Is Frailty a Good Predictor of Postoperative Complications in Elective Abdominal Surgery?—A Single-Center, Prospective, Observational Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Patients
2.2. Frailty Measures
2.3. Perioperative Risk Measures
2.4. Follow-Up and Outcome Measures
2.5. Statistical Analysis
3. Results
4. Discussion
4.1. Application of Frailty Assessment Scales in a Surgical Patient Population
4.2. In Search for the Optimal Frailty Threshold—Is Frail Really Vulnerable?
4.3. Frailty and the Risk of a Negative Outcome after Surgery
4.4. “Traditional” Ways of Risk Assessment
4.5. In Search of the Optimal Endpoint
4.6. Strengths and Limitations of the Study
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- United Nations Department of Economic and Social Affairs Population Division World Population Prospects 2022: Summary of Results. UN DESA/POP/2022/TR/NO. 3. Available online: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf (accessed on 14 September 2022).
- Fowler, A.J.; Abbott, T.E.F.; Prowle, J.; Pearse, R.M. Age of Patients Undergoing Surgery. Br. J. Surg. 2019, 106, 1012–1018. [Google Scholar] [CrossRef] [PubMed]
- United Nations. Department of Economic and Social Affairs. Population Division. World Population Ageing 2020 Highlights: Living Arrangements of Older Persons (ST/ESA/SER. A/451). Available online: https://www.un.org/development/desa/pd/ (accessed on 27 February 2023).
- Eurostat Ageing Europe: Looking at the Lives of Older People in the EU: 2020 Edition; Corselli-Nordblad, L.; Strandell, H. (Eds.) Publications Office of the European Union: Luxembourg, Luxembourg, 2020; ISBN 9789276098140. [Google Scholar]
- Panayi, A.C.; Orkaby, A.R.; Sakthivel, D.; Endo, Y.; Varon, D.; Roh, D.; Orgill, D.P.; Neppl, R.L.; Javedan, H.; Bhasin, S.; et al. Impact of Frailty on Outcomes in Surgical Patients: A Systematic Review and Meta-Analysis. Am. J. Surg. 2019, 218, 393–400. [Google Scholar] [CrossRef]
- Li, V.; Awan, A.; Serrano, P.E. Frailty Predicts Postoperative Complications Following Pancreaticoduodenectomy. Eur. Surg. Res. 2022, 63, 232–240. [Google Scholar] [CrossRef] [PubMed]
- Cui, P.; Wang, P.; Wang, J.; Liu, X.; Kong, C.; Lu, S. The Impact of Frailty on Perioperative Outcomes in Patients Receiving Short-Level Posterior Lumbar Interbody Fusion: A Stepwise Propensity Score Matching Analysis. Clin. Interv. Aging 2022, 17, 1297–1306. [Google Scholar] [CrossRef]
- Dale MacLaine, T.; Baker, O.; Burke, D.; Howell, S.J. Prevalence of Frailty and Reliability of Established Frailty Instruments in Adult Elective Colorectal Surgical Patients: A Prospective Cohort Study. Postgrad. Med. J. 2022, 98, 456–460. [Google Scholar] [CrossRef] [PubMed]
- McGovern, J.; Dolan, R.D.; Horgan, P.G.; Laird, B.J.; McMillan, D.C. The Prevalence and Prognostic Value of Frailty Screening Measures in Patients Undergoing Surgery for Colorectal Cancer: Observations from a Systematic Review. BMC Geriatr. 2022, 22, 260. [Google Scholar] [CrossRef] [PubMed]
