The world is witnessing an unprecedented demographic transition, with a rapid increase in the proportion of elderly individuals owing to advances in healthcare, nutrition, and socioeconomic development. Geriatrics, the branch of medicine concerned with health care of older adults, focuses on promoting health by preventing and treating diseases and disabilities in elderly people. The term “elderly” or “geriatric” is generally applied to individuals aged 65 years and above, a threshold widely accepted across nations including India. With increasing life expectancy, a growing number of elderly patients now present for surgical intervention, both elective and emergency, bringing unique challenges to surgeons and anesthesiologists.^[1][2]

Abdominal surgery in elderly patients poses distinctive risks due to physiological, anatomical, and biochemical changes associated with aging. Aging is accompanied by reduced physiological reserves, impaired immune function, diminished cardiac output, decreased pulmonary compliance, delayed renal clearance, and altered hepatic metabolism. These changes compromise the ability to maintain homeostasis under surgical stress, predisposing to higher postoperative morbidity and mortality. Moreover, the coexistence of comorbidities -such as hypertension, diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and malignancy -further aggravates surgical risk. Consequently, elderly patients represent a unique and vulnerable surgical population requiring individualized preoperative assessment and perioperative management.^[3][4]

The morbidity and mortality following abdominal surgery in older patients are multifactorial. Prognostic factors include patient-related (age, nutritional status, comorbidities), disease-related (malignancy, perforation, infection), and procedure-related (duration of surgery, intraoperative blood loss, type of anesthesia, urgency of operation). Among these, the urgency of surgery (elective versus emergency) often serves as a decisive determinant of outcome. Elective procedures typically allow preoperative optimization of comorbidities, whereas emergency surgeries frequently involve patients in compromised physiological states with minimal preparation time, leading to substantially higher postoperative complications and deaths.^[5]

Morbidity, derived from the Latin morbidus meaning “sick” or “unhealthy,” represents the presence of disease or poor health due to any cause. Mortality, on the other hand, refers to the measure of the number of deaths in a given population over a specific period, often expressed per 1,000 or 100,000 individuals. In surgical terms, morbidity encompasses postoperative complications such as wound infection, pneumonia, sepsis, deep venous thrombosis, renal dysfunction, or cardiac events, whereas mortality denotes death occurring during or following surgery, often within 30 days.^[6][7]

Predicting morbidity and mortality is essential to guide preoperative counseling, informed consent, surgical planning, and postoperative management. Prognostic factors serve as vital tools to stratify surgical risk, optimize patient selection, and improve resource allocation. Identification of modifiable factors -such as anemia, hypoalbuminemia, or poorly controlled diabetes -provides an opportunity for timely intervention to mitigate complications. Various scoring systems, including the American Society of Anesthesiologists (ASA) Physical Status Classification, POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity), and Charlson Comorbidity Index, have been developed to predict surgical outcomes. However, the predictive accuracy of these systems varies across populations and surgical contexts, necessitating local and institutional validation.^[8]

In the elderly, preoperative optimization plays a pivotal role. Nutritional status, particularly serum albumin levels, is a well-recognized predictor of postoperative recovery. Hypoalbuminemia (<3.3 g/dl) reflects poor nutritional reserve, chronic illness, or ongoing inflammation and correlates strongly with delayed wound healing, increased infection rates, prolonged hospitalization, and mortality. Similarly, anemia (Hb <10 g/dl) diminishes tissue oxygenation, impairs wound repair, and increases susceptibility to postoperative complications. Both conditions are potentially modifiable risk factors, highlighting the importance of early identification and correction prior to surgery.^[9]

Aim

To study the prognostic factors affecting morbidity and mortality in elderly patients undergoing abdominal surgeries in a tertiary care hospital.

Objectives

1. To identify preoperative, intraoperative, and postoperative factors predicting morbidity in elderly patients undergoing abdominal surgeries.
2. To determine independent risk factors associated with postoperative mortality in this population.
3. To evaluate the impact of timely surgical intervention and optimization on improving outcomes and reducing mortality.

Source of Data

The study was conducted on patients admitted to Unit I, Department of Surgery, Sassoon General Hospital, Pune, who underwent abdominal surgeries during the study period. All patients above 65 years of age who consented to participate were included.

