PD09.06. Frailty in Patients Undergoing Esophagectomy for Cancer Is Associated With Complication Cascade and Failure to Rescue

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Esophagectomy is poorly tolerated in frail patients. Frailty is associated with decreased resilience, resulting in "failure to rescue" (FTR) after a complication. This study investigates the intersection between frailty and FTR in patients undergoing this operation and introduces the concept of the Complication Cascade in the setting of esophagectomy. This is a single-institution retrospective study (2000-2014) for patients with esophageal cancer who underwent resection. We harmonized the modified 5-factor frailty (mFI-5) score with Society of Thoracic Surgeons variables including performance status and comorbidities. Surgical approaches and postoperative outcomes were reviewed. FTR was defined as death during index hospitalization following 31 operative complication. The Extended FTR (E-FTR) was defined as mortality during the index hospitalization, non-home discharge, and/or readmission within 30 days. Total number of non-fatal complications was used to inform the Complication Cascade (CC), a phenomenon that occurs when one complication appears to trigger additional complications. Logistic regression models were used to evaluate any risk factors associated with FTR and E-FTR, and linear regression models were used to evaluate factors associated with the total number of complications. The association between frailty score and CC was assessed using Chi-square tests. Of 388 patients, mean age was 62.8±11.7 and mFI-5 scores 0-4 were 28%, 41%, 25%, 5%, and 1%, respectively. Surgical approach included 63.7% open, 12.1% hybrid, and 21.6% minimally invasive. 15% of patients had non-home discharge and 11% were readmitted <30 days. Mortality was 4.9%, FTR 4.6%, and E-FTR 24%. On multivariate analysis, mFI-5 and surgical approach were associated with E-FTR and mean number of complications (Table). There were no significant associations between the measured variables and FTR. The total number of complications was linearly related to frailty score (p<0.001, ANOVA) and frailty score was significantly associated with FTR and E-FTR (Figure; p<0.001). Higher mFI-5 scores correlated with increased CC severity, suggesting that diminished preoperative reserve heightens susceptibility to compounding surgical complications. Preoperative frailty is a potent predictor of a patient's inability to recover from postoperative complications following esophagectomy. A higher frailty score correlates significantly with an increased risk of E-FTR. This is mechanistically related to lack of resilience and a resultant Complication Cascade. Integrating frailty assessment into preoperative risk stratification and targeted prehabilitation are essential for identifying high-risk patients and implementing individualized strategies to reduce operative risk and mitigate the progression of postoperative morbidity.