The Role of Frailty and ASA Classification in Perioperative Outcomes Stratification for Esophagectomy Patients: A Retrospective Study

The Role of Frailty and ASA Classification in Perioperative Outcomes Stratification for Esophagectomy Patients: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Frailty and ASA Classification in Perioperative Outcomes Stratification for Esophagectomy Patients: A Retrospective Study Wongsakorn Chaochankit, Chutida Sungworawongpana, Nachawan Gosiyaphant, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5551548/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Esophagectomy is a high-risk procedure associated with significant morbidity and mortality. Accurate preoperative risk assessment tools are essential for identifying patients who are most vulnerable to complications. The primary objective of this study was to evaluate the predictive accuracy of the modified frailty index (mFI-5) and the American Society of Anesthesiologists Physical Status (ASA-PS) classification in identifying patients at high risk of postoperative morbidity and mortality following esophagectomy. Methods: This retrospective study analyzed 127 patients who underwent esophagectomy at Songklanagarind Hospital. Patient demographics, perioperative variables, and outcomes were collected. Predictors of 30-day morbidity were identified using logistic regression, and the performance of mFI-5 and ASA-PS scores was assessed using Receiver Operating Characteristic (ROC) curves. Results: Severe postoperative complications were 48%. Significant predictors included ASA ≥ 3, preoperative chemoradiotherapy (CRT), and prolonged ICU and hospital stays. The ASA-PS classification offered better overall accuracy in predicting morbidity. While the mFI-5 showed high sensitivity, it exhibited poor specificity, resulting in a high false-positive rate. Conclusions: Both mFI-5 and ASA-PS have limitations in predicting morbidity and mortality after esophagectomy. However, a model that integrates various perioperative factors, particularly preoperative and postoperative variables, demonstrated significance. Esophagectomy morbidity Modified frailty index ASA classification Perioperative risk Clavien-Dindo classification Frailty assessment Figures Figure 1 Figure 2 Background Esophageal cancer is a major global health concern, ranking as the seventh most common cancer and the sixth leading cause of cancer-related mortality [1]. Esophagectomy remains a high-risk procedure with morbidity rates exceeding 60% despite advancements in surgical techniques[2]. Postoperative management is particularly challenging due to the high risk of pulmonary complications, anastomotic leaks, and nutritional challenges, requiring intensive monitoring and multidisciplinary care [3]. The American Society of Anesthesiologists Physical Status (ASA-PS) classification is widely used for evaluating surgical risk and categorizing patients based on their preoperative health status [4]. Several studies have been conducted on the usefulness of the ASA-PS as a predictive tool for morbidity and mortality after surgery[5,6]. However, ASA-PS does not account for functional reserve or frailty. Over the past decade, frailty has gained increasing recognition as a crucial factor in perioperative risk assessment[7]. Frailty is characterized by reduced physiological reserve and increased vulnerability to stressors, making it a stronger predictor of prolonged hospitalization, 30-day readmissions, and postoperative complications[8,9]. Unlike ASA-PS, which primarily reflects the burden of comorbidities, the 5-item Modified Frailty Index-5 (mFI-5) emphasizes functional decline and physiological reserve—both of which are essential for surgical recovery. Both are simple and quick tools that help identify patients who may need more intensive perioperative care. This study aims to evaluate the predictive utility of mFI-5 compared to ASA-PS classification in forecasting high morbidity and mortality in esophagectomy patients and identifies factors associated with severe postoperative complications. Materials and Methods Study design and patients Data from the university hospital’s information system was used in this retrospective study. Records of patients who underwent esophagectomy were reviewed from January 2012 to December 2022. The study included patients who underwent esophagectomy. Exclusion criteria involved missing data, patients aged <18 years, and those who were transferred to other hospitals after surgery. Finally, 127 patients were included in this study. The study protocol was approved by the Ethics Committee of the Prince of Songkla University (REC.66-118-10-1). Clinical variables Demographic, clinical, and operative data were systematically collected. The variables included age, sex, American Society of Anesthesiologists (ASA) classification, comorbidities, and frailty status assessed using the 5-item Modified Frailty Index (mFI-5). The Modified Frailty Index-5 (mFI-5) is a simplified version of the Modified Frailty Index (mFI) used to assess frailty and predict postoperative outcomes, particularly in surgical patients. It consists of five key clinical factors, as shown in Table 1. Diagnosis, pathological report, history of preoperative or postoperative chemoradiation(CRT), preoperative pulmonary function tests, and echocardiography were reviewed. Additional perioperative factors recorded included timing of surgery, operative duration, estimated blood loss, and intraoperative fluid treatment. The morbidity was classified using the Clavien-Dindo system, which categorizes patients into low morbidity for Clavien-Dindo < III and high morbidity for Clavien-Dindo ≥III groups (definition in Table 2). The most severe complication per patient was selected for analysis, prioritizing the highest-grade complication. Lastly, the length of hospital stays (LOS) and ICU stays was documented. Outcomes The primary outcome was to evaluate whether the modified frailty index (mFI-5) could serve as a more accurate predictor of postoperative morbidity compared to the American Society of Anesthesiologist’s Physical Status (ASA-PS) classification in patients