Patients Undergoing Emergency Laparotomy Research Articles

Effect of anemia with surgical emergency laparotomy in a peripheral set-up of Punjab.

Objective: To determine the effect of anemia in patient undergoing emergency laparotomy and post-operative complications. Study Design: Prospective observational study. Setting: We monitored individuals having emergency laparotomies at a tertiary care hospital. Period: June 2021 to May 2023. Methods: Patients undergoing emergency laparotomies for various reasons. Post-operative complications were the main variable noted in this study. Estimation of risk for complications analyses by using Poisson regression method in patient with anemia. Approval was obtained from the local ethics committee with reference number: SMC/0058. Results: About 76 patients, mostly male (79.3) with median age of 42 years. Complications were noted in 16.3% (12). 14 patients (23%) were pre-operatively anemic at time of operation. Patients with moderate to severe anemia had more complications post-operatively (96% CI). Conclusion: Anemia increase the risk of complications and morbidity of patients undergoing emergency laparotomies due to various reasons but anemia is amenable to increase the morbidity and complications post-operatively.

Interhospital variability of risk-adjusted mortality rates and associated structural factors in patients undergoing emergency laparotomy: England and Wales population-level analysis.

Emergency surgical admissions represent the majority of general surgical workload. Interhospital variations in outcomes are well recognized. This analysis of a national laparotomy data set compared the best- and worst-performing hospitals according to 30-day mortality and examined differences in process and structural factors. A retrospective multicenter cohort study was performed using data from the England and Wales National Emergency Laparotomy Audit (December 2013 to November 2020). The data set was divided into quintiles based on the risk-adjusted mortality calculated using the National Emergency Laparotomy Audit score risk prediction model. Primary outcome was 30-day mortality. Hospital-level factors were compared across all five quintiles, and logistic regression analysis was conducted comparing the lowest with the highest risk-adjusted mortality quintiles. Risk-adjusted 30-day mortality in the poorest performing quintile was significantly higher than that of the best performing (11.4% vs. 6.6%) despite equivalent predicted mortality (9.4% vs. 9.7%). The best-performing quintile was more likely to be a tertiary surgical (49.5% vs. 37.1%, p < 0.001) or medical school-affiliated center (26.4% vs. 18.0%, p < 0.001). In logistic regression analysis, the strongest associations were for surgery performed in a tertiary center (odds ratio, 0.690 [95% confidence interval, 0.652-0.731], p < 0.001) and if surgery was performed by a gastrointestinal specialist (0.655 [0.626-0.685], p < 0.001). Smaller differences were seen for postoperative intensive care stay (0.848 [0.808-0.890], p < 0.001) and consultant anesthetist involvement (0.900 [0.837-0.967], p = 0.004). This study has identified significant variability in postoperative mortality across hospitals. Structural factors such as gastrointestinal specialist delivered emergency laparotomy and tertiary surgical center status appear to be associated with improved outcomes. Original Research Article; Level II.

Implementation of modified enhanced recovery after surgery (ERAS) following surgery for abdominal trauma; Assessment of feasibility and outcomes: A randomized controlled trial (RCT)

BackgroundEnhanced recovery after surgery(ERAS) is a set of multiple perioperative care component not a rigid protocol with improved outcomes for elective surgeries. This study aimed to assess the feasibility and outcomes in trauma patients undergoing laparotomy. Study designProspective single-centre randomized controlled trial(RCT). Patients undergoing emergency laparotomy following trauma were randomized into ERAS(early removal of catheters, early mobilization and initiation of diet, use of opioid-sparing multimodal analgesia) and conventional care groups 24 ​h post-surgery. Outcome measures included length of hospitalization(LOH), recovery of bowel function, duration of removal of catheters and 30-day complications(Clavien-Dindo). ResultsFifty patients were randomized into ERAS(n ​= ​25) and conventional care(n ​= ​25) groups. Ninety-two percent of patients were young males, 58 ​% had blunt trauma to the abdomen and the most common indication of surgery was hollow viscus injury(88 ​%). ERAS group had a reduced median LOH(days) (6 versus 8, p ​= ​0.007), early recovery of bowel function(p ​= ​0.010) and shorter times for nasogastric tube(p ​= ​0.001), urinary catheter(p ​= ​0.007) and drain(p ​= ​0.006) removal. The complications were comparable in both groups except for deep surgical site infection[significantly lower in ERAS group(p ​= ​0.009)]. ConclusionERAS is safe and significantly reduces LOH in select trauma patients undergoing laparotomy.

