Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair

Abstract

Background

The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs.

Methods

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility.

Results

2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis.

Conclusions

Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.

Keywords

modified frailty index parastomal hernia repair postoperative complications predictor national surgical quality improvement program

Key Takeaways

• The 5-mFI score is a validated tool to identify ideal candidates for surgical intervention.

• Our study found that parastomal hernia repair patients with a 5-mFI score of at least one, had a higher risk of renal, pulmonary, cardiovascular and hematologic complications, readmissions, discharge to care facility, and mortality.

• The 5-mFI score can be a useful tool for surgeons during preoperative risk stratification.

Introduction

Some surgeons believe that parastomal hernias are an inevitable sequela of colostomy creation with an incidence rate of 30%–48%.^1-4 Previous studies have found that the majority of parastomal hernias occur within 2 years of stoma creation, with the incidence of herniation increasing with time.^1-8 Parastomal hernias are often asymptomatic and have no definitive guideline for determining when elective repairs should be offered.^1,3 However, intractable pain, skin breakdown, and interference with the integrity of the stoma appliance seal are often cited as relative indications for surgical intervention.^1,7,9 Options for repair broadly include laparoscopic and open primary suture repair, mesh-based repairs, or relocation of the stoma.^1,6,9 Regardless of the methods used, these reconstructive operations carry a high risk of postoperative complications, with rates as high as 30%-76%.^3,7,8,10 Potential complications from surgical repair of parastomal hernias include infection, postoperative pain, delayed bowel function, readmission, and reoperation.^1,7,8

Given the overall cost and morbidity associated with complications of parastomal hernia repair, it is imperative that surgeons diligently risk-stratify patients and identify those who would benefit most from surgical repair. Previous studies have identified patient-related factors such as advanced age, increased intra-abdominal pressure, diabetes mellitus, obesity, and emphysema as poor prognosticators.⁷ However, these proposed risk factors by themselves are limited in their ability to provide a standardized way to risk-stratify patients in the preoperative stage.⁷

Recently, there has been growing evidence that frailty, the decrease in physiologic reserve against stressors, can be used preoperatively to quantify risk.^11-15 Originally adapted from an 11-variable frailty index, the modified 5-factor frailty index (5-mFI) is a validated scoring system of frailty that has been proven to be a robust predictor of adverse outcomes.¹⁶ Factors assessed in 5-mFI scoring include diabetes mellitus, newly diagnosed congestive heart failure (CHF) or exacerbation of existing CHF within 30 days of surgery, history of hypertension requiring medication, history of severe chronic obstructive pulmonary disease (COPD) and non-independent functional status.^11,14,16-22

The 5-mFI score can become a beneficial tool for identifying ideal candidates for parastomal hernia repair, to reduce the cost and overall incidence of complications.^11,16,23 The purpose of this study was to the assess 5-mFI score as a predictor of 30-day overall complications as well as 30-day readmission, reoperation, and need to discharge to a care facility (acute rehabilitation center and skilled nursing facility) in patients undergoing parastomal hernia repair.

Methods

Database and Patient Selection

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted to identify adult patients (>18 years old) who underwent elective parastomal hernia repair or relocation between 2015 and 2020. ACS-NSQIP is a risk-adjusted, outcomes database that has de-identified records of patient demographics, perioperative variables, and 30-day postoperative outcomes. This database is compliant with Health Insurance Portability and Accountability Act (HIPAA) and was deemed exempt from Institutional Review Board (IRB) review based on institutional guidelines.

To identify patients who underwent parastomal hernia repair, a combination of International Classification of Diseases (ICD)-9 and ICD-10 diagnostic codes along with Current Procedural Terminology (CPT) codes were utilized. First, ICD-9 codes (569.60, 569.62, 569.69, 569.89) for “stomal hernia or prolapse” or ICD-10 codes (K43.3, K43.4, K43.5) for “parastomal hernia with or without obstruction and gangrene” were used to select cases that represent true parastomal hernias. Next, CPT codes (44346, 49560, 49561, 49565, 49566, 44238, 49652-49657, 49659) were used to identify patients who underwent hernia repair. Concurrent ventral hernia repair, relocation of stoma, and bowel resection (small and large bowel) were identified using additional CPT codes (Supplemental Table 1). All other types of hernia repairs were excluded from this study. The following information was collected for each included patient: sex, age, body mass index (BMI), smoking status, comorbidities, and 30-day postoperative outcomes.

