The Surgical Apgar score and frailty as outcome predictors in short- and long-term evaluation of fit and frail older patients undergoing elective laparoscopic cholecystectomy – a prospective cohort study

Introduction
Frailty increases the risk of poor surgical outcomes in the older population. Some intraoperative factors may also influence the final result and can be evaluated. The Surgical Apgar Score (SAS) is a simple system predicting postoperative mortality and morbidity. However, the utility of the SAS remains unknown in fit and frail older patients undergoing elective laparoscopic cholecystectomy due to benign gallbladder diseases.

Aim
To evaluate the usefulness of the SAS in predicting 30-day morbidity and 1-year mortality in older fit and frail patients undergoing elective laparoscopic cholecystectomy.

Material and methods
Consecutive patients (≥ 70 years) were enrolled in the prospective study. The Comprehensive Geriatric Assessment (CGA) was used to diagnose frailty. Logistic regression was conducted to investigate the association between the scores and the outcomes.

Results
The study included 144 consecutive older patients with a median age of 76 (range: 70–91) years. The prevalence of frailty was 44.4%. The 30-day mortality and morbidity were 0% and 11.8%, respectively. The 1-year mortality was 6.3% and 7 out of 9 occurred in the frail group. SAS < 7 points was identified as an independent predictor of 30-day postoperative morbidity (OR = 5.1; 95% CI: 1.5–18.1). Age > 85 years (OR = 1.9; 95% CI: 1.2–16.4) and frailty (OR = 3.4; 95% CI: 1.1–19.3) were predictors of 1-year mortality.

Conclusions
Laparoscopic cholecystectomy can be safely performed in older fit and frail patients. The SAS, not age, turned out to be the most important predictor of 30-day morbidity. Frailty and age > 85 years were predictors of 1-year mortality. Older patients with SAS < 7 points should be followed meticulously in order to diagnose and treat potential complications early on.