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Surgical outcomes in nonagenarian versus octogenarian patients: a propensity-matched analysis with implications for
Fahim Kanani1, Eduard Khabarov2, Andrey Chopen2
1From the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Kanani, Khabarov, Chopen, Messer, Zoabi, Zahalka, Shimonov, Dayan, Kamar); the Department of Surgery, Wolfson Medical Center, Holon (Kanani, Zahalka, Shimonov, Dayan, Kamar); the Emergency Department, Wolfson Medical Center, Holon (Kanani, Khabarov, Chopen, Kamar); the Tel Aviv Sourasky Medical Center, Tel Aviv (Kanani, Messer); the Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel (Zoabi) faheemk@wmc.gov.il.
Background:
Although surgical outcomes among octogenarian patients are well documented, evidence for nonagenarian patients is limited. We sought to compare surgical outcomes between these age groups to guide clinical decision-making.
Methods:
We conducted a retrospective cohort study (2013 to 2023) with 1:1 propensity-score matching. We included patients aged 80 to 99 years who underwent general surgery. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day and 1-year mortality, functional status at last follow-up, complications (Clavien-Dindo classification), and hospital readmissions.
Results:
From 700 screened patients aged 80 to 99 years who underwent general surgery, 174 met inclusion criteria (73 nonagenarian and 101 octogenarian patients), yielding 73 matched pairs for analysis. Nonagenarian patients had significantly higher 30-day mortality (26.0% v. 9.6%, p = 0.02), 90-day mortality (49.3% v. 23.3%, p = 0.002), and 1-year mortality (75.3% v. 39.7%, p < 0.001) than octogenarian patients. At last follow-up (median 11 to 12 mo), poor functional status was observed in 34.2% of nonagenarian versus 23.3% of octogenarian patients. Hospital readmissions within 30 days occurred in 42.5% of nonagenarian versus 21.9% of octogenarian patients (p = 0.002). Despite propensity matching, the Fried frailty phenotype remained significantly imbalanced between groups (standardized mean difference 0.714, p < 0.001).
Conclusion:
Nonagenarian patients face substantially worse surgical outcomes than octogenarian patients, with nearly triple the 30-day mortality and high rates of functional impairment among survivors. The persistent frailty imbalance despite matching suggests inherent selection bias in surgical nonagenarians. Unlike octogenarians, for whom selective surgery may be justified, these findings support careful consideration of nonoperative management as the default approach for nonagenarians, with surgery reserved for highly select cases after comprehensive geriatric assessment and thorough shared decision-making with the patient.
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