Study Design

A 5-factor modified frailty index score (5-mFI) was calculated for each patient. The score was calculated by adding 1 point for the presence of each one of the following 5 comorbidities: (1) history of diabetes mellitus, (2) congestive heart failure (CHF)—new diagnosis or exacerbation within 30 days of surgery, (3) history of hypertension requiring medication, (4) history of severe chronic obstructive pulmonary disease (COPD), and (5) non-independent functional status (partially or fully dependent). The minimum possible score was 0, while the maximum possible score was 5. The 5-mFI score has been validated in previous studies and has been shown to have a strong predictive ability for postoperative complications, involving a spearmen rho correlation of .95 and C statistic greater than .7.^{11,13,16,17,24-31}

The primary endpoint of this study was 30-day overall complications. Complications were grouped into the following categories: wound complications (superficial infection, deep infection, organ space infection, and wound dehiscence), pulmonary complications (unplanned reintubation, pneumonia, and pulmonary embolus), cardiovascular complications (cardiac arrest, myocardial infarction, and cerebral vascular accident), renal complications (renal insufficiency, acute renal failure, and urinary tract infection) and hematologic complications (bleeding requiring blood transfusion, postoperative sepsis, postoperative septic shock, and deep vein thrombosis). The secondary endpoints for this study included: 30-day readmission, reoperation, length of stay and need to discharge to care facility (acute rehabilitation center or skilled nursing facility).

Statistical Analysis

Patients were grouped based on their 5-mFI score: 5-mFI = 0, 5-mFI = 1, and 5-mFI >2 (patients with 2 or more frailty factors were combined to avoid underpowering the study). Patient risk factors such as age, BMI, smoking status, and comorbidities were compared between the groups. Continuous variables presented as mean (standard deviation) were compared using a one-way analysis of variance, whereas categorical variables presented as frequency (percentages) were compared using a chi-squared test. Patients’ incidence of complications, and other outcomes were stratified by 5-mFI scores and compared using one-way analysis of variance or chi-squared test, as appropriate. Multivariate logistic regressions were used to further compare the complication rates between the different 5-mFI groups, while controlling for potential confounding factors. Variables included in the regression models were: 5-mFI score, age, sex, body mass index (BMI), dyspnea, preoperative sepsis, concurrent ventral hernia repair, stomal relocation, and bowel resection. Male sex, no dyspnea, no preoperative sepsis, no concurrent ventral hernia repair, no stomal relocation, no bowel resection, and a 5-mFI score of 0 were all used as the referent conditions. Statistical significance was defined a as P value <.05. All analysis was performed using IBM SPSS Statistics Version 28.0.1.0.

Results

The query of the ACS-NSQIP database identified 2924 (52.2% female) patients who underwent elective parastomal hernia repair between 2015 and 2020. All descriptive statistics of patient preoperative variables are presented in Table 1. The mean (standard deviation, SD) patient age was 63.4 (+13.2) years, and the mean (SD) BMI was 30.9 (+6.4).

Table 1.

Demographics and Preoperative Variables.

Variable (n = 2924)
Age (mean, SD)		63.4 (13.2)
BMI (mean, SD)		30.9 (6.4)
Sex, n (%)	Male	1399 (47.8%)
Sex, n (%)	Female	1525 (52.2%)
Race, n (%)	Asian	22 (.8%)
	Black or African American	140 (4.8%)
	Native/Hawaiian/Pacific Islander	3 (.1%)
	White	2483 (84.9%)
	Unknown/Unreported	276 (9.5%)
Frailty index, n (%)	0	1134 (38.8%)
	1	1197 (40.9%)
	2	528 (18.1%)
	3	60 (2.1%)
	4	4 (.1%)
	5	1 (.0%)

SD, standard deviation; BMI, body mass index; 5-mFI, 5-factor modified frailty index.

