When it Comes to Frail Patients, There's No Such Thing as Low-Risk Surgery

Study calls for universal pre-surgery frailty screenings, even for procedures determined to be of low or moderate risk.

When it comes to frail patients, there's no such thing as low-risk surgery.

A Vanderbilt University Medical Center-led study has determined that even a laparoscopic gallbladder removal can prove to be a high-risk and even fatal procedure for frail patients.

"It's been established that frailty is a strong predictor of complications and death related to surgery, but what we learned in this study is that frail patients have alarmingly high rates of postoperative death, no matter how minor the surgical procedure," lead author Myrick "Ricky" Shinall Jr., MD, said in a media release. "Our data indicate that there are no 'low-risk' procedures among frail patients." 

"A laparoscopic cholecystectomy is one of the most common operations I do as a general surgeon, and this has really given me pause to think that for frail to very frail patients — about 10% of our sample — this is a big deal," said Shinall, an assistant professor and general surgeon at Vanderbilt University Medical Center.  

The study, published this week in JAMA Surgery, looked at 432,828 patients who underwent a non-cardiac surgical procedure, and found that patients who were frail or very frail had up to 43% higher mortality rates after surgeries with low and moderate operative stress, such as minimally invasive gallbladder removal. 

Patient frailty is measured before surgery by a Risk Analysis Index that assesses symptoms such as unintentional weight loss, shortness of breath, weakness, and difficulties with daily activities like walking, eating or bathing. 

The study looked at patient medical records over four-years from the VA Surgical Quality Improvement Program database, a representative sample of all surgeries conducted across the country in the Veterans Health Administration. The data included patient information for a minimum of one year following surgery, and the patients' postoperative mortality was noted at 30, 90 and 180 days.

Shinall and his colleagues created an Operative Stress Score and put patients into five categories of physiologic stress, ranging from the lowest (OSS1) to the highest (OSS5). Of the study's patient sample, 8.5% were classified as frail, and 2.1% were very frail.

The 30-day mortality rates for frail patients undergoing the lowest stress operations and moderate stress operations were 1.55% and 5.13%, both exceeding the 1% mortality rate often used to define high-risk surgery.

For very frail patients, 30-day mortality rates after the lowest and moderate-stress procedures was 10.34% and 18.74%.

For frail and very frail patients, mortality continued to rise at 90 days and 180 days after surgery, reaching 43% for very frail patients 180 days after moderate-stress operations. 

With such a high risk, the study calls for universal pre-surgery frailty screenings, even for procedures determined to be of low or moderate risk, with patients and their families made aware of the heightened risk.

"The greatest volume of surgeries performed at hospitals are those that cause moderate operative stress, and it is expected that all procedures at ambulatory surgical centers are considered to be those with a low mortality risk, but clinicians spend little time considering whether or not their patients can actually endure the stress of surgery," Shinall said.

"It is worth pausing to assess every patient to determine whether they are frail, and if they are, taking steps to mitigate the factors contributing to their frailty before a procedure is ever scheduled or re-evaluating whether they should even undergo a procedure at all," he said.