Frailty Predicts Morbidity and Mortality After Laparoscopic Cholecystectomy for Acute Cholecystitis: An ACS-NSQIP Cohort Analysis

Abstract

Background Current guidelines recommend laparoscopic cholecystectomy be offered for patients with acute cholecystitis except those deemed as high risk. Few studies have examined the impact of frailty on outcomes for patients undergoing laparoscopic cholecystectomy. Therefore, the aim of this study was to determine the association of frailty with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Methods Patients undergoing laparoscopic cholecystectomy for acute cholecystectomy were identified from 2005 to 2010 in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). The Modified Frailty Index (mFI) was used a surrogate for frailty, and patients were stratified as non-frail (mFI 0), low frailty (mFI 1-2), intermediate frailty (mFI 3-4) and high frailty (mFI ≥ 5). Univariable and multivariable analyses were performed. Receiver operator curves (ROC) and an area under the curve (AUC) were generated to determine accuracy of mFI in predicting postoperative morbidity and mortality. Results Of the 6898 patients undergoing laparoscopic cholecystectomy, 3245 (47%) patients were non-frail. There were 2913 (42%) patients with low-frailty, 649 (9%) patients with intermediate frailty, and 91 (2%) with high frailty. Clavien IV complications were higher for intermediate frail patients (OR 1.81, 95% CI 1.00-3.28, p = 0.050) and high-frail patients (OR 4.59, 95% CI 1.98-10.7, p < 0.001). Additionally, mortality was higher for patients with intermediate frailty (OR 4.69, 95% CI 1.37-16.0, p = 0.014) and high frailty (OR 12.2, 95% CI 2.67-55.5, p = 0.001). The mFI had excellent accuracy for mortality (AUC = 0.83) and Clavien IV complications (AUC = 0.73). Conclusion Frailty is associated with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

Mortality Risk Estimation in Acute Calculous Cholecystitis: Beyond the Tokyo Guidelines

“…In the current series, the distributions of TG18 severity classi cation were clearly more slanted toward severity than the majority of other series of non-selected ACC where the severe proportion oscillates between 5% and 19% 3,12,27,28 . This plethora of severe is mainly due to higher proportions of Kidney and Neurological dysfunction, and/or international normalized ratio ≥ 1.5 among our patients.…”

“…Advanced age, high ASA score, and CCI are almost universally cited as mortality risk factors, not only for ACC but for any emergency procedure 12,34,35 . However, not every discrete comorbidity factor of the CCI carries the same relative risk for mortality, their ORs ranging from 1 to 12, as depicted in Fig.…”

“…There is no consensus on which of the already available surgical risk scores better predicts postoperative mortality in acute cholecystitis. APACHE II > 15 40 , CCI > 6 12 , and P-POSSUM > 40 10,11 have all been used to support ST. None of them were speci cally created for ACC; therefore, none of them are particularly advantageous over the others, and none of them offer an outstanding prediction ability.…”

“…In the quest to de ne the high-risk patient, a collection of aggregate scores (APACHE, ASA 9 , P-POSSUM 10,11 , Charlson comorbidity index (CCI) 12 , AAST 13 , Frailty Score 14, and one or multiple organ dysfunction 15 have been employed to predict mortality losing precision in the process and creating confusion of who is the patient un t for surgery. The objective of the current study was to create a simpler and effective method for identifying high-risk patients isolating the discrete risk factors that predict mortality after ACC to select the patients best suited for NST.…”

Using the modified frailty index to predict negative outcomes in free‐flap breast reconstruction: A National Surgical Quality Improvement Project‐based study

“…However, in the early 2010s, NSQIP downsized the number of preoperative variables collected. In response, the 5-factor modified frailty index was developed, which has been demonstrated to be effective in laparoscopic surgery, oncologic surgery, neurosurgery, orthopedic surgery, and recently in plastic surgery in relation to panniculectomies, among others (Fagenson et al, 2020;Khalafallah et al, 2020;Lee et al, 2020;Saadeddin et al, 2020;Simon et al, 2020;Tracy et al, 2020). Thus, we sought to demonstrate its effectiveness in free flap breast reconstruction, an important and widespread procedure in our field.…”