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The Compressed Rescue Window: Frailty and the Pathways to Postoperative Mortality in Older Surgical Patients
Journal article   Peer reviewed

The Compressed Rescue Window: Frailty and the Pathways to Postoperative Mortality in Older Surgical Patients

Faisal S. Jehan, Brian Longbottom, Sean Y. Kim and Hassan Aziz
Surgery, 110764
10/13/2026
DOI: 10.1016/j.surg.2026.110764

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Abstract

Background Frailty predicts postoperative mortality and may act through both increased complication risk and a reduced ability to survive complications. Clarifying their relative contributions may guide perioperative strategies. Methods Retrospective cohort study of the ACS NSQIP Participant Use Files (2020–2024) including patients aged 65 years or older undergoing general/gastrointestinal, vascular, orthopedic, thoracic, or urologic surgery. Emergent and urgent procedures were excluded. Preoperative frailty was measured using the NSQIP-adapted Risk Analysis Index (naRAI) and the 5-factor modified frailty index (mFI-5). A four-way causal mediation decomposition (mediator: major complication) partitioned the frailty–mortality effect into complication-occurrence and rescue (direct) pathways. A multi-state model assessed frailty as a modifier of the complication→death transition. Results Thirty-day mortality was 1.9%, major complications occurred in 11.3%, and failure to rescue occurred in 12.2% of the patients with complications. Each 1-SD increase in naRAI was associated with higher mortality (adjusted OR, 2.08; 95% CI, 2.06–2.11). Most frailty-attributable excess mortality occurred through the rescue pathway (pooled 70% by naRAI, 63% by mFI-5), ranging from 58% (vascular) to 77% (orthopedic) across specialties (heterogeneity, P < .001). Frailty accelerated the complication→death transition (naRAI HR, 1.37 per SD; 95% CI, 1.36–1.39); cumulative mortality reached 5% within 2 days in the most-frail quintile versus 13 days in the remainder, and failure to rescue increased from 3.9% to 19.8% across frailty quintiles. Conclusions In older surgical patients, frailty was associated with both increased complication occurrence and reduced survival after complications, the latter accounting for a larger proportion of excess mortality. These findings support preoperative optimization to improve physiological reserve and frailty-informed postoperative surveillance to detect and treat complications within a limited rescue window.

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