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Anderson JE, Seib CD, Campbell MJ. Association of Patient Frailty With Increased Risk of Complications After Adrenalectomy. JAMA Surg. 2018;153(10):966–967. doi:10.1001/jamasurg.2018.1749
The frequency of adrenal tumors increases with patient age.1 As the US population continues to grow older, surgeons will more frequently be asked to evaluate elderly patients for adrenalectomy owing to concern for adrenocortical cancer or to mitigate the effects of a hormonally active tumor.2 Frailty, a measure of physiological reserve independent of age, is associated with an increased risk of postoperative morbidity and readmissions in patients undergoing a variety of elective surgical procedures,3-5 but its association with complications after adrenalectomy has not been well established. The purpose of this study is to evaluate the association of patient frailty with complications after adrenalectomy.
Using the 2005-2011 American College of Surgeons National Surgical Quality Improvement Project database, we identified patients who underwent laparoscopic or open adrenalectomy. Postoperative International Classification of Diseases, Ninth Revision diagnosis codes were used to identify malignant vs benign pathologic characteristics of adrenal tumors. This study was deemed exempt from the University of California Davis Institutional Review Board. Because the National Surgical Quality Improvement Project database is a deidentified, aggregate database, informed consent was not obtained from participants.
Outcomes of interest were length of stay and any serious 30-day postoperative complication, which were previously described by Seib et al.3 Frailty was defined using the validated modified frailty index.3 One point was given for each frailty variable and patients were categorized into 4 groups: 0, 1, 2, or 3 or more frailty variables.
Multivariable logistic regression was used to examine the association of frailty with complications, adjusting for malignant neoplasms, sex, race/ethnicity, corticosteroid use for a chronic condition (within 30 days of surgery), and smoking (current smoker within 1 year). Statistical significance was defined as P < .05 (2-sided). Statistical analysis was performed from July 1 to September 1, 2017, using Stata, version 14.2 (StataCorp).
Of 4043 patients (2430 women, 1604 men, and 9 unknown), 3091 (76.5%) underwent a laparoscopic adrenalectomy. Most patients had benign tumors (2180 [53.9%]), while 553 patients (13.7%) had malignant tumors and 1310 (32.4%) had pathologic characteristics that could not be classified. Median patient age was 53 years (range, 16-90 years), and 270 patients (6.7%) were older than 75 years. Most patients (2948 [72.9%]) had a frailty score of 0 or 1, but 282 (7.0%) had a frailty score of 3 or more.
The 30-day complication rate was 8.0% (n = 324). The most common complications were bleeding requiring transfusion (128 [3.2%]), pneumonia (61 [1.5%]), mechanical ventilation required for more than 48 hours (57 [1.4%]), and sepsis (n = 57 [1.4%]). Laparoscopic procedures were associated with fewer complications than open procedures (134 of 3091 [4.3%] vs 190 of 952 [20.0%]; P < .001) and shorter mean [SD] length of stay (2.9 [5.1] days; 95% CI, 2.7-3.1; vs 7.7 [14.3] days; 95% CI 6.7-8.6; P < .001) (Table 1). Patients with benign tumors also had fewer complications than those with malignant tumors (135 of 2180 [6.2%] vs 89 of 553 [16.1%]; P < .001) and shorter mean (SD) length of stay (3.7 [9.7] days; 95% CI, 3.2-4.1; vs 5.9 [8.2] days; 95% CI 5.2-6.6; P < .001). A higher frailty score was associated with increased complications and length of stay regardless of type of operation or diagnosis.
On multivariable logistic regression, the risk of serious complications was associated with a higher frailty score (frailty score of ≥3 vs 0: odds ratio, 7.21; 95% CI, 4.06-12.79; P < .001), open operations (vs laparoscopic: odds ratio, 4.81; 95% CI, 3.50-6.61; P < .001), and malignant tumors (vs benign: odds ratio, 1.84; 95% CI, 1.30-2.59; P = .001) (Table 2).
We found that, among patients undergoing adrenalectomy, higher patient frailty scores (as well as malignant tumors and open operations) are more associated with postoperative complications than is older age. This novel finding complements research by Murphy et al,6 who did not find an association between age and complications but did find poorer outcomes associated with a higher Charlson comorbidity index. These findings are in contrast to research by Kazaure et al,1 who reported that increasing age was associated with higher risk of complications, but their analysis did not evaluate frailty.
In this study, frailty was associated with complications even after laparoscopic adrenalectomy, which has been shown to have shorter operative times, less blood loss, and decreased long-term morbidity than the open approach.2 Our results suggest that patient frailty should be considered in patient selection for adrenal operations even if a laparoscopic approach is anticipated.
Accepted for Publication: March 31, 2018.
Corresponding Author: Jamie E. Anderson, MD, MPH, Department of Surgery, University of California Davis Medical Center, 2215 Stockton Blvd, Ste OP512, Sacramento, CA 95817 (email@example.com).
Published Online: July 3, 2018. doi:10.1001/jamasurg.2018.1749
Author Contributions: Dr Anderson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Anderson.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Anderson.
Administrative, technical, or material support: Campbell.
Supervision: Seib, Campbell.
Conflict of Interest Disclosures: None reported.
Disclaimer: The American College of Surgeons National Surgical Quality Improvement Program and hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program are the source of the data used herein; they have not verified and are not responsibility for the statistical validity of the data analysis or the conclusions derived by the authors.
Previous Presentation: This article was presented at the 89th Annual Meeting of the Pacific Coast Surgical Association; February 17, 2018; Napa, California.
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