When stratified by 5-mFI score, 1134 (38.8%) patients had a 5-mFI of 0, 1197 (40.9%) patients had a 5-mFI of 1, and 593 (20.3%) patients had a 5-mFI of 2 or more. The preoperative variables stratified are presented in Table 2. Patients with a 5-mFI score of 2 or more were significantly older (P < .001), had a higher BMI (P < .001), were more likely to have dyspnea (P < .001) and preoperative sepsis (P < .001). No significant differences were noted between groups when it came to additional concurrent ventral hernia repairs, stoma relocation, or bowel resection.

Table 2.

Univariate Analysis of Preoperative Factors.

Variable		5-mFI = 0, n = 1134	5-mFI = 1, n = 1197	5-mFI >2, n = 593	P value
Female, n (%)		614 (54.1)	611 (51.0)	300 (50.6)	n/a
Male, n (%)		520 (45.9)	586 (49.0)	293 (49.4)	n/a
Age (years, mean, SD)		59.2 (13.9)	65.5 (12.3)	67.1 (11.2)	<.001
BMI (mean, SD)		30.0 (6.2)	31.0 (6.4)	32.2 (6.5)	<.001
Concurrent ventral hernia repair n (%)		93 (8.2)	101 (8.4)	42 (7.1)	.599
Stoma relocation, n (%)		29 (2.6)	41 (3.4)	17 (2.9)	.461
Bowel resection, n (%)		25 (2.2)	23 (1.9)	12 (2.0)	.889
Medical comorbidities, n (%)	Smoker	196 (17.3)	188 (15.7)	100 (16.9)	.576
	Dyspnea	43 (3.8)	98 (8.2)	91 (15.3)	<.001
	Renal failure (preoperative)	1 (.1)	1 (.1)	2 (.3)	.335
	Dialysis (re-operative)	9 (.8)	10 (.8)	6 (1.0)	.892
	Disseminated cancer	37 (3.3)	31 (2.6)	11 (1.9)	.220
	Steroid use	100 (8.8)	90 (7.5)	38 (6.4)	.186
	Preoperative sepsis	4 (.4)	14 (1.2)	13 (2.2)	<.001
	CHF	0 (0)	2 (.2)	17 (2.9)
	Severe COPD	0 (0)	64 (5.3)	146 (24.6)	<.001
	Diabetes	0 (0)	119 (9.9)	453 (76.4)	<.001
	Hypertension	0 (0)	972 (81.2)	573 (96.6)	<.001
	Partially or totally dependent	0 (0)	40 (3.3)	68 (11.5)	<.001
Wound classification n (%)	Class I—clean	495 (43.7)	546 (45.6)	260 (43.8)	.726
	Class II—clean/contaminated	542 (47.8)	543 (45.4)	275 (46.4)
	Class III—contaminated	81 (7.1)	83 (6.9)	48 (8.1)
	Class IV—dirty	16 (1.4)	25 (2.1)	10 (1.7)

SD, standard deviation; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; 5-mFI, 5-factor modified frailty index.

Univariate analysis of primary and secondary outcomes stratified by 5-mFI score is demonstrated in Table 3. Analysis of primary outcome showed that patients with modified frailty index scores of 2 or more had significantly higher rates of overall complications (5-mFI >2: 20.6%, 5-mFI = 1: 15.4%, 5-mFI = 0:15.2%, P = .008), pulmonary complications (5-mFI >2: 5.1%, 5-mFI = 1: 3.5%, 5-mFI = 0: 1.9%, P = .002), cardiovascular complications (5-mFI >2: 2.2%, 5-mFI = 1:1.0%, 5-mFI = 0:0.4%, P = .003), hematologic complications (5-mFI >2:8.3%, 5-mFI = 1:4.6%, 5-mFI = 0: 4.9%, P = .003), and renal complications (5-mFI >2: 6.1%, 5-mFI = 1: 3.3%, 5-mFI = 0: 2.7%, P = .002). Furthermore, this group also had a higher rate of readmission (5-mFI >2:15.9%, 5-mFI = 1:10.8%, 5-mFI = 0:12.6%, P = .009), reoperation (5-mFI >2: 8.8%, 5-mFI = 1: 4.5%, 5-mFI = 0: 6.7%, P = .001), discharge to care facility (5-mFI >2: 12.5%, 5-mFI = 1:7.0%, 5-mFI = 0: 4.1%, P < .001), and death (5-mFI >2: 1.2%, 5-mFI = 1:0.5%, 5-mFI = 0:0.2%, P = .021). No significant differences were found in the rate of wound complication, average length of stay, or operative time.