undergoing esophagectomy. Postoperative morbidity was defined by the occurrence of complications classified according to the Clavien-Dindo classification system. Data on morbidity were systematically collected from patient records throughout their hospital stay, from admission until discharge. Patients were categorized into two groups based on postoperative outcomes: those with low Clavien-Dindo group (< III) and those with high Clavien-Dindo group (Clavien-Dindo grade ³ III). Statistical analysis Comparisons between patients in the low Clavien-Dindo group and those in the high Clavien-Dindo group were performed using the Chi-square test for categorical variables and the Mann–Whitney U test for continuous variables. A multivariable logistic regression analysis was conducted using a forward stepwise selection method to identify independent predictors. The final model was refined by retaining only predictors with a p-value of less than 0.05. Preoperative, intraoperative, and postoperative factors were analyzed in three models to identify more accurate predictors for morbidity after esophagectomy. The predictive performance of mFI-5 and ASA classification for mortality and morbidity was evaluated using Receiver Operating Characteristic (ROC) curve analysis. All statistical analyses were conducted using R software version 4.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Results Patient characteristic Between January 2012 and December 2022, a total of 127 patients underwent esophagectomy. Among them, 61 patients (48%) experienced the high Clavien-Dindo group. The median age of the high Clavien-Dindo group was 62 years old, significantly higher than the low Clavien-Dindo group. However, both groups exhibited comparable proportions of smokers, alcohol consumers, and frailty status. The primary indication for esophagectomy in both groups was cancer, with most patients receiving preoperative chemoradiotherapy (CRT). ASA classification revealed that most patients were ASA Class II, and most underwent minimally invasive esophagectomy (MIE). Despite the differences in the Clavien-Dindo group, operative time remained similar in both groups (median: 525 min) (Table 3). Table 4 lists the details of postoperative complications, and the rate of in-hospital mortality is 18%. Comparison of Predictive Tools: ASA vs. mFI-5 ASA classification emerged as a more reliable tool for predicting severe morbidity in esophagectomy patients than mFI-5. While mFI-5 demonstrated high sensitivity, its poor specificity resulted in a high false-positive rate. Conversely, ASA classification provided better overall accuracy in predicting mortality. For morbidity prediction, mFI-5 exhibited high specificity but low sensitivity, meaning it failed to identify many at-risk patients. (see in Fig.1,2) Multivariable analysis across perioperative phases Model 1 - Multivariate Analysis of Preoperative Variables ASA ≥ 3 was significantly associated with high morbidity (OR: 3.27, 95% CI: 1.4–7.63, P = 0.005), reinforcing its role in risk stratification. Preoperative CRT showed a trend toward significance (OR: 2.31, 95% CI: 0.86–6.18, P = 0.09). Age ≥ 60 years did not reach statistical significance (OR: 2.03, 95% CI: 0.91–4.51, P = 0.08). Model 2 - Multivariate Analysis of Intraoperative Variables Colloid use was significantly associated with high morbidity (OR: 2.41, 95% CI: 1.15–5.05, P = 0.02), indicating its potential impact on perioperative hemodynamics and postoperative outcomes. Estimated blood loss (EBL) ≥ 500 mL was not significantly associated with complications (P = 0.09–0.65) Model 3 - Multivariate Analysis of Postoperative Variables ICU stay ≥ 10 days demonstrated the highest odds ratio (OR: 20.44, 95% CI: 2.41–173.13, P < 0.001), highlighting the strong link between prolonged ICU admission and severe complications. LOS ≥ 15 days was also a significant predictor (OR: 7.34, 95% CI: 2.71–19.93, P < 0.001), suggesting that extended hospitalization correlates with increased morbidity. To evaluate predictive performance, models combining multiple perioperative factors were analyzed. Model 1+3 (Preoperative + Postoperative Factors) demonstrated the best balance between predictive power and simplicity, achieving the lowest AIC (130.88). Model 1+2+3 (Full Model) had the highest likelihood (-58.11) but a slightly higher AIC (132.22), indicating that intraoperative factors contributed less to overall prediction. (see in Table 5) Discussion This study identified a high morbidity rate of 48% following esophagectomy, which is consistent with previous reports. However, our in-hospital mortality rate (18%) was notably higher than the 5% reported in a large U.S. cohort [ 10 ]. Our findings suggest that ASA classification is a more reliable predictor of morbidity than mFI-5. This is supported by previous studies indicating that ASA-PS performs well in predicting adverse outcomes [ 11 ]. In contrast, mFI-5 underestimates risk due to its low sensitivity, making it insufficient for predicting postoperative complications and unsuitable for major or complex surgeries [ 12 , 13 ]. While ASA classification shows better predictive ability than mFI-5, both have limitations due to their low AUC values. This suggests that these tools may be too generalized to fully assess the multifactorial risks associated with esophagectomy. Given the predictive limitations of ASA and mFI-5, we further explored morbidity through an analysis of different perioperative phases. When considering all phases together, the intraoperative phase (type of surgery, fluid management, blood loss) had a minimal effect on morbidity, indicating that while surgical techniques and intraoperative management are vital for patient safety, they do not have the power to determine complications related to morbidity. In the preoperative phase, preoperative chemoradiotherapy (CRT) was the key factor associated with higher morbidity. Studies suggest that neoadjuvant CRT damages surrounding tissues, impairs healing, and increases the risk of complications such as anastomotic leakage [ 11 , 14 ]. Furthermore, the postoperative phase emerged as the most critical determinant of