Heterogeneity Within Frailty: Physiological Reserve Phenotypes and Postoperative Recovery After Abdominal Surgery

<b>Background:</b> 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. <b>Methods:</b> 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. <b>Results:</b> 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. <b>Conclusions:</b> 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.