Table 3.

Univariate Analysis of Outcomes Stratified by 5-mFI.

Variables	5-mFI = 0 n = 1134	5-mFI = 1 n = 1197	5-mFI >2 n = 593	P value
Primary outcomes, n (%)
Overall complications	172 (15.2%)	184 (15.4%)	122 (20.6%)	.008
Wound complications	112 (9.9%)	100 (8.4%)	59 (9.9%)	.365
Superficial wound infection	64 (5.6%)	63 (5.3%)	25 (4.2%)	.443
Deep wound infection	15 (1.3%)	15 (1.3%)	10 (1.7%)	.748
Organ space infection	29 (2.6%)	23 (1.9%)	20 (3.4%)	.170
Wound dehiscence	7 (.6%)	10 (.8%)	8 (1.3%)	.291
Pulmonary complications	22 (1.9%)	42 (3.5%)	30 (5.1%)	.002
Pneumonia	13 (1.1%)	29 (2.4%)	19 (3.2%)	.010
Pulmonary embolism	2 (.2%)	7 (.6%)	3 (.5%)	.280
Failure to wean from ventilator	8 (.7%)	12 (1.0%)	8 (1.3%)	.418
Unplanned reintubation	7 (.6%)	13 (1.1%)	12 (2.0%)	.028
Cardiovascular complications	5 (.4%)	12 (1.0%)	13 (2.2%)	.003
Cerebrovascular accident	3 (.3%)	0 (.0%)	2 (.3%)	.166
Cardiac arrest	0 (.0%)	2 (.2%)	6 (1.0%)	<.001
Myocardial infarction	2 (.2%)	10 (.8%)	7 (1.2%)	.028
Hematologic complications	66 (4.9%)	55 (4.6%)	49 (8.3%)	.003
Postoperative bleeding	18 (1.6%)	22 (1.8%)	16 (2.7%)	.270
Deep vein thrombosis	6 (.5%)	7 (.6%)	2 (.3%)	.767
Postoperative sepsis	23 (2.0%)	22 (1.8%)	27 (4.6%)	.001
Postoperative septic shock	8 (.7%)	22 (1.8%)	7 (1.2%)	.593
Renal complications	31 (2.7%)	40 (3.3%)	36 (6.1%)	.002
Postoperative renal insufficiency	2 (.2%)	3 (.3%)	12 (2.0%)	<.001
Postoperative renal failure	3 (.3%)	5 (.4%)	5 (.8%)	.226
Urinary tract infection	28 (2.5%)	32 (2.7%)	19 (3.2%)	.668
Secondary outcomes n (%)
Need for readmission	143 (12.6%)	129 (10.8%)	94 (15.9%)	.009
Need for reoperation	76 (6.7%)	54 (4.5%)	52 (8.8%)	.001
Discharge to care facility	47 (4.1%)	84 (7.0%)	74 (12.5%)	<.001
Death	2 (.2%)	6 (.5%)	7 (1.2%)	.021
Average length of stay days (SD)	4.2 (4.2)	4.2 (6.9)	4.5 (9.7)	.779
Average operating time minutes (SD)	166.9 (98.9)	162.4 (94.9)	165.5 (101.8)	.527

5-mFI, 5-factor modified frailty index; SD, standard deviation.

Multivariate regression analyses of primary and secondary outcomes (Table 4) were used to account for potential confounders. Results from the regression models showed that compared to patients with a 5-mFI score of 0, patients with a 5-mFI score of 2 or more had 1.40 times higher risk for developing overall complications [1.40, 1.03-1.78, P = .032], 2.97 times higher risk of pulmonary complications [2.97, 1.63-5.39; P < .001], 1.60 times higher risk of hematological complications [1.60, 1.03-2.47, P = .035], 2.04 times higher risk of renal complications [2.04, 1.19-3.46, P = .009], 1.47 times increased risk of readmission [1.47, 1.10-1.99, P = .013], and 2.50 times risk of discharging to care facility [2.50, 1.66-3.77, P < .001]. After multivariate regression, need for reoperation was no longer significant.