morbidity. Patients with prolonged ICU stays had a significantly higher risk, often due to early postoperative complications such as aspiration leading to respiratory failure, sepsis, or hemodynamic instability [ 15 ]. The need for prolonged ventilatory support or repeated interventions increases the likelihood of secondary complications, further delaying recovery [ 16 ]. Extended hospital stays were clearly associated with severe morbidity, as complications like infections, delayed wound healing, anastomotic leaks, and nutritional deficiencies contributed to poor outcomes [ 17 ]. Prolonged immobility further raises the risk of thromboembolism and functional decline that impacts overall recovery and long-term prognosis [ 18 ]. These findings highlight the urgency of accelerating patient recovery through proactive postoperative management and nursing care to prevent further complications. Early mobilization, optimized pain control, nutritional support, and infection prevention should be prioritized to reduce complications and shorten ICU and hospital stays. Postoperative care of esophagectomy is complex and requires a multidisciplinary approach involving surgeons, anesthesiologists, intensivists, rehabilitation teams, and nursing staff to optimize recovery, minimize morbidity, and improve surgical outcomes [ 19 , 20 ]. Close monitoring is essential to prevent complications such as aspiration, pulmonary issues, and anastomotic leakage, which can lead to severe consequences. A well-coordinated team is crucial in ensuring safe and effective postoperative management, ultimately enhancing patient outcomes and quality of life. It highlights the dominant role of postoperative care in morbidity, emphasizing the need for optimized ICU management and promoting early recovery strategies as a recent strategy [ 21 ]. Although ASA and mFI-5 provide some level of risk assessment, their predictive accuracy remains limited, as shown. Strengths and Limitations This study evaluates commonly used clinical tools such as ASA-PS and mFI-5 in parallel; the research provides comparative evidence that can guide risk stratification practices in daily clinical care. Additionally, offers valuable insights into the perioperative factors contributing to morbidity following esophagectomy, particularly in a real-world clinical setting. A key strength lies in the comprehensive analysis across all surgical phases—preoperative, intraoperative, and postoperative—allowing for a more holistic understanding of risk contributors. The inclusion of a decade-long patient cohort strengthens the study’s relevance and generalizability within similar institutional contexts. However, this single-center retrospective study also has limitations. All complications were grouped into a single outcome variable, which may obscure tool-specific predictive accuracy for certain complication types. Furthermore, key risk factors such as nutritional status and inflammatory markers were unavailable. The ASA classification and mFI-5 both demonstrated relatively low predictive accuracy (AUC), limiting their utility in high-stakes surgical settings. To enhance predictive models and improve patient outcomes, future studies should incorporate multi-center data, evaluate specific complication types, integrate additional risk factors, and include longer-term outcomes such as 90-day mortality. Conclusion Although the ASA-PS classification demonstrated superior predictive reliability compared to mFI-5, both tools showed limitations in precisely identifying patients at high risk. The findings underscore the importance of considering both preoperative and postoperative factors to improve patient outcomes. Abbreviations ASA American Society of Anesthesiologists Min Minute SD Standard deviation EBL Estimated blood loss IQR Interquartile range ICU Intensive care unit LOS Length of stay OR Odds ratio CI Confidence interval mFI Modified frailty index Preop Preoperative Intraop Intraoperative Postop Postoperative mL Milliliter AIC Akaike information criterion CHF Congestive heart failure COPD Chronic obstructive pulmonary disease CRT Chemoradiotherapy FEV Forced expiratory volume Declarations Acknowledgment None Author Contributions W.: Analysis, C.: Create manuscript, R., N., Ch.: Data curation All authors have read and agreed to the final version of the manuscript Funding None Data availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and Consent to Participate The study protocol was approved by the Ethics Committee of the Prince of Songkla University (REC.66-118-10-1). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients. Consent to participate Informed consent was waived by IRB of the Prince of Songkla University Hospital because data analyses were performed retrospectively using anonymized data derived from the database system of Prince of Songkla University Hospital Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Jin W, Huang K, Ding Z, Zhang M, Li C, Yuan Z, et al. Global, regional, and national burden of esophageal cancer: a systematic analysis of the Global Burden of Disease Study 2021. Biomarker Research. 2025;13(1):3. Ke J, Xie Y, Liang J, Wang M, Lin W. Surgical intervention after neoadjuvant therapy in esophageal cancer: a narrative review. J Thorac Dis. 2023;15(4):2261-76. Edmondson J, Hunter J, Bakis G, O'Connor A, Wood S, Qureshi AP. Understanding Post-Esophagectomy Complications and Their Management: The Early Complications. J Clin Med. 2023;12(24). Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55(2):111-5. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. Jama. 1961;178:261-6. Foley C, Kendall MC, Apruzzese P, De Oliveira GS. American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: an analysis of 2,089,830 ACS-NSQIP outpatient cases. BMC Surgery. 2021;21(1):253. Dhesi JK, Lees NP, Partridge JS. Frailty in the perioperative setting. Clin Med (Lond). 2019;19(6):485-9. Lin HS, McBride RL, Hubbard RE. Frailty and anesthesia - risks during and post-surgery. Local Reg Anesth. 2018;11:61-73. Chung MS, Patel N, Abdelmalek G, Coban D, Changoor S, Elali F, et al. The 5-factor modified frailty index (mFI-5) predicts adverse outcomes after elective anterior cervical discectomy and fusion (ACDF). North American Spine Society Journal (NASSJ). 