Background The decision as to whether a patient can tolerate surgery is often subjective and can misjudge a patient's true physiologic state. The concept of frailty is an important assessment tool in ...the geriatric medical population, but has only recently gained attention in surgical patients. Frailty potentially represents a measureable phenotype, which, if quantified with a standardized protocol, could reliably estimate the risk of adverse surgical outcomes. Study Design Frailty was prospectively evaluated in the clinic setting in patients consenting for major general, oncologic, and urologic procedures. Evaluation included an established assessment tool (Hopkins Frailty Score), self-administered questionnaires, clinical assessment of performance status, and biochemical measures. Primary outcome was 30-day postoperative complications. Results There were189 patients evaluated: 117 from urology, 52 from surgical oncology, and 20 from general surgery clinics. Mean age was 62 years, 59.8% were male, and 71.4% were Caucasian. Patients who scored intermediately frail or frail on the Hopkins Frailty Score were more likely to experience postoperative complications (odds ratio OR 2.07, 95% CI 1.05 to 4.08, p = 0.036). Of all other preoperative assessment tools, only higher hemoglobin (p = 0.033) had a significant association and was protective for 30-day complications. Conclusions The aggregate score of patients as “intermediately frail or frail” on the Hopkins Frailty Score was predictive of a patient experiencing a postoperative complication. This preoperative assessment tool may prove beneficial when weighing the risks and benefits of surgery, allowing objective data to guide surgical decision-making and patient counseling.
Background Frailty is an objective method of quantifying a patient’s fitness for surgery. Its clinical use is limited by the time needed to complete, as well as a lack of evidence-based interventions ...to improve outcomes in identified frail patients. The purpose of this study was to critically analyze the components of the Fried Frailty Criteria, among other preoperative variables, to create a simplified risk assessment amenable to a busy clinical setting, while maintaining prognostic ability for surgical outcomes. Study Design We performed a prospective evaluation of patients that included the 5-component Fried Frailty Criteria, traditional surgical risk assessments, biochemical laboratory values, and clinical and demographic data. Thirty-day postoperative outcomes were the outcomes of interest. Results There were 351 consecutive patients undergoing major intra-abdominal operations enrolled. Analysis demonstrated that shrinking and grip strength alone hold the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality. The addition of American Society of Anesthesia (ASA) score and serum hemoglobin creates a composite risk score, which facilitates easy classification of patients into discrete low (ref), intermediate (odds ratio OR 1.974, 95% CI 1.006 to 3.877, p = 0.048), and high (OR 4.889, 95% CI 2.220 to 10.769, p < 0.001) risk categories, with a corresponding stepwise increase in risk for 30-day postoperative complications. Internal validation by bootstrapping confirmed the results. Conclusions This study demonstrated that 2 components of the Fried Frailty Criteria, shrinking and grip strength, hold the same predictive value as the full frailty assessment. When combined with American Society of Anesthesiologists score and serum hemoglobin, they form a straightforward, simple risk classification system with robust prognostic information.
Abstract Background Frailty is an objective measurement capable of preoperatively identifying patients with increased risk of 30-day morbidity and mortality, though less is known about its utility ...beyond that timeframe. We hypothesized that preoperative frailty is associated with an increased risk of one-year mortality in patients undergoing major intra-abdominal surgery. Materials and Methods Demographics, laboratory values, and traditional surgical risk assessments (American Society of Anesthesiologists scale, Eastern Cooperative Oncology Group Performance Status, Charlson Comorbidity Index) were collected prospectively. Preoperative frailty was evaluated using Fried criteria. Postoperative complications were defined by Clavien-Dindo Classification. One-year mortality data was gathered from phone calls, medical records, and the National Death Index. Results This study included 189 patients with a mean age of 62 years. 59.8% were male and 71.4% were Caucasian. At enrollment, 139 (73.5%) patients were considered “not frail”, while 50 (26.5%) were considered “intermediately frail” or “frail”. A total of 73 (38.6%) patients experienced a 30-day postoperative complication. At one year, 15 (7.9%) patients had died, 5 (3.6%) not frail and 10 (20.0%) intermediately frail/frail patients. Postoperative mortality occurred < 30 days, between 31-100 days, and > 100 days in 3, 4, and 8 patients respectively. Malignant neoplasm was documented as the underlying cause of death in 12 patients. All 30-day mortalities occurred in frail patients who had a postoperative complication. Conclusions Frailty status is predictive of one-year postoperative mortality. The Fried Frailty Criteria has the potential to more accurately evaluate surgical patients’ mortality risk beyond the immediate postoperative period, particularly when considered collectively with traditional surgical risk assessment tools.