Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Microsurgery. 2024 May;44(4):e31156. doi: 10.1002/micr.31156.
Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR).
We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period.
A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001).
In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.
身体虚弱的患者功能下降明显，死亡率和发病率高，这是其特征。改良虚弱指数 5（mFI-5）是一种风险预测评分，已在外科手术中作为基于合并症的量表得到验证。血清白蛋白水平<3.5g/dL（低白蛋白血症）也与术后不良结局有关。然而，这两个参数之间的关系仍有待研究。我们旨在阐明术前白蛋白水平和虚弱程度（由 mFI-5 评分评估）之间的相互依赖性，并评估其在游离皮瓣重建（FFR）中预测术后结果的可靠性。
我们进行了一项多中心回顾性队列研究，并从 2008 年到 2021 年访问了 ACS 国家手术质量改进计划（ACS-NSQIP）。我们确定了所有接受 FFR 的成年患者（≥18 岁）。我们提取了围手术期数据和实验室值，包括白蛋白。多变量线性和逻辑回归分析用于确定独立的风险预测因素。主要结局包括术后 30 天内的死亡率、住院时间、再次手术、医疗和手术并发症以及出院去向。
共纳入 34571 名患者，平均年龄为 53.9 岁（标准差[SD]为 12.2），平均 BMI 为 28.8（SD 为 6.1）。这些患者中，7484 例为男性（21.6%），22363 例（64.7%）无虚弱（mFI=0）。此外，9466 例患者的虚弱评分为 1（27.4%），2505 例患者的虚弱评分为 2（7.2%），226 例患者的虚弱评分为 3（0.7%），11 例患者的虚弱评分为 4 或更高（0.0%）。白蛋白水平可用于 16250 名患者（47.0%），其中 1334 名（8.2%）患有低白蛋白血症。回归分析显示，较高的 mFI 评分是任何、手术和医疗并发症的独立预测因素，也是再次手术、计划外再入院和住院时间延长的更高发生率的预测因素。低白蛋白血症独立预测任何、手术和医疗并发症，以及更高的死亡率、再次手术和更长的住院时间。当同时考虑虚弱和白蛋白水平（mFI-5 和白蛋白）时，这种综合评估被发现是所有主要结局（任何、医疗和手术并发症、死亡率和再次手术）的更准确预测因素。此外，我们的分析发现血清白蛋白水平和 mFI 评分之间存在弱负相关（Spearman R：-.1；p<.0001）。
总之，这项队列研究强调了低白蛋白血症与术后不良结局之间的关联，包括与虚弱无关的不良结局。同时，较高的 mFI 评分独立预测与低白蛋白血症无关的结局。基于这些发现，我们建议在接受 FFR 的患者中同时考虑血清白蛋白水平和虚弱。这种围手术期算法可能有助于提供更个体化的规划，包括多学科护理和术前和术后康复。