Study Design

A prospective observational study was conducted to evaluate the prognostic factors influencing morbidity and mortality.

Study Location

Department of Surgery, Sassoon General Hospital, Pune - a tertiary care teaching hospital serving a large and diverse population.

Study Duration

The study was carried out over a defined period (e.g., January 2023 to December 2024), ensuring adequate follow-up of each case until discharge or death.

Sample Size

A total of 100 patients aged above 65 years undergoing abdominal surgery (elective or emergency) were included.

Inclusion Criteria

• Patients aged ≥65 years undergoing abdominal surgery.
• Both elective and emergency cases included.
• Surgical procedures encompassing exploratory laparotomy (traumatic/non-traumatic), surgeries for abdominal malignancies, gall bladder, appendix, hernia, and genitourinary surgeries (e.g., nephrectomy, pyelolithotomy).

Exclusion Criteria

• Patients aged <65 years.
• Obstetric and gynecological surgical cases.
• Patients with incomplete clinical records or refusal to consent.

Procedure and Methodology

Each patient underwent detailed history taking, clinical examination, and relevant investigations.

History: Presenting complaints such as pain abdomen, distension, vomiting, fever, trauma, or altered bowel habits.

Examination: Vital signs, hydration, sensorium, and systemic examination with emphasis on cardiovascular, respiratory, and abdominal findings.

Investigations: Complete blood count, renal and liver function tests, electrolytes, coagulation profile, X-ray (erect abdomen/chest), ultrasound, CT scan where indicated, and HIV/HBsAg screening.

Perioperative Parameters: Type of surgery, duration, anesthesia type, blood loss, transfusion requirement, and peritoneal contamination were recorded.

Postoperative Monitoring: Wound status, hemodynamics, urine output, laboratory parameters, and complications such as sepsis, DVT, pneumonia, electrolyte disturbances, and wound dehiscence were documented.

Each patient was followed up till discharge or death. Those discharged early were followed up telephonically for 30 days.

Sample Processing

Laboratory analyses including hemoglobin, serum albumin, electrolytes, renal and hepatic parameters were processed in the hospital’s central laboratory following standard protocols. Data were verified for consistency and completeness.

Statistical Methods

All collected data were tabulated and analyzed using SPSS version 25.0.Descriptive statistics such as mean ± standard deviation (SD) were used for continuous variables.Chi-square test or Fisher’s exact test was applied to assess association between categorical variables.t-tests/ANOVA were used for comparing continuous variables.Logistic regression analysis identified independent predictors of morbidity and mortality.A p-value <0.05 was considered statistically significant.Results were expressed with 95% confidence intervals and odds ratios where applicable.

Data Collection

A structured proforma was used for data entry, including demographic profile, comorbidities, laboratory values, surgical details, postoperative course, complications, and outcomes. Data were verified by cross-checking surgical and ICU records.

Table 1: Baseline profile and crude association with any adverse outcome (morbidity or mortality) (N=100)

*Peritoneal contamination includes perforation peritonitis, feculent/ bilious contamination at laparotomy.

