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

Dear Editor,

We read with great interest the study by Raju et al.,[1] which offers valuable prospective insights into the correlation between frailty and postoperative outcomes in elective abdominal surgeries. The authors are commended for integrating the Clavien–Dindo classification and maintaining a standardised perioperative assessment protocol that strengthens internal validity. Despite these strengths, particular methodological choices merit scrutiny.

Notably, the complete absence of Clavien–Dindo grade III complications, even among patients with modified frailty index (mFI) ≥ 0.27 undergoing major surgeries, warrants concern. This could reflect an overly conservative classification threshold or procedural underreporting, particularly given the established incidence of grade III events in similar cohorts.[2] Moreover, the study’s odds ratios for anaesthesia-related complication risk are derived from subgroups with extremely small sample sizes (e.g. five neuraxial patients with mFI ≥ 0.27), resulting in exaggerated confidence intervals and unstable estimates. This undermines the reliability of comparative risk assertions across anaesthesia techniques.

Additionally, the decision to preselect mFI ≥ 0.27 as the sole binary threshold overlooks the observed inflection at 0.18, where sensitivity and specificity were optimal. Bypassing a multivariate model incorporating this lower cut-off restricts the translational potential of the findings for nuanced preoperative risk stratification.[3] Lastly, while postoperative mortality was absent, attributing this solely to elective case selection may overlook confounders such as early discharge bias or loss of granular follow-up fidelity inherent in telephonic tracking.[4]

In summary, while the study advances the perioperative frailty discourse, further refinement is required to calibrate its predictive claims to clinical complexity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient consented to the images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity; however, anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Generative AI use statement

Generative AI tools, including Paperpal and ChatGPT-4, were utilised solely for language, grammar, and stylistic refinement. These tools had no role in the conceptualisation, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis, and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality, and integrity of the work presented.

Data availability statement

Not applicable, as no data were generated or analysed in this study

Presentation at conferences/CMEs and abstract publication

None.

Declaration of Use of Permitted Tools

ChatGPT-4 and Paperpal.

Author contribution

RM: Conceptualisation, Methodology, Writing—Original Draft, Writing—Review and Editing. RS: Validation, Supervision, Project Administration, Writing—Original Draft, Writing—Review and Editing.

Funding Statement

Nil.