Should We Fear the Frail? A Review on the Impact of Frailty on Liver Surgery.

BACKGROUND: Frailty is a multidimensional syndrome characterized by reduced physiological reserve and resilience and has become a crucial predictor of outcomes in liver surgery. Unlike chronological age, frailty reflects broader vulnerabilities that significantly influence postoperative recovery. AIM: To review and synthesize current evidence on the relationship between frailty and postoperative outcomes following liver resection, with an emphasis on short-term complications, mortality, and long-term survival. METHODS: A comprehensive literature review was performed, drawing on recent meta-analyses, large-scale cohort studies, and prospective observational data. Frailty was evaluated using a range of assessment tools, including the Modified Frailty Index (mFI), Clinical Frailty Scale (CFS), Kihon Checklist (KCL), and claims-based measures such as the Johns Hopkins Frailty Indicator. RESULTS: Across studies, frailty has been consistently linked to a higher incidence of postoperative complications, such as post-hepatectomy liver failure (PHLF), infections, extended hospital stays, and increased mortality. In patients undergoing liver resection for cancer, frailty is also associated with poorer long-term survival. Importantly, frailty serves as an independent risk factor, even after adjusting for age, comorbid conditions, and tumor characteristics. Preoperative identification of frailty enhances risk stratification, informs surgical planning, potentially favoring parenchymal-sparing or minimally invasive approaches, and highlights patients who may benefit from prehabilitation. CONCLUSIONS: Frailty is a strong and independent predictor of poor outcomes after liver resection. Incorporating frailty assessment into routine preoperative evaluation can improve surgical decision-making, facilitate informed patient counseling, and optimize perioperative care strategies.