Identifying surgical patients at the end of life (EOL) is the first step in integrating palliative and perioperative practices. Palliative prognostic tools (PPTs) are established frameworks from palliative care that assess patients at risk of early death. We conducted a systematic review investigating PPTs in adult surgical populations, their role in surgical decision-making, and their association with perioperative outcomes.

A prospectively registered systematic review was performed (PROSPERO registration: CRD42023411303). Ovid MEDLINE, Ovid EMBASE, and Cochrane CENTRAL (Wiley) databases were searched for studies investigating PPTs in surgical patients. The primary outcome was the decision to proceed to surgery; secondary outcomes included mortality, quality of life, palliative care consultation, and EOL documentation completion. Abstract screening, full-text review, and study quality appraisal were performed by two authors independently. Results were synthesised narratively owing to study heterogeneity.

Seven studies assessing four different PPTs were included in the review. Studies identified that 12-61% of surgical patients were at the EOL. Patients identified as being at the EOL by a PPT using an illness phase, trajectory approach, or both had an increased in-hospital and 12-month mortality. The impact on decisions to proceed to surgery was uncertain because of conflicting results. Palliative care referral and EOL document completion occurred in <15% of surgical patients at the EOL. No studies described patient-reported outcomes.

Palliative prognostic tools have significant potential for incorporation into preoperative assessment. Future research should focus on preoperative end of life assessments and patient-reported outcomes such as quality of life, decision satisfaction, and disability-free survival.

As the global population ages and older patients undergo surgery, understanding the association between frailty and postoperative outcomes is crucial to informed decision-making and patient care. There is a lack of research assessing the association between frailty and long-term outcomes in patients admitted to ICUs after surgery.

We conducted a multicentre retrospective cohort study using Australian and New Zealand Intensive Care Society Adult Patient Database, linked with the Australian National Death Index. Adults aged ≥16 yr admitted to the 175 ICUs in Australia between January 1, 2018, and March 31, 2022, after surgery were included. We excluded patients with cancer or admission to ICU for palliation or organ donation purpose. Patients with Clinical Frailty Scale score 5-8 were considered frail. The primary outcome was survival time up to 4 yr after ICU admission. Survival analysis was performed using mixed-effects Cox regression models and adjusted for age, sex, comorbidities, acute illness severity, and hospital types.

We included 216 922 patients of whom 30 860 (14.2%) were frail. Patients with frailty had shorter overall survival time (median [IQR]: 16 [6-29] vs 21 [10-34] months; P<0.01) when compared with patients without frailty. After adjusting for confounders, frailty was associated with a shorter time to death (HR: 2.33, 95% CI: 2.26-2.40). This association was consistent across sensitivity analyses and subgroups. Of note, this association between frailty and shorter time to death was more pronounced in patients aged <65 yr, those undergoing elective surgery, and those without treatment limitations.

In this multicentre study, frailty was associated with shorter time to death amongst postoperative ICU patients without cancer. The association was concordant across all subgroups.

The predictive ability of the modified frailty index (mFI) for postoperative outcomes and survival in patients with gastric cancer (GC) remains uncertain.

Studies were retrieved from 11 electronic databases. Odds ratio (OR) and 95% confidence intervals (CIs) were used to report surgical outcomes, including overall survival (OS), complications, mortality, readmission, and nonhome discharge. The fixed or random effects model was used depending on the heterogeneity. Subgroup and meta-regression analyses were performed to determine the source of heterogeneity.

This meta-analysis of 13 studies, including 15 359 GC patients, showed that high mFI scores were associated with reduced OS (OR = 1.35) and increased risk of poor postoperative outcomes (OR = 2.61). The older patients with higher mFI scores had a higher risk of worse OS after gastrectomy (OR = 1.69).

This study demonstrated that high mFI scores were strongly associated with reduced OS and increased risk of poor outcomes following surgery in patients with GC, with a more than two-fold increase in the overall risk of poor outcomes. Compared to other tools, the mFI is easy to operate, making it an effective tool for prognosis assessment and personalized treatment and care planning.

PROSPERO (Registration Number: CRD42024613727).

Endoscopic submucosal dissection (ESD) has emerged as the standard treatment for colorectal lesions. Considering aging of the global population, we aimed to assess effectiveness and safety of colorectal ESD in patients aged ≥ 80 years compared with those aged 65 to 79 years in a large Western cohort.

We retrospectively enrolled patients aged > 64 years undergoing colorectal ESD, classifying them into a very elderly group (VE-Group, aged > 80 years) and elderly group (E-Group, 65-79 years). Procedure outcomes and safety were compared between the VE-Group and E-Group and between patients with comorbidities and those who were healthy (1-CM-Group and H-Group).

A total of 980 patients were included (269; 27.5% in the VE-Group and 711; 72.5% in the E-Group). En-bloc, R0, and oncological curative resection rates did not differ, nor did intra-procedure or post-procedure adverse events (AEs). Delirium occurrence was registered in VE-group [6 (2.2%) in VE-Group vs 1 (0.1%) in E-Group; P = 0.001; OR = 16.2, (95%CI:1.9-135.2)]. The 1-CM-Group had a higher rate of intra-procedure bleeding ( P = 0.001), delayed perforation ( P = 0.03), fever onset ( P < 0.001), and systemic infections ( P = 0.02) compared with the H-Group. Having one or more comorbidities was associated with increased overall AEs ( P < 0.001; OR 2.3, 95% CI 1.5-3.6).

Colorectal ESD is feasible in elderly patients. Physicians should consider delirium a possible AE in patients older than age 80 years. These findings, which bridge the gap between Asian and Western clinical data, underscore the importance of tailored pre-procedure and post-procedure assessments in a global clinical context.

With the advances in systemic therapy and radiotherapy, the life expectancy of patients battling cancer has increased. The oculofacial plastic surgeon should be aware of the potential impacts a patient in remission or one being actively treated may pose. The goal of this review is to discuss the considerations a surgeon should have in this patient population.MethodsThe authors performed a computerized search using PubMed, Embase, and Google Scholar. The search terms used were "chemotherapy AND surgery", "immunotherapy AND surgery", "radiotherapy AND surgery", "nutrition AND surgery", "(oculoplastic OR orbit OR eyelid OR lacrimal OR puncta) AND (chemotherapy OR immunotherapy OR radiotherapy)", "(facial OR facial plastic OR oculoplastic) AND (chemotherapy OR immunotherapy OR radiotherapy)", "(cancer OR malignancy) AND surgery", "(cancer OR malignancy) AND (surgery OR surgical) complications", "wound healing AND (cancer OR malignancy)", "infection AND (cancer OR malignancy)", "(bleeding OR blood loss) AND (cancer OR malignancy) AND surgery", "(chemotherapy OR immunotherapy OR radiotherapy) AND wound healing", "(chemotherapy OR immunotherapy OR radiotherapy) AND (bleeding OR blood loss)", "(chemotherapy OR immunotherapy OR radiotherapy) AND infection".ResultsA total of 89 articles, published from 1993 to 2023 in the English language or with English translations were included. Articles published earlier than 2000 were cited for foundational knowledge. References cited in the identified articles were also used to gather further data for the review.Conclusions and RelevancePatients who are being treated for cancer or are undergoing current treatment for cancer require special considerations. Systemic therapies and radiotherapy impact the physiology of patients and the integrity of tissue in ways that significantly impact surgical interventions. It is imperative for the oculofacial plastic surgeon to have a complete understanding on how a previous or current diagnosis of cancer can influence surgical outcomes.

