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Value of Geriatric Frailty and Nutritional Status Assessment in Predicting Postoperative Mortality in Gastric Cancer Surgery

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Objectives

This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery.

Methods

Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality.

Results

From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3 %. Patients with a GFI ≥ 3 (n = 30, 24 %) had a mortality rate of 23.3 % versus 5.2 % in the lower GFI group (OR 4.0, 95%CI 1.1–14.1, P = 0.03). For patients who underwent surgery with curative intent (n = 125), this was 27.3 % for patients with GFI ≥ 3 (n = 22, 18 %) versus 5.7 % with GFI < 3 (OR 4.6, 95 % CI 1.0–20.9, P = 0.05). SNAQ ≥ 1 (n = 98, 61 %) was associated with a mortality rate of 13.3 % versus 3.2 % in patients with SNAQ = 0 (OR 5.1, 95 % CI 1.1–23.8, P = 0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification.

Conclusions

This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.

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Authors and Affiliations

  1. Department of Surgery, Orbis Medical Center, Sittard-Geleen, The Netherlands

    Juul J. W. Tegels, M. F. G. de Maat, K. W. E. Hulsewé, A. G. M. Hoofwijk & J. H. M. B. Stoot

  2. Dr. H. van der Hoffplein 1, P.O. Box 5500, 6130MB, Sittard, The Netherlands

    Juul J. W. Tegels

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  1. Juul J. W. Tegels
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Correspondence to Juul J. W. Tegels.

Additional information

Discussant

Dr. Michael Zenilman (Bethesda, Maryland): This is one of an impressive new series focusing on the importance of frailty indicators for general, and specifically, gastrointestinal surgery

We are on the midst of a paradigm shift in risk assessment. The old school focused on complicated mathematical models based on clinical factors such as comorbidities, a history of cardiac disease, while the new school is based on the simple presence of frailty indicators and geriatric syndromes. It is now established that the presence of frailty is a much more powerful indicator than the others.

The challenge is how to measure it. While this study, using preop questionairres, captured some of frailty markers, they did not measure any objective variables such as serum albumin, dementia (measured by the mini-mental score), timed up and go, gait speed, and simply obtaining a history of falls. All of these are powerful univariate variables for postop risk.

My first question is did the authors confirm the presumed nutritional status of the patients w a serum albumin?

Second, both GFI and SNAQ measure self reported nutritional assessment, so doesn’t including both in a mutivariate analysis bias your results towards statistical significance? I am concerned by using it twice in a MV analysis and then using a combine score again in the same analysis.

Lastly, I applaud the use of six month outcomes in assessing surgical risk. Why did they not use it as a primary outcome? Thirty-day rates are much less critical in centers such as yours where the surgeons and institutions almost guaranty success.

Closing Discussant

Dr. Juul Tegels: Thank you Dr. Zenilman for taking the time to discuss our study and the excellent questions.

Due to the retrospective design of the study we could not verify results of the nutritional status questionnaire with other tests like serum albumin. Also serum albumin testing is not part of routine lab testing of patients who are evaluated for gastric cancer surgery.

With regard to your second question, I can say that we did notice the fact that both questionnaires incorporate items regarding unintentional weight loss. So in the manuscript and multivariate analyses, we also performed analyses when we removed the data with regard to unintentional weight loss in one of the two questionnaires. In these analyses, predictive value of the questionnaires remained. The reason for analyzing combined scores was to evaluate whether these two questionnaires perhaps amplified each others’ predictive value for perioperative mortality.

Your last remark is a good one and last week at the Dutch national surgical conference where these data were also presented a similar question was raised by one of the attending surgeons. In the present study, we also looked at 6-month mortality, but as a secondary outcome parameter. We took 30-day mortality or in-hospital mortality as the primary outcome parameter. Most important reason for choosing 30-day or in-hospital mortality was the idea to research wheter these scores were predictive of outcomes in short postoperative period. But we were obviously interested in their predictive value of GFI and SNAQ for other outcomes; therefore, we took these (serious adverse events, length-of-stay, and 6-month mortality) as secondary outcome parameters.

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Tegels, J.J.W., de Maat, M.F.G., Hulsewé, K.W.E. et al. Value of Geriatric Frailty and Nutritional Status Assessment in Predicting Postoperative Mortality in Gastric Cancer Surgery. J Gastrointest Surg 18, 439–446 (2014). https://doi.org/10.1007/s11605-013-2443-7

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  • DOI: https://doi.org/10.1007/s11605-013-2443-7

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