Frailty, not age, predicted complications after ambulatory surgery

FROM JAMA SURGERY

Frailty was associated with a significant increase in 30-day complications after ambulatory hernia repair or ambulatory surgery of the breast, thyroid, or parathyroid, according to the results of a large retrospective cohort study.

The findings reinforce prior work indicating that frailty, not chronologic age, should be a primary factor when deciding about and preparing for surgery, Carolyn D. Seib, MD, and her associates at the University of California, San Francisco, wrote in JAMA Surgery. “Informed consent should be adjusted based on frailty to ensure that patients have an accurate assessment of their risk when making decisions about whether to undergo surgery,” the researchers said.

To test the hypothesis that frailty predicts morbidity and mortality after ambulatory general surgery, the researchers studied 140,828 patients older than 40 years from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program (JAMA Surg. 2017 Oct 11. doi: 10.1001/jamasurg.2017.4007 ). Nearly 2,500 (1.7%) patients experienced perioperative complications, and 0.7% had serious complications, the researchers said. After controlling for age sex, race or ethnicity, smoking, type of anesthesia, and corticosteroid use, patients with an intermediate (0.18-0.35) frailty score had a 70% higher odds of any complication (odds ratio, 1.7; 95% confidence interval, 1.5-1.9) and a 100% higher odds of serious complications (OR, 2.0; 95% CI, 1.7-2.3), compared with patients with a low frailty score.

An intermediate score reflected the presence of two to three frailty traits, such as impaired functional status, history of diabetes, pneumonia, chronic cardiovascular or lung disease, or impaired sensorium, the investigators noted. Notably, having a high modified frailty index (four or more frailty traits) was associated with 3.3-fold higher odds of any complication and with nearly 4-fold higher odds of serious complications, even after controlling for potential confounders.

Among modifiable risk factors, only the use of local and monitored anesthesia was associated with a significant decrease in the likelihood of serious 30-day complications (adjusted OR, 0.66; 95% CI, 0.53-0.81). Single-center studies of elderly patients undergoing inguinal hernia repair have reported similar findings, the researchers said. “For frail patients who choose to undergo hernia repair, local and monitored anesthesia care should be used whenever possible,” they wrote. “The use of local with monitored anesthesia care may be challenging in complex surgical procedures for breast cancer, such as modified radical mastectomy or axillary dissection, but it should be considered for patients with increased anesthesia risk who are undergoing ambulatory breast surgery.”

The National Institute on Aging provided partial funding. The investigators reported having no conflicts of interest.

acssurgerynews@frontlinemedcom.com

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