Society for Surgery of the Alimentary Tract
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Christopher L. Cramer*, Paul Clancy, Minghui Huang, Lena Turkheimer, Florence Turrentine, Victor M. Zaydfudim
Surgery, University of Virginia, Charlottesville, VA

Background: Postoperative complications are associated with mortality in geriatric patients following major abdominal operations. Predicting which geriatric patients are at the highest risk for mortality after a complication may aid in preventing deaths. Failure to rescue (FTR) is a publicly reported metric of quality and is broadly defined as mortality after a potentially preventable complication following surgery. Typically, a 30-day follow-up period is used for reporting FTR, but there is concern that this inadequately captures postoperative deaths; instead, a 90-day follow-up period has been advocated. Our objective was to examine the association of a validated frailty metric, the Risk Analysis Index (RAI-A), with 90-day FTR (FTR-90).

Methods: Patients 65 years or older who underwent a major abdominal operation between 2014-2020 at a quaternary care center were abstracted. Institutional data, the ACS NSQIP Procedure Targeted Participant Use Data, and Geriatric Surgery Research File were merged and 90-day clinical outcomes were collected. Univariable analysis compared baseline characteristics. Multivariable logistic regression was used to evaluate the association between RAI-A and FTR-90.

Results: Of the 1565 patients included in the institutional data abstraction, 398 patients had a postoperative complication and were included. Fifty-two (13.0%) of the patients with a postoperative complication died during 90-day follow-up. Of the 398 patients, 178 (44.7%) underwent colorectal surgery, 135 (33.9%) underwent hepatopancreatobiliary surgery, and 85 (21.4%) underwent other types of major abdominal operations. Patients who experienced FTR-90 were older (median age 76 vs 73, p = 0.002), had a greater preoperative ASA classification (p < 0.001), and had a higher NSQIP estimated risk of morbidity (0.33% vs 0.20%, p < 0.001) and mortality (0.067% vs 0.012%, p < 0.001). The FTR-90 group had a greater median RAI-A score (23 vs 19, p = 0.002). A greater proportion of patients with FTR-90 experienced a major complication after surgery (pneumonia, re-intubation, prolonged ventilation, myocardial infarction, cardiac arrest, pulmonary embolism, renal failure, sepsis, septic shock, deep wound or organ space infection, and stroke) (86.5% vs 47.7%, p < 0.0001). The RAI-A score was independently associated with FTR-90 (OR 1.04, 95% CI 1.0042 – 1.077, p = 0.028), but was not independently associated with FTR-30 (p = 0.13).

Conclusion: Pre-operative frailty, as defined by RAI-A, is independently associated with failure to rescue at 90 days, but not 30 days, after major abdominal surgery. The use of a 90-day failure to rescue definition captured nearly 57% more deaths compared to 30-day failure to rescue. Frailty has major implications beyond the typical 30-day follow-up period and a longer follow-up period must be considered in this patient population.

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