The purpose of this study was to determine whether frailty, quantified by an electronic Frailty Index (eFI), was associated with the likelihood of receiving surgery or laser treatment in patients with glaucoma.

Single-center retrospective review of patients presenting with glaucoma who had a calculable eFI. A repeated measures multivariable logistic regression model was used to determine the relationship between eFI score and the likelihood of having glaucoma surgery, and a multivariable survival model was also created to assess time to glaucoma surgery. Similar models were constructed for laser treatment (LT). Models were adjusted for age, race/ethnicity, sex, baseline intraocular pressure, and severity based on mean deviation.

A total of 1168 patients (2248 eyes) were included in this study. Glaucoma surgery was significantly more likely among those with severe [OR=2.89] or moderate glaucoma [OR=1.89] (p<0.001). Older age (per 10 year increase) was associated with a significantly lower likelihood of receiving glaucoma surgery [OR=0.581, p<0.001], longer times to glaucoma surgery [HR=0.719, p=0.007], and lower likelihood of LT [OR=0.774, p=0.05]. For every 0.1 unit increase in eFI, indicating greater frailty, there was a significantly reduced likelihood of receiving surgical treatment [OR=0.672, p<0.001], longer time to surgery [HR=0.670, p=0.001], and lower likelihood of LT [OR=0.725, p=0.010], independent of IOP, glaucoma severity, age, sex, or race.

Increased age and frailty scores are associated with reduced likelihood of receiving glaucoma surgery or LT and longer time to glaucoma surgery, even after controlling for baseline IOP and glaucoma severity. Future studies should investigate whether frailty impacts surgical outcomes in glaucoma.

Patient frailty has been shown to be a powerful predictor of poor surgical outcome across specialties and may guide patient selection. In awake craniotomy, patient selection is particularly important for completion of intraoperative mapping and to reduce conversion to general anesthesia. We evaluated whether frailty is associated with unsuccessful awake craniotomy or poor outcome.

We performed a single-center retrospective study of adult patients with tumor, epilepsy, and vascular pathologies that underwent first-time awake craniotomy between 2018 and 2024. The Modified Frailty Index-11 (mFI-11) was calculated for each patient, and frailty was defined as a mFI-11 ≥2. We evaluated the association of frailty with unsuccessful awake craniotomy and postoperative complications.

In total, 143 patients met inclusion criteria. There were 39 (27%) frail patients (mFI-11 ≥ 2) and 104 (73%) nonfrail patients (mFI-11 <2). Frail patients were significantly older ( P < .001), had a higher American Society of Anesthesia classification ( P = .015), higher rates of obstructive sleep apnea ( P = .001), higher body mass index ( P = .035), and glioblastoma ( P < .001) compared with the nonfrail group. Frail patients had longer length of stay ( P = .008) and had more than 2 times increased odds of discharge to skilled nursing facility or inpatient rehab facility ( P = .01). Frail patients had no significant increased risk of conversion to general anesthesia or incomplete mapping, intraoperative deficit, 24-hour postoperative deficit, 30-day readmission, or residual neurologic deficit at follow-up.

In our cohort, frailty was associated with higher anesthetic risk and longer length of stay but was not significantly associated with unsuccessful awake craniotomy, postoperative complications, or neurologic outcome.

Surgery is an essential part of cancer treatment, particularly for localised solid tumours. Geriatric assessments (GA) with tailored interventions or comprehensive GA (CGA) can identify frailty factors and needs of older adults with cancer, assisting treatment decisions and care strategies to reduce postoperative complications. This systematic review summarises the effects of GA/CGA compared to usual care for older adults with cancer intended for surgery: their impact on treatment decisions, supportive care interventions, postoperative complications, survival, and health-related quality of life (HRQOL).

We conducted a systematic search of MEDLINE, EMBASE, CINAHL, and PubMed (January 2000-October 2022) for randomised controlled trials (RCTs) or cohort studies with a comparison group on the effects of GA/CGA in older adults with cancer (≥65 years) intended for surgery. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Due to heterogeneity in study designs and reporting, a meta-analysis was not possible; results are narratively described.

From 12,440 citations, 312 were selected for full-text review. Thirteen studies reporting on 12 trials were included for analysis: four RCTs and eight cohort studies with comparison groups (three prospective, five retrospective). RCTs ranged in sample size (122-475; mean 249), with variability in who performed GA/CGA, disciplines involved, and team integration. Primary outcomes included impact of GA/CGA on postoperative delirium (two studies), Clavien-Dindo (CD) grade II-V postoperative complications (one study), hospital length of stay (one study), and a composite criterion including mortality, functional impairment, and weight loss (one study). All RCTs scored high for risk of bias due to underpowering for their primary outcome; none met their primary endpoint. After adjustment for prespecified factors in secondary analyses, one RCT found GA/CGA significantly reduced the odds of postoperative complications (CD grade I-V) (adjusted-OR: 0.33, 95 %CI: 0.11-0.95; p = 0.05) due to fewer grade I-II complications. One RCT reported no significant difference between groups in HRQOL: intervention patients reported less pain at discharge, but this difference disappeared at three-month follow-up.

Well-powered, high-quality trials are needed to determine the impact of GA/CGA on optimising surgical treatment decisions, supportive care and postoperative outcomes for older adults with cancer.

Frailty has become an increasingly recognized perioperative risk stratification tool. While frailty has been strongly correlated with worsening surgical outcomes, the individual determinants of frailty have rarely been investigated in the setting of aortic disease. The aim of this study was to examine the determinants of an 11-factor modified Frailty Index (mFI-11) on mortality and postoperative complications in patients undergoing endovascular aortic aneurysm repair (EVAR).

Data from the National Surgical Quality Improvement Program database were queried for all patients undergoing nonemergent EVAR between 2005 and 2019. Univariate logistic regression was used to assess associations between mFI-11 variables and complications occurring within 30 days of surgery. Significant variables were then used for multivariate analysis. Variables included in mFI-11 scoring are diabetes, nonindependent functional status, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction (MI), previous percutaneous coronary intervention, cardiac surgery or angina, hypertension requiring medication, peripheral vascular disease, impaired sensorium, and previous transient ischemic attack or cerebrovascular accident. Overall complications included superficial surgical site infection, deep incisional surgical site infection, deep vein thrombosis, readmission, reintervention, bleeding requiring transfusions, major adverse events (MAEs), and mortality. MAEs included those classified as Clavien-Dindo grade IV, defined as life-threatening complications requiring intensive care unit-level management and single or multiple organ failure. Odds ratios (ORs) were calculated using SPSS 29.