2024;18. Torre LA, Siegel RL, Ward EM, Jemal A. Global Cancer Incidence and Mortality Rates and Trends--An Update. Cancer Epidemiol Biomarkers Prev. 2016;25(1):16-27. Sato S, Nakatani E, Higashizono K, Nagai E, Taki Y, Nishida M, et al. The impact of the American Society of Anesthesiology-Physical Status classification system on the treatment and prognosis of patients with esophageal cancer undergoing esophagectomy. Int J Clin Oncol. 2022;27(8):1289-99. Agathis AZ, Bangla VG, Divino CM. Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs. Hernia. 2024;28(1):135-45. Agathis AZ, Bangla VG, Divino CM. Role of mFI-5 in predicting geriatric outcomes in laparoscopic cholecystectomy. The American Journal of Surgery. 2023;226(5):697-702. Créhange G, Modesto A, Vendrely V, Quéro L, Mirabel X, Rétif P, et al. Radiotherapy for cancers of the oesophagus, cardia and stomach. Cancer Radiother. 2022;26(1-2):250-8. Lai CC, Tseng KL, Ho CH, Chiang SR, Chen CM, Chan KS, et al. Prognosis of patients with acute respiratory failure and prolonged intensive care unit stay. J Thorac Dis. 2019;11(5):2051-7. Frisvold S, Coppola S, Ehrmann S, Chiumello D, Guérin C. Respiratory challenges and ventilatory management in different types of acute brain-injured patients. Crit Care. 2023;27(1):247. Fabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus. 2021;34(1). Chindamo MC, Marques MA. Role of ambulation to prevent venous thromboembolism in medical patients: where do we stand? J Vasc Bras. 2019;18:e20180107. Sims CR, III, Abou Chaar MK, Kerfeld MH, Cassivi SD, Hofer RE, Nichols FC, et al. Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes. The Annals of Thoracic Surgery. 2024;117(4):847-57. Elliott JA, Guinan E, Reynolds JV. Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer. Diseases of the Esophagus. 2023;37(3). Rubinkiewicz M, Witowski J, Su M, Major P, Pędziwiatr M. Enhanced recovery after surgery (ERAS) programs for esophagectomy. J Thorac Dis. 2019;11(Suppl 5):S685-s91. Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5551548","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440238460,"identity":"35b99ea7-1b73-4b11-a833-f6124d7ab520","order_by":0,"name":"Wongsakorn Chaochankit","email":"","orcid":"","institution":"Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Wongsakorn","middleName":"","lastName":"Chaochankit","suffix":""},{"id":440238462,"identity":"30a235aa-ae92-4f10-80ff-a78aa67a9a40","order_by":1,"name":"Chutida Sungworawongpana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYBAC/hlAIoENSLA3wMR48GuRuMHA2ADWwnMAKsRGQItBBFALA0iLRAKxWqR7zB88KLNjkJ/59vBnHgY7eQb53gP4tcicMWxIOJfMYHA7L02ahyHZsIGNLwG/Fokcw4bENmagdTlmzDwMzAlAhxkQo6Ue6LAzxkCH1ROhJQKs5TADww0eA6DDDhPWInEjrXBGwrnjPAZn8tIk5xgcN2xjy8GvhX9G8oaPP8qq5eTbzx7+8KaiWp6f+Qx+LTDAA4l0oGI2otTDdY2CUTAKRsEowAYAx9A6fXos9cwAAAAASUVORK5CYII=","orcid":"","institution":"Prince of Songkla University","correspondingAuthor":true,"prefix":"","firstName":"Chutida","middleName":"","lastName":"Sungworawongpana","suffix":""},{"id":440238463,"identity":"ef1ac0c8-ab30-4fac-8fa0-8065eb17b0c8","order_by":2,"name":"Nachawan Gosiyaphant","email":"","orcid":"","institution":"Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Nachawan","middleName":"","lastName":"Gosiyaphant","suffix":""},{"id":440238465,"identity":"c746292b-dafe-44a1-ad88-564814e99f0c","order_by":3,"name":"Chayaporn Subanphanichkul thongaek","email":"","orcid":"","institution":"Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Chayaporn","middleName":"Subanphanichkul","lastName":"thongaek","suffix":""},{"id":440238466,"identity":"b105057a-687a-4972-890d-bda091b19750","order_by":4,"name":"Ratikorn Boonchai","email":"","orcid":"","institution":"Prince of Songkla University","correspondingAuthor":false,"prefix":"","firstName":"Ratikorn","middleName":"","lastName":"Boonchai","suffix":""}],"badges":[],"createdAt":"2024-11-29 22:38:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5551548/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5551548/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80295013,"identity":"8675dd62-d191-4353-850f-8937ba285a44","added_by":"auto","created_at":"2025-04-10 08:31:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":122515,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity and specificity for morbidity prediction between mFI-5 and ASA classification This curve compares mFI-5 (green) and ASA classification (red) for morbidity prediction. The ASA classification shows higher sensitivity (0.43) and accuracy (0.62) than mFI-5 (sensitivity 0.08, accuracy 0.51), while mFI-5 has higher specificity (0.94).\u003c/p\u003e\n\u003cp\u003eThis suggests that ASA is a better predictor of morbidity in this study.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5551548/v1/fd39d17dfcd91bc328e548f0.png"},{"id":80295015,"identity":"b3e4901a-2228-4125-afb3-be14867a7563","added_by":"auto","created_at":"2025-04-10 08:31:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":129094,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity and specificity for mortality prediction between mFI-5 and ASA classification\u003c/p\u003e\n\u003cp\u003eThis curve compares mFI-5 (green) and ASA classification (red) for mortality prediction. mFI-5 has higher sensitivity (0.94) but low specificity (0.19), while ASA classification shows a better balance with higher specificity (0.64) and overall accuracy (0.68).\u003c/p\u003e\n\u003cp\u003eThis suggests ASA is a more reliable predictor of mortality in this study.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5551548/v1/6a556d1a7529f6d5b82e29a3.png"},{"id":93569913,"identity":"57c404b0-3987-4d9a-b457-3ef0562374b0","added_by":"auto","created_at":"2025-10-15 08:55:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":759903,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5551548/v1/1c09a290-a542-485b-8540-f9342200f174.pdf"},{"id":80295014,"identity":"146e1c03-9e99-42e5-95c2-b405a405339f","added_by":"auto","created_at":"2025-04-10 08:31:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27111,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5551548/v1/42ae7113754c5341642aed04.