- Nguyen, S.; Kim, R.B.; Cox, P.; Gamboa, N.T.; Karsy, M.; Couldwell, W.T.; Menacho, S.T. Impact of Modified Frailty Index-11 (MFI-11) on Postoperative Complications in Patients Undergoing Transsphenoidal Resection of Pituitary Tumors: Analysis of 2006–2014 ACS-NSQIP Database. J. Clin. Neurosci. 2021, 92, 22–26. [Google Scholar] [CrossRef]
- Halvorsen, S.; Mehilli, J.; Cassese, S.; Hall, T.S.; Abdelhamid, M.; Barbato, E.; de Hert, S.; de Laval, I.; Geisler, T.; Hinterbuchner, L.; et al. 2022 ESC Guidelines on Cardiovascular Assessment and Management of Patients Undergoing Non-Cardiac Surgery. Eur. Heart J. 2022, 43, 3826–3924. [Google Scholar] [CrossRef]
- Clegg, A.; Young, J.; Iliffe, S.; Rikkert, M.O.; Rockwood, K. Frailty in Elderly People. Lancet 2013, 381, 752–762. [Google Scholar] [CrossRef]
- Rolfson, D.B.; Majumdar, S.R.; Tsuyuki, R.T.; Tahir, A.; Rockwood, K. Validity and Reliability of the Edmonton Frail Scale. Age Ageing 2006, 35, 526–529. [Google Scholar] [CrossRef]
- Velanovich, V.; Antoine, H.; Swartz, A.; Peters, D.; Rubinfeld, I. Accumulating Deficits Model of Frailty and Postoperative Mortality and Morbidity: Its Application to a National Database. J. Surg. Res. 2013, 183, 104–110. [Google Scholar] [CrossRef] [PubMed]
- Rockwood, K.; Song, X.; MacKnight, C.; Bergman, H.; Hogan, D.B.; McDowell, I.; Mitnitski, A. A Global Clinical Measure of Fitness and Frailty in Elderly People. CMAJ 2005, 173, 489–495. [Google Scholar] [CrossRef] [PubMed]
- Shinall, M.C.; Arya, S.; Youk, A.; Varley, P.; Shah, R.; Massarweh, N.N.; Shireman, P.K.; Johanning, J.M.; Brown, A.J.; Christie, N.A.; et al. Association of Preoperative Patient Frailty and Operative Stress with Postoperative Mortality. JAMA Surg. 2020, 155, e194620. [Google Scholar] [CrossRef]
- Glance, L.G.; Lustik, S.J.; Hannan, E.L.; Osler, T.M.; Mukamel, D.B.; Qian, F.; Dick, A.W. The Surgical Mortality Probability Model: Derivation and Validation of a Simple Risk Prediction Rule for Noncardiac Surgery. Ann. Surg. 2012, 255, 696–702. [Google Scholar] [CrossRef]
- Dindo, D.; Demartines, N.; Clavien, P.-A. Classification of Surgical Complications: A New Proposal with Evaluation in a Cohort of 6336 Patients and Results of a Survey. Ann. Surg. 2004, 240, 205–213. [Google Scholar] [CrossRef]
- Zampino, M.; Polidori, M.C.; Ferrucci, L.; O’Neill, D.; Pilotto, A.; Gogol, M.; Rubenstein, L. Biomarkers of Aging in Real Life: Three Questions on Aging and the Comprehensive Geriatric Assessment. Geroscience 2022, 44, 2611–2622. [Google Scholar] [CrossRef]
- Hewitt, J.; Long, S.; Carter, B.; Bach, S.; McCarthy, K.; Clegg, A. The Prevalence of Frailty and Its Association with Clinical Outcomes in General Surgery: A Systematic Review and Meta-Analysis. Age Ageing 2018, 47, 793–800. [Google Scholar] [CrossRef] [PubMed]
