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Frailty As a Predictor of Morbidity and Mortality Following Liver Surgery
Faiz Gani*, Marcelo Cerullo, Neda Amini, Stefan Buettner, Georgios A. Margonis, Kazunari Sasaki, Yuhree Kim, Timothy M. Pawlik
Surgery, Johns Hopkins Hospital, Baltimore, MD
Background: Patients undergoing liver surgery can experience adverse postoperative outcomes. Given the high number of elderly and comorbid patients undergoing surgery, there is increased interest in preoperatively identifying patients at high risk of morbidity and mortality. We sought to assess the use of a modified frailty index (mFI) as a predictor of poor postoperative outcomes following liver surgery.
Methods: The National Surgical Quality Improvement Program Hepatectomy-targeted database was used to identify patients undergoing a liver resection between January 01, 2014 and December 31, 2014. An mFI score was calculated using 11 preoperative patient characteristics (Table). Multivariable logistic regression was utilized to examine the use of frailty in predicting postoperative clinical outcomes including length-of-stay (LOS), postoperative morbidity, liver failure and postoperative mortality.
Results: A total of 3,064 patients underwent a liver resection. The median age of the cohort was 60 years (IQR: 50-68) and 52.4% (n=1,604) of patients were female. Among the 2,300 (78.9%) patients who underwent surgery for a malignant indication, 62.9% (n=1,446) had metastatic disease. Using the mFI, 48.0% (n=1,470) of patients were identified as frail (mFI=1) while 14.8% were categorized as very-frailty (mFI≥2). The median LOS for all patients was 6 days (IQR: 4-8); frail patients had a 46% increased odds for an extended LOS (LOS >8 days: frail: 22.8% vs. non-frail: 30.3%, P<0.001; OR 1.46, 95%CI 1.25-1.72, P<0.001). Overall postoperative morbidity was 16.5% (n=505). Frailty was associated with a step-wise higher risk of morbidity as the degree of frailty increased (mFI=0: 13.8% vs. mFI=1: 17.9% vs. mFI≥2: 21.8%, p<0.001, Figure). Similarly, while 4.9% (n=149) of patients developed postoperative liver failure (n=149), the incidence of liver failure was higher among frail patients compared with non-frail patients (mFI=0: 4.1% vs. mFI=1: 4.9% vs. mFI≥2: 7.3%, p=0.022). Specifically, patients with an mFI≥2 were 82% more likely to develop postoperative liver failure (OR 1.82, 95% CI 1.18-2.81, p=0.006). Postoperative 30-day mortality was 1.5% (n=47). Of note, mortality was higher among frail patients versus non-frail patients (0.82% vs. 2.3%, p=0.001; OR 2.88, 95% CI 1.51-5.48, p=0.001) with an incremental higher risk among patients with an increasing mFI score (mFI=0: 0.8% vs. mFI=1: 1.6% vs. mFI≥2: 4.0%, p<0.001).
Conclusions: Frailty as measured by the modified Frailty Index (mFI) was predictive of increased risk of morbidity and mortality following liver surgery. Frailty can be used an important preoperative risk-stratification tool to guide patient decision-making, as well as identify patients at greatest risk for adverse postoperative outcomes.
Table: The 11 variables assessed under the modified Frailty Index (mFI)
| 1 | History of diabetes mellitus |
| 2 | Functional status 2 (not independent) |
| 3 | History of chronic obstructive pulmonary disease or pneumonia |
| 4 | History of congestive heart failure |
| 5 | History of myocardial infarction |
| 6 | History of percutaneous coronary intervention, stenting, or angina |
| 7 | History of hypertension requiring medication |
| 8 | History of peripheral vascular disease or ischemic rest pain |
| 9 | History of impaired sensorium |
| 10 | History of transient ischemic attack or cerebrovascular accident |
| 11 | History of cerebrovascular accident with neurological deficit |
**mFI score for each patient was calculated as the sum of the number of comorbid conditions present. For example, a patient presenting with a history of diabetes mellitus and a history of myocardial infarction would have a calculated mFI score of 2.
Figure: Postoperative outcomes including length-of-stay (LOS), postoperative morbidity, liver failure, 30-day unplanned readmission and postoperative mortality by modified Frailty Index (mFI) score.
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