Novel frailty index predicts short-term outcomes after esophagectomy in elderly patients with esophageal cancer

Despite advances in perioperative care, esophageal cancer patients undergoing esophagectomy have a high risk of postoperative major morbidity and death. We sought to determine the association between frailty defined by a novel scoring system and short-term outcomes of elderly patients. We identified 467 esophageal cancer patients older than 65 years who underwent esophagectomy between 01/2011 and 03/2021. Frailty was assessed using a novel validated institutional frailty score, a composite score of functional status and 10 medical comorbidities. We excluded 10 patients without available functional component and 10 without available ECOG performance status, a covariate included in our multivariable models, leaving 447 patients for final analysis. Associations between frailty and short-term outcomes—90-day mortality, 30-day major complication, readmission within 30-days of discharge, discharge to a facility—were assessed using multivariable logistic regression models for each of the outcomes separately, with continuous frailty score as the predictor, and adjusted for age and ECOG performance status. Patients had a median age of 71 years, were predominantly male (81%) and white (88%), underwent neoadjuvant therapy (81%), Ivor Lewis esophagectomy (86%), and minimally invasive surgery (55%). The 30-day and 90-day mortality rate was 2.2% and 4.9%, respectively. One hundred thirty-eight patients (31%) had a major complication (≥ grade 3), 78 (18%) were readmitted, and 31 (7.2%) were discharged to another facility. Among patients with 90-days of follow-up, 137 had major complications within 30-days of surgery, of whom 19 died within 90 days of surgery, yielding a failure to rescue rate of 14% (95% CI 8.8%-21%). Preoperative frailty predicted increased risk of 30-day major complications (OR 1.23, 95%CI 1.08-1.41, p=0.002), of hospital readmissions (OR 1.32, 95%CI 1.14-1.54, p < 0.001), and discharge to a facility (OR 1.86, 95%CI 1.49-2.37, p < 0.001). However, no association between preoperative frailty and 90-day mortality was found. Frailty assessed by our novel frailty assessment is associated with increased risk of 30-day major complications, hospital readmissions, and discharge to a facility, but not with 90-day mortality. Incorporating frailty assessment in presurgical evaluation identifies a subgroup of patients at major risk for morbidity for which pre-abilitation measures or aggressive perioperative interventions should be tailored to improve outcomes.