A total of 50,798 patients were identified, resulting in a cohort that was 81% male with an average age of 73.3 ± 8.5 years. Binary regression revealed a significant increase in 30-day mortality (OR = 1.49; 95% confidence interval [CI]: 1.34-1.66; P < 0.001), overall complications (OR = 1.30; 95% CI: 1.25-1.35; P < 0.001), MAEs (OR = 1.55; 95% CI: 1.45-1.65; P < 0.001), stroke (OR = 1.41; 95% CI: 1.15-1.72; P < 0.001), prolonged mechanical ventilation (OR = 1.63; 95% CI: 1.47-1.81; P < 0.001), acute kidney injury (OR = 1.37; 95% CI: 1.20-1.57; P < 0.001), cardiac arrest (OR = 1.71; 95% CI: 1.44-2.04; P < 0.001), and MI (OR = 1.54; 95% CI: 1.35-1.75; P < 0.001) per 1-point increase in mFI-11 score. Multivariate analysis demonstrated that functional dependency was highly associated with increased odds of all outcomes except stroke, cardiac arrest, and MI, and impaired sensorium was highly associated with 30-day mortality.

The mFI-11 is a strong predictor for postoperative complications and mortality in patients undergoing nonemergent EVAR. Measurement of frailty should be considered in the preoperative assessment of patients being evaluated for EVAR, with particular attention to the risk/benefit of aortic repair in those with dependent functional status or impaired sensorium.

Frailty increases the risk of mortality in the head and neck cancer population. This study examines the association between frailty and survival outcomes in patients with laryngeal squamous cell cancer (LSCC).

Retrospective data collection from patients in the West of Scotland diagnosed with LSCC between 2014 and 2020. The Modified Five Item Frailty Index (mFI-5) measures frailty and categorizes patients according to their level of frailty. Statistical tests used were the Mann-Whitney U-test or ANOVA for differences in means and survival analyses for overall survival time.

There were 867 patients included. Seventy-eight percent (n = 676) of patients were deemed frail. Median survival for "not frail" patients was 78 months and "severely frail" was 23 months. The palliative treatment group had worse overall survival outcomes compared to curative (hazard ratio (HR) of 7.96, p < 0.001).

This study demonstrates frailty is common in patients with LSCC and leads to worse mortality and survival outcomes.

Risk stratification is a crucial tool to help in surgical planning and counseling. Historically, this has been measured by age, BMI, smoking status, or medical comorbidities. Frailty, the combined burden of the patient's comorbidities and risk factors, has gained traction as a method of combining disparate risk factors into one number. The modified 5-factor frailty index (mFI-5) is simple to calculate and takes only moments to assign a risk level to a patient.

This study aimed to study the application and efficacy of the mFI-5 as a measurement of operative risk in immediate breast reconstruction.

A total of 650 patients undergoing breast reconstruction at our institution were identified. Patients were divided into 5 mFI-5 groups based on their associated comorbidities. Surgical outcomes were compared using the χ 2 or Fisher exact tests for categorical variables and t tests for continuous variables.

There were 452 patients stratified into the mFI-5 0 group, 155 patients into the mFI-5 1 group, 40 patients into the mFI-5 2 group, and 3 patients into the mFI-5 3 group. There were no patients in our cohort in either the mFI-5 4 or 5 groups. In comparison of the mFI-5 0 group to 1 group, there was a significant difference in postoperative day of infection (32.06 vs. 21.5 days. respectively; P = 0.049). When comparing to the mFI-5 2 group, there was a significant difference in overall complications on univariate analysis ( P = 0.012), minor infections on univariate and multivariate analysis ( P = 0.050 and P < 0.001), seroma formation on univariate analysis ( P = 0.017), hematoma formation ( P < 0.001), return to OR ( P < 0.001), and replaced implant ( P < 0.001) on multivariate analysis. When comparing the mFI-5 1 group to the mFI-5 2 group, there was a significant difference between overall complications on both univariate and multivariate analyses ( P = 0.012 and P = 0.041) and minor infections on univariate analysis ( P = 0.032).

The modified 5-factor frailty index is effective in predicting increased complication risks seen after IBR and may be helpful for surgeons when counseling patients and assessing overall operative risk.

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.

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.

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).

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.

The modified 5-item frailty index (mFI-5), an index of reduced physiological reserve, has risen as a predictor of complications following surgical procedures. We examined the association of mFI-5 and surgical outcomes following the management of nontraumatic subarachnoid hemorrhage (nSAH). We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients who received surgical management of nSAH between 2006 and 2021. We computed the mFI-5 by granting a point for each of 1) congestive heart failure, 2) hypertension requiring medications, 3) diabetes, 4) chronic obstructive pulmonary disease or pneumonia within 30 days before surgery, and 5) dependent functional status. Our 30-day endpoints were minor complications (Clavien-Dindo: 1 & 2), major complications (Clavien-Dindo: 3 & 4), and mortality. Using the Chi-squared test, we compared baseline patient demographics and comorbidities between patients with a mFI-5 ≥ 2, patients with a mFI-5 = 1, and non-frail patients. Then, we fitted a multivariable logistic regression adjusting for patient demographics, comorbidities, operative time, and frailty status. The cohort included 1,139 patients, of which 33.7 % were men and 2.9 % had a bleeding diathesis. After adjusting for covariates, mFI-5 ≥ 2 was independently associated with minor complications (1.93, 95 %CI: 1.31-2.84, p = 0.001), major complications (aOR: 1.62, 95 %CI: 1.10-2.37, p = 0.015), and mortality (aOR: 2.90, 95 %CI: 1.66-5.08, p = 0.003). The mFI-5 can be independently used by surgeons for risk stratification and postoperative planning.

Frailty has emerged as a critical predictor of postoperative outcomes, particularly in older surgical patients. However, its role in mastectomy patients remains underexplored. This study evaluates the utility of the 5-item Modified Frailty Index (mFI-5) in predicting 30-day postoperative complications in mastectomy patients, aiming to improve risk stratification and inform clinical decision-making.

A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2008 to 2022. Patients were categorized into high-risk (mFI-5 ≥ 2) and low-risk (mFI-5 < 2) groups. Propensity score matching (PSM) was applied to create balanced cohorts and multivariate logistic regression was used to evaluate associations between frailty and postoperative outcomes.

Of the 252,054 adult female patients who underwent mastectomy, 1.2 % were identified as high-risk frail. High-risk patients were older (70 ± 9.9 vs. 60 ± 14 years, P < .001) and had a higher BMI (35 ± 9.1 vs. 29 ± 7.1 kg/m², P < .001) compared to low-risk patients. After PSM, high-risk patients had significantly higher odds of any complication (OR: 2.05, 95 % CI: 1.70-2.47, P < .001), surgical complications (OR: 1.70, 95 % CI: 1.38-2.10, P < .001), and medical complications (OR: 3.81, 95 % CI: 2.64-5.50, P < .001). Key complications included infections, bleeding requiring transfusion, and unplanned readmissions.

The mFI-5 effectively identifies mastectomy patients at higher risk of postoperative complications, including medical complications and unplanned reoperation or readmission, underscoring its value in preoperative risk stratification. Incorporating frailty assessments into clinical practice could enhance surgical decision-making, optimize resource allocation, and improve patient outcomes.

The management of distal femoral fractures (DFFs) can be challenging, with a historically high rate of non-union and reoperations. While lateral locked plating and intramedullary nailing were shown to have similar rates of non-union, nail-plate combinations (NPC) have been shown to have higher rates of union and improved clinical outcomes compared to single constructs (SC). The purpose of this meta-analysis was to compare NPC and SC in the treatment of DFFs.