EP349 - Use of Pre-operative Risk and Frailty Assessment in patients undergoing Emergency Laparotomy

Abstract Aims Formal preoperative assessment of risk of complications and death in all patients undergoing Emergency Laparotomy is recommended by NELA (National Emergency Laparotomy Audit) in the UK. In addition, frailty assessment in patients who are 65years or older and frail undergoing Emergency Laparotomy is also recommended. In a previous 2018 audit, we had recorded Preoperative Mortality Risk in 77% patients undergoing Emergency Laparotomy and Frailty was not part of our assessment in these patients. In this audit our aim was to evaluate documentation of preoperative frailty and risk assessment in patients undergoing Emergency Laparotomy from 2019 to 2023. Methods Details of all patients who underwent Emergency Laparotomy at a University Hospital under care of one surgical team between January 2019 and December 2023 were obtained from theatre logbooks. Patient notes were retrospectively reviewed to see if frailty assessment and preoperative risk assessment scores were recorded. This data was collected and analyzed using Microsoft Excel. Results During this period, sixty-seven patients were identified. The median age was sixty-seven with an age range from four to ninety-one. Of these 38 (57%) were females. A preoperative p-possum score was documented in 59 (88.1%), 39 (58.2%) patients were 65 years or older of these 26 (66.7%) had frailty assessment carried out. Conclusions Our data suggests that we have over time made progress in the use of Perioperative Risk assessment scores and incorporated frailty assessment in our perioperative practice in patient’s undergoing Emergency Laparotomy. However there remains room for improvement.

WP7.11 - An Audit of Geriatric Input and Analysis of The Barriers For Elderly Patients Undergoing Emergency Laparotomy

Abstract Background Older people over the age of 65 years are recognized as higher risk surgical candidates and it is therefore recommended that their care should be coordinated through a multidisciplinary team (MDT) approach involving senior geriatricians, anaesthetists and surgeons. We audited 150 geriatric patients for medical input. Further in addition to the liaison services we analysed the characteristics of this group that would have benefitted from a liaison service. Methods An audit of 150 geriatric patients undergoing emergency laparotomy was carried. Our primary outcome was to look at input from geriatricians following laparotomy. Further we assessed the clinical characteristics of these patients and analysed the complexity of medical needs to benefit from a physician input. Results Only around 10% patients received a medical/geriatric input following an emergency laparotomy. Our audit highlighted the gap that exists in the clinical care for geriatric population against the NELA recommendations. Further we were able to work out a model of implementation for a geriatric liaison service. Conclusions Management of older patients with complexity requires surgical, critical care and geriatricians to collaborate. Implementing a local service with regular MDT’s will only serve to improve care and outcomes.

SP7.5 - Time to CT for Acute General Surgery and Trauma in patients undergoing emergency laparotomy. A major trauma centre experience

Abstract Introduction In our institution separate care pathways exist for patients presenting with major trauma and acute abdomen (AA). Trauma patients activate a Consultant led trauma team attendance on arrival and CT imaging within 30 minutes where indicated. Our acute abdomen pathway attracts ST3+ general surgical review within 2 hours of emergency department referral and CT within a further 1 hour. We aimed to compare the two laparotomy cohorts with respect to clinical outcomes. Methods A retrospective analysis was performed on patients that underwent an emergency laparotomy following CT at our institution between December 2020 and February 2022. Patients were identified from the NELA and TARN databases. Results 66 trauma and 64 AA patients were identified. The mean time to CT in trauma was 56.1 minutes ± 24.8 and in AA 390.7 minutes ± 306.1 (p&amp;lt;0.001). There was no difference in length of ITU stay (mean days 3.1 ± 8.1 vs 4.2 ±9.8 p=0.260) or hospital stay (mean days 13.7 ± 19.2 vs 13.8 ±11.7 p=0.494). no correlation between time to CT and length of hospital stay (r=0.233 p=0.97) or ITU stay (r=0.224 p=0.964) in trauma patients or AA (r=0.217 p=0.58 and -0.001 p=0.562 respectively for hospital and ITU stays) was detected. However, there was a trend towards lower mortality in the trauma cohort (3% vs 7.8% p=0.227). Conclusion Trauma patients were scanned quicker than acute abdomen presentations likely due to greater personnel resource and better care pathways. This was associated with a trend towards lower mortality because of earlier pathology detection and Consultant directed care from hospital arrival.

