A multidimensional approach to frailty in emergency surgery for perforated peptic ulcer.

BACKGROUND: Perforated peptic ulcer (PPU) remains a high-risk surgical emergency. Although sarcopenia has been proposed as an objective surrogate of frailty, its independent prognostic value in emergency surgery is unclear. This study evaluated sarcopenia within a multidimensional frailty framework incorporating nutritional, inflammatory, and clinical parameters. METHODS: This retrospective cohort study included adult patients who underwent emergency surgery for PPU at a tertiary center. Sarcopenia was assessed using computed tomography-derived psoas muscle area and psoas muscle index with population-specific cut-off values. Immunonutritional and inflammatory indices (hemoglobin-albumin-lymphocyte-platelet [HALP], neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], and systemic immune-inflammation index [SII]) were calculated from admission laboratory data. The primary outcome was in-hospital mortality. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were performed to identify independent predictors and discriminatory performance. RESULTS: Ninety-seven patients were included; 30.9% were sarcopenic. Sarcopenic patients exhibited lower serum albumin, higher inflammatory markers, higher clinical severity scores, and longer intensive care unit and hospital stays (all p<0.05). However, sarcopenia was not independently associated with in-hospital mortality. In multivariable analysis, advanced age (odds ratio [OR] 1.07, p=0.010) and low serum albumin (OR 0.75, p<0.001) were the strongest independent predictors of mortality. Low HALP score and elevated NLR and PLR were significantly associated with sarcopenia. ROC analysis showed that age and albumin had superior discriminatory ability for mortality compared with morphometric muscle parameters. CONCLUSION: In PPU surgery, frailty is better characterized as a multidimensional biological phenotype rather than isolated muscle loss. While sarcopenia reflects increased vulnerability, mortality risk is more strongly driven by age and nutritional-inflammatory reserve. Integrated frailty assessment may improve risk stratification in emergency surgical patients.