Table 4.

Multivariate Logistic Regression of Primary and Secondary Outcomes.

Variable odds ratio [CI] P-value	5-mFI = 1	5-mFI ≥2
Overall complications	1.01 [.79-1.27] P = .970	1.40 [1.03-1.78] P = .032
Pulmonary complications	1.90 [1.11-3.27] P = .020	2.97 [1.63-5.39] P < .001
Hematologic complications	.92 [.62-1.38] P = .697	1.60 [1.03-2.47] P = .035
Renal complications	1.16 [.71-1.91] P = .554	2.04 [1.19-3.46] P = .009
Need for readmission	.92 [.71-1.19] P = .534	1.47 [1.10-1.99] P = .013
Need for reoperation	.69 [.48-1.00] P = .052	1.38 [.93-2.05] P = .111
Discharge to care facility	1.45 [.99-2.13] P = .059	2.50 [1.66-3.77] P < .001

5-mFI, 5-factor modified frailty index. CI, confidence interval.

The odds ratio for categorical variables was determined through multivariate logistic regression. All regression models included 5-mFI score, age, sex, body mass index (BMI), dyspnea, preoperative sepsis, concurrent ventral hernia repair, stomal relocation, and bowel resection. Male sex, no dyspnea, no preoperative sepsis, no concurrent ventral hernia repair, no stomal relocation, no bowel resection, and a 5-mFI score of 0 were all used as the referent conditions.

Additional variables that were found to be independent risk factors are described in Table 5. Bowel resection during parastomal hernia repair was found to be an independent risk factor for pulmonary complication [3.16, 1.20-8.26, P = .02] and discharge to care facility [3.55, 1.79-7.04, P < .001]. Additionally, stoma relocation was also found to be an independent risk factor for overall complications [1.81, 1.10-2.97, P = .02]. Concurrent additional ventral hernia repair was not found to be an independent risk factor.

Table 5.

Multivariate Logistic Regression of Additional Risk Factors.

Variable odds ratio [CI] P-value	BMI	Bowel resection	Stoma relocation	Concurrent ventral hernia repair
Overall complications	1.01 [.99-1.05] P = .193	1.95 [1.10-3.46] P = .23	1.81 [1.10-2.97] P = .02	1.32 [.94-1.86] P = .114
Pulmonary complications	.96 [.921-.991] P = .016	3.16 [1.20-8.26] P = .02	1.02 [.31-3.35] P = .979	1.65 [.86-9.90] P = .131
Hematologic complications	1.03 [1.00-1.05] P = .031	1.95 [.85-4.44] P = .113	1.94 [.94-4.01] P = .072	1.14 [.65-2.03] P = .645
Renal complications	1.00 [.97-1.04] P = .846	1.23 [.37-4.09] P = .743	1.66 [.65-4.24] P = .293	.83 [.38-1.81] P = .623
Need for readmission	.98 [.97-1.00] P = .091	1.42 [.60-3.35] P = .425	.751 [.416-1.09] P = .341	1.34 [.92-1.95] P = .746
Need for reoperation	1.99 [.97-1.02] P = .689	2.05 [.49-8.51] P = .324	1.36 [.49-3.78] P = .553	1.22 [.67-2.23] P = .915
Discharge to care facility	1.01 [.99-1.04] P = .385	3.55 [1.79-7.04] P < .001	1.21 [.53-2.75] P = .648	1.10 [.64-1.86] P = .724

5-mFI, 5-factor modified frailty index. CI, confidence interval.

The odds ratio for categorical variables was determined through multivariate logistic regression, whereas negative binomial regression was used for continuous variables. All regression models included 5-mFI score, age, sex, body mass index (BMI), dyspnea, preoperative sepsis, concurrent ventral hernia repair, stomal relocation, and bowel resection. Male sex, no dyspnea, no preoperative sepsis, no concurrent ventral hernia repair, no stomal relocation, no bowel resection, and a 5-mFI score of 0 were all used as the referent conditions.

