How frail is too frail? Impact of frailty on complex abdominal wall reconstruction

Preoperative frailty predicts morbidity and mortality in complex abdominal surgery, but its impact on outcomes in complex abdominal wall reconstruction (CAWR) is not well established. This study aims to examine how frailty relates to surgical outcomes in CAWR patients.

We conducted a retrospective review of a prospectively maintained database of patients who underwent CAWR from 2018 to 2024 at our institution. Patients were stratified by the ACS-NSQIP Modified 5-item Frailty Index, with non-frail defined as a score of 0-1 and frail defined as a score ≥ 2. Demographic and perioperative variables were compared using univariate analysis. To address confounding, a propensity score-matched analysis was performed to compare outcomes between frail and non-frail patients. The primary outcome was hospital length of stay. Secondary outcomes included hernia recurrence, surgical site morbidity, readmission, and reoperation rates.

Three hundred and ninety-four patients were included in the final analysis, for a study period of 81 months. Eighty-three patients were classified as frail (mFI-5 ≥ 2). The frail group was older (65.6 vs. 60.1 years, p = 0.0002) and was more likely to have hypertension, diabetes mellitus, COPD, and CHF (p < 0.0001). The frail group had a male predominance (56.6 vs 42.8%, p = 0.0243) and a higher BMI (32.2 vs. 30.6 kg/m2, p = 0.0292). There was no difference in hernia defect area between groups. On univariate analysis, frail patients had a longer hospital length of stay (6.1 vs. 5.0 days, p = 0.0119). However, in propensity score-matched analysis, frailty was not independently associated with length of stay, hernia recurrence, or surgical site morbidity.

Frailty, as measured by the mFI-5, was not an independent predictor of perioperative or hernia-specific outcomes following complex abdominal wall reconstruction. While frailty may be associated with increased unadjusted resource utilization, it should not be used in isolation to preclude appropriately selected patients from undergoing CAWR.