PubMed, Cochrane, and Google Scholar databases (pages 1-20) were queried through October 2024. Studies that compared NPC to SC in patients with DFF were included. Outcomes including overall complications, specific complications (implant failure, heterotopic ossification (HO), nonunion, malunion, and surgical site infection (SSI)), reoperations, immediate post-operative weight-bearing status, and surgery-related parameters (operative room (OR) time, estimated blood loss (EBL), and length of stay (LOS)) were compared between the two groups.

Five retrospective studies including 637 patients met the inclusion criteria (146 patients in the NPC group and 491 patients in the SC group). The NPC group had a lower rate of overall complications (OR 0.21, p < 0.001), reoperations (OR 0.29, p < 0.001), implant failure (OR 0.15, p = 0.01), non-unions (OR 0.12, p < 0.001), and malunion (OR 0.29, p = 0.03). Furthermore, the NPC group had a lower rate of patients instructed to be non-weightbearing post-operatively (OR 0.06; p < 0.001). There was no difference in HO, SSI, OR time, EBL or LOS between the 2 groups.

The present meta-analysis demonstrates a reduced rate of complications, reoperations, implant failure, nonunions and malunions in patients undergoing NPC for DFFs.

III.

Frailty is common among surgical patients and predicts poor surgical outcomes. This study aimed to analyze transitions in frailty state among patients undergoing lower extremity care for chronic limb-threatening ischemia (CLTI).

Between 2018 and 2022, all patients undergoing a primary intervention for CLTI (endovascular intervention [EV], bypass [BYP], major amputation [AMP]) or wound care were analyzed. Frailty was assessed by Vascular Quality Initiative-derived Risk Analysis Index. Frailty was defined as a Vascular Quality Initiative-derived Risk Analysis Index score of ≥35. Transition in frailty state between preoperative and follow-up measurement at 1 month and 1 year were analyzed. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis. Amputation-free survival (survival without AMP) and freedom from major adverse limb events (above-ankle amputation of the index limb or major re-intervention (new BYP graft, jump/interposition graft revision) were evaluated.

We included 1859 patients (56% male; mean age, 65 ± 11 years) who underwent either EV (52%), a BYP (29%), AMP (13%), or wound care (6%). Amon them, 25% were considered frail on initial evaluation (28%, 16%, 32%, and 30% EV, BYP, AMP, and wound care, respectively). At 30 days, overall frailty increased to 34%: 13% of patients moved from nonfrail to frail (9%, 18%, 22%, and 5% for EV, BYP, AMP, and wound care, respectively), and 4% of patients moved from frail to nonfrail (6%, 2%, 1%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, overall frailty increased to 40%: an additional 13% of patients shifted from nonfrail to frail (15%, 6%, 23%, and 8% for EV, BYP, AMP, and wound care, respectively), and 5% of patients shifted from frail to nonfrail (4%, 8%, 2%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, frailty increased by 28% in EV, 16% for BYP, 32% in AMP, and 43% in wound care. Frailty at baseline, 30 days, and 1 year was associated with a high Charlson's Comorbidity Index. Shifting to a frail state postoperatively was associated with decreased survival and a lower amputation-free survival at 1 year.

After major interventions for CLTI at 1 year, 27% of patients shift from a nonfrail to a frail state, and 9% of patients shift from a frail to a nonfrail state with differences across modalities in comparison to wound care, where 13% of patients moved from a nonfrail to a frail state, and none shifted from a frail to a nonfrail state. Shifting to a frail state after intervention is associated with poor outcomes and should be considered when evaluating and intervention in a patient with CLTI.

 Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate preoperative assessment can aid in appropriate risk stratification and peri-operative optimization. The modified five-item frailty index (mFI-5) is a validated risk-assessment scale; however, its utility in head and neck free-flap reconstruction is unknown when compared with other common risk factors.

 A retrospective, single-institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A high mFI-5 score was defined as greater than 2. The total score, as well as other patient factors, was correlated to postoperative flap complications.

 A total of 214 patients were deemed appropriate for conclusion. The mean age was 63.9 ± 12.8 years. There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent preoperative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any postoperative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p < 0.019) and total flap loss (16.7% vs. 6.6%, p < 0.033). Preoperative radiation was found to be associated with an increased complication rate (p < 0.003).

 The mFI-5 score may be a potentially significant tool in the risk stratification of patients undergoing head and neck free-flap reconstruction as opposed to commonly utilized risk factors. Preoperative radiotherapy is significantly associated with postoperative complications. Appropriate preoperative assessment may help tailor patient care preoperatively.

We evaluate the impact of frailty and malnutrition on breast cancer surgery outcomes in older adults using the ACS 5-factor modified frailty index (MFI) and Global Leadership Initiative on Malnutrition (GLIM) definition.

Single institution retrospective review of a prospective database of the older adult (>60 years old) breast cancer surgery patients (2000-2016); cases stratified into groups as per MFI (0-2) and GLIM. Characteristics, 90-day post-op events, and 5-year follow-up data were analyzed to report survival and complication outcomes.

Among 436 patients at diagnosis, 213 (48.9%) were >80 years old. 377 (86.5%) were alive at 5 years. 274 (62.8%) had MFI > 0, and 69 (15.8%) had malnutrition. Patients ≥ 80, MFI > 0, and PR-negative tumors had worse 5-year survival. There was no survival difference in patients >80 with/without malnutrition (HR = 1.01, p = 0.971), and there was no difference in mastectomy or lumpectomy (p = 0.560) between patients ≥ 80 or patients younger than 80; however, 94% of immediate reconstruction were in pts < 80. On multivariate regression, complications were associated with age < 80, readmission, MFI > 0, and history of HTN; serious complications were associated with age < 80, readmission, anticoagulation, and not receiving endocrine therapy.

MFI showed a significant predictive value for 5-year survival for patients ≥ 80 and should be part of the preoperative evaluation.

Older adults undergoing surgery frequently have multiple comorbidities and reduced physical and cognitive reserves. This study aims to assess the effect of physical and cognitive frailty on long-term mortality in older patients undergoing elective non-cardiac surgery in a tertiary center.

Patients aged ≥65 years old admitted to surgical wards at the University of Malaya Medical Centre were recruited. Physical frailty and cognitive status were assessed using the Fried Frailty Index (FFI) and the Montreal Cognitive Assessment, respectively. Patients were stratified into six groups based on their frailty and cognitive status: Group 1, normal cognition and non-frail (reference group); Group 2, normal cognition and frail; Group 3, mild cognitive impairment (MCI) and non-frail; Group 4, MCI and frail; Group 5, dementia and non-frail; and Group 6, dementia and frail.

A total of 406 patients with a mean FFI score of 1.1±1.2 were recruited. Predictors of mortality include male sex (hazard ratio [HR]=1.96; 95% confidence interval [CI], 1.14-3.37; p=0.015), presence of active malignancy (HR=3.86; 95% CI, 2.14-6.95; p<0.001), and high FFI scores (1.8±1.2 vs. 1.0±1.1; p=0.013). Compared to Group 1, long-term mortality risk was significantly increased in Group 4 (HR=3.17; 95% CI, 1.36-7.38) and Group 6 (HR=3.91; 95% CI, 1.62-9.43) patients.