- Garland, M.; Hsu, F.-C.; Shen, P.; Clark, C.J. Optimal Modified Frailty Index Cutoff in Older Gastrointestinal Cancer Patients. Am. Surg. 2017, 83, 860–865. [Google Scholar] [CrossRef]
- Sonny, A.; Kurz, A.; Skolaris, L.A.; Boehm, L.; Reynolds, A.; Cummings, K.C.; Makarova, N.; Yang, D.; Sessler, D.I. Deficit Accumulation and Phenotype Assessments of Frailty Both Poorly Predict Duration of Hospitalization and Serious Complications after Noncardiac Surgery. Anesthesiology 2020, 132, 82–94. [Google Scholar] [CrossRef]
- Church, S.; Rogers, E.; Rockwood, K.; Theou, O. A Scoping Review of the Clinical Frailty Scale. BMC Geriatr. 2020, 20, 393. [Google Scholar] [CrossRef]
- Chao, Y.-S.; Wu, H.-C.; Wu, C.-J.; Chen, W.-C. Index or Illusion: The Case of Frailty Indices in the Health and Retirement Study. PLoS ONE 2018, 13, e0197859. [Google Scholar] [CrossRef] [PubMed]
- Romero-Ortuno, R. An Alternative Method for Frailty Index Cut-off Points to Define Frailty Categories. Eur. Geriatr. Med. 2013, 4, 299–303. [Google Scholar] [CrossRef] [PubMed]
- Fronczek, J.; Polok, K.; de Lange, D.W.; Jung, C.; Beil, M.; Rhodes, A.; Fjølner, J.; Górka, J.; Andersen, F.H.; Artigas, A.; et al. Relationship between the Clinical Frailty Scale and Short-Term Mortality in Patients ≥ 80 Years Old Acutely Admitted to the ICU: A Prospective Cohort Study. Crit. Care 2021, 25, 231. [Google Scholar] [CrossRef]
- McIsaac, D.I.; Taljaard, M.; Bryson, G.L.; Beaulé, P.E.; Gagné, S.; Hamilton, G.; Hladkowicz, E.; Huang, A.; Joanisse, J.A.; Lavallée, L.T.; et al. Frailty as a Predictor of Death or New Disability After Surgery: A Prospective Cohort Study. Ann. Surg. 2020, 271, 283–289. [Google Scholar] [CrossRef]
- Aucoin, S.D.; Hao, M.; Sohi, R.; Shaw, J.; Bentov, I.; Walker, D.; McIsaac, D.I. Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery: A Systematic Review and Meta-Analysis. Anesthesiology 2020, 133, 78–95. [Google Scholar] [CrossRef]
- Gearhart, S.L.; Do, E.M.; Owodunni, O.; Gabre-Kidan, A.A.; Magnuson, T. Loss of Independence in Older Patients after Operation for Colorectal Cancer. J. Am. Coll. Surg. 2020, 230, 573–582. [Google Scholar] [CrossRef]
- Amrock, L.G.; Neuman, M.D.; Lin, H.-M.; Deiner, S. Can Routine Preoperative Data Predict Adverse Outcomes in the Elderly? Development and Validation of a Simple Risk Model Incorporating a Chart-Derived Frailty Score. J. Am. Coll. Surg. 2014, 219, 684–694. [Google Scholar] [CrossRef] [PubMed]
- Kapoor, A.; Matheos, T.; Walz, M.; McDonough, C.; Maheswaran, A.; Ruppell, E.; Mohamud, D.; Shaffer, N.; Zhou, Y.; Kaur, S.; et al. Self-Reported Function More Informative than Frailty Phenotype in Predicting Adverse Postoperative Course in Older Adults. J. Am. Geriatr. Soc. 2017, 65, 2522–2528. [Google Scholar] [CrossRef]
- Kenig, J.; Zychiewicz, B.; Olszewska, U.; Barczynski, M.; Nowak, W. Six Screening Instruments for Frailty in Older Patients Qualified for Emergency Abdominal Surgery. Arch. Gerontol. Geriatr. 2015, 61, 437–442. [Google Scholar] [CrossRef]
