveness of new treatment tactics to improve the surgical treatment of elderly patients with hernias with a high frailty index. Patients in the control group (n=43) received traditional postoperative treatment. The main group of patients (n=49) received treatment using the method we proposed, which included: all patients had a nasogastric tube installed, central vein catheterization, infusion of broad-spectrum antibiotics, intravenous administration of colloid and crystalloid solutions, subject to stabilization of central venous pressure and blood pressure, as well as 6 hours, during which the patient is taken to surgery. In the early postoperative period in the intensive care unit, breathing exercises, early oral nutrition, the use of painkillers through an epidural catheter to relieve pain, and early motor and cognitive exercises to increase the functional activity of the brain were performed. A comparison of the results obtained in the main (n = 49) and control (n=43) groups, showed that according to the Clavien-Dindo classification, complications of classes II and III were more common in the control group. The course of the postoperative period was better in the main group. The effectiveness of our new method is confirmed by better indicators of inflammation in blood tests.