Elena Montanari

Background: Chronological age remains deeply embedded in perioperative risk assessment because it is readily available and intuitively associated with adverse outcomes. In clinical practice, however, patients of similar age frequently experience markedly different postoperative trajectories, suggesting that physiological reserve may more accurately reflect vulnerability to surgical stress than years lived alone. We therefore investigated whether age-based stratification inadequately captures perioperative vulnerability when compared with functional phenotyping based on frailty status and baseline handgrip strength (HGS). Methods: We conducted a prospective multicenter observational cohort study including 223 adults undergoing elective abdominal surgery between January 2023 and June 2025. Chronological age was evaluated both continuously and using a conventional threshold ( 10 days, was used as a pragmatic clinical benchmark. Cross-classification analyses, logistic regression, and receiver operating characteristic (ROC) curve analyses were performed to compare the discriminatory performance of chronological age, frailty phenotype, and HGS. Results: Substantial discordance was observed between chronological age and frailty phenotype. Among patients younger than 70 years, 7.7% met criteria for frailty, whereas 58.0% of patients aged ≥70 years were classified as fit or pre-frail. Prolonged hospitalization occurred in 48 patients (21.5%) and varied markedly according to frailty status within each age group. Frail patients younger than 70 years demonstrated higher rates of prolonged LOS than fit older patients (40.0% vs. 10.5%). Chronological age demonstrated limited discrimination for prolonged hospitalization (AUC 0.579), while the ≥70-year threshold showed poor discriminatory performance (AUC 0.541). Frailty phenotype demonstrated improved discrimination (AUC 0.679), whereas the combined multivariable model integrating age, frailty, HGS, sex, and oncologic indication achieved good discriminatory performance (AUC 0.810). In multivariable analyses, frailty remained independently associated with prolonged LOS, whereas chronological age did not. Conclusions: Chronological age alone demonstrated limited discriminatory performance for perioperative risk stratification. Functional phenotyping based primarily on frailty status, complemented by objective functional measures such as HGS, may better capture physiological reserve and support more individualized, function-centered perioperative assessment in abdominal surgery.

Background: Chronological age remains deeply embedded in perioperative risk assessment because it is readily available and intuitively linked to adverse outcomes. In clinical practice, however, patients of similar age frequently experience markedly different postoperative trajectories. This observation may suggest that physiological reserve, rather than years lived, more accurately reflects vulnerability to surgical stress. We therefore examined whether age-based stratification misclassifies perioperative risk when compared with functional phenotyping using frailty status and baseline handgrip strength. Methods: We conducted a prospective, multicenter observational cohort study including 223 adults undergoing elective abdominal surgery between January 2023 and June 2025. Chronological age was evaluated both continuously and using a conventional threshold (<70 vs ≥70 years). Physiological reserve was characterized using a phenotype-based frailty model (fit, pre-frail, frail) and baseline handgrip strength measured at hospital admission. Prolonged hospitalization, defined a priori as a length of stay exceeding 10 days, was used as an external benchmark to examine classification performance. Analyses were primarily descriptive and classificatory, focusing on discordance, overlap, and risk re-ranking across age and functional strata rather than outcome prediction. Results: Substantial discordance was observed between chronological age and frailty phenotype. Among patients younger than 70 years, 7.7% met criteria for frailty, whereas 58.0% of patients aged 70 years or older were classified as fit or pre-frail. Prolonged hospitalization occurred in 48 patients (21.5%) and varied markedly by frailty status within each age group. Frail individuals consistently exhibited the highest hospitalization burden regardless of age, while fit and pre-frail older patients often demonstrated outcomes comparable to, or better than, younger fit patients. Baseline handgrip strength showed wide dispersion and extensive overlap between age groups, indicating substantial inter-individual variability in physiological reserve that chronological age alone did not capture. Conclusions: Chronological age appears to provide limited discriminatory resolution for perioperative risk stratification. Functional phenotyping using frailty status and baseline handgrip strength may better reflect underlying physiological reserve and support more individualized, function-centered perioperative decision-making.

Background: Chronological age inadequately captures biological vulnerability among surgical patients. Frailty and muscle strength reflect physiological reserve, yet their combined contribution to postoperative length of stay (LOS) remains insufficiently explored. Methods: We conducted a prospective multicenter observational cohort study including 223 adults undergoing elective abdominal surgery. Frailty was assessed using the Fried phenotype, and admission handgrip strength (HGS) was measured with a calibrated dynamometer. Prolonged LOS was defined as >10 days (75th percentile) and also analyzed continuously using ln(LOS + 1). Multivariable logistic and linear regression models adjusted for age, sex, frailty status, and surgical indication. Patients were additionally stratified into four physiological reserve phenotypes combining frailty and HGS. Results: LOS ranged from 0 to 68 days; a total of 48 patients (21.6%) experienced prolonged hospitalization. In multivariable logistic regression, frailty (adjusted OR 3.12, 95% CI 1.72–5.67) and oncologic surgery (adjusted OR 7.63, 95% CI 3.12–18.65) were independently associated with prolonged LOS, whereas chronological age was not. Female sex was associated with lower odds of prolonged LOS (adjusted OR 0.39, 95% CI 0.18–0.87). Similar associations were observed when LOS was analyzed continuously. Physiological reserve phenotyping revealed graded LOS distributions: Fit–Strong patients had the shortest stays (mean 5.5 ± 4.3 days), while Frail–Weak patients experienced the longest and most variable hospitalization. Conclusions: Postoperative LOS clusters according to multidimensional physiological reserve rather than chronological age. Integrating frailty and muscle strength identifies clinically meaningful phenotypes that may improve perioperative risk stratification beyond age-based approaches and inform personalized perioperative planning, resource allocation, and patient-centered decision-making across heterogeneous surgical populations in worldwide settings.