Table 1, Among the 100 elderly patients who underwent abdominal surgeries, the mean age was 70.2 ± 4.1 years, with those developing adverse outcomes being significantly older (71.1 ± 4.2 years) compared to those with uneventful recovery (69.0 ± 3.7 years, p=0.009). Males constituted 56% of the cohort, with a slightly higher proportion among those with complications (63%) compared to those without (47.8%), though the difference was not statistically significant (p=0.13).
Emergency surgery was performed in 62% of patients and was strongly associated with adverse outcomes -81.5% of those with complications or mortality had undergone emergency procedures versus 39.1% among those with smooth recovery (χ²=18.91, p<0.001). Similarly, patients with higher ASA grades (III–IV) demonstrated a markedly increased risk, with 75.9% developing adverse outcomes compared to 37% in lower grades (χ²=14.24, p<0.001). Hematological and biochemical parameters further reflected significant differences. The mean hemoglobin level was 10.1 ± 1.4 g/dL, but those with complications or death had significantly lower levels (9.7 ± 1.5 g/dL) than the uneventful group (10.6 ± 1.2 g/dL, p=0.002). Anemia (<9 g/dL) increased the risk of adverse outcomes almost fourfold (RR=3.82, p=0.004). Likewise, serum albumin emerged as a potent prognostic marker -patients with albumin <3.3 g/dL constituted 74.1% of the adverse outcome group compared to 32.6% among those recovering well (χ²=17.26, p<0.001). Intraoperative determinants were also influential. Peritoneal contamination was observed in 40% overall but was significantly more common among those with poor outcomes (59.3% vs 17.4%, p<0.001). Operative time ≥120 minutes and blood loss ≥500 mL were both associated with increased postoperative complications (p=0.004 and p=0.027, respectively). Furthermore, ICU admission was required in 35% of all cases, with 53.7% belonging to the adverse outcome group compared to only 13% in those with uneventful recovery (p<0.001). The mean hospital stay was significantly prolonged in patients with complications (13.7 ± 4.8 days) compared to those with smooth recovery (9.3 ± 3.7 days, p<0.001), emphasizing the overall burden of morbidity. Collectively, these findings underscore that advanced age, emergency status, high ASA class, anemia, hypoalbuminemia, prolonged operative time, peritoneal contamination, and ICU requirement are significant contributors to poor outcomes in elderly surgical patients.

Table 2: Preoperative, intraoperative, and postoperative predictors of morbidity (excluding deaths) (N=100)

*Deaths (n=18) excluded to isolate morbidity predictors. “No morbidity” group had uneventful recovery and survivors without complications.

Table 2, To isolate predictors of morbidity, the analysis excluded 18 deaths, leaving 82 survivors. Among these, 28 (34.1%) developed postoperative complications. Patients aged ≥75 years were nearly three times more likely to develop morbidity (RR=2.89, p=0.018). Emergency surgery again demonstrated a strong association with morbidity (85.7% vs 44.4%, p<0.001). Similarly, higher ASA grades (III–IV) significantly increased complication rates (82.1% vs 46.3%, p=0.002).

Biochemical parameters reflected similar trends: mean hemoglobin was lower among those with morbidity (9.8 ± 1.4 g/dL) compared to those without (10.5 ± 1.2 g/dL, p=0.016), and anemia (<9 g/dL) doubled the risk of postoperative complications (RR=2.57, p=0.047). Likewise, mean serum albumin was significantly reduced in the morbidity group (3.05 ± 0.49 g/dL) compared to non-morbid patients (3.36 ± 0.47 g/dL, p=0.006). Hypoalbuminemia (<3.3 g/dL) increased the odds of complications more than fivefold (OR=5.32, p<0.001).

Intraoperative parameters were major determinants -peritoneal contamination (71.4%), prolonged operative time ≥120 minutes (53.6%), and blood loss ≥500 mL (35.7%) all showed significant associations with morbidity (p<0.001, 0.003, and 0.007, respectively). Postoperative factors such as hyperglycemia (>180 mg/dL), electrolyte imbalance, and pneumonia/atelectasis were also significantly higher among those with complications (p=0.008, 0.010, and 0.003, respectively).
The mean hospital stay was notably longer for patients with morbidity (14.1 ± 4.7 days) compared to those without (9.8 ± 3.9 days, p<0.001). Thus, advanced age, emergency procedures, high ASA class, anemia, hypoalbuminemia, intraoperative contamination, prolonged surgery, excessive blood loss, and postoperative metabolic or respiratory complications emerged as dominant predictors of postoperative morbidity.

Table 3: Multivariable logistic regression: independent risk factors for postoperative mortality (N=100; deaths=18)

Model performance: Hosmer–Lemeshow p=0.62; AUC=0.86 (0.78–0.94); Nagelkerke R²=0.41.
(Collinearity checked; variance inflation factors <2 for retained covariates.)

