Impact of preoperative frailty on short-term outcomes following major digestive surgery: a prospective cohort study

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Background: Frailty is a multidimensional clinical syndrome characterized by reduced physiological reserve and increased vulnerability to surgical stress. Conventional perioperative risk assessment based on chronological age and comorbidity burden may inadequately reflect biological vulnerability in patients undergoing major digestive surgery. The Frailty Index (FI) provides a comprehensive measure of frailty; however, prospective evidence evaluating its association with short-term postoperative outcomes remains limited. Methods: This prospective cohort study, reported in accordance with the STROCSS 2025 guidelines, included 45 consecutive adults undergoing elective or emergency major digestive surgery at IRCS Hospital, Baghdad, Iraq between January 2024 and December 2025. Preoperative frailty was assessed using a 20-deficit accumulation FI. Patients were classified as non-frail (FI < 0.15), pre-frail (FI: 0.15–0.24), or frail (FI ≥ 0.25). The primary outcomes were postoperative complications (Clavien–Dindo grade ≥II), postoperative length of hospital stay, and 30-day all-cause mortality. Postoperative intensive care unit (ICU) admission was a secondary outcome. Multivariable logistic regression was used to evaluate the associations between frailty status and postoperative complications, adjusting for age, American Society of Anesthesiologists (ASA) physical status, and surgical urgency. Results: Eighteen patients (40.0%) were non-frail, 15 (33.3%) were pre-frail, and 12 (26.7%) were frail. Postoperative complications occurred in 16.7%, 33.3%, and 66.7% of patients, respectively ( P = 0.023). Median postoperative length of hospital stay increased from 6 to 9 to 14 days across the three frailty categories ( P < 0.001). ICU admission occurred in 11.1%, 26.7%, and 58.3% of patients, respectively ( P = 0.024). Thirty-day mortality occurred only among frail patients (2/12, 16.7%), although the overall between-group difference was not statistically significant ( P = 0.067). After multivariable adjustment, pre-frailty [adjusted odds ratio (aOR): 2.40, 95% confidence interval (CI): 1.10–5.20; P = 0.041] and frailty (aOR: 6.90, 95% CI: 2.30–20.40; P < 0.001) were independently associated with postoperative complications. Conclusions: Preoperative frailty was independently associated with higher odds of postoperative complications and was also associated with adverse short-term postoperative outcomes following major digestive surgery. Routine preoperative frailty assessment may contribute to perioperative risk stratification and facilitate targeted perioperative optimization. Larger multicenter prospective studies are warranted to validate these exploratory findings.