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
Abstract Background Frailty has gained recognition as an objective measure of a patient's physiologic reserve that ideally can replace the subjective biases of surgeons. In this study, we sought to ...examine the concordance between patient and attending surgeon perceptions of the patient's “fitness” before surgery. We then correlated these ratings with the patient's objective frailty scores. Methods Patients were prospectively enrolled from urology, general surgery, and surgical oncology clinics. Patients were asked to rate their ability to withstand the physical stress of the scheduled surgery on a visual analog scale. The operating surgeon then independently rated his assessment of the patient's ability to withstand surgery blinded to the patient's self assessment. Results A total of 203 patients were included. Median patient age and body mass index were 62 (range = 21–87) years and 28.1 kg/m2 (18.0–53.1), respectively. The majority of patients were white (67%) and male (60.6%). A patients' self-assessment showed no correlation with their age; however, surgeons' ratings showed a positive correlation with patients' age. Patients' self-rated scores showed a positive correlation with their frailty score, although surgeons' ratings showed a stronger correlation. However, when stratified by age group, the positive correlation and predictive ability were lost ( P value = 0.198). Conclusions Although age is an established risk factor, our data demonstrate surgeons may place an overreliance on a patient's age in place of an objective measure of physiologic reserve. Conversely, patients tended to overestimate their ability to withstand the stress of surgery, possibly leading to unrealistic expectations of their recovery and outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The American Urological Association Nephrolithiasis Guidelines Panel recently conducted a critical meta-analysis of the existing literature to determine the optimal management for staghorn calculi. ...This article briefly discusses the pathophysiology of staghorn calculi and, based on the panel's recommendations, examines the alternative medical treatments (eg, chemolysis) and surgical treatments (eg, shock wave lithotripsy, open surgery, ureteroscopy, and percutaneous nephrolithotomy) available for staghorn patients. Considering the various modalities for staghorn disease, percutaneous nephrolithotomy should be the first-line treatment for most patients based on its superior efficacy and low morbidity.
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