- Joseph, B.; Zangbar, B.; Pandit, V.; Fain, M.; Mohler, M.J.; Kulvatunyou, N.; Jokar, T.O.; O’Keeffe, T.; Friese, R.S.; Rhee, P. Emergency General Surgery in the Elderly: Too Old or Too Frail? J. Am. Coll. Surg. 2016, 222, 805–813. [Google Scholar] [CrossRef]
- McIsaac, D.I.; Moloo, H.; Bryson, G.L.; van Walraven, C. The Association of Frailty with Outcomes and Resource Use after Emergency General Surgery: A Population-Based Cohort Study. Anesth. Analg. 2017, 124, 1653–1661. [Google Scholar] [CrossRef] [PubMed]
- Kim, S.; Han, H.-S.; Jung, H.; Kim, K.; Hwang, D.W.; Kang, S.-B.; Kim, C.-H. Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg. 2014, 149, 633–640. [Google Scholar] [CrossRef]
- Serretta, V.; Muffoletto, F.; Tulone, G.; Dioguardi, S.; Guzzardo, C.; Billeci, S.; Baiamonte, D.; Giannone, S.; Sanfilippo, C.; Gesolfo, C.S.; et al. MP10-12 comparison between the asa score and the modified frailty index (mfi) in urologic oncological and non oncological urological interventional procedures. J. Urol. 2019, 201, 256. [Google Scholar] [CrossRef]
- Kovacs, J.; Moraru, L.; Antal, K.; Cioc, A.; Voidazan, S.; Szabo, A. Are Frailty Scales Better than Anesthesia or Surgical Scales to Determine Risk in Cardiac Surgery? Korean J. Anesthesiol. 2017, 70, 157–162. [Google Scholar] [CrossRef] [PubMed]
- Cooper, Z.; Rogers, S.O.; Ngo, L.; Guess, J.; Schmitt, E.; Jones, R.N.; Ayres, D.K.; Walston, J.D.; Gill, T.M.; Gleason, L.J.; et al. Comparison of Frailty Measures as Predictors of Outcomes After Orthopedic Surgery. J. Am. Geriatr. Soc. 2016, 64, 2464–2471. [Google Scholar] [CrossRef]
- Krishnan, M.; Beck, S.; Havelock, W.; Eeles, E.; Hubbard, R.E.; Johansen, A. Predicting Outcome after Hip Fracture: Using a Frailty Index to Integrate Comprehensive Geriatric Assessment Results. Age Ageing 2014, 43, 122–126. [Google Scholar] [CrossRef]
- Wilson, M.E.; Vakil, A.P.; Kandel, P.; Undavalli, C.; Dunlay, S.M.; Kennedy, C.C. Pretransplant Frailty Is Associated with Decreased Survival after Lung Transplantation. J. Heart Lung Transplant. 2016, 35, 173–178. [Google Scholar] [CrossRef]
- Lingsma, H.F.; Bottle, A.; Middleton, S.; Kievit, J.; Steyerberg, E.W.; Marang-van de Mheen, P.J. Evaluation of Hospital Outcomes: The Relation between Length-of-Stay, Readmission, and Mortality in a Large International Administrative Database. BMC Health Serv. Res. 2018, 18, 116. [Google Scholar] [CrossRef]
- Brasel, K.J.; Lim, H.J.; Nirula, R.; Weigelt, J.A. Length of Stay: An Appropriate Quality Measure? Arch. Surg. 2007, 142, 461–465; discussion 465-6. [Google Scholar] [CrossRef]
- McAleese, P.; Odling-Smee, W. The Effect of Complications on Length of Stay. Ann. Surg. 1994, 220, 740–744. [Google Scholar] [CrossRef]
- Brown, E.G.; Yang, A.; Canter, R.J.; Bold, R.J. Outcomes of Pancreaticoduodenectomy: Where Should We Focus Our Efforts on Improving Outcomes? JAMA Surg. 2014, 149, 694–699. [Google Scholar] [CrossRef] [PubMed]