The combination of physical frailty and cognitive impairment was associated with long-term mortality risk among older patients who underwent elective non-cardiac surgery. This highlights the importance of assessing physical frailty and cognitive function of all older surgical patients to guide targeted intervention, especially for those with impairments which may be potentially reversible.

Frailty is one of the most common symptoms in patients with cirrhosis. Many researchers have identified it as a prognostic factor for patients with cirrhosis. However, no quantitative meta-analysis has evaluated the prognostic value of frailty in patients with cirrhosis.

This systematic review and meta-analysis aimed to assess the prognostic significance of frailty in patients with cirrhosis.

The systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. We conducted a comprehensive search of the literature using databases such as PubMed, Cochrane Library, Embase, and Web of Science, as well as China National Knowledge Infrastructure, encompassing the period from inception to 22 December 2023. Data were extracted for frailty to predict adverse outcomes in patients with cirrhosis. RevMan (version 5.3) and R (version 4.2.2) were used to assess the extracted data.

A total of 26 studies with 9597 patients with cirrhosis were included. Compared with patients having low or no frailty, the frail group had a higher mortality rate (relative ratio, RR=2.07, 95% CI 1.82-2.34, P<.001), higher readmission rate (RR=1.50, 95% CI 1.22-1.84, P<.001), and lower quality of life (RR=5.78, 95% CI 2.25-14.82, P<.001). The summary receiver operator characteristic (SROC) curve of frailty for mortality in patients with cirrhosis showed that the false positive rate (FPR) was 0.25 (95% CI 0.17-0.34), diagnostic odds ratio (DOR) was 4.17 (95% CI 2.93-5.93), sensitivity was 0.54 (95% CI 0.39-0.69), and specificity was 0.73 (95% CI 0.64-0.81). The SROC curve of readmission showed that the FPR, DOR, sensitivity, and specificity were 0.39 (95% CI 0.17-0.66), 1.38 (95% CI 0.64-2.93), 0.46 (95% CI 0.28-0.64), and 0.60 (95% CI 0.28-0.85), respectively.

This meta-analysis demonstrated that frailty is a reliable prognostic predictor of outcomes in patients with cirrhosis. To enhance the prognosis of patients with cirrhosis, more studies on frailty screening are required.

Pre-injury frailty among older adults with trauma injuries is a predictor of increased morbidity and mortality.

We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED).

Using a retrospective cohort design, we pooled trauma data from a single institutional trauma database from August 2020 to June 2023. We limited the data to adults 65 years and older, who had trauma injuries and frailty screening at ED presentation (N = 2,862). The predictor variable was frailty status, measured as either robust (score 0), pre-frail (score 1-2), or frail (score 3-5) using the FRAIL index. The outcome variables were measures of clinical care trajectory: trauma team activation, inpatient admission, ED discharge, length of hospital stay, in-hospital death, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, health insurance type, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories.

The mean (SD) age of the study population was 80 (8.9) years, and the population was predominantly female (64%) and non-Hispanic White (60%). Compared to those classified as robust, those categorized as frail had 2.5 (95% CI: 1.86-3.23), 3.1 (95% CI: 2.28-4.12), and 0.3 (95% CI: 0.23-0.42) times the adjusted odds of trauma team activation, inpatient admission, and ED discharge, respectively. Also, those classified as frail had significantly longer lengths of hospital stay as well as 3.7 (1.07-12.62), 0.4 (0.28-0.47), and 2.2 (95% CI: 1.71-2.91) times the odds of in-hospital death, home discharge, and discharge to rehabilitation, respectively.

Pre-injury frailty is a predictor of clinical care trajectories for older adults with trauma injuries.

Frailty is a significant factor contributing to an increased risk of adverse clinical outcomes in older cancer patients. This study aims to investigate the impact of the 5-item modified frailty index (mFI) on both short-term and long-term prognosis in elderly rectal cancer patients who underwent radical resection. And, by integrating the 5-item mFI with clinicopathological characteristics, a postoperative severe complications nomogram and a cancer-specific survival (CSS) prediction nomogram were further constructed. Demographic, clinical, and therapeutic data were collected from 1,034 patients aged ≥ 70 years with rectal cancer who underwent proctectomy between 2017 and 2022. Patients were categorized into three groups based on their mFI scores: 318 patients with mFI = 0, 404 patients with mFI = 1, and 312 patients with mFI ≥ 2. Comparisons among these groups revealed that higher 5-item mFI scores were associated with an increased incidence of both overall and severe postoperative morbidity, prolonged recovery times, and elevated total medical costs. Multivariate logistic regression analysis indicated that an mFI score of ≥ 2 [odds ratio = 2.856, 95% confidence interval (CI): 1.542-5.290, P < 0.001] was an independent risk factor for severe postoperative complications. Similarly, in competing risk analysis, the 5-item mFI was identified as an independent prognostic factor for CSS (subdistribution hazard ratio = 2.00, 95% CI: 1.47-2.72, P < 0.001). The postoperative severe complications nomogram and CSS prediction nomogram AUC values were 0.726 and 0.844, respectively, both demonstrating promising predictive capabilities. In conclusion, the 5-item mFI serves as a concise and effective tool for preoperative frailty stratification and for predicting clinical outcomes in elderly rectal cancer patients.

Despite growing interest in how patient frailty affects outcomes (eg, in neuro-oncology), its role after transsphenoidal surgery for Cushing disease (CD) remains unclear. We evaluated the effect of frailty on CD outcomes using the Registry of Adenomas of the Pituitary and Related Disorders (RAPID) data set from a collaboration of US academic pituitary centers.

Data on consecutive surgically treated patients with CD (2011-2023) were compiled using the 11-factor modified frailty index. Patients were classified as fit (score, 0-1), managing well (score, 2-3), and mildly frail (score, 4-5). Univariable and multivariable analyses were conducted to examine outcomes.

Data were analyzed for 318 patients (193 fit, 113 managing well, 12 mildly frail). Compared with fit and managing well patients, mildly frail patients were older (mean ± SD 39.7 ± 14.2 and 48.9 ± 12.2 vs 49.4 ± 8.9 years, P < .001) but did not different by sex, race, and other factors. They had significantly longer hospitalizations (3.7 ± 2.0 and 4.5 ± 3.5 vs 5.3 ± 3.5 days, P = .02), even after multivariable analysis (β = 1.01, P = .007) adjusted for known predictors of prolonged hospitalization (age, Knosp grade, surgeon experience, American Society of Anesthesiologists grade, complications, frailty). Patients with mild frailty were more commonly discharged to skilled nursing facilities (0.5% [1/192] and 4.5% [5/112] vs 25% [3/12], P < .001). Most patients underwent gross total resection (84.4% [163/193] and 79.6% [90/113] vs 83% [10/12]). No difference in overall complications was observed; however, venous thromboembolism was more common in mildly frail (8%, 1/12) than in fit (0.5%, 1/193) and managing well (2.7%, 3/113) patients ( P = .04). No difference was found in 90-day readmission rates.

These results demonstrate that mild frailty predicts CD surgical outcomes and may inform preoperative risk stratification. Frailty-influenced outcomes other than age and tumor characteristics may be useful for prognostication. Future studies can help identify strategies to reduce disease burden for frail patients with hypercortisolemia.

