Response to comments on “Association of frailty with postoperative outcomes in patients undergoing elective non-malignant abdominal surgeries under general or neuraxial anaesthesia”

Dear Editor,

We appreciate the remarks related to our article.[1,2] While the complete absence of Clavien–Dindo (CD) grade III complications among patients with a modified frailty index (mFI) of ≥0.27 undergoing major surgeries may initially appear concerning, it is also plausible that this finding reflects genuine improvements in perioperative care and patient management. One of the limitations of CD classification often includes concerns over differentiating grade III and IV complications. Furthermore, some surgeons tend to favour watchful waiting or conservative management, while others advocate for early radical interventions to avoid potential unforeseen aggravation and prolonged hospitalisation. The choice is usually influenced, or even determined, by the available local means and expertise.[3] Few other studies have reported a very low incidence of grade III complications (1%–2.5%).

We agree that the small sample size may have resulted in exaggerated odds ratios. To address this, we have computed the adjusted odds ratio (AOR) using a logistic regression model for patients with an mFI of 0.27 who underwent neuraxial and general anaesthesia. The AOR is 1.55, indicating that patients undergoing general anaesthesia have a 55% increased risk of complications compared to those undergoing neuraxial anaesthesia, further supporting our result.[4]

The inflection at 0.18 may optimise sensitivity and specificity statistically. Still, the threshold of 0.27 could reflect a more clinically meaningful level of frailty severity, aligning with prior studies or practical risk categories that clinicians use.[5] Using a single, well-established cut-off makes the findings easier to apply in real-world settings. Adding multiple thresholds or a complex multivariate model may reduce usability and adherence among clinicians who favour clear, actionable risk categories.[6]

We acknowledge the possibility of confounders; however, the impact of early discharge bias or limitations in telephonic follow-up on a major endpoint, such as mortality, is likely to be minimal. Deaths, unlike minor complications, are rarely missed even with telephonic follow-up, and are reliably reported by families or captured through institutional or public records.[7] Furthermore, the elective nature of these cases inherently implies careful preoperative optimisation and a lower baseline risk, which is the most plausible explanation for the observed zero mortality. Therefore, attributing the absence of deaths primarily to the elective case selection is reasonable and consistent with established surgical outcomes literature.[8]

Conflicts of interest

There are no conflicts of interest.

Authors contributions

RR: Concept, Design. PS: Concept, Definition of intellectual content, Manuscript writing. PM: Manuscript Review. VM: Manuscript Review. STK Manuscript Writing, Manuscript Review.

Presentation at conferences/CMEs and abstract publication

Nil.

Study data availability

De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ institution’s policy.

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The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI.

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The grammar checking tool and citation manager is used for writing this manuscript.

Funding Statement

Nil.