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Sioutas et al. Hepatoma Res 2020;6:4 I http://dx.doi.org/10.20517/2394-5079.2019.43 Page 5 of 9

Table 1. Frailty assessment tools
Tools Ref.
Physical frailty phenotype [14,42]
Deficit accumulation index [15]
Comprehensive geriatric assessment [50,51]
Abbreviated comprehensive geriatric assessment [54,55]
Geriatric-8 [52,53]
Vulnerable elders survey-13 [52,53]
FRAIL index [56]
Edmonton frail scale [58,59]
Clinical frailty scale [62]
Kihon checklist [64,65]
The handgrip test [52]
The “Up & Go” test [52,67]

FRAIL: fatigue, resistance, ambulation, illness, and weight loss

handgrip test can be applied in multiple settings, another tool particularly useful for hospitalized patients is
[67]
the timed “Up & Go” test . This test requires the patient to stand up and walk three meters, then to turn,
[52]
walk back and sit down and can accurately assess balance and functional mobility . Data suggest that it is
[68]
particularly useful in identifying cancer patients at risk of postoperative complications . A comprehensive
list of the various tools used for the assessment of frailty is shown in Table 1.
LIVER RESECTION AND FRAILTY
There is a growing body of evidence that frailty assessment tools are useful in identifying frail patients
at higher risk of postoperative morbidity and mortality, as well as extended LOS in the hospital. In fact,
[53]
Kaibori et al. evaluated the utilization of the G8 CGA tool in patients ≥ 70 years undergoing liver
resection for HCC. Patients with a score lower than 14 demonstrated higher postoperative morbidity rate
[53]
and extended LOS, but no difference in mortality when compared to patients with scores ≥ 14 . Notably,
on multivariate analysis, G8 score < 14 was significantly associated with postoperative morbidity, while
[53]
age ≥ 77 years was not found to be a significant risk factor . It is worth mentioning that patients with
HCC arising on a background of cirrhosis demonstrated a tendency towards inferior outcomes after liver
[53]
resection ; however, further research is warranted in order to deduce meaningful conclusions.
[48]
Louwers et al. investigated the impact of frailty, assessed by the 11-point mFI tool, on morbidity and
mortality after open hepatectomy in 10,300 patients from the National Surgical Quality Improvement
Project (NSQIP) database. As the mFI score increased, a statistically significant increase was associated
with Clavien 4 complications, mortality, and extended LOS. Notably, this statistical significance was
maintained in all types of hepatectomy (partial, right, left, and extended). Although this study highlighted
the importance of mFI in preoperative planning and risk stratification, the authors stressed the need for
[48]
simpler hepatectomy-specific frailty assessment tools . Another study utilizing NSQIP hepatectomy
data described the revised FI (rFI) on a “training set” of patients and compared it with the 11-point mFI
[49]
(“validation set”) . rFI incorporates several variables, such as preoperative serum albumin and hematocrit,
American Society of Anesthesiologists score, BMI, the extent of liver resection, and underlying pathology.
Higher rFI scores were significantly associated with postoperative complications, prolonged LOS, and
mortality, while higher mFI scores were linked only to a higher risk of morbidity but neither mortality
[49]
[69]
nor LOS . Chen et al. evaluated the use of a five-item mFI to assess the effect of frailty on outcomes
in patients undergoing combined colorectal and liver resection for colorectal cancer and liver metastases.
Patients with higher mFI scores exhibited a higher incidence of mortality, overall and severe morbidity,
as well as prolonged LOS. On multivariate analysis, higher mFI scores were found to be independent risk
factors for overall and severe morbidity, while age was not found to be a significant factor that affects
morbidity.