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Role of Frailty and ASA Classification in Perioperative Outcomes Stratification for Esophagectomy Patients: A Retrospective Study","fulltext":[{"header":"Background","content":"\u003cp\u003eEsophageal cancer is a major global health concern, ranking as the seventh most common cancer and the sixth leading cause of cancer-related mortality [1]. Esophagectomy remains a high-risk procedure with morbidity rates exceeding 60% despite advancements in surgical techniques[2]. Postoperative management is particularly challenging due to the high risk of pulmonary complications, anastomotic leaks, and nutritional challenges, requiring intensive monitoring and multidisciplinary care [3].\u003c/p\u003e\n\u003cp\u003eThe American Society of Anesthesiologists Physical Status (ASA-PS) classification is widely used for evaluating surgical risk and categorizing patients based on their preoperative health status [4].\u0026nbsp;Several studies have been conducted on the usefulness of the ASA-PS as a predictive tool for morbidity and mortality after surgery[5,6]. However, ASA-PS\u0026nbsp;does not account for functional reserve or frailty. Over the past decade, frailty has gained increasing recognition as a crucial factor in perioperative risk assessment[7]. Frailty is characterized by reduced physiological reserve and increased vulnerability to stressors, making it a stronger predictor of prolonged hospitalization, 30-day readmissions, and postoperative complications[8,9]. Unlike ASA-PS, which primarily reflects the burden of comorbidities, the 5-item Modified Frailty Index-5 (mFI-5) emphasizes functional decline and physiological reserve\u0026mdash;both of which are essential for surgical recovery. Both are simple and quick tools that help identify patients who may need more intensive perioperative care.\u003c/p\u003e\n\u003cp\u003eThis study aims to evaluate the predictive utility of mFI-5 compared to ASA-PS classification in forecasting high morbidity and mortality in esophagectomy patients and identifies factors associated with severe postoperative complications.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the university hospital\u0026rsquo;s information system was used in this retrospective study. \u0026nbsp;Records of patients who underwent\u0026nbsp;esophagectomy were reviewed from January 2012 to December 2022. The study included patients who underwent esophagectomy. Exclusion criteria involved missing data, patients aged \u0026lt;18 years, and those who were transferred to other hospitals after surgery. Finally, 127 patients were included in this study. The study protocol was approved by the Ethics Committee of the Prince of Songkla University\u0026nbsp;(REC.66-118-10-1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical variables\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDemographic, clinical, and operative data were systematically collected. The variables included age, sex, American Society of Anesthesiologists (ASA) classification, comorbidities, and frailty status assessed using the 5-item Modified Frailty Index (mFI-5). The Modified Frailty Index-5 (mFI-5) is a simplified version of the Modified Frailty Index (mFI) used to assess frailty and predict postoperative outcomes, particularly in surgical patients. It consists of five key clinical factors, as shown in Table 1.\u0026nbsp;Diagnosis, pathological report, history of preoperative or postoperative chemoradiation(CRT), preoperative pulmonary function tests, and echocardiography were reviewed. Additional perioperative factors recorded included timing of surgery, operative duration, estimated blood loss, and intraoperative fluid treatment.\u003c/p\u003e\n\u003cp\u003eThe morbidity was classified using the Clavien-Dindo system, which categorizes patients into low morbidity for Clavien-Dindo \u0026lt; III and high morbidity for Clavien-Dindo \u0026ge;III groups (definition in Table 2).\u0026nbsp;The most severe complication per patient was selected for analysis, prioritizing the highest-grade complication. Lastly, the length of hospital stays (LOS) and ICU stays was documented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was to evaluate whether the modified frailty index (mFI-5) could serve as a more accurate predictor of postoperative morbidity compared to the American Society of Anesthesiologist\u0026rsquo;s Physical Status (ASA-PS) classification in patients undergoing esophagectomy. Postoperative morbidity was defined by the occurrence of complications classified according to the Clavien-Dindo classification system. Data on morbidity were systematically collected from patient records throughout their hospital stay, from admission until discharge. Patients were categorized into two groups based on postoperative outcomes: those with low Clavien-Dindo group (\u0026lt; III) and those with high Clavien-Dindo group (Clavien-Dindo grade \u0026sup3; III).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparisons between patients in the low Clavien-Dindo group and those in the high Clavien-Dindo group were performed using the Chi-square test for categorical variables and the Mann\u0026ndash;Whitney U test for continuous variables. A multivariable logistic regression analysis was conducted using a forward stepwise selection method to identify independent predictors. The final model was refined by retaining only predictors with a p-value of less than 0.05. Preoperative, intraoperative, and postoperative factors were analyzed in three models to identify more accurate predictors for morbidity after esophagectomy. The predictive performance of mFI-5 and ASA classification for mortality and morbidity was evaluated using Receiver Operating Characteristic (ROC) curve analysis. All statistical analyses were conducted using R software version 4.4.2 (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient characteristic\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween January 2012 and December 2022, a total of 127 patients underwent esophagectomy. Among them, 61 patients (48%) experienced the high Clavien-Dindo group. The median age of the high Clavien-Dindo group was 62 years old, significantly higher than the low Clavien-Dindo\u0026nbsp;group. However, both groups exhibited comparable proportions of smokers, alcohol consumers, and frailty status.