Table 3, Multivariate logistic regression identified several independent predictors of postoperative mortality. The model achieved good discrimination with an AUC of 0.86 (95% CI: 0.78–0.94) and satisfactory calibration (Hosmer–Lemeshowp=0.62). The strongest predictor was ASA IV grade, which increased the odds of death nearly sixfold (OR=5.90, 95% CI: 2.10–16.6, p=0.001). Emergency surgery also remained an independent determinant of mortality (OR=3.80, 95% CI: 1.40–10.3, p=0.008). Biochemical markers were highly relevant -hypoalbuminemia (<3.3 g/dL) doubled the risk of death (OR=2.60, p=0.049), and anemia (Hb <9 g/dL) tripled it (OR=3.10, p=0.033). Peritoneal contamination significantly elevated mortality risk (OR=2.90, p=0.028). Although age ≥75 years and operative time ≥120 minutes showed a positive trend, they did not reach statistical significance (p=0.078 and p=0.13, respectively).

Table 4: Impact of timely surgery and pre-op optimization on outcomes (N=100)

1. A) Early vs Delayed surgery (threshold = surgery start <24h from admission)

3. B) Optimization bundle (pre-op correction of Hb to ≥9 g/dL, albumin support to ≥3.3 g/dL if feasible, glycemic control <180 mg/dL)**

Table 4, Analysis of timing and optimization revealed two major modifiable determinants of improved outcomes. In early surgery (<24 hours from admission), mortality was significantly lower (10.3%) compared to delayed surgery (≥24 hours) where mortality reached 28.6% (p=0.015). Likewise, postoperative morbidity, ICU admissions, and hospital stay were all significantly reduced in the early surgery group (p=0.014, 0.041, and <0.001, respectively). Patients operated early had an average hospital stay of 10.2 ± 4.1 days versus 13.8 ± 5.0 days in delayed cases.

Similarly, patients receiving a preoperative optimization bundle -correction of anemia and hypoalbuminemia with proper glycemic control -demonstrated strikingly better outcomes. Mortality was 8.3% in optimized patients versus 26.9% in non-optimized (p=0.010), while morbidity rates dropped from 61.5% to 29.2% (p=0.001). ICU admission was also significantly lower (20.8% vs 48.1%, p=0.005). The average hospital stay was reduced by almost 4 days (9.7 vs 13.5 days, p<0.001) in the optimized group.

Baseline risks and crude associations (Table 1)

Cohort (mean age 70.2 ± 4.1 y) shows a clear age gradient: patients with adverse outcomes were older by 2.1 years (p=0.009). This aligns with classic surgical audits and contemporary geriatric surgery data showing age-related decline in physiological reserve and higher complication rates, particularly beyond 75–80 years.^[10] Multiple series and reviews document this monotonic age–risk relationship, often mediated by frailty and multimorbidity rather than age alone. Emergency surgery was strongly over-represented among those with adverse outcomes (81.5% vs 39.1%; p<0.001). This mirrors large database studies and focused geriatric cohorts in which emergency status is one of the most powerful independent predictors of both morbidity and mortality because of limited time for optimization, higher sepsis burden, and delayed presentation.^[11]

Signal for high ASA grades (III–IV) (75.9% vs 37.0%; p<0.001) is also concordant with evidence that ASA is a robust prognostic discriminator in older surgical patients; several analyses -including systematic reviews -find ASA the most consistent predictor of postoperative death. Nutritional and hematologic markers behaved as expected.^[12] Lower mean hemoglobin ( -0.9 g/dL; p=0.002) and anemia <9 g/dL (RR3.8) were associated with adverse outcomes, paralleling large perioperative cohorts where preoperative anemia independently predicts complications and death. Likewise, hypoalbuminemia showed one of the strongest crude associations (albumin <3.3 g/dL OR5.9), reflecting well-established literature that preoperative albumin is among the best single-variable predictors of surgical risk, including in the elderly. Intraoperative contamination, longer procedures, and higher blood loss also tracked with poor outcomes -findings that echo abdominal emergency series where peritoneal soiling, prolonged operative stress, and hemorrhage amplify the inflammatory and septic burden with downstream pulmonary, renal, and infectious complications.^[13] The substantially higher ICU use and longer length of stay (LOS) in the adverse-outcome group are in line with prior reports that high ASA, anemia, and low albumin cluster with increased critical-care needs and prolonged hospitalization.^[14]