Frailty and multimorbidity are common in older adults, but the prevalence and interaction of these conditions in surgical patients remain unclear. This study describes the clinical characteristics of a heterogeneous cohort of older UK surgical patients.

We conducted a prospective observational cohort study during 5 days in March 2022, aiming to recruit all UK patients aged 60 yr and older undergoing surgery, excluding minor procedures (e.g. cataract surgery). Data were collected on patient characteristics, clinical care, frailty, and multimorbidity measures.

A total of 7134 patients from 214 NHS hospitals were recruited, with a mean (sd) age of 72.8 (8.1) yr. Of all operations, 69% (95% confidence interval [CI] 67.9-70.1%) were elective, and 34% (95% CI 32.7-34.8%) were day cases. Of the patients, 19% (95% CI 18.3-20.1%) were living with frailty (Clinical Frailty Score ≥5), and 63.1% (95% CI 62.0-64.3%) were living with multimorbidity (count of ≥2 comorbidities). Those living with frailty, multimorbidity, or both were typically older, were from lower socioeconomic backgrounds, and experienced greater polypharmacy and reduced independence. Patients living with frailty were less likely to undergo elective and day-case surgeries. Four out of five (78.8% [1079/1369]) of those who were living with frailty were also living with multimorbidity; 27.1% (1079/3978) of those who were living with multimorbidity were also living with frailty.

In the UK, one in five older patients undergoing surgery is living with frailty, and almost two-thirds of older patients are living with multimorbidity. These data highlight the importance of frailty screening. In addition, they can serve to guide resource allocation and provide comparative estimates for future research.

Sigmoid volvulus (SV) is a common cause of bowel obstruction, especially in older patients. SV can be mesenteroaxial (M-SV) or organoaxial (O-SV). The purpose of this study was to assess if CT findings in SV are associated with clinical outcomes. including recurrence, choice of management, and mortality.

This study includes patients with SV and a CT within 24 hours of presentation. CT features, including mesenteraoxial/organoaxial arrangement, direction of rotation, transition points, distension, whirl-sign, ischemia, and perforation were determined. Demographics, treatment, recurrence, and outcome data were recorded.

One hundred and seventeen cases were diagnosed in 80 patients (54 male). The mean age was 70 years (± 17.1). M-SV and O-SV were equally prevalent (n = 39 vs. n = 41, respectively). M-SV was significantly more common with anticlockwise rotation in the axial plane (p = 0.028) and clockwise rotation in the coronal plane (p = 0.015). All patients with imaging features of ischemia underwent surgery (n = 6). There was no significant difference in outcome variables (30-day mortality, 30-day readmission, recurrence) between the O-SV and M-SV groups. The degree of bowel distension on initial presentation was a significant predictor of recurrence, with ≥ 9 cm vs < 9 cm associated with an increased odds of any recurrence (OR: 3.23; 95%CI: 1.39-7.92).

In SV, sigmoid distension of more than 9 cm at baseline CT was associated with an increased risk of recurrence. Imaging features of ischemia predicted surgical over endoscopic intervention. Organoaxial and mesenteroaxial SV had similar prevalence, but the type of volvulus was not associated with clinical outcomes or choice of management.

There is a risk of recurrent sigmoid volvulus with colonic distension greater than 9 cm. This work, comparing volvulus subtypes, shows that this finding at the initial presentation could expedite consideration for surgical management.

Reports of outcomes for different subtypes and rotational directions of volvuli have been contradictory. No difference in measured outcomes was found between subtypes; distension ≥ 9 cm predicted recurrence. CT features can aide management of sigmoid volvulus and can prompt surgical intervention.

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

This study aims to evaluate the potential association of perioperative hearing outcomes with frailty by Modified 5-Item Frailty Index (mFI-5).

Retrospective cross-sectional study.

Single-institutional study conducted at a tertiary care hospital between January 2018 and January 2022.

All adult patients older than 50 years who underwent cochlear implantation (CI).

Cochlear implantation.

Hearing outcomes were measured using pre-CI and longitudinal post-CI quiet AzBio scores. Frailty was determined by mFI-5 scores (0 = not frail, 1 = prefrail, and 2+ = frail). Univariable and multivariable linear regressions, ordinal logistic regressions, and time-to-event curves were used to determine perioperative speech perception and likelihood of high-performance hearing (defined as ≥70% on AzBio).

Of the 126 patients, the median age was 70 (63-77) years, 50% (63) were female, and 39% (49) identified as non-Hispanic Black, Hispanic, or other. By mFI-5 scoring, 38% (48) had no frailty, with 34% (43) and 28% (35) scoring 1 and 2+, respectively. When adjusting for age, sex, race, and BMI, scoring 1 point on mFI-5 was associated with significantly lower pre-implantation and post-implantation AzBio scores (pre: = -15 [-26, -3.4], p < 0.05; post: = -14 [-25, -3.0], p < 0.05). When controlling for all covariates, prefrailty and frailty were associated with significantly decreased likelihood of high-performance hearing (prefrailty OR: 0.22 [0.07, 0.63], p < 0.01; frailty OR: 0.31 [0.10, 0.92], p < 0.05). Time-to-event curves demonstrate significantly reduced likelihood of reaching high-performance hearing within 7 months after CI in patients with mFI-5 scores >0 (p < 0.05).

Our findings suggest that prefrailty is associated with worse pre-CI and post-CI hearing and lower likelihood of high-performance hearing within 7 months post-CI. Preoperative frailty screening in adult CI candidates may better inform providers of patients' long-term risk-to-benefit.

Spatially fractionated radiation therapy (SFRT) is an irradiation technique developed to improve large cancer response. Although preliminary studies report highly positive results, data are still limited. The aim of this retrospective monocentric study was to investigate SFRT safety and activity.

We analyzed all patients who underwent SFRT as a palliative treatment for large solid extracranial cancer (>4.5 cm) at our institution. The primary endpoint was objective response rate assessment at 3 months. Additionally, patients' antalgic response, target volume reduction, and performance status modification were measured. Toxicity data were recorded.

From November 2021 to August 2023, 20 consecutive patients (20 lesions) underwent SFRT. We prescribed a minimum dose of 20 Gy in 5 fractions to 95% of the Planning Target Volume (PTV_20) and a minimum dose of 50 Gy to 50% of the sphere volume. The median beam-on time was 5 minutes (IQR1-3, 4-7 minutes; range, 3-16 minutes). Patients' median age was 70 years (range, 18-85 years). The median lesion volume was 560.4 cm3 (IQR1-3, 297.4-931.5 cc; range, 168.3-3838.3 cm3). Of the 20 patients, 14 and 10 were alive at 3 and 6 months, respectively. The 3-month objective response rate was 79% (95% CI, 49%-95%), with a median target volume reduction of 54% (IQR1-3, 32%-69%; range, 6%-80%). At 6 months, all patients were free from local disease progression. All patients reported an antalgic response with a rapid onset. All treatment-related toxicities occurred within 1 month after SFRT and quickly recovered. No acute toxicity ≥ grade 3 and late toxicity was reported. No patient experienced a worsening in performance status.

Our results provide further evidence supporting SFRT as a safe and promising option for palliative patients affected by large neoplastic lesions.

