SURGICAL INDICATION IN HIGH-RISK PATIENTS: BALANCING CLINICAL BENEFIT, PERIOPERATIVE RISK, AND INDIVIDUALIZED DECISION-MAKING

Abstract

Population aging, multimorbidity, and the increased complexity of procedures have broadened the number of patients undergoing surgery in borderline clinical conditions, rendering assessments based solely on traditional scores insufficient. This narrative review aimed to critically analyze current evidence on risk stratification, frailty, sarcopenia, biomarkers, surgical futility, shared decision-making, and perioperative optimization strategies. A targeted search was conducted in the PubMed, SciELO, and Cochrane databases, complemented by contemporary guidelines from scientific societies, with an emphasis on review studies, meta-analyses, clinical trials, and clinical practice documents applicable to high-risk surgical patients. The findings indicate that tools such as ASA, RCRI, and ACS NSQIP remain useful, but have limited performance when used in isolation. The incorporation of NT-proBNP, troponins, functional assessment, frailty, sarcopenia, and patient-centered goals improves prognostic discrimination and decision quality. It is concluded that surgical indication in high-risk patients should result from a multidimensional integration of probability of benefit, risk of complications, chance of functional recovery, and patient values, preferably in a multidisciplinary setting and with structured perioperative planning.