Discussion

Frailty is the measure of decreased physiological reserve and the vulnerability to adverse events from physiological and pathologic stressors.³² A patient’s frailty does not necessarily correlate with an increase in chronologic age. The 5-mFI score, a validated scoring system for frailty, has been established as an important prognosticator of surgical outcomes across various fields of surgery.^10,16,33 In general surgery, it has been proven to be an objective metric that physicians can utilize while making preoperative risk stratifications as well as for patient counseling. While previous authors have explored the validity of the 5-mFI score in various types of hernia repairs, there is a dearth of literature regarding its utility as a prognosticator of parastomal hernia repair. To fill the knowledge gap, we performed a retrospective analysis of the ACS-NSQIP database evaluating 2924 patients who underwent elective parastomal hernia repair between 2015 and 2020. We found that when compared to patients with a 5-mFI score of zero, patients with a score of at least 2 were 1.4 times more likely to suffer from 30-day overall complications (primarily attributed to pulmonary, cardiovascular, renal, and hematological complications), 1.5 times more likely to require 30-day unplanned readmission, and 2.5 times more likely to be discharged to a care facility (skill nursing facility and acute rehabilitation center). We also found stomal relocation, and bowel resection as independent risk factors.

Frail patients are at a higher risk of developing postoperative complications.³⁴ In our study we found that patients with a 5-mFI score of 2 or more, were 1.4 times more likely to have any type of postoperative complications. The significant postoperative complications included pneumonia, unplanned intubations, cardiac arrest, myocardial infarction, postoperative sepsis, and postoperative renal insufficiency. The findings from our study were similar to findings by Balla et al who performed a retrospective analysis of ventral hernia repairs and found that the accumulation of frailty factors was associated with increased frequency of postoperative complications.¹⁶ However, the overall complications rate with 1 and 2 frailty factors in our study was 15.4% and 20.6% compared to 5.1% and 7.6% found in their study. This difference may be attributed to the fact that, while Balla et al¹⁶ investigated a wide range of ventral hernia patient, our study focused solely on parastomal hernia patients—a population that may have undergone more major surgical and medical interventions for underlying disease. Similarly, Chimukangara et al performed a retrospective review and found higher complication rates for patients with increasing frailty scores.¹⁰ They reported a 5.9% and 10.5% overall complication rate for patients with 5-mFI of 1 and 2, respectively. Our study also found that the accumulation of frailty factors was associated with an increase in the rate of postoperative mortality, similar to findings reported by both Balla et al¹⁶ and Chimukangara et al.¹⁰ Finally, we also noted that stomal relocation was a stronger independent risk factor for any overall complications than 5-mFI score of 2 or more.

Our study found that a 5-mFI of 2 or was associated with 1.5 times higher risk of need for readmission. This finding was similar to Wahl et al²⁷ who in their retrospective review of the NSQIP database showed that an increased number of frailty variables were linearly associated with an increased need for unplanned readmissions after orthopedic, vascular, and general surgeries. Similarly, in a retrospective study of free flap breast reconstruction, Magno-Pardon et al¹⁸ also observe that a 5-mFI > 2 was associated with a 1.8 times higher risk of readmission. However, Chimukangara et al¹⁰ in their review of paraesophageal hernia patients did not find a significant increase in unplanned readmission rates associated with the accumulation of frailty factors. The differences in our results may be due to the baseline disease etiology of the hernias that were analyzed. While postoperative readmissions are difficult to anticipate even with granular information about a patient, other studies using different frailty indexes, such as the Canadian Study of Health and Aging Clinical Frailty Scale, have also shown a similar predictive ability for readmission.^35-38

