Page 8 - Read Online

Sioutas et al. Hepatoma Res 2020;6:4 I http://dx.doi.org/10.20517/2394-5079.2019.43 Page 3 of 9

Figure 1. “Physical Frailty Phenotype” model by Fried et al. [14]

rates did not differ significantly between older and younger patients undergoing hepatic resection for
HCC, while the risk of mortality for younger patients was 2.7 times lower when compared to the elderly for
[39]
colorectal liver metastases . Interestingly, another meta-analysis reported that hepatic resection for liver
malignancies is associated with a higher risk of postoperative renal failure, infection, and mortality in older
vs. younger patients, while the length of stay (LOS) in the hospital, transfusions, and disease-free survival
[40]
did not differ significantly between the two groups . Nevertheless, the considerable variability in patient
outcomes after liver resection in the elderly underlines the inability of age alone to predict postoperative
outcomes accurately. Instead, factors that reflect the overall health status of the patient, such as frailty, may
serve as more accurate predictors of postoperative outcomes. On that grounds, several frailty assessment
tools have been developed in order to preoperatively determine patients at risk of adverse postoperative
outcomes.

FRAILTY ASSESSMENT TOOLS
Numerous frailty screening tools have been described over the years [17,18,41] . The most commonly
implemented one is the “Physical Frailty Phenotype” model by Fried et al. , which describes frailty as
[14]
the decrease in physiological reserve secondary to a multisystem functional decline. This tool assesses the
following criteria to identify frail patients: (1) walking speed; (2) grip strength; (3) weight loss; (4) physical
activity; and (5) exhaustion [Figure 1]. Patients meeting one or two of these criteria are deemed “pre-frail”,
[42]
[14]
while those meeting at least three criteria are categorized as frail . Makary et al. further validated this
definition, and at the same time defined as “pre-frail” those fulfilling two or three of the above-mentioned
criteria. The Phenotypic frailty tool requires only a questionnaire, a stopwatch, and a dynamometer, and
[17]
thus can be completed in only 10-15 min . It is also recognized by the American College of Surgeons
and the American Geriatric Society for the assessment of the elderly preoperatively . Nevertheless, the
[43]
[44]
inherent drawback of this assessment method is the lack of psychosocial evaluation of the older patient .
The second most commonly used frailty assessment tool is the “Deficit Accumulation Index” by
[15]
Rockwood et al. [Figure 2]. It defines frailty using a frailty index (FI) with the number of deficits or
abnormal characteristics accumulated over several areas (i.e., physical, social, functional, and cognitive)
on the numerator and the total number of characteristics assessed on the denominator [15,45,46] . Higher index
values have been associated with an increased likelihood of frailty, adverse patient outcomes, disability,
hospitalization, and death . Although it is considered more sensitive than the Phenotypic frailty tool ,
[16]
[45]
its downsides include the fact that it is time-consuming (up to 70 characteristics assessed sometimes) and
its extensive focus on comorbidities (symptoms, diagnoses, abnormal values on laboratory tests, etc.) rather
[18]
than on functional decline . With the aim to assess frailty in a timely fashion and in a more efficient way,
[47]
several modified FIs (mFIs), which may measure as few as five factors, have been generated . In fact,
11-point mFIs have already been used to evaluate patients undergoing liver resection [48,49] .
Comprehensive geriatric assessment (CGA) is another well-established approach implemented to evaluate
frailty in older patients [50,51] . It utilizes assessment tools and laboratory values to assess patients from several