[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Table 1.  Outcomes and Length of Stay by Frailty Score
Outcomes and Length of Stay by Frailty Score
Table 2.  Univariate and Multivariable Logistic Regressions Showing Association With Serious Morbidity
Univariate and Multivariable Logistic Regressions Showing Association With Serious Morbidity
1.
Kazaure  HS, Roman  SA, Sosa  JA.  Adrenalectomy in older Americans has increased morbidity and mortality: an analysis of 6,416 patients.  Ann Surg Oncol. 2011;18(10):2714-2721.PubMedGoogle ScholarCrossref
2.
Zeiger  MA, Thompson  GB, Duh  QY,  et al; American Association of Clinical Endocrinologists; American Association of Endocrine Surgeons.  American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas: executive summary of recommendations.  Endocr Pract. 2009;15(5):450-453.PubMedGoogle ScholarCrossref
3.
Seib  CD, Rochefort  H, Chomsky-Higgins  K,  et al.  Association of patient frailty with increased morbidity after common ambulatory general surgery operations.  JAMA Surg. 2018;153(2):160-168.PubMedGoogle ScholarCrossref
4.
Wahl  TS, Graham  LA, Hawn  MT,  et al.  Association of the Modified Frailty Index with 30-day surgical readmission.  JAMA Surg. 2017;152(8):749-757.PubMedGoogle ScholarCrossref
5.
Revenig  LM, Canter  DJ, Master  VA,  et al.  A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery.  J Endourol. 2014;28(4):476-480.PubMedGoogle ScholarCrossref
6.
Murphy  MM, Witkowski  ER, Ng  SC,  et al.  Trends in adrenalectomy: a recent national review.  Surg Endosc. 2010;24(10):2518-2526.PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Research Letter
    Pacific Coast Surgical Association
    October 2018

    Association of Patient Frailty With Increased Risk of Complications After Adrenalectomy

    Author Affiliations
    • 1Department of Surgery, University of California Davis Medical Center, Sacramento
    • 2Department of Surgery, University of California San Francisco Medical Center, San Francisco
    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.

    Methods

    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).

    Results

    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).

    Discussion

    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.

    Back to top
    Article Information

    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 (jeanderson@ucdavis.edu).

    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.

    References
    1.
    Kazaure  HS, Roman  SA, Sosa  JA.  Adrenalectomy in older Americans has increased morbidity and mortality: an analysis of 6,416 patients.  Ann Surg Oncol. 2011;18(10):2714-2721.PubMedGoogle ScholarCrossref
    2.
    Zeiger  MA, Thompson  GB, Duh  QY,  et al; American Association of Clinical Endocrinologists; American Association of Endocrine Surgeons.  American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas: executive summary of recommendations.  Endocr Pract. 2009;15(5):450-453.PubMedGoogle ScholarCrossref
    3.
    Seib  CD, Rochefort  H, Chomsky-Higgins  K,  et al.  Association of patient frailty with increased morbidity after common ambulatory general surgery operations.  JAMA Surg. 2018;153(2):160-168.PubMedGoogle ScholarCrossref
    4.
    Wahl  TS, Graham  LA, Hawn  MT,  et al.  Association of the Modified Frailty Index with 30-day surgical readmission.  JAMA Surg. 2017;152(8):749-757.PubMedGoogle ScholarCrossref
    5.
    Revenig  LM, Canter  DJ, Master  VA,  et al.  A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery.  J Endourol. 2014;28(4):476-480.PubMedGoogle ScholarCrossref
    6.
    Murphy  MM, Witkowski  ER, Ng  SC,  et al.  Trends in adrenalectomy: a recent national review.  Surg Endosc. 2010;24(10):2518-2526.PubMedGoogle ScholarCrossref
    ×