USE OF A 5-ITEM MODIFIED FRAILTY INDEX FOR ASSESSING OUTCOMES AFTER RECTAL PROLAPSE SURGERY: AN ACS-NSQIP STUDY
Andrew Mitchell*, David Palange, Caroline Polito, Ashar Ata, Jonathan J. Canete, Brian T. Valerian, A. David Chismark, Edward C. Lee
Colon and Rectal Surgery, Albany Medical Center, Albany, NY
Background:
Rectal prolapse is now managed through several different surgical approaches. There is a current trend toward more aggressive use of minimally invasive (MIS) rectopexy in higher risk patient populations that would traditionally receive a perineal approach. Many of these patients receive a perineal surgery still, however, due to a variety of factors including the patient's perceived frailty. A five-item modified frailty index (mFI-5) has been shown in multiple studies to be a useful tool in predicting postoperative outcomes across multiple specialties and may be useful for assessing outcomes after rectal prolapse repair. Our hypothesis is that frail patients were more likely to have adverse outcomes regardless of the operative approach utilized.
Methods:
Retrospective de-identified information from the ACS-NSQIP database was compiled from 2009-2019 to calculate the mFI-5 and determine its predictive value on mortality and post-operative complications for CPT codes 45540, 45550 (Open), 45130 (Perineal), 45400, and 45402 (minimally invasive).
Results:
Of 12,335 patients, 2,343 underwent an open procedure, 5,729 patients underwent a perineal procedure, and 4,263 patients underwent an MIS procedure. 5,391 had a mFI-5 of 0, 4,896 had a mFI-5 of 1, and 2,048 had an mFI-5 ? 2. Univariant analysis comparing non-frail vs frail patients within the MIS and perineal groups had a significantly increased risk of morbidity (RR 2.04, 1.49-2.77, p<0.01; RR 1.51, 1.21-1.88, p<0.01) and mortality (RR 6.11, OR 1.78-21.01, p<0.01; RR 4.90, 2.27-10.60). Morbidities included pneumonia, reintubation, renal insufficiency, myocardial infarction, and bleeding. Frailty was additionally predictive of increased length of stay in both groups (RR 3.67, 2.46-5.48, p<0.01; RR 2.16, 1.51-3.08, p<0.01). When comparing MIS and perineal approaches in frail patients, however, there was a 4-fold higher mortality for patients with a mFI-5 of 1 in the perineal group (p<0.01) and no difference in morbidity (p=0.26). For patients with a mFI-5 of ? 2 there was no significant difference in morbidity (p=0.96) or mortality (p=0.235).
Conclusion:
Patients with a higher mFI-5 undergoing rectal prolapse surgery had greater morbidity and mortality when compared to lower mFI-5. The mFI-5 is an easy-to-use predictor of postoperative complications in these patients and can be used in pre-operative counseling. Frailty alone, however, does not appear predictive of adverse outcomes when considering which surgical approach to offer patients with rectal prolapse.
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