Other studies have suggested that a high frailty score and its associated postoperative complications can lead to a higher likelihood a lengthier hospitalization and being discharged to somewhere other than home.^16,39,40 They also determined that frailty was an independent predictor for this disposition, regardless of the complications experienced by patients. Ramdass et al⁴¹ performed a prospective study on hospitalized elderly patients using the Reported Edmonton Frailty Scale (REFS) and found that mildly frail patients were 2.0 times more likely and moderate to severely frail patients were 2.7 times more likely to discharge to a skilled nursing facility or inpatient rehabilitation center. Similarly, Pearl et al performed a retrospective review of radical cystectomy patients and found that patients with a higher level of frailty were 2.3 times more likely to be discharged to inpatient rehabilitation or a skilled nursing facility.⁴² In the realm of hernia surgeries, Balla et al¹⁶ and Chimukangara et al¹⁶ both showed that higher frailty was linearly associated with discharge to a location other than home. Along the same lines, our study also found that a 5-mFI > 2 was associated with 2.5 times higher risk of being discharged to a care facility. Although our study did not specifically delineate individual factors of the 5-mFI, other studies have suggested that dependent functional status was also an independent risk factor for discharge to a location other than home.^10,16,39,40 This is an important distinction, because patients who develop medical or surgical complications due to overall frailty might require ongoing medical care at a skilled nursing facility, whereas those with limited functional status may only require physical rehabilitation due to mobility and strength issues. This is significant because previous studies have shown that mortality is higher amongst patients discharged to skilled nursing facilities compared to acute rehabilitation centers.⁴⁰

To our knowledge, this is the first study to specifically evaluate the association of 5-mFI with postoperative outcomes and complications after parastomal hernia repair. Preoperative frailty assessment provides an opportunity to improve discussions between clinicians and patients such that they can better anticipate perioperative risk.⁴³ There are advantages to using this index for risk assessment in surgical populations. It is easy to use and allows for an objective method to calculate surgical outcomes and complications. Furthermore, this index can be used to assess a patient’s physiologic reserve while accounting for age as a confounder. In fact, 5-mFI frailty assessment can identify potentially modifiable components of frailty to rehabilitate patients to enhance their functional capacity to buffer against physiologic stress induced by surgical intervention.^44-47

While our study utilized a large patient population, it was not without limitations. Notable limitations associated with the ACS-NSQIP database include inaccurate data entry, complications reported for only 30 days postoperatively, and lack of relevant complications relating to specifically parastomal hernia. Furthermore, this database is limited in providing surgeon-specific information (surgeon experience), facility-specific information (low volume vs high volume center), and surgical techniques used (type of parastomal hernia repair). Although the use of both ICD and CPT codes allowed us to use a systematic approach to identifying patients who underwent parastomal hernia repair, it was limited in recognizing the use of mesh in laparoscopic procedures. While open procedures have an additional CPT code to denote the use of mesh, laparoscopic CPT codes are combined. Due to this limitation, we were unable to reliably analyze the effect of mesh-based repair. Another notable limitation we faced during our analysis was the lack of information regarding bowel preparation—which plays a significant role in wound complications. We were also limited in our analysis because we were unable to identify the reason patients originally received their ostomy. This prevented us from analyzing other confounders such as chemotherapy and radiation treatments. Finally, in our analysis, we found that majority of our patients have hypertension and diabetes as their main comorbidities – therefore, this index may be more reflective of the impact of mainly diabetes and hypertension.

Conclusions

The 5-mFI score is a validated tool to identify ideal candidates for surgical intervention. The purpose of our study was to query the ACS-NSQIP database to assess the utility of the 5-mFI score to risk-stratify patients who need parastomal hernia repair. Our study found that parastomal hernia repair patients with a 5-mFI score of at least 1, had a higher risk of renal, pulmonary, cardiovascular and hematologic complications, readmissions, discharge to care facility, and mortality. Hence, the 5-mFI score can be a useful tool for surgeons during preoperative risk stratification.

Supplemental Material

Supplemental Material - Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair

Supplemental Material for Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair by Mustafa Khan, Ronit Patnaik, Melinda Lue, Haisar Dao Campi, Lisandro Montorfano, Mauricio Sarmiento Cobos, Roberto J. Valera, Raul J. Rosenthal, and Steven D. Wexner in The American Surgeon™

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: None of the authors have relevant financial conflicts of interest to disclose. Dr Wexner reports received consulting fees from ARC/Corvus, Astellas, Baxter, Becton Dickinson, GI Supply, ICON Language Services, Intuitive Surgical, Leading BioSciences, Livsmed, Medtronic, Olympus Surgical, Stryker, Takeda and receiving royalties from Intuitive Surgical and Karl Storz Endoscopy America Inc.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ronit Patnaik

Supplemental Material

Supplemental material for this article is available online.

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