Predictors of morbidity among survivors (Table 2): When deaths are excluded, the same risk architecture persists. Age ≥75 y, emergency status, ASA III–IV, anemia, and hypoalbuminemia retained significant associations with postoperative morbidity. This pattern is consistent with comparative studies of elderly abdominal surgery showing that modifiable preoperative deficits (Hb, albumin) and acute disease severity (emergency indication, contamination) dominate morbidity risk.^[15] Intraoperative drivers -peritoneal contamination, ≥120 min operative time, and ≥500 mL blood loss -again matched prior evidence, reinforcing that both baseline vulnerability and operative insult shape complication trajectories.Postoperative metabolic derangements (hyperglycemia, electrolyte disorders) and respiratory complications (pneumonia/atelectasis) also tracked morbidity and LOS, in keeping with geriatric surgical pathways where metabolic and pulmonary complications are common and prognostically important.^[16][17]

Independent predictors of mortality (Table 3): Multivariable model (AUC 0.86) identifies ASA IV, emergency surgery, hypoalbuminemia, anemia, and peritoneal contamination as independent mortality predictors, which is highly concordant with the external literature. Prior analyses repeatedly show ASA to be a strong independent predictor of death in older adults undergoing abdominal procedures; several reviews cite ASA as the only factor consistently linked to mortality across heterogeneous studies.^[18][19] Emergency status likewise remains independently lethal after adjustment, echoing database comparisons of emergency vs elective general surgery in the elderly.^[20][21] The independent effects of low albumin and anemia mirror large cohorts (e.g., VA and multi-institutional studies) in which these parameters outperform age alone as mortality markers and respond to preoperative correction strategies when feasible. The contribution of peritoneal contamination is also consistent with emergency laparotomy literature tying intra-abdominal sepsis to excess death in older patients.^[22][23]

Timeliness and optimization effects (Table 4): Data demonstrate clinically meaningful benefits from early surgery (<24 h): lower mortality (10.3% vs 28.6%), morbidity, ICU use, and shorter LOS.[24] This matches the consensus that minimizing preoperative delay in unstable abdominal pathologies reduces physiologic deterioration and sepsis progression -an effect accentuated in elderly physiology.^[25] In parallel, the optimization bundle (Hb ≥9 g/dL, albumin ≥3.3 g/dL, glycemic control) halved morbidity and substantially lowered mortality and ICU utilization. These findings are highly congruent with prior evidence that correction of anemia and optimization of nutritional and metabolic parameters is associated with better outcomes in older surgical cohorts.^[26]

The present study concludes that postoperative morbidity and mortality among elderly patients undergoing abdominal surgeries are influenced by a complex interplay of preoperative, intraoperative, and postoperative factors. Increasing age, emergency surgical intervention, higher ASA grade, anemia, hypoalbuminemia, peritoneal contamination, prolonged operative duration, and significant intraoperative blood loss were identified as major determinants of poor outcomes. Among these, emergency surgery, hypoalbuminemia, high ASA status, and anemia emerged as independent predictors of mortality.

Timely surgical intervention within 24 hours of admission and preoperative optimization -particularly correction of anemia, improvement of nutritional status, and glycemic control -significantly reduced morbidity, mortality, ICU stay, and duration of hospitalization. These findings emphasize the importance of early diagnosis, risk stratification, and comprehensive preoperative optimization in improving surgical outcomes among the geriatric population. Multidisciplinary perioperative care with vigilant postoperative monitoring is essential to minimize complications and enhance recovery in this high-risk group.

1. Single-center design: The study was conducted in a single tertiary care hospital, which may limit the generalizability of the findings to other healthcare settings or populations.
2. Limited sample size: With a sample of 100 patients, subgroup analysis for specific types of surgeries or comorbidities was restricted.
3. Short-term follow-up: Outcomes were assessed only up to hospital discharge or 30 days; long-term morbidity and survival were not evaluated.
4. Selection bias: The inclusion of both elective and emergency cases, without randomization, may have introduced selection bias in the outcome distribution.
5. Unmeasured confounders: Factors such as frailty index, nutritional scoring, and specific intraoperative anesthetic techniques were not quantified, which might have influenced outcomes.

Despite these limitations, the study provides valuable insights into modifiable and non-modifiable prognostic factors in elderly surgical patients and highlights the need for larger, multicentric studies for validation.

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