- Mazmudar, A.; Castle, J.; Yang, A.D.; Bentrem, D.J. The Association of Length of Hospital Stay with Readmission after Elective Pancreatic Resection. J. Surg. Oncol. 2018, 118, 7–14. [Google Scholar] [CrossRef] [PubMed]
Variable | Value | |
---|---|---|
Male sex | 43 (43%) | |
Age (years) | 70 (65–74) | |
Height (cm) | 166.5 (161.5–172) | |
Weight (kg) | 70 (61–84.3) | |
BMI (kg/m2) | 26.3 (23.6–29.7) | |
Obesity (BMI ≥ 30 kg/m2) | 22 (22%) | |
Arterial hypertension | 71 (71%) | |
Diabetes | 18 (18%) | |
History of stroke or TIA | 5 (5%) | |
Polypragmasy (≥5 medications) | 40 (40%) | |
Type of surgery | Surgery of the pancreas | 25 (25%) |
Surgery of the large intestine | 25 (25%) | |
Cholecystectomy | 15 (15%) | |
Surgery of the small intestine | 9 (9%) | |
Gastric surgery | 8 (8%) | |
Hernia repair surgery | 6 (6%) | |
Surgery of the esophagus | 1 (1%) | |
Liver surgery | 1 (1%) | |
Other abdominal surgery | 10 (10%) | |
ASA-PS Class | II | 34 (34%) |
III | 61 (61%) | |
IV | 5 (5%) | |
Edmonton Frail Scale (EFS) | 0–5 = Not Frail | 67 (67%) |
6–7 = Vulnerable | 19 (19%) | |
8–9 = Mild Frailty | 6 (6%) | |
10–11 = Moderate Frailty | 7 (7%) | |
12 or more = Severe Frailty | 1 (1%) | |
Modified Frailty Index (mFI) | 0.18 (0.09–0.27) | |
Clinical Frailty Scale (CFS) | 3 (2–3) |
Surgical Complications | Number of Patients |
---|---|
Anastomotic leakage | 4 |
Eventration | 2 |
Fluid collection at surgical site/abscess | 4 |
Gastrointestinal bleeding | 1 |
Gastrointestinal obstruction | 1 |
Gastrointestinal perforation | 1 |
Hematoma | 2 |
Wound healing disorder | 1 |
Medical Complications | Number of Patients |
Acute Kidney injury | 7 |
Anaemia | 1 |
Cardiac insufficiency | 7 |
Hemorrhagic diathesis | 1 |
Pulmonary embolism | 1 |
Respiratory failure | 5 |
Sepsis and septic shock | 7 |
Clavien Dindo Classification of Surgical Complications Grade [18] | Number of Patients |
---|---|
I | 5 |
II | 11 |
III | |
IIIa | 2 |
IIIb | 7 |
IV | |
IVa | 0 |
IVb | 1 |
V | 5 |
Complications/ Clavien–Dindo Classification | mFI | CFS | Edmonton | ||||||
---|---|---|---|---|---|---|---|---|---|
Non-Frail | Mildly– Severely Frail | p-Value | Non-Frail | Frail | p-Value | Non-Frail | Frail | p-Value | |
Complications (n) | 2 | 25 | 0.1961 | 23 | 4 | 0.6159 | 19 | 8 | 0.6645 |
Medical Complications (n) | 0 | 16 | 0.5572 | 14 | 2 | 0.5342 | 12 | 4 | 0.4600 |
Surgical Complications (n) | 2 | 15 | 0.0667 | 15 | 2 | 0.4649 | 12 | 5 | 0.7311 |
Clavien–Dindo Classification | 0.2828 | 0.7288 | 0.5727 | ||||||
II | 0 | 11 | 9 | 2 | 8 | 3 | |||
III | 2 | 7 | 7 | 2 | 5 | 4 | |||
IV | 1 | 0 | 1 | 0 | 1 | 0 | |||
V | 0 | 5 | 5 | 0 | 5 | 0 |
Variables | mFI | EFI | CFS | ASA-PS | S-MPM | OSS |
---|---|---|---|---|---|---|
mFI | 1.0 | |||||
EFI | 0.426 * | 1.0 | ||||
CFS | 0.378 * | 0.594 * | 1.0 | |||
ASA-PS | 0.409 * | 0.346 * | 0.306 * | 1.0 | ||
S-MPM | 0.284 * | 0.356 * | 0.241 | 0.738 * | 1.0 | |