WP3.12 - The influence between frailty, sarcopenia and physical status on mortality in patients undergoing emergency laparotomy

Abstract Aims Frailty and sarcopenia predict mortality in emergency laparotomy (EmLap) and both can be indicative of poor physical status. We aim to assess the prevalence of frailty, sarcopenia and physical status in EmLap and explore the relationship between these factors and 30-day, 90-day and 1-year mortality. Methods Retrospective analysis was performed on two Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) databases (2017-2019) which included patients ≥18years. Clinical frailty scale was used to classify frailty (score ≥4 as frail). Sarcopenia was assessed via total psoas index. Poor physical status (PPS) was defined by American Society of Anaesthesiologists physical status classification (ASA)≥4. One-way ANOVA and logistic regression were used for statistical analysis. Results 215 patients were included with 57.2% female and median age of 64years. Frailty was present in 17.2%, sarcopenia in 25.1% and 14.5% had PPS; 3.3% had all three factors. Frail patients had significantly higher risk for 30-day (p=0.003), 90-day (p=0.006) and 1-year mortality (p=0.032). Sarcopenic patients did not show significant differences in mortality risks up to 1 year. Patients with PPS had significantly higher mortality rates at 30-day (p&amp;lt;0.001), 90-day (p&amp;lt;0.001) and 1-year (p=0.001). Patients with all three factors had higher 30-day (p&amp;lt;0.001), 90-day (p=0.005) and 1-year mortality (p=0.049) than patients who have none of the factors. Conclusions Frailty, sarcopenia and PPS are prevalent in EmLap. Frailty and PPS were independently associated with short and long-term mortality but not sarcopenia. While overlap exists between frailty, sarcopenia and PPS, more studies are required to understand the complex interplay.

WP5.6 - Beyond the Left Side: Emergency Colonic Stenting for Acute Malignant Large Bowel Obstruction

Abstract Introduction Acute malignant large bowel obstruction (LBO) is traditionally treated by surgical diversion or resection in patients who are fit enough. European guidelines suggest colonic stenting as a bridge to surgery in curative disease. The aim was to examine the safety and efficacy of a change in practice from emergency laparotomy towards colonic stenting for acute malignant LBO. Methods Patients with LBO from 01/01/2019 to 31/12/2022 were included and data was obtained from the NELA database and electronic patient records. Results 42 patients underwent emergency laparotomy (EL) for LBO. 33% (14/42) patients had right-sided tumours (n=14) and/or perforated disease (n=6) where stenting was contraindicated. 28/42 patients (22% of total) went straight to EL for clinical/ organisation factors. 73 patients were stented; 44% (32/73) were at/ proximal to splenic flexure. Perforation rate was 10% (7/73) with 4/7 requiring EL. Failure rate was 14% (10/73) with 6/10 patients requiring EL. 41% (30/73) were stented with curative intent; 70% (21/30) then underwent elective resection. The rate of stoma formation and minimally invasive surgery in patients stented with curative intent was 40% (12/30) and 60% (18/30) respectively (including 9 EL following stent complications). Compared with 88% (37/42) and 19% (8/42) in patients undergoing primary EL. Conclusion Almost 2/3 of patients presenting with acute malignant LBO were suitable for stenting. Stenting reduced the need for a stoma and enabled elective minimally invasive surgery with low complication rates. This rate of colonic stenting was achievable without a 24/7 colonic stenting rota or sub-specialty cover.

ThP7.16 - Multidisciplinary management of elderly patients undergoing emergency laparotomy: an audit at a small district general hospital

Abstract Aims The National Emergency Laparotomy Audit (NELA) suggests early involvement of the multidisciplinary geriatrician team for preoperative care of elderly patients aged over 80, or 65 and frail. Methods we audited our unit against the NELA guidelines for elderly patients. We looked at all emergency laparotomies carried out at our hospital over a 6 month period against the audit standards as set out by NELA. Results A total of 55 laparotomies were carried out in 6 months. 17 patients fit the criteria of patients needing early geriatrician involvement. Of the 34 patients aged 65 and above, 22 patients had their frailty score recorded in the notes (64%). Less than 10% of patients had early geriatrician input. Overall, six patients (11%) died within 30 days of their initial operation, and all were aged over 65. Conclusions we must take the perioperative care of elderly patients seriously and work with the Geriatric Medicine teams for early perioperative review, including accurate clinical frailty score assessments. We will initiate a project with the Geriatric Medicine department to implement an Elderly Laparotomy Perioperative Pathway for these patients.

