The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Perioperative Evaluation and Management of Frailty Among Older Adults Undergoing Colorectal Surgery

Abstract

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science and prevention and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health-care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Aging of the population has led to increasing rates of older adults requiring surgery‚ and due to the increased rate of postoperative morbidity and mortality associated with these patients, special considerations should be made before pursuing surgical intervention in this patient population.1 Older adult patients presenting to a colorectal surgery practice often have comorbidities and impaired functional status in addition to their presenting condition that needs to be considered when recommending a care plan. Specifically, older adults with frailty could be at risk for poor surgical outcomes.2 In general, frailty can be defined as an accumulation of deficits resulting in an inability to tolerate stress. Fried’s phenotypic definition of having 3 of the following 5 traits is the basis for the objective evaluation of frailty: slow walking speed, impaired grip strength, self-reported declining activity level, unintended weight loss, or exhaustion.3,4 It is especially challenging for surgeons to fully understand the impact of a proposed surgical intervention in the context of benefit versus harm among vulnerable patients. Reliable preoperative clinical assessment is essential to stratify risk and assist with decision-making under these circumstances. Improving the care of older and/or frail surgical patients begins with acknowledging the fact that frailty is more predictive of surgical outcomes than chronological age and that currently available frailty assessment tools are reliable and useful.5–7 Accurately assessing frail older patients facilitates opportunities to identify and address vulnerabilities that can potentially improve outcomes. Four major emerging categories for quality improvement in these patients include using prehabilitation, providing multidisciplinary care in partnership with geriatricians or practitioners with geriatrics expertise, adopting programs and techniques aimed at reducing stress during and after surgery, and assessing goals of care based on a consideration of realistic outcomes. These categories are not mutually exclusive‚ and optimal perioperative care should ideally encompass aspects of each category. In the following guideline, we evaluate the evidence and provide recommendations regarding the perioperative assessment and management of frail older patients undergoing colorectal surgery. Of note, from a practice standpoint, following recommendations regarding the care and management of frail older patients may require resources from a hospital or health system organization. Understandably, limited access to support may be a barrier to adoption at the individual practitioner level. Although previous ASCRS Clinical Practice Guidelines address issues relevant to the care of frail older patients (eg, bowel preparation, prevention of thromboembolic disease, and survivorship), these topics are beyond the scope of this guideline. MATERIALS AND METHODS As no previous ASCRS Clinical Practice Guideline has specifically addressed the topic of frailty, this guideline is an original body of work and not based on a particular previous publication. A systematic literature search limited to the English language and to studies with human subjects was performed using PubMed, Medline, EMBASE, Cochrane Database of Collected Reviews, and CINAHL databases from January 1, 2014, through November 24, 2021,8 using medical subject headings and keywords outlined in Appendix A at https://links.lww.com/DCR/B899. A total of 2235 articles were identified using the defined inclusion and exclusion criteria. Directed searches using embedded references from primary articles were performed in selected circumstances and yielded an additional 189 articles (Fig. 1). After the duplicates were removed, 1978 articles were evaluated for their level of evidence favoring clinical trials, meta-analyses/systematic reviews, comparative studies, and large registry retrospective studies over single institutional series, retrospective reviews, and peer-reviewed observational studies.9,10 A final list of 166 sources was evaluated for methodologic quality; the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).11 When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice-chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS clinical practice guidelines committee, other fellows of ASCRS, and 3 geriatricians worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were reviewed by the entire clinical practice guidelines committee and members of the ASCRS geriatrics task force. The guideline was peer-reviewed by Diseases of the Colon and Rectum, and the final guideline was approved by the ASCRS executive council. In general, each ASCRS clinical practice guideline is updated every 5 years. No funding was received for preparing this guideline‚ and the authors have declared no competing interests related to this material. This guideline conforms to the appraisal of guidelines research and evaluation checklist. TABLE 1. - The GRADE system: grading recommendations Grade Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong recommendation, high-quality evidence Benefits clearly outweigh risks and burdens or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation; can apply to most patients in most circumstances without reservation 1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risks and burdens or vice versa RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Strong recommendation; can apply to most patients in most circumstances without reservation 1C Strong recommendation, low- or very low-quality evidence Benefits clearly outweigh risks and burdens or vice versa Observational studies or case series Strong recommendation but may change when higher-quality evidence becomes available 2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burdens RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation; best action may differ depending on circumstances or patients’ or societal values 2B Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burdens RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation; best action may differ depending on circumstances or patients’ or societal values 2C Weak recommendation, low- or very low-quality evidence Uncertainty in the estimates of and and burdens may be closely balanced Observational studies or case series other may be with from Grades of Recommendation, Assessment, Development, and literature search for systematic and recommendations regarding colorectal surgery should patients’ of frailty than chronological Grade of strong recommendation based on high-quality age has of the most in research assessing and outcomes of a of surgery. studies outcomes of patients older and than a at of this age has often chosen as the to older as has increased over older age of and have of patients based on chronological age have in of an age and as a has a in that is a risk and have that age should not be the when treatment in that of on patients’ or frailty should be and consideration when clinical Although is that frail patients are more vulnerable to due to is important to that the of frailty has not in the frailty to postoperative outcomes are using a of frailty In of the to frailty as a of postoperative a systematic evaluated studies and the assessment which multidisciplinary related to patients’ and and functional surgical outcomes in patients who a of This that in of preparing and and frailty were associated with and that in was predictive of to an institutional not the Although major were more in patients with and in and of and of and was not associated with a a Cochrane and of of patients who surgery for that patients that using the and/or to surgical care may mortality risk In the same Cochrane of patients who that using assessment the rate of to a level of care care in an institutional or risk of a of patients undergoing surgery demonstrated that frailty by the of in the was associated with mortality after surgery for each in the a of preoperative functional and age were not associated with mortality in this a of patients from the American of Surgeons who colorectal age that frailty, using an frailty not was associated with a of surgery of patients who colorectal surgery for any and that frailty, as using a was associated with risks of of to an institutional morbidity and mortality of the literature regarding frailty, these studies large databases and retrospective that more on the of frailty from a comorbidities and than on objective frailty grip and walking in the vulnerable and frail older Grade of strong recommendation based on high-quality tools patients’ functional and Although the is considered the for frailty assessment and care as may be to and a assessment composed of assessing of can often be frailty to the assessment of patients’ frailty status by surgeons in the can be as as the in postoperative In a of patients older than undergoing surgery for a of that in and an were the most important of postoperative and that as by in or or an was associated with an hospital In a of patients undergoing surgery for that a and the a patient to of a chair, 3 and to the major postoperative was associated with a of and more than 3 during the In the same impaired status and than or to 3 with poor postoperative in a evaluated patients undergoing colorectal surgery and that more than in the before the was associated with a rate of postoperative versus and postoperative versus the and the a frailty among surgical patients, have to of for care to and and mortality after surgical In the use of evaluated patients from the who a of during an In this frailty, as using the was associated with increased rates and to mortality after a after low- and In of other to potentially identify vulnerable patients before and after surgery, assessing of and to of and in can be by a by the at the of the total or the and these have to with postoperative and surgery, frailty can be in the that the of the can be in the to in decision-making for frail older patients. 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Grade of strong recommendation based on low-quality When the care for a frail the goals of care should be with the or and other members of the multidisciplinary that may include from surgery, primary and these address as functional and In circumstances surgical to with surgery should the treatment outcomes versus and patient and A realistic should be presented based on the risks of and for each of the proposed treatment consideration the of frailty, and functional Specifically, patients may their functional and status more than other considerations as a patients may base their decisions on the of a level of is in statement Of note, the of associated with an individual surgery or is the performed a of patients and that to and surgery was associated with an individual patient is important to most to and resources are available to these (eg, the American in Aging In may be to include a and/or the primary care physician in treatment When is to patients’ and to goals for postoperative as as 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