P. Bou-Samra1, D. Van Der Windt1, P. Varley1, X. Chen1, A. Tsung1 1University Of Pittsburg,Hepatobiliary & Pancreatic Surgery,Pittsburgh, PA, USA
Introduction: Given the aging of our population, increasing numbers of elderly patients are evaluated for surgery. Preoperative assessment of frailty, defined as the lack of physiological reserve, is a novel concept that has recently gained interest to predict postoperative complications. The comprehensive Risk Analysis Index (RAI) for frailty has been shown to predict mortality in a large cohort of surgical patients. RAI is now measured in all patients presenting to surgical clinics in our institution. Initial analysis showed that patients with hepatopancreatobiliary disease have the highest frailty scores, only second to patients presenting for cardiovascular surgery. Therefore, the aim of this study was to specifically evaluate the performance of RAI in predicting short-term post-operative outcomes in patients undergoing hepatopancreatobiliary surgery, a significantly frail patient population.
Methods: From June-December 2016, the RAI was determined in 162 patients prior to surgery. RAI includes 12 variables to evaluate e.g. age, kidney disease, congestive heart failure, cognitive functioning, independence in daily activities, and weight loss. Data on 30-day post-operative outcomes were prospectively collected. Complications were scored according to the Clavien-Dindo classification and summarized in the Comprehensive Complication Index (CCI). Other assessed post-operative outcomes included ICU admission, length of stay, and rates of readmissions. Logistic and linear regressions were done to assess for correlation of RAI score and each measured outcome. A multivariate analysis was done to control for the magnitude of the operation, coronary artery disease, cancer stage, and intraoperative blood loss.
Results: Our cohort of 162 patients (79 M; 83 F, median age 67, range 19-95), included 55 undergoing minor operation, 56 undergoing intermediate operation, and 51 undergoing major surgery. Their RAI scores ranged from 0 to 25, with a median of 7. With every unit increase in RAI score, length of stay increased by 5% (IRR 1.05; 95%CI 1.04-1.07, P<0.01), the odds of discharging the patient to a special facility increased by 10% (OR 1.10; 95%CI 1.02-1.17, P<0.01), the odds of admission to the ICU increased by 11% (OR 1.11; 95%CI 1.02-1.20, P=0.01), the expected ICU length of stay increased by 17% (IRR=1.17; CI 1.06-1.30), the odds of readmission increased by 8% (OR=1.08; CI 0.99-1.17, P=0.054), the CCI increased by 1.6 units (coefficient=1.60; CI 0.61-2.58, p<0.01). In multivariate analysis, frailty remained positively associated with CCI (p=0.01)
Conclusion: The RAI score is predictive of short-term post-operative outcomes after hepatopancreatobiliary surgery. Pre-operative risk assessment with RAI could aid in decision-making for treatment allocation to surgery versus less morbid locoregional treatment options in frail patients.