FP7.6 - Comprehensive Analysis of Emergency Laparotomy in the Geriatric Population: A Retrospective Study

Abstract Aims The British Society of Geriatrics recommends that all patients undergoing emergency laparotomy aged &amp;gt;= 65 who score more than 5 on Clinical Frailty Score (CFS) or &amp;gt;= 80 years with any CFS should receive comprehensive geriatric assessment within 72 hours of admission to a ward or step down from critical care. Despite substantial evidence outlining an improvement in postoperative outcomes, efforts to refer patients and record CFS are still insufficient. The aim of our study is to evaluate the use of CFS assessment in patients aged ≥ 65 years undergoing emergency laparotomy. Methods This was a retrospective audit of 94 patients aged ≥ 65 years old undergoing emergency laparotomy between September 2022 to October 2023. Results The mean age of the cohort was 75 years old. The average length of hospital stay was 21 days. 50% of patients were referred for an in-patient geriatrician review. The interval between surgery and geriatrician referral averaged 7 days. However, the average duration between geriatrician referral and assessment only spanned 1 day. CFS were recorded for only 11% of patients during their hospitalisation, pointing to an area for potential improvement. Conclusion Understanding the factors contributing to prolonged stays is pivotal in enhancing postoperative care. These insights not only shed light on the procedural intricacies surrounding emergency laparotomies in the elderly but also highlight opportunities for refining patient care pathways and optimising interdisciplinary care.

WP5.13 - National Emergency Laparotomy (NELA) critical care admissions: A cohort study

Abstract Aims NELA is committed to enhancing quality of peri-operative care of patients undergoing emergency laparotomy. NELA emphasizes importance of identifying high risk patients, who are associated with significant morbidity &amp; mortality. Critical care allows close monitoring, organ (basic/advanced) support. Aim of study is to review the NELA critical care patients. Methods Cohort study of NELA patients that received post-operative ITU care (direct/indirect admission) at single centre. Descriptive demography, and outcomes were evaluated. NELA parsimonious risk &amp; CCMDS ITU scores used. NELA patient that did not require ITU care were controls. Results NELA critical care (n = 400) NELA non critical care (n = 466) Mann Whitney U (p value) Deaths (n) - (n) Age(yrs) 71.8 64.0 &amp;lt; 0.0001 Sex(M:F) 173 : 227 220 : 246 NS ASA 3 2 &amp;lt; 0.0001 BMI(kg/m2) 26.3 25.0 NS Lap(n) 67 168 Open(n) 333 293 Op time(mins) 131.0 109.4 &amp;lt; 0.0001 LOS(days) 18 9.5 &amp;lt; 0.0001 Deaths 30 day 50 25 60 day 66 37 90 day 73 40 Lactate(mmol/L) 2.4 1.8 &amp;lt;0.01 WCC(x109/L) 13.0 11.8 &amp;lt;0.05 CRP(mg/L) 90.1 56.6 &amp;lt;0.0001 Physiological-score 25.6 19.8 &amp;lt;0.0001 Operative-severity-score 17.9 15.9 &amp;lt;0.0001 Prepossum-score 21.6 7.5 &amp;lt;0.0001 PPmortality-score 11.9 4.9 &amp;lt;0.0001 PPmorbidity-score 77.3 55.7 &amp;lt;0.0001 Survival Rate (%) 1styear 75.4 86.2 5thyear 53.8 70.8 Logrank 10thyear 41.1 58.7 p&amp;lt;0.0001 Conclusion NELA critical care patients had poorer survival rates in our study. Theatre return or indirect critical care transfers can adversely affect survival. These patients were older, frail, multiple co-morbid status. NELA parsimonious mortality risk score &amp;gt;5% should encourage consultant level supervision, mortality risk score &amp;gt;10% should encourage direct critical care involvement.