\u0026nbsp;The primary indication for esophagectomy in both groups was cancer, with most patients receiving preoperative chemoradiotherapy\u0026nbsp;(CRT). ASA classification revealed that most patients were ASA Class II, and most underwent minimally invasive esophagectomy (MIE). Despite the differences in the Clavien-Dindo group, operative time remained similar in both groups (median: 525 min) (Table 3). Table 4 lists the details of postoperative complications, and the rate of in-hospital mortality is 18%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eComparison of Predictive Tools: ASA vs. mFI-5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eASA classification emerged as a more reliable tool for predicting severe morbidity in esophagectomy patients than mFI-5. While mFI-5 demonstrated high sensitivity, its poor specificity resulted in a high false-positive rate. Conversely, ASA classification provided better overall accuracy in predicting mortality. For morbidity prediction, mFI-5 exhibited high specificity but low sensitivity, meaning it failed to identify many at-risk patients. (see in Fig.1,2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMultivariable analysis across perioperative phases\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModel 1 - Multivariate Analysis of Preoperative Variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eASA \u0026ge; 3 was significantly associated with high morbidity (OR: 3.27, 95% CI: 1.4\u0026ndash;7.63, P = 0.005), reinforcing its role in risk stratification. Preoperative CRT showed a trend toward significance (OR: 2.31, 95% CI: 0.86\u0026ndash;6.18, P = 0.09). Age \u0026ge; 60 years did not reach statistical significance (OR: 2.03, 95% CI: 0.91\u0026ndash;4.51, P = 0.08).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModel 2 - Multivariate Analysis of Intraoperative Variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eColloid use was significantly associated with high morbidity (OR: 2.41, 95% CI: 1.15\u0026ndash;5.05, P = 0.02), indicating its potential impact on perioperative hemodynamics and postoperative outcomes. Estimated blood loss (EBL) \u0026ge; 500 mL was not significantly associated with complications (P = 0.09\u0026ndash;0.65)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModel 3 - Multivariate Analysis of Postoperative Variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eICU stay \u0026ge; 10 days demonstrated the highest odds ratio (OR: 20.44, 95% CI: 2.41\u0026ndash;173.13, P \u0026lt; 0.001), highlighting the strong link between prolonged ICU admission and severe complications. LOS \u0026ge; 15 days was also a significant predictor (OR: 7.34, 95% CI: 2.71\u0026ndash;19.93, P \u0026lt; 0.001), suggesting that extended hospitalization correlates with increased morbidity.\u003cbr\u003e\u0026nbsp;To evaluate predictive performance, models combining multiple perioperative factors were analyzed. Model 1+3 (Preoperative + Postoperative Factors) demonstrated the best balance between predictive power and simplicity, achieving the lowest AIC (130.88).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eModel 1+2+3 (Full Model) had the highest likelihood (-58.11) but a slightly higher AIC (132.22), indicating that intraoperative factors contributed less to overall prediction. (see in Table 5)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study identified a high morbidity rate of 48% following esophagectomy, which is consistent with previous reports. However, our in-hospital mortality rate (18%) was notably higher than the 5% reported in a large U.S. cohort [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Our findings suggest that ASA classification is a more reliable predictor of morbidity than mFI-5. This is supported by previous studies indicating that ASA-PS performs well in predicting adverse outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In contrast, mFI-5 underestimates risk due to its low sensitivity, making it insufficient for predicting postoperative complications and unsuitable for major or complex surgeries [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While ASA classification shows better predictive ability than mFI-5, both have limitations due to their low AUC values. This suggests that these tools may be too generalized to fully assess the multifactorial risks associated with esophagectomy. Given the predictive limitations of ASA and mFI-5, we further explored morbidity through an analysis of different perioperative phases. When considering all phases together, the intraoperative phase (type of surgery, fluid management, blood loss) had a minimal effect on morbidity, indicating that while surgical techniques and intraoperative management are vital for patient safety, they do not have the power to determine complications related to morbidity. In the preoperative phase, preoperative chemoradiotherapy (CRT) was the key factor associated with higher morbidity. Studies suggest that neoadjuvant CRT damages surrounding tissues, impairs healing, and increases the risk of complications such as anastomotic leakage [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, the postoperative phase emerged as the most critical determinant of morbidity. Patients with prolonged ICU stays had a significantly higher risk, often due to early postoperative complications such as aspiration leading to respiratory failure, sepsis, or hemodynamic instability [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The need for prolonged ventilatory support or repeated interventions increases the likelihood of secondary complications, further delaying recovery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Extended hospital stays were clearly associated with severe morbidity, as complications like infections, delayed wound healing, anastomotic leaks, and nutritional