Frailty in Colorectal Surgery
Research type
Research Study
Full title
The assessment and quantification of frailty in patients undergoing elective colorectal surgery
IRAS ID
184906
Contact name
Michael Lim
Contact email
Sponsor organisation
NHS Highland
Duration of Study in the UK
2 years, 0 months, 1 days
Research summary
Patients with colorectal cancer are increasingly elderly and have numerous co-morbidities. There is an increasing expectation that patients receive and then recover from their operations, despite the risks associated with their index or subsequent operations should they develop complications. Mortality rates for individual surgeons are now available in the public domain and the decision to perform or withhold an operation for individual patients, will ultimately impact on such figures. The concept of fitness for surgery has received suitable attention in the past (with both subjective and objective assessments such cardiopulmonary testing) as a decision tool. However, a further concept of patient frailty requires further attention. Patients who are generally malnourished, weak, unmotivated and inactive are less likely to survive surgery.
Intervening on a cancer in the elderly is a gamble against their length of life. Any negative effect from surgical intervention will outweigh purported benefits because a good proportion of elderly patients may have very little trouble from their cancer between time of presentation and their ‘end of life’. The closer an elderly individual is to his or her life’s natural end, the less there is 'Time to Benefit'. This is particularly an issue with major surgery as physical, cognitive and social impairment after elective surgery could shorten that time.
The Hopkins Frailty Score has been used in several surgical and non surgical studies. In one such American study from 2013, 189 patients who underwent various types of general surgical and urological procedures were assessed with this score. Thirty day mortality was the primary outcome. On univariate analysis, the Hopkins Frailty Score (OR 2.07, CI 1.05-4.08) as well as its subscores were significant predictors of complication; most other evaluative methods were not. A similar study by the same group of authors was then repeated in 2015.4 In this study, 351 patients all undergoing major intra-abdominal surgery were recruited. The results from this study demonstrated that 2 components of the Hopkins Frailty Score, hold the same predictive value as the full previous frailty assessment. Other assessment tools have been employed predominantly by American researchers and a plausible link between patient frailty and poor outcomes has been demonstrated in several vascular, gynaecology, urology, orthopaedic and cardiac studies. Hitherto, only one American colorectal series has examine the link between frailty and postoperative outcomes.
The Montreal Cognitive Assessment (MOCA) tool assesses several cognitive domains. The short-term memory recall task (5 points) involves two learning trials of five nouns and delayed recall after approximately 5 minutes. Visuospatial abilities are assessed using a clock-drawing task (3 points) and a three-dimensional cube copy (1 point). Multiple aspects of executive functions are assessed using an alternation task adapted from the trail-making B task (1 point), a phonemic fluency task (1 point), and a two-item verbal abstraction task (2 points). Attention, concentration and working memory are evaluated using a sustained attention task (target detection using tapping; 1 point), a serial subtraction task (3 points), and digits forward and backward (1 point each). Language is assessed using a three-item confrontation naming task with low-familiarity animals (lion, camel, rhinoceros; 3 points), repetition of two syntactically complex sentences (2 points), and the aforementioned fluency task. Finally, orientation to time and place is evaluated (6 points). It was validated in the setting of mild cognitive impairment, and has subsequently been adopted in numerous other settings clinically, including that of surgical patients.
The purpose of this study is to measure frailty in a cohort of NHS Highland patients who have surgery for colorectal cancer and to examine whether their postoperative outcomes are influenced by their preoperative physical state.
REC name
North of Scotland Research Ethics Committee 2
REC reference
16/NS/0073
Date of REC Opinion
15 Jul 2016
REC opinion
Unfavourable Opinion