WP3.15 - National Emergency Laparotomy (NELA) deaths within 90 days: A cohort study

Abstract Aims NELA is committed to enhancing quality of care of patients undergoing emergency laparotomy. NELA care pathways include: initial clinical assessment, resuscitation, prompt diagnosis, early surgery, peri-operative care. NELA emphasizes the importance of identifying high risk patients, who are associated with significant morbidity &amp; mortality. Aim of study is to review the NELA 90-day deaths. Methods Cohort study of NELA deaths within 90 days, from Jan'2014 to Jan'2024 at single centre. Descriptive demography, outcomes were evaluated. NELA survivors beyond 90 days were controls. Results 90 Day (n = 113) Others (n = 751) Mann Whitney U (p value) Age(yrs) 74.3 66.6 &amp;lt; 0.0001 Sex(M:F) 58 : 55 334 : 417 NS ASA 3 2 &amp;lt; 0.0001 BMI(kg/m2) 25.1 25.7 NS Lap(n) 16 218 Ns Open(n) 97 533 &amp;lt; 0.01 Op time(mins) 120.2 119.1 NS LOS(days) 17 12 NS ITU/HDU 70 318 &amp;lt; 0.001 ITU stay(day) 3 2 &amp;lt; 0.05 Lactate(mmol/L) 3.0 1.9 0.0002 WCC(x109/L) 13.2 12.3 NS CRP(mg/L) 93.6 68.8 &amp;lt; 0.0001 Physiological score 28.2 21.6 &amp;lt; 0.0001 Operative severity score 20.0 16.4 &amp;lt; 0.0001 Pre possum score 29.4 11.9 &amp;lt; 0.0001 PP mortality score 23.4 6.1 &amp;lt; 0.0001 PP morbidity score 82.9 63.5 &amp;lt; 0.0001 Survival Rate (%) 1styear 81.4 5thyear 63.0 10thyear 50.7 Conclusion 90-day NELA mortality rate is 13.1 %. NELA deaths occurred in older, frail, multi-comorbid &amp; higher ASA status Patient survival appears to plateau out beyond 90-days (natural deaths). NELA risk scores were greater amongst the 90-day deaths. NELA risk scores can identify high risk patients, where early collaborative senior assessment by consultant surgeons, anaesthetist and intensivists may identify and allocate appropriate surgical &amp; critical care intervention.

EP442 - An Audit on the Application of Enhanced Recovery Post Emergency Laparotomy

Abstract Aim This audit aims to evaluate the efficiency of NG tube and catheter removal post emergency laparotomies, assess the occurrence of postoperative complications, and analyse hospital practices related to enhanced recovery in the context of emergency laparotomies. Methods Data was collected retrospectively from [Hospital Name] for a specified time period, including patient demographics, surgical details, time to NG tube and catheter removal, postoperative complications, and adherence to enhanced recovery protocols. The audit included a thorough review of medical records, nursing notes, and relevant documentation. Results Preliminary findings indicate variations in the time taken for NG tube and catheter removal across emergency laparotomy cases. The occurrence of postoperative complications, such as infections, delayed recovery, and prolonged hospital stays, was also assessed. Furthermore, an analysis of hospital practices, including the implementation of enhanced recovery protocols, was conducted. Conclusion The results of this audit will contribute valuable insights into the effectiveness of current practices related to NG tube and catheter management post emergency laparotomies. The findings may highlight areas for improvement in enhancing recovery, optimising patient outcomes, and minimising complications. Recommendations for refining hospital protocols and promoting timely interventions will be proposed based on the audit results, with the ultimate goal of improving the overall quality of care for patients undergoing emergency laparotomies.

EP503 - A retrospective assessment of quantitative futility in emergency laparotomy using pre-operative frailty as the predictor

Abstract Background Recent literature has proposed that emergency laparotomy in the frail population may be qualitatively futile leading to negative desired morbidity and missed opportunities for palliation. The aim of this study was to appraises the futility of emergency laparotomies within a 3 month period based on the predictor of pre-operative frailty with in a large district general hospital. Method Retrospective analysis of all patients undergoing emergency laparotomy in a 3 month time period in the Dumfries Royal Infirmary. Futility was defined as all-cause mortality within 3 days of emergency laparotomy and frailty based on the characteristics set out by the Rockwood frailty score. A assessment of surgical futility in emergency laparotomy was carried out based on the pre-operative frailty. Conclusions Increased frailty demonstrates an increase in futile emergency laparotomies. It is therefore recommended that a multidisciplinary team approach with careful assessment and consent should be made prior to any surgical intervention on this patient cohort.