deficiencies contributed to poor outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Prolonged immobility further raises the risk of thromboembolism and functional decline that impacts overall recovery and long-term prognosis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These findings highlight the urgency of accelerating patient recovery through proactive postoperative management and nursing care to prevent further complications. Early mobilization, optimized pain control, nutritional support, and infection prevention should be prioritized to reduce complications and shorten ICU and hospital stays. Postoperative care of esophagectomy is complex and requires a multidisciplinary approach involving surgeons, anesthesiologists, intensivists, rehabilitation teams, and nursing staff to optimize recovery, minimize morbidity, and improve surgical outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Close monitoring is essential to prevent complications such as aspiration, pulmonary issues, and anastomotic leakage, which can lead to severe consequences. A well-coordinated team is crucial in ensuring safe and effective postoperative management, ultimately enhancing patient outcomes and quality of life. It highlights the dominant role of postoperative care in morbidity, emphasizing the need for optimized ICU management and promoting early recovery strategies as a recent strategy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although ASA and mFI-5 provide some level of risk assessment, their predictive accuracy remains limited, as shown.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study evaluates commonly used clinical tools such as ASA-PS and mFI-5 in parallel; the research provides comparative evidence that can guide risk stratification practices in daily clinical care. Additionally, offers valuable insights into the perioperative factors contributing to morbidity following esophagectomy, particularly in a real-world clinical setting. A key strength lies in the comprehensive analysis across all surgical phases\u0026mdash;preoperative, intraoperative, and postoperative\u0026mdash;allowing for a more holistic understanding of risk contributors. The inclusion of a decade-long patient cohort strengthens the study\u0026rsquo;s relevance and generalizability within similar institutional contexts. However, this single-center retrospective study also has limitations. All complications were grouped into a single outcome variable, which may obscure tool-specific predictive accuracy for certain complication types. Furthermore, key risk factors such as nutritional status and inflammatory markers were unavailable. The ASA classification and mFI-5 both demonstrated relatively low predictive accuracy (AUC), limiting their utility in high-stakes surgical settings. To enhance predictive models and improve patient outcomes, future studies should incorporate multi-center data, evaluate specific complication types, integrate additional risk factors, and include longer-term outcomes such as 90-day mortality.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough the ASA-PS classification demonstrated superior predictive reliability compared to mFI-5, both tools showed limitations in precisely identifying patients at high risk. The findings underscore the importance of considering both preoperative and postoperative factors to improve patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASA\u0026nbsp; \u0026nbsp;\u0026nbsp;American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eMin Minute\u003c/p\u003e\n\u003cp\u003eSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Standard deviation\u003c/p\u003e\n\u003cp\u003eEBL\u0026nbsp; \u0026nbsp; \u0026nbsp;Estimated blood loss\u003c/p\u003e\n\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; \u0026nbsp;Interquartile range\u003c/p\u003e\n\u003cp\u003eICU\u0026nbsp; \u0026nbsp; \u0026nbsp;Intensive care unit\u003c/p\u003e\n\u003cp\u003eLOS\u0026nbsp; \u0026nbsp; \u0026nbsp;Length of stay\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odds ratio\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence interval\u003c/p\u003e\n\u003cp\u003emFI\u0026nbsp; \u0026nbsp; \u0026nbsp;Modified frailty index\u003c/p\u003e\n\u003cp\u003ePreop\u0026nbsp; \u0026nbsp;Preoperative\u003c/p\u003e\n\u003cp\u003eIntraop\u0026nbsp;Intraoperative\u003c/p\u003e\n\u003cp\u003ePostop\u0026nbsp;Postoperative\u003c/p\u003e\n\u003cp\u003emL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Milliliter\u003c/p\u003e\n\u003cp\u003eAIC\u0026nbsp; \u0026nbsp; \u0026nbsp;Akaike information criterion\u003c/p\u003e\n\u003cp\u003eCHF\u0026nbsp; \u0026nbsp;\u0026nbsp;Congestive heart failure\u003c/p\u003e\n\u003cp\u003eCOPD\u0026nbsp;\u0026nbsp;Chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003eCRT\u0026nbsp; \u0026nbsp;\u0026nbsp;Chemoradiotherapy\u003c/p\u003e\n\u003cp\u003eFEV\u0026nbsp; \u0026nbsp; \u0026nbsp;Forced expiratory volume\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW.: Analysis, C.: \u0026nbsp; Create manuscript, R., N., Ch.: Data curation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors have read and agreed to the final version of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of the Prince of Songkla University\u0026nbsp;(REC.66-118-10-1). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was waived by IRB of the Prince of Songkla University\u0026nbsp;Hospital because data analyses were performed retrospectively using anonymized data derived from the database system of Prince of Songkla University\u0026nbsp;Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJin W, Huang K, Ding Z, Zhang M, Li C, Yuan Z, et al. Global, regional, and national burden of esophageal cancer: a systematic analysis of the Global Burden of Disease Study 2021. Biomarker Research. 2025;13(1):3.\u003c/li\u003e\n \u003cli\u003eKe J, Xie Y, Liang J, Wang M, Lin W. Surgical intervention after neoadjuvant therapy in esophageal cancer: a narrative review. J Thorac Dis. 2023;15(4):2261-76.\u003c/li\u003e\n \u003cli\u003eEdmondson J, Hunter J, Bakis G, O\u0026apos;Connor A, Wood S, Qureshi AP. Understanding Post-Esophagectomy Complications and Their Management: The Early Complications. J Clin Med. 2023;12(24).