The Modified Fragility Index and Perioperative Albumin as Predictors of Complications in Complex Abdominal Wall Reconstruction.

Abstract

Background and significance: Complex abdominal wall reconstruction (CAWR) is performed to restore the structure and function of the abdominal wall. These procedures carry the risk of complications such as delayed wound healing, skin necrosis, infection, recurrence, or even death. The 5-factor modified fragility index (5-mFI) has gained popularity as a concise method of evaluating preoperative risk across various surgical specialties. Additionally, perioperative hypoalbuminemia has been previously associated with delayed wound healing after surgery. The purpose of this study was to assess the utility of the 5-mFI in combination with perioperative albumin levels for assessing risk in complex abdominal wall reconstruction.

Methods: This was a retrospective, single-institution chart review study of all patients who underwent CAWR by the senior author (A.L.) from 2002 to 2023. Demographics, comorbidities, details of surgery, perioperative albumin levels, ASA scores, and complications were collected for each patient. Five-factor modified fragility indices were calculated for each patient. Statistical analysis consisted of χ2 and Fisher exact tests for categorical variables, t tests for continuous variables, and multivariate analysis.

Results: Our analysis included 437 patients. The average age of our patients was 54.3 years, the average BMI was 32.1 kg/m2, and the average length of follow-up with the plastic surgery service was 264 days. A total of 118 (27.0%) developed complications, with the most common complications being delayed wound healing (89 patients, 20.4%) and infection (78 patients, 17.8%). Other complications included skin necrosis, fistula formation, hematoma, seroma, infection, and death. Sixty patients (13.7%) experienced recurrence of their hernias within the follow-up period. An mFI of 2 or greater was significantly associated with delayed wound healing (LR, 11.42; P = 0.0436) as well as skin necrosis (LR, 4.826; P = 0.028). The presence of an mFI of 2 or greater and perioperative hypoalbuminemia was significantly associated with development of major complications (LR, 3.221; P = 0.0457), delayed wound healing (LR, 5.999; P = 0.0143), skin necrosis (LR, 9.19; P = 0.0024), and mortality (LR, 5.287; P = 0.0215). On multivariate analysis, the presence of an mFI of 2 or greater when combined with perioperative hypoalbuminemia was found to be independently associated with mortality (LR, 1524.5; P < 0.0001).

Conclusions: We found the 5-factor mFI to be significantly associated with delayed wound healing and skin necrosis in our patient population. When an mFI of 2 or greater was present along with perioperative hypoalbuminemia, patients were significantly more likely to experience complications, issues with wound healing, and mortality. Surgeons should take these findings into account when counseling patients preoperatively.