Frailty assessment in thoracic surgery.

A best evidence topic in thoracic surgery was performed according to a structured protocol. The question addressed was the role of frailty scores in predicting outcomes of patients undergoing thoracic surgery. Seventy-one papers were found using the reported search, of which three studies and one conference abstract represented the best evidence to answer the clinical question. The authors, journal date, country of publication, patient group, study type, relevant outcomes and results are tabulated. Despite an extensive literature search, few studies were identified which addressed the clinical dilemma posed, all of which were retrospective observational series. A study analysed 971 434 patients across a wide range of surgical specialties, 4648 of which were classified as thoracic. A statistically significant relationship was demonstrated between increasing frailty and higher rates of postoperative complications and mortality (P < 0.0001). Another study reported a similar association between modified frailty index (mFI) scores and postoperative outcomes in patients undergoing lobectomies. Morbidity increased uniformly with mFI and multivariant analysis found an mFI of >0.27 (P = 0.002) to be an independent predictor of mortality. Another paper demonstrated higher rates of major postoperative complications and increased mortality (P < 0.001) in patients with higher preoperative dependency. A study examined geriatric frailty assessment tools for the prediction of postoperative outcomes in patients over 70 undergoing thoracic surgery for neoplasms. The Geriatric Depression Screen, Mini Mental State Examination, Fatigue Inventory, Eastern Co-Operative Oncology Group Performance Scale and Instrumental Activities of Daily Living were used as a means of determining preoperative frailty. Their conclusion supported the conclusions drawn from the larger studies that a single frailty measure alone did not predict an increase in morbidity or mortality, but in combination several measures may have a role in predicting postoperative outcomes. The clinical bottom line is that there is a paucity of evidence to either fully support or fully refute the use of preoperative frailty scoring as a reliable means of predicting morbidity and mortality in thoracic surgery. The evidence presented does however indicate the potentially important clinical role that frailty scores may have in the future.

Gastric ischaemia following a fall.

A previously well 73-year-old gentleman presented 5 days after a fall from 6 feet from a ladder with abdominal pain and vomiting. X-rays demonstrated evidence of bowel perforation. On arrival, the patient was peritonitic and displayed a severely septic picture. He was subsequently taken for emergency laparotomy. A 5 mm perforation was found in the small bowel which was repaired but unusually a large segment in the fundus and greater curvature of the stomach was found to be necrotic. A partial gastrectomy was performed and histology confirmed ischaemia likely to be secondary to trauma. The patient has now been successfully discharged home.