\u003c/li\u003e\n \u003cli\u003eDaabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55(2):111-5.\u003c/li\u003e\n \u003cli\u003eDripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. Jama. 1961;178:261-6.\u003c/li\u003e\n \u003cli\u003eFoley C, Kendall MC, Apruzzese P, De Oliveira GS. American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: an analysis of 2,089,830 ACS-NSQIP outpatient cases. BMC Surgery. 2021;21(1):253.\u003c/li\u003e\n \u003cli\u003eDhesi JK, Lees NP, Partridge JS. Frailty in the perioperative setting. Clin Med (Lond). 2019;19(6):485-9.\u003c/li\u003e\n \u003cli\u003eLin HS, McBride RL, Hubbard RE. Frailty and anesthesia - risks during and post-surgery. Local Reg Anesth. 2018;11:61-73.\u003c/li\u003e\n \u003cli\u003eChung MS, Patel N, Abdelmalek G, Coban D, Changoor S, Elali F, et al. The 5-factor modified frailty index (mFI-5) predicts adverse outcomes after elective anterior cervical discectomy and fusion (ACDF). North American Spine Society Journal (NASSJ). 2024;18.\u003c/li\u003e\n \u003cli\u003eTorre LA, Siegel RL, Ward EM, Jemal A. Global Cancer Incidence and Mortality Rates and Trends--An Update. Cancer Epidemiol Biomarkers Prev. 2016;25(1):16-27.\u003c/li\u003e\n \u003cli\u003eSato S, Nakatani E, Higashizono K, Nagai E, Taki Y, Nishida M, et al. The impact of the American Society of Anesthesiology-Physical Status classification system on the treatment and prognosis of patients with esophageal cancer undergoing esophagectomy. Int J Clin Oncol. 2022;27(8):1289-99.\u003c/li\u003e\n \u003cli\u003eAgathis AZ, Bangla VG, Divino CM. Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs. Hernia. 2024;28(1):135-45.\u003c/li\u003e\n \u003cli\u003eAgathis AZ, Bangla VG, Divino CM. Role of mFI-5 in predicting geriatric outcomes in laparoscopic cholecystectomy. The American Journal of Surgery. 2023;226(5):697-702.\u003c/li\u003e\n \u003cli\u003eCr\u0026eacute;hange G, Modesto A, Vendrely V, Qu\u0026eacute;ro L, Mirabel X, R\u0026eacute;tif P, et al. Radiotherapy for cancers of the oesophagus, cardia and stomach. Cancer Radiother. 2022;26(1-2):250-8.\u003c/li\u003e\n \u003cli\u003eLai CC, Tseng KL, Ho CH, Chiang SR, Chen CM, Chan KS, et al. Prognosis of patients with acute respiratory failure and prolonged intensive care unit stay. J Thorac Dis. 2019;11(5):2051-7.\u003c/li\u003e\n \u003cli\u003eFrisvold S, Coppola S, Ehrmann S, Chiumello D, Gu\u0026eacute;rin C. Respiratory challenges and ventilatory management in different types of acute brain-injured patients. Crit Care. 2023;27(1):247.\u003c/li\u003e\n \u003cli\u003eFabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus. 2021;34(1).\u003c/li\u003e\n \u003cli\u003eChindamo MC, Marques MA. Role of ambulation to prevent venous thromboembolism in medical patients: where do we stand? J Vasc Bras. 2019;18:e20180107.\u003c/li\u003e\n \u003cli\u003eSims CR, III, Abou Chaar MK, Kerfeld MH, Cassivi SD, Hofer RE, Nichols FC, et al. Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes. The Annals of Thoracic Surgery. 2024;117(4):847-57.\u003c/li\u003e\n \u003cli\u003eElliott JA, Guinan E, Reynolds JV. Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer. Diseases of the Esophagus. 2023;37(3).\u003c/li\u003e\n \u003cli\u003eRubinkiewicz M, Witowski J, Su M, Major P, Pędziwiatr M. Enhanced recovery after surgery (ERAS) programs for esophagectomy. J Thorac Dis. 2019;11(Suppl 5):S685-s91.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Esophagectomy morbidity, Modified frailty index, ASA classification, Perioperative risk, Clavien-Dindo classification, Frailty assessment","lastPublishedDoi":"10.21203/rs.3.rs-5551548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5551548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEsophagectomy is a high-risk procedure associated with significant morbidity and mortality. Accurate preoperative risk assessment tools are essential for identifying patients who are most vulnerable to complications. The primary objective of this study was to evaluate the predictive accuracy of the modified frailty index (mFI-5) and the American Society of Anesthesiologists Physical Status (ASA-PS) classification in identifying patients at high risk of postoperative morbidity and mortality following esophagectomy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis retrospective study analyzed 127 patients who underwent esophagectomy at Songklanagarind Hospital. Patient demographics, perioperative variables, and outcomes were collected. Predictors of 30-day morbidity were identified using logistic regression, and the performance of mFI-5 and ASA-PS scores was assessed using Receiver Operating Characteristic (ROC) curves.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSevere postoperative complications were 48%. Significant predictors included ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, preoperative chemoradiotherapy (CRT), and prolonged ICU and hospital stays. The ASA-PS classification offered better overall accuracy in predicting morbidity. While the mFI-5 showed high sensitivity, it exhibited poor specificity, resulting in a high false-positive rate.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBoth mFI-5 and ASA-PS have limitations in predicting morbidity and mortality after esophagectomy. However, a model that integrates various perioperative factors, particularly preoperative and postoperative variables, demonstrated significance.\u003c/p\u003e","manuscriptTitle":"The Role of Frailty and ASA Classification in Perioperative Outcomes Stratification for Esophagectomy Patients: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 08:31:41","doi":"10.21203/rs.3.rs-5551548/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"855e11e9-38b3-4974-bf3b-bee09b651d80","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T08:54:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-10 08:31:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5551548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5551548","identity":"rs-5551548","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}