An old hospitalized patient lying in bed.

Frailty before emergency surgery isn’t the only factor linked to adverse outcomes. In fact, the risk of the procedure itself has even more negative implications for older adults, according to a study published on April 25 in the Journal of the American College of Surgeons.

“We are seeing a lot more elderly patients in the emergency department with acute surgical problems that require a major operation. And the outcomes for these individuals, compared to younger patients, are much worse,” Raul Coimbra, MD, an author of the report and surgeon-in-chief of the Riverside University Health System in Moreno Valley, said in a statement. Coimbra is also a  professor of surgery at Loma Linda University School of Medicine, both in California.

“We need to counsel patients and their families about all the risks they are incurring when patients undergo a major emergency operation and be transparent about what to expect afterward. Sometimes, the family believes the patient will return home. But in fact, a significant number of patients who have major surgery end up in nursing homes or rehab facilities and never go home,” he said.

In the trial, researchers assessed data on 59,633 people over the age of 65 who had emergency surgeries between 2018 and 2020. The participants were classified as not frail, frail and severely frail; they were also grouped according to the risk level associated with a procedure. Next, the team looked at five different outcomes: 30-day mortality, 30-day postoperative complications, failure to rescue, hospital readmission and 30-day reoperation. 

Of the people, 29.3% weren’t frail, 66.4% were frail and 4.3% were severely frail. There were 25,157 in the low-risk operation group and 34,476 in the high-risk procedure group.

Frailty and procedure risk were both linked to higher risk for death, complications after surgery, failure to rescue, and readmissions. But when people were grouped according to the risk of a certain procedure, the chance of having an adverse outcome was even stronger when the risk was higher. 

People who weren’t frail and had high-risk emergency surgeries had a 7.1% mortality rate, while the mortality rate of low-risk procedures was 0.2%. Frail and severely frail patients who had high-risk procedures had mortality rates of 11.5% and 25.8%, while death rates after low-risk procedures were 1.0% and 4.1%, respectively.

In nonfrail people, high-risk procedures accounted for a fourfold increase in surgical complications compared to low-risk procedures. Higher-risk procedures also accounted for a fourfold increase in complications among frail and severely frail patients, data showed.

The difference between high-risk and low-risk procedures was at least four times greater in every outcome compared to only measuring it based on frailty status. “The message from our study is that elderly patients should undergo surgical treatment when they first present with their disease,” Coimbra said. “It should not be put off until complications develop to the point where an emergency operation is needed.”