Adrenal masses are being found more and more often over the years. Given the association of these masses with advancing age, the decision to perform surgery in older, sometimes asymptomatic patients presents a clinical dilemma. These patients are potentially more vulnerable to adverse postoperative outcomes due to increased frailty. Therefore, this study aimed to compare the postoperative course after adrenalectomy in patients aged 70 years and older to that of a younger cohort. This single center retrospective study included patients aged ≥ 70 years who underwent adrenalectomy between 2000-2020, and propensity-score matched younger patients (< 70 years). Patients were matched based on hormonal overproduction, malignant diagnosis, surgical approach and year of surgery. The study included 77 elderly patients (median age 74 years) and 77 younger patients (median age 52 years; p < 0.001). Serious complications (Clavien-Dindo ≥ 3) occurred in 9.1% of elderly patients and 6.5% of the matched younger cohort (p = 0.773). The overall complication rate was 44.2% in elderly and 40.3% in younger patients (p = 0.771), with similar duration of hospital admission and mortality in both groups. Elderly patients experienced mostly infectious (33.8%) or cardiovascular complications (27.0%), and cardiovascular complications were more frequent in elderly than in younger patients (6.7%, p = 0.039). In conclusion, patients aged 70 years and older who undergo adrenalectomy have a similar postoperative course and complication rate as younger patients, with most postoperative complications being minor, and mortality being minimal. Therefore, older age itself should not be a reason to refrain from adrenalectomy.

Examine the association between age and treatment outcomes in conditions causing single- versus multilevel airway restriction.

Multi-institutional retrospective cohort study.

Tertiary laryngology centers.

Participants included younger (18-64 years) and geriatric (≥65 years) adults with posterior glottic stenosis (PGS), multilevel airway stenosis (MLAS), and bilateral vocal fold paralysis (BVFP). Subgroup demographics, comorbidities, type, and etiology of airway compromise were described. Associations between age and primary outcome variables (i.e., tracheostomy and decannulation rates, number of surgeries performed, time between surgeries, and change in quality-of-life patient-reported outcome measures [PROMs]) were evaluated. Statistical analyses included independent t tests, χ2, Fisher's exact, or Mann-Whitney tests.

In 158 patients [96 younger (30 PGS, 29 MLAS, 37 BVFP) and 62 geriatric (24 PGS, 9 MLAS, 29 BVFP)], age differences were not significant for gender (P = .990), tracheostomy placement (70% vs 66%, P = .629), or decannulation success (40% vs 24%, P = .091) in younger versus geriatric groups, respectively. In younger patients, MLAS was more common (30.2% vs 14.5%, P = .024), and BVFP patients were more likely to decannulate (50% vs 12%, P = .017). Geriatric patients were more likely to have a history of prior radiation (26% vs 10%, P = .016), stenosis due to malignancy (23% vs 9%, P = .022), and fewer overall surgeries (median 1 vs 3, P = .003). Median PROMs were comparable between age subgroups (P > .05).

Younger adults underwent more surgeries, but overall comorbidities, tracheostomy decannulation rates, and PROMs were comparable between groups. Age does not negatively impact treatment outcomes and should not be a deterrent in treatment decision-making.

To investigate the utility of the five-item Modified Frailty Index (MFI-5) as a preoperative risk-stratification tool in video-assisted thoracoscopic surgery (VATS) for patients with the same American Society of Anesthesiologists (ASA) class.

This was a retrospective cohort study utilizing data from The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database from 2008 to 2021.

The NSQIP includes 685 participating hospitals in all 50 states, the majority being large, academic medical centers.

All patients undergoing VATS were identified via CPT codes in the deidentified NSQIP dataset. Patients with invalid values for any variables of interest or significant covariates were excluded.

No interventions were applied to any patients in this retrospective cohort study.

69,145 patients undergoing VATS were included, with the largest number having single lobectomy (32%) or unilateral wedge resection (26%). A total of 1,277 (1.8%) had unplanned reintubation, and 1,155 (1.7%) had ventilator dependence (VentDep) >48 hours after surgery. Of these patients, 66% were ASA class 3. Overall, ASA classification had a stronger correlation with both VentDep rates (adjusted R2 difference: +6.1%) and reintubation rates (adjusted R2 difference: +1.5%) than the MFI-5 score. However, combining ASA class with MFI-5 score was a stronger predictor for both primary outcomes than the ASA class alone (adjusted R2 difference: +1.5%, p < 0.001). The MFI-5 had the strongest correlation with both outcomes among ASA class 3 patients, demonstrating exponentially increasing odds of VentDep and reintubation (MFI 3 v MFI 0: odds ratio = 5.1 [3.7, 7], p = 0.002). MFI-5 also helped classify risk within ASA class 2 patients but not as reliably as for ASA class 3 (ASA class 2 reintubation: increased probability from MFI 0-1 and 1-2; VentDep: increased probability from MFI 0-1 only, p = 0.005).

The MFI-5 is a comorbidity-based scale that can be calculated preoperatively and considers distinct, but complementary information to the ASA class. Among VATS patients with identical ASA classes 2 and 3, the MFI-5 further stratified risk for reintubation and ventilator dependence >48 hours postsurgery.

Frailty is a well-recognized predictor of poor surgical outcomes for older adults, yet effective measurements and interventions remain limited. Technological advances offer an opportunity to address this gap and improve surgical care for older adults. This paper reviews the background of frailty and comprehensive geriatric assessments in surgery, and how technological innovations can advance frailty measurement and intervention in surgical settings. We review two broad areas of technological advancement as applied to frailty in surgery: 1) Innovation in the use of electronic health records (EHR) using Artificial Intelligence (AI) and Machine Learning (ML), and 2) Novel uses for wearable sensors and mobile health (mHealth) applications. We explore the integration of AI and ML with EHR systems, which can surpass traditional comorbidity indices by providing comprehensive health assessments and enhancing prediction models. Innovations like the electronic Frailty Index (eFI) show promise in expanding the reach of frailty assessments and facilitating real-time screening. Additionally, wearable devices and mobile health (mHealth) applications offer new ways to monitor and improve physical activity, nutrition, and psychological well-being, supporting perioperative rehabilitation. While these technologies present challenges, such as the need for infrastructure, training, and data interoperability, they offer promising strategies to facilitate the assessment and management of frailty among surgical patients. Continued research and tailored implementation strategies will be essential to fully realize the potential of these advancements in improving surgical outcomes for frail older adults.

COVID-19 survivors are at greater risk for new medical conditions. Among older adults, where multimorbidity and functional impairment are common, frailty measurement provides a tool for understanding how infection impacts future health beyond a one-disease-at-a-time approach. We investigated whether COVID-19 was associated with change in frailty among older Veterans.

Data were from the Veterans Affairs (VA) COVID-19 Observational Research Collaboratory, which extracted VA medical record data. We included Veterans who had COVID-19 from March 1, 2020, to April 30, 2021 and matched uninfected controls. We excluded those <50 years at index or did not survive 12 months after. Frailty was assessed at the index date and 12 months using the VA Frailty Index (VA-FI). We assessed the number of new VA-FI deficits over 12 months. Analysis was done by negative binomial regression adjusted for age, gender, race, ethnicity, and BMI. Coefficients are given as the ratio of the mean number of new deficits in COVID-19 cases versus controls during follow-up.