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Open inguinal lymphadenectomy for regionally metastatic melanoma is associated with a high wound-related morbidity. Videoscopic inguinal lymphadenectomy (VIL) is a minimally invasive ...approach with fewer wound-related complications, yet its adoption has been hindered by a lack of oncologic outcomes data. Study Design Data were prospectively collected on all VILs performed for melanoma from 2008 to 2012 (n = 40) and compared with a retrospective cohort of open superficial inguinal lymphadenectomies from 2005 to 2012 (n = 40). Continuous variables were analyzed with Student's t -test, binomial variables with chi-square, and survival curves using log-rank comparison. Results Median follow-up for patients undergoing VIL was 19.1 months compared with 33.9 months in the open inguinal lymphadenectomy group. There were no statistical differences in demographics (age, sex, body mass index, smoking status, Charlson comorbidity index) or clinicopathologic features (primary site, stage, Breslow depth, ulceration). Lymph node yield was similar (VIL, 12.6; open, 14.2; p = 0.131). Overall recurrence rates were also similar: 27.5% in the VIL group and 30.0% in the open group (p = 0.805). One patient in the VIL group and 2 in the open group suffered recurrence in the nodal basin. Although median survival was not reached in the VIL group, Kaplan-Meier estimates of disease-free survival (p = 0.226) and overall survival (p = 0.308) were similar. In a comprehensive analysis of wound complications including infection, skin necrosis, and seroma, patients undergoing VIL had markedly less morbidity (VIL, 47.5%; open, 80.0%; p = 0.002). Conclusions Videoscopic inguinal lymphadenectomy is associated with similar oncologic outcomes and markedly reduced wound complications when compared with open inguinal lymphadenectomy. The minimally invasive procedure may be the preferred method for inguinal lymphadenectomy in melanoma.
Surgical decision-making often relies on a surgeon's subjective assessment of a patient's frailty status to undergo surgery. Certain patient demographics can influence subjective judgment when ...compared to validated objective assessments. In this study, we explore the relationship between subjective and objective frailty assessments according to patient age, sex, and race.
Patients were prospectively enrolled in urology, general surgery, and surgical oncology clinics. Using a visual analog scale (0−100), operating surgeons independently rated the patient's frailty status. Objective frailty was classified using the Fried Frailty Criteria ranging from 0 to 5. Multivariable proportional odds models were conducted to examine the potential association of factors with objective frailty, according to surgeon frailty rating. Subgroup analysis according to patient sex, race, and age was also performed.
Seven male surgeons assessed 203 patients preoperatively with a median age of 65. A majority of patients were male (61 %), white (67 %), and 60 % and 40 % underwent urologic and general surgery/surgical oncology procedures respectively. Increased subjective surgeon rating (OR 1.69; p < 0.001) was significantly associated with the presence of objective frailty. On subgroup analysis, a higher magnitude of such association was observed more in females (OR 1.86; p = 0.0007), non-white (OR 1.84; p = 0.0019), and older (>60, OR 1.75; p = 0.0001) patients, compared to male (OR 1.45; p = 0.0243), non-white (OR 1.48; p = 0.0109) and patients under 60 (OR 1.47; p = 0.0823).
The surgeon's subjective assessment of frailty demonstrated tendencies to rate older, female, and non-white patients as frail; however, differences in patient sex, age, and race were not statistically significant.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Postoperative pain is an unavoidable consequence of open abdominal surgery. Although cryotherapy, the application of ice to a surgical wound site, has been shown to be effective in ...reducing postoperative pain in orthopaedic, gynecologic, and hernia operations, it has not been assessed in patients who undergo major open abdominal operations. We hypothesized that patients who receive cryotherapy would report lower pain scores as a primary outcomes measure. Study Design Patients undergoing abdominal operations with midline incisions were randomized to receive cryotherapy for a minimum of 24 hours in time intervals dictated by patient preference vs no cryotherapy. The primary outcome of pain relief was assessed with visual analog pain scores (VAS). The study was powered to detect a clinically significant difference in VAS between the control and cryotherapy group. Comparisons between groups were measured by Student's t -test or Mann-Whitney U test for parametric and nonparametric data, respectively. Results There were 55 patients randomized: 28 to the control group and 27 to the cryotherapy group. For the primary measure, mean postoperative pain score on postoperative days (PODs) 1 and 3 after surgery was significantly lower between the control and cryotherapy groups on the visual analog pain scale (p < 0.005). Narcotic use was decreased in the cryotherapy group on POD 1 by 3.9 morphine equivalents (p = 0.008). No statistically significant difference was found between the 2 treatment groups with respect to length of hospital stay, pulmonary complications, and wound infection rate in terms of secondary measures. Conclusions Ice packs are a simple, cost-effective adjuvant for decreasing postoperative pain and narcotic use in patients undergoing major abdominal operations.
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