Socioeconomic factors and rural-urban differences in patients undergoing emergency laparotomy

Background: Emergency laparotomy (EL) is a common surgical procedure with high rates of mortality and complications. Socioeconomic circumstances and regional differences have an influence on the utilization of care and outcomes in many diagnostic groups, but there are only few studies focusing on their effect in EL population. The aim of this study was to examine the socioeconomic and regional differences in the rate of EL within one tertiary care hospital district. Methods: Retrospective single-center study of 573 patients who underwent EL in Oulu University Hospital between May 2015 and December 2017. The postal code area of each patient’s home address was used to determine the socioeconomic status and rurality of the location of residence. Results: The age adjusted rate of EL was higher in patients from low-income areas compared to patients from high-income areas (1.46 ((95% CI 1,27-1.64)) vs. 1.15 ((95% CI, 0.96-1.34))). The rate of EL was higher in rural areas compared to urban areas (1.29 (95% CI 1.17-1.41 vs. 1.42 (1.18-1.67) ). Peritonitis was more common in patients living in low-income areas. There were no differences in operation types or mortality between the groups. Conclusions: The study findings suggest that there are socioeconomic and regional differences in the need of EL. The patients living in low-income areas had a higher rate of EL and a higher rate of peritonitis. These differences cannot be explained by patient demographics or comorbidities alone.

Preoperative high dose of dexamethasone in emergency laparotomy: randomized clinical trial.

Patients undergoing emergency laparotomy present with a profound inflammatory response, which could be an independent pathophysiological component in prolonged recovery. The aim of this study was to investigate the effects of a single preoperative high dose of intravenous dexamethasone on the inflammatory response and recovery after emergency laparotomy. In this double-blinded placebo-controlled trial, patients were prospectively stratified according to surgical pathology (intestinal obstruction and perforated viscus) and randomized to preoperative 1 mg/kg dexamethasone or placebo at a ratio of 1 : 1. The primary outcome was C-reactive protein on postoperative day 1. Secondary outcomes were postoperative recovery, morbidity, and mortality. A total of 120 patients were included in the trial. On postoperative day 1, the C-reactive protein response was significantly lower in the dexamethasone group (a median of 170 versus 220 mg/l for dexamethasone and for placebo respectively; P = 0.015; mean difference = 49 (95% c.i. 13 to 85) mg/l) and when stratified according to intestinal obstruction (a median of 60 versus 160 mg/l for dexamethasone and for placebo respectively; P = 0.002) and perforated viscus (a median of 230 versus 285 mg/l for dexamethasone and for placebo respectively; P = 0.035). Dexamethasone administration was associated with improved recovery (better haemodynamics, better pulmonary function, less fatigue, and earlier mobilization). Furthermore, the dexamethasone group had a lower 90-day mortality rate (7% versus 23% for dexamethasone and for placebo respectively; relative risk 0.33 (95% c.i. 0.11 to 0.93); P = 0.023) and a decreased incidence of postoperative major complications (27% versus 45% for dexamethasone and for placebo respectively; relative risk 0.62 (95% c.i. 0.37 to 1.00); P = 0.032). A single preoperative high dose of intravenous dexamethasone significantly reduces the inflammatory response after emergency laparotomy and is associated with enhanced recovery and improved outcome. NCT04791566 (http://www.clinicaltrials.gov).

Frailty using the Clinical Frailty Scale to predict short- and long-term adverse outcomes following emergency laparotomy: meta-analysis.

Emergency laparotomy has high morbidity and mortality rates. Frailty assessment remains underutilized in this setting, in part due to time constraints and feasibility. The Clinical Frailty Scale has been identified as the most appropriate tool for frailty assessment in emergency laparotomy patients and is recommended for all older patients undergoing emergency laparotomy. The prognostic impact of measured frailty using the Clinical Frailty Scale on short- and long-term mortality and morbidity rates remains to be determined. Observational cohort studies were identified by systematically searching Medline, Embase, Scopus and CENTRAL databases up to February 2024, comparing outcomes following emergency laparotomy for frail and non-frail participants defined according to the Clinical Frailty Scale. The primary outcomes were short- and long-term mortality rates. A random-effects model was created with pooling of effect estimates and a separate narrative synthesis was created. Risk of bias was assessed. Twelve articles comprising 5704 patients were included. Frailty prevalence was 25% in all patients and 32% in older adults (age ≥55 years). Older patients with frailty had a significantly greater risk of postoperative death (30-day mortality rate OR 3.84, 95% c.i. 2.90 to 5.09, 1-year mortality rate OR 3.03, 95% c.i. 2.17 to 4.23). Meta-regression revealed that variations in cut-off values to define frailty did not significantly affect the association with frailty and 30-day mortality rate. Frailty was associated with higher rates of major complications (OR 1.93, 95% c.i. 1.27 to 2.93) and discharge to an increased level of care. Frailty is significantly correlated with short- and long-term mortality rates following emergency laparotomy, as well as an adverse morbidity rate and functional outcomes. Identifying frailty using the Clinical Frailty Scale may aid in patient-centred decision-making and implementation of tailored care strategies for these 'high-risk' patients, with the aim of reducing adverse outcomes following emergency laparotomy.

Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study.

The OI was originally evaluated as a prognostic tool for acute hypoxemic respiratory failure in children and was an independent predictor for mortality in adult patients with acute respiratory distress syndrome (ARDS). Oxygenation index and OSI of 201 adult patients undergoing emergency surgery were evaluated at different time points. The primary objective of this study was to find the correlation between OI and OSI. The secondary objectives were to find the prognostic utility of OI and OSI for postoperative mechanical ventilation and mortality. Significant statistical correlation was found between OI and OSI both at the beginning (r 2 = 0.61; p < 0.001) and immediately after surgery (r 2 = 0.47; p < 0.001). Oxygen saturation index at the beginning [area under the receiver operating characteristics curve (AUROC) (95% CI) 0.76 (0.62-0.89); best cutoff 3.9, sensitivity 64% and specificity 45%] and immediately after surgery [AUROC (95% CI) 0.82 (0.72-0.92); best cutoff 3.57, sensitivity 79%, and specificity 62%] were reasonable predictors of the requirement of invasive ventilatory support. Exploratory analysis reported that older age (p = 0.02), higher total leukocyte count (p = 0.002), higher arterial lactate (p = 0.02), and higher driving pressure (p < 0.001) were independently associated with hospital mortality. In adult patients undergoing emergency laparotomy under general anesthesia, OI and OSI were found to be correlated. Both metrics demonstrated reasonable accuracy in predicting the need for invasive ventilatory support beyond 24 hours and hospital mortality. Thakuria R, Ernest EE, Chowdhury AR, Pangasa N, Kayina CA, Bhattacharjee S, et al. Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(7):645-649.

Assessing the impact of frailty in elderly patients undergoing emergency laparotomies in Singapore.

The global rise in ageing populations poses challenges for healthcare systems. By 2030, Singapore anticipates a quarter of its population to be aged 65 or older. This study addresses the dearth of research on frailty's impact on emergency laparotomy (EL) outcomes in this demographic, emphasising the growing significance of this surgical intervention. Conducted at 2 tertiary centres in Singapore from January to December 2019, a retrospective cohort study examined EL outcomes in patients aged 65 or older. Frailty assessment, using the Clinical Frailty Scale (CFS), was integrated into demographic, diagnostic and procedural analyses. Patient data from Tan Tock Seng Hospital and Khoo Teck Puat Hospital provided a comprehensive view of frailty's role in EL. Among 233 participants, 26% were frail, revealing a higher vulnerability in the geriatric population. Frail individuals exhibited elevated preoperative risk, prolonged ICU stays, and significantly higher 90-day mortality (21.3% versus 6.4%). The study illuminated a nuanced connection between frailty and adverse outcomes, underlining the critical need for robust predictive tools in this context. Frailty emerged as a pivotal factor influencing the postoperative trajectory of older adults undergoing EL in Singapore. The integration of frailty assessment, particularly when combined with established metrics like P-POSSUM, showcased enhanced predictive accuracy. This finding offers valuable insights for shared decision-making and acute surgical unit practices, emphasising the imperative of considering frailty in the management of older patients undergoing emergency laparotomy.

The value of frailty assessments in older surgical patients undergoing emergency laparotomies in Singapore

Mortality in emergency laparotomy (EL) far exceeds that of elective bowel surgery, and standards for the National Emergency Laparotomy Audit (NELA) in the UK were introduced due to the high mortality within 1 month of EL.1 In Singapore, 30-day mortality varies between 5.4% and 14.7% after EL.2,3 However, 30-day mortality in older patients has been reported to be as high as 31.5%.3