We identified 91,338 COVID-19-infected Veterans and an equal number of matched controls. Median (IQR) age was 68.9 years (60.3-74.2), 5% were female, 71% were White, and baseline VA-FI was 0.16 (0.10, 0.26). Median (IQR) number of new deficits at 1 year was 1 (0-2) for infected and 0 (0-1) for uninfected controls. After adjustment, those with COVID-19 accrued 1.54 (95% CI 1.52-1.56) times more deficits than those who did not. The five most common new deficits were fatigue (9.7%), anemia (6.8%), muscle atrophy (6.5%), gait abnormality (6.2%), and arthritis (5.8%).

We found a greater increase in frailty among older Veterans with COVID-19 compared with matched uninfected controls, suggesting that COVID-19 infection has long-term implications for vulnerability and disability among older adults. Functional impairments such as fatigue, impaired mobility, and joint pain may warrant specific attention in this population.

Our objective was to assess potential racial bias within the Risk Analysis Index (RAI).

Patient risk measures are rarely tested for racial bias. Measures of frailty, like the RAI, need to be evaluated for poor predictive performance among Black patients.

Retrospective cohort study using April 2010-March 2019 Veterans Affairs Surgical Quality Improvement Program and 2010-2019 National Surgical Quality Improvement Program data. The performance of the RAI and several potential variants were compared between Black and White cases using various metrics to predict mortality (180-day for Veterans Affairs Surgical Quality Improvement Program, 30-day for National Surgical Quality Improvement Program).

Using the current, clinical threshold, the RAI performed as good or better among Black cases across various performance metrics versus White. When a higher threshold was used, Black cases had higher true positive rates but lower true negative rates, yielding 2.0% higher balanced accuracy. No RAI variant noticeably eliminated bias, improved parity across both true positives and true negatives, or improved overall model performance.

The RAI tends to predict mortality among Black patients better than it predicts mortality among White patients. As existing bias-reducing techniques were not effective, further research into bias-reducing techniques is needed, especially for clinical risk predictions. We recommend using the RAI for both statistical analysis of surgical cohorts and quality improvement programs, such as the Surgical Pause.

Although cholecystectomy is a common surgery, it carries higher risks of postoperative complications and mortality for older adults. Age alone is not a reliable predictor of postoperative outcomes, whereas frailty may provide a more accurate assessment of a patient's health and functional status. Frailty, characterized by physical deterioration and reduced resilience, has been shown to predict mortality, prolonged recovery, and morbidity after various surgeries, including cholecystectomy. Thus, incorporating frailty evaluations into preoperative assessments can improve patient outcomes by individualizing treatment strategies. This systematic review and meta-analysis aims to evaluate how well frailty predicts postoperative outcomes following cholecystectomy.

In accordance with PRISMA guidelines, we searched PubMed, Embase, and Web of Science on August 14th, 2024, without restrictions on publication year or language. The quality of the studies was assessed using the Newcastle-Ottawa scale, and meta-analysis was conducted using odds ratios with 95% confidence intervals as the effect size, employing a random-effects model.

Nine cohort studies comprising a total of 128,421 participants were included. The pooled results showed significantly higher odds of short-term mortality (OR: 5.54, 95% CI: 1.65-18.60, p = 0.006), postoperative morbidity (OR: 2.65, 95% CI: 1.51-4.64, p = 0.001), major morbidity (OR: 3.61, 95% CI: 1.52-8.59), and respiratory failure (OR: 3.85, 95% CI: 1.08-13.79) among frail patients. Additionally, frail patients had longer hospital stays (mean difference: 2.98 days, 95% CI: 1.91-4.04) and significantly higher odds of postoperative infection and sepsis. However, no association was evident with reoperation rates.

This study highlights the value of utilizing frailty assessment tools in preoperative settings for predicting outcomes after cholecystectomy. These tools could improve decision-making in both emergency and elective situations, aiding in the choice between surgical and medical management, as well as between open and laparoscopic procedures tailored to each patient.

Peripheral arterial disease (PAD) involves atherosclerotic stenosis and occlusion of lower leg arteries, leading to significant disability, high cardiovascular and cerebrovascular morbidity and mortality. Critical limb ischemia (CLI) is the most severe form of PAD. With the UK's aging population set to increase, the prevalence of PAD and the burden on vascular teams are expected to rise. This study evaluates the impact of regular input from the Proactive Care of Older People Undergoing Surgery (POPS) team on vascular surgery outcomes.

This prospective cohort study examined the impact of Care of the Elderly (CoE) input on predefined parameters, focussing primarily on the length of stay (LoS) over 12 months. Data included baseline demographics, comorbidities, frailty scores (assessed using the Rockwood frailty score), LoS and referrals to medical specialties. A retrospective pilot study of 50 consecutive patients indicated a need for CoE input, showing higher local LoS compared with the national average.

Patients in both pilot and project groups were matched for comorbidities, frailty scores and interventions. Despite higher mean age and a greater proportion of patients aged 75+ years in the project group, the study aimed to reduce LoS. Post-quality improvement project implementation, LoS beyond fit-for-discharge decreased from 11.7 days to 9 days in 6 months and to 6 days after 12 months. Referrals to medical specialties decreased from 77% to 40%, and new diagnoses on discharge increased from 28% to 37%.

CoE team input in vascular surgery patient care significantly improved outcomes, reducing LoS and medical specialty referrals, demonstrating cost-effectiveness and suggesting a feasible multidisciplinary approach for other regions.

The functional decline seen in frail patients is associated with significant morbidity and mortality. The modified frailty index 5 (mFI-5) score is an accepted risk predictor score in surgery. Hypoalbuminemia has been correlated with poor postoperative outcomes.There exists, however, a gap in the literature regarding the combined assessment of frailty and hypoalbuminemia and the predictive power of this combined assessment. This retrospective cohort study aimed to investigate the association of preoperative albumin and frailty, as assessed with the mFI-5 score, and its ability to predict surgical outcomes.

We queried the ACS-NSQIP database (2008-2021) to identify all surgical patients. Perioperative data, including demographics and preoperative laboratory values, including albumin, were collected. The predictive power of the mFI-5 and hypoalbuminemia (Alb) independently and in combination (mFI-5+Alb), was assessed using multivariable linear and logistic regression models 30-day outcomes were assessed including mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination.

A total of 9 782 973 patients were identified, of whom 4 927 520 (50.4%) were nonfrail (mFI=0), 3 266 636 had a frailty score of 1 (33.4%), 1 373 968 a score of 2 (14.0%), 188 821 a score of 3 (1.9%), and 26 006 a score greater or equal to 4 (0.3%). Albumin levels were available for 4 570 473 patients (46.7%), of whom 848 315 (18.6%) had hypoalbuminemia. The combined assessment (mFI-5+Alb) was found to be a more accurate risk predictor than each factor independently for all outcomes. A weak negative correlation between serum albumin levels and mFI scores was established (Spearman R : -0.2; <0.0001).

Combined assessment of frailty and albumin was the strongest risk predictor. Therefore, for patients undergoing surgery, we recommend consideration of both serum albumin and frailty in order to optimally determine perioperative planning, including multidisciplinary care mobilization and prehabilitation and posthabilitation.