OSS | 0.019 | 0.038 | 0.119 | 0.141 | 0.527 * | 1.0 |
Variable | All n = 100 (100%) | Complications (In General) | p-Value | Medical Complications | p-Value | Surgical Complications | p-Value | |||
---|---|---|---|---|---|---|---|---|---|---|
Present n = 26 (26%) | Absent n = 74 (74%) | Present n = 16 (16%) | Absent n = 84 (84%) | Present n = 17 (17%) | Absent n = 83 (83%) | |||||
mFI | 0.18 (0.09–0.27) | 0.09 (0.09–0.18) | 0.18 (0.18–0.21) | 0.084 | 0.18 (0.09–0.27) | 0.18 (0.18–0.18) | 0.961 | 0.09 (0.09–0.18) | 0.18 (0.18–0.18) | 0.046 |
CFS | 3 (2–3) | 3 (2–3) | 3 (3–3) | 0.719 | 3 (2–3) | 3 (2.6–3) | 0.652 | 3 (2–3) | 3 (3–3) | 0.464 |
EFI | 4.5 (2–6) | 4 (2.25–5.75) | 5 (2–6) | 0.794 | 5 (3–5.4) | 4 (3–5) | 0.821 | 5 (2–6) | 4 (3–5) | 0.754 |
Demographic | Any Complications (In General) | Medical Complications | Surgical Complications | ||||
---|---|---|---|---|---|---|---|
OR (95% CI) | p-Value | OR (95% CI) | p-Value | OR (95% CI) | p-Value | ||
Age (years) | 1.02 (0.96–1.09) | 0.515 | 1.03 (0.95–1.12) | 0.462 | 1.013 (0.934–1.09) | 0.760 | |
Sex (male) | 2.48 (1.01–6.11) | 0.046 | 0.39 (0.13–1.17) | 0.093 | 0.34 (0.12–1.02) | 0.054 | |
BMI | 1.02 (0.93–1.12) | 0.698 | 1.04 (0.93–1.16) | 0.538 | 1.03 (0.92–1.15) | 0.640 | |
Diabetes | Yes = 1 | 0.48 (0.128–1.823) | 0.283 | 0.61 (0.12–2.94) | 0.536 | 0.56 (0.12–2.69) | 0.468 |
Hypertension | Yes = 1 | 1.23 (0.46–3.34) | 0.681 | 1.94 (0.51–7.40) | 0.331 | 0.70 (0.23–2.12) | 0.532 |
COPD | Yes = 1 | 0.31 (0.04–2.63 | 0.284 | 0.63 (0.07–5.45) | 0.677 | 0.59 (0.07–5.02) | 0.626 |
ASA-PS | 2.81 (1.16–6.79) | 0.022 | 4.67 (1.45–15.16) | 0.009 | 2.01 (0.75–5.34) | 0.164 | |
S-MPM | 1.88 (1.12–3.14) | 0.017 | 2.13 (1.08–4.19) | 0.029 | 1.79 (1.06–3.29) | 0.042 | |
OSS | 1.86 (1.05–3.31) | 0.034 | 1.44 (0.74–2.81) | 0.282 | 1.85 (1.04–3.63) | 0.047 | |
EFI | 1.02 (0.88–1.20) | 0.772 | 1.02 (0.84–1.23) | 0.855 | 1.04 (0.87–1.25) | 0.682 | |
mFI | 0.96 (0.92–1.01) | 0.093 | 0.99 (0.95–1.05) | 0.838 | 0.95 (0.90–1.00) | 0.063 | |
CFS | 0.99 (0.65–1.50) | 0.963 | 1.02 (0.62–1.68) | 0.951 | 0.96 (0.58–1.58) | 0.876 |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Czajka, S.; Taborek, M.; Krzych, Ł.J. Is Frailty a Good Predictor of Postoperative Complications in Elective Abdominal Surgery?—A Single-Center, Prospective, Observational Study. J. Pers. Med. 2023, 13, 869. https://doi.org/10.3390/jpm13050869
Czajka S, Taborek M, Krzych ŁJ. Is Frailty a Good Predictor of Postoperative Complications in Elective Abdominal Surgery?—A Single-Center, Prospective, Observational Study. Journal of Personalized Medicine. 2023; 13(5):869. https://doi.org/10.3390/jpm13050869
Chicago/Turabian StyleCzajka, Szymon, Maria Taborek, and Łukasz J. Krzych. 2023. "Is Frailty a Good Predictor of Postoperative Complications in Elective Abdominal Surgery?—A Single-Center, Prospective, Observational Study" Journal of Personalized Medicine 13, no. 5: 869. https://doi.org/10.3390/jpm13050869