Physiological Fitness, Not Age Alone, Should Guide Surgery in Nonagenarians, suggests study
Researchers have found in a new study that surgical decision-making in patients aged 90 years and older should go beyond chronological age and focus on physiological reserve, frailty status, and inflammatory markers, which are key predictors of survival. Elective surgeries can be performed safely with thorough preparation and multidisciplinary care, whereas emergency procedures are associated with markedly higher mortality. Comprehensive preoperative assessment and individualized treatment planning are essential to improving outcomes in this highly vulnerable population. The study was published in BMC Surgery by Bilge O. and colleagues.
The authors carried out a retrospective study on nonagenarians who underwent surgery at Giresun Training and Research Hospital from November 2021 to April 2023. The study assessed the demographic features, pre-existing comorbidities, preoperative risk factors, including the ASA classification system, and the modified five-factor frailty index (mFI-5), of nonagenarian patients.
In addition, the parameters of the laboratory tests and perioperative clinical parameters were recorded. These included the values of the inflammatory markers, which were the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and the red cell distribution width (RDW). The researchers utilized the Kaplan-Meier survival curve and the ROC curve to assess the predictors of 30-day and 1-year mortality.
Key findings:
The retrospective study included a sample of 177 surgical patients aged 90 years or older, with a mean age of 92.5 ± 2.4 years, of whom 56.1% were female.
The study showed a 14.1% rate of mortality within 30 days, while the rate of mortality within a year was 36.2%.
Emergency surgery increased the risk of death within 30 days by 2.3 times and increased the risk of death within a year by 1.85 times.
Inflammation, as measured by preoperative inflammatory markers, was associated with increased mortality, including neutrophil-lymphocyte ratio, with an AUC of 0.779, platelet-lymphocyte ratio, with an AUC of 0.680, and red cell distribution width, with an AUC of 0.664.
Increasing ASA and mFI-5, general anesthesia, intensive care unit admission, mechanical ventilation, and blood transfusion increased the risk of death.
The survival time was 261.7 days in emergency surgery patients, while it was 251.9 days in elective surgery patients, with no significant difference in survival time between the two groups (p = 0.343).
The study has clearly shown that survival after surgery is significantly influenced by the status of frailty, physiological reserve, and systemic inflammatory biomarkers, and not by the age factor. Though elective surgeries can be safely performed by preparing the patients, emergency surgeries have higher mortality risks. Therefore, preoperative assessment and treatment planning might be important factors for improving the outcome of patients aged 90 years and older.
Reference:
Olgun Keleş, B., Şahin, Y., Tekir Yilmaz, E. et al. Predictors of postoperative survival and mortality in nonagenarian surgical patients: a retrospective cohort study. BMC Surg (2026). https://doi.org/10.1186/s12893-026-03604-w
