An investigation into the measurement and management of frailty in surgical patients

Trotter, John Martin

November 2019

Thesis or dissertation

© 2019 John Martin Trotter. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.

This thesis intends to investigate a method of identification of frailty in the surgical population, CT defined sarcopenia, and a possible method to attenuate its effects in the preoperative period, prehabilitation.

845 patients that underwent emergency laparotomy in 4 acute hospitals were screened for sarcopenia by review of CT scans assessing sarcopenia by psoas density (PD) and area (PA). Primary outcomes were 30 day and 1 year mortality.
A pilot RCT was undertaken to assess the acceptability and achievability of walking- based prehabilitation monitored by wearable technology. Participants were randomised to either normal activity or a walking based exercise programme.

Sarcopenia measured by PD was associated with increased mortality compared to non-sarcopenic patients at 30-days (23.2% vs. 9.6% p<0.0001 OR=2.84 (95% CI 1.88-4.30) and 1-year 37% vs. 19.2% p<0.0001 OR=2.46 (95% CI 1.75-3.47). Increased mortality was seen in sarcopenic patients measured by PA at 30-days (16.3% vs. 7.8% p=0.001 OR=2.31 (95% CI 1.38-3.88) and 1-year 32% vs. 18.7% p=<0.0001 OR=2.25 (95% CI 1.52-3.34)
For the RCT 45 patients were approached to recruit 40 participants. The median time in study was 12.5days (IQR 6-18). Mean compliance to the exercise programme was 58%. Mean distance change between initial and pre-operative assessment for the exercise and normal-activity groups was +16.4m and -13.6m respectively, p=0.013. Mean distance change between initial and 3-month postoperative assessment was - 11.4m and -40m p=0.11.

Sarcopenia assessed by PD and PA on CT is associated with increased mortality following emergency laparotomy. The use of sarcopenia as a predictive tool may be useful to direct geriatric input and guide expectations in emergency surgery.
This pilot study confirms that acceptable compliance can be achieved using a user- friendly pedometer and that this is associated with measurable improvements in fitness. Further work is required to establish whether this translates into improved patient outcomes after surgery.

Hull York Medical School, The University of Hull and the University of York
McNaught, Clare; MacFie, John; Hartley, John Edward
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