The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single-centre, observational cohort study

The influence between frailty, sarcopenia and physical status on mortality in patients undergoing emergency laparotomy

BACKGROUND

Frailty and sarcopenia have been independently shown to predict mortality in emergency laparotomy (EmLap), and both can be indicative of poor physical status. We aim to assess the prevalence of frailty, sarcopenia, and physical status in EmLap and explore the relationship between these factors and 30-day, 90-day and 1-year mortality.

METHODS

Retrospective analysis was performed on prospectively maintained Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database (2017-2019) which included patients ≥ 18 years who underwent EmLap. Clinical frailty scale (CFS) was used to classify frailty (score ≥ 4 as frail). Sarcopenia was assessed using total psoas index (TPI). Poor physical status (PPS) was defined by American Society of Anaesthesiologists physical status classification (ASA) ≥ 4. Binary logistic regression and fisher's exact tests were used for statistical analysis.

RESULTS

215 patients were included in the study, with 57.2% female and median age of 64 years. Frailty was present in 17.2%, sarcopenia in 25.1% and 14.4% had PPS; 3.3% had all three factors. Frail patients had significantly higher risk for 30-day (p = 0.003), 90-day (p = 0.006) and 1-year mortality (p = 0.032). Patients with poor physical status also showed significantly higher mortality at 30-day (p < 0.001), 90-day (p < 0.001) and 1-year (p = 0.001). Sarcopenic patients did not show significant differences in mortality risks up to 1 year. Patients with all three factors had significantly higher 30-day (p = 0.003), 90-day (p = 0.046) and 1-year mortality (p = 0.108) compared to patients who had none of the factors.

CONCLUSIONS

Frailty, sarcopenia, and PPS are prevalent in EmLap. Frailty and PPS were independently associated with short and long-term mortality, but not sarcopenia. While overlap exists between three factors, more research is required to understand the complex interplay.

Impact of frailty on outcomes and biliary drainage strategies in acute cholangitis: A retrospective cohort analysis

BACKGROUND

Acute cholangitis (AC) is a potentially fatal infection of the biliary tract characterized by varying degrees of severity, with endoscopic retrograde cholangiopancreatography (ERCP) serving as the primary drainage modality. Though frailty is linked to poor outcomes in general, its implications for AC patients remain unexplored.

METHODS

Using the National Inpatient Sample Database 2017-2020, we identified adult AC hospitalizations, which were further stratified based on frailty. A multivariate regression model was used for analysis.

RESULTS

We included 32,310 AC patients, out of whom 11,230 (34.76 %) were frail. Frail patients had elevated AC severity as well as in-hospital mortality (adjusted odds ratio [aOR] 6.89; P < 0.01). Additionally, frail patients were found to have significantly higher odds of complications including septic shock (aOR 15.87), acute renal failure (aOR 5.67), acute respiratory failure (aOR 11.11) and need for mechanical ventilation (aOR 13.80). From a procedural viewpoint, frail patients had higher odds of undergoing percutaneous biliary drainage (PBD) but lower odds of undergoing "early" ERCP (ERCP within 24 h of admission). When compared to non-frail counterparts, frail patients were more likely to undergo PBD as opposed to early ERCP (aOR 1.46; P = 0.01).

CONCLUSION

Frailty independently predicts poor AC outcomes and has a notable impact on the choice of biliary drainage procedure. Recognizing frailty instead of age alone as a determinant of AC outcomes can aid clinicians in risk stratification and guide tailored interventions in this population.

Impact of Frailty on Early Readmissions of Endoscopic Retrograde Cholangiopancreatography in the United States: Where Do We Stand?

Background/Objectives: We assessed the impact of frailty on outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. Methods: The National Readmission Database (2016-2020) was used to identify index and 30-day ERCP readmissions, which were categorized into low-frailty, intermediate-frailty, and high-frailty groups based on the Hospital Frailty Risk Score (HFRS). Outcomes were then compared. Results: Of 885,416 index admissions, 9.9% were readmitted within 30 days of ERCP. The odds of 30-day readmission were higher in the intermediate-frailty group (12.59% vs. 8.2%, odds ratio [OR] 1.67, 95% confidence interval [CI] 1.64-1.71, p < 0.001) and the high-frailty group (10.57% vs. 8.2%, OR 1.62, 95% CI 1.52-1.73, p < 0.001) compared to the low-frailty group. On readmission, a higher HFRS also increased mean length of stay (intermediate-frailty vs. low-frailty: 8.49 vs. 4.22 days, mean difference (MD) 4.26, 95% CI 4.19-4.34, p < 0.001; high-frailty vs. low-frailty: 10.9 vs. 4.22 days, MD 10.9 days, 95% CI 10.52-11.28, p < 0.001) and mean total hospitalization charges (intermediate-frailty vs. low-frailty: $118,996 vs. $68,034, MD $50,962, 95% CI 48, 854-53,069, p < 0.001; high-frailty vs. low-frailty: $195,584 vs. $68,034, MD $127,550, 95% CI 120,581-134,519, p < 0.001). The odds of inpatient mortality were also higher for the intermediate-frailty and high-frailty compared to the low-frailty subgroup. Conclusions: Frailty was associated with worse clinical outcomes after ERCP.

Effect of Frailty on the Management of Suspected Choledocholithiasis

INTRODUCTION

The American Society for Gastrointestinal Endoscopy and The Society of American Gastrointestinal and Endoscopic Surgeons (ASGE-SAGES) guidelines for managing choledocholithiasis (CDL) omit patient-specific factors like frailty. We evaluated how frail patients with CDL undergoing same-admission cholecystectomy were managed within ASGE-SAGES guidelines.

METHODS

We analyzed patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016 to 2019 at 12 US academic medical centers. Patients were grouped by Charlson comorbidity index into non-frail (NF), moderately frail (MF), and severely frail (SF). ASGE-SAGES guidelines stratified likelihood of CDL and were used to compare actual to suggested management. Rate of guideline deviation was our primary outcome. Secondary outcomes included rates of surgical site infections (SSIs), biliary leaks, and 30-day surgical readmissions. Rates are presented as NF, MF, and SF.

RESULTS

Among 844 patients, 43.3% (n = 365) were NF, 25.4% (n = 214) were MF, and 31.4% (n = 265) were SF. Frail patients were older (33y vs 56.7y vs 73.5y, P < .0001) and more likely to have ABP (32.6% vs 47.7% vs 43.8%, P = .0005). As frailty increased, guideline deviation increased (41.1% vs 43.5% vs 53.6%, P < .006). Severe frailty was predictive of guideline deviation compared to MF (aOR 1.47, 95% CI 1.02-2.12, P = .04) and NF (aOR 1.46, 95% CI 1.01-2.12, P = .04). There was no difference in SSIs (P = .2), biliary leaks (P = .7), or 30-day surgical readmission (P = .7).

CONCLUSION

Frail patients with common bile duct stones had more management deviating from guidelines yet no difference in complications. Future guidelines should consider including frailty to optimize detection and management of CDL in this population.