Influence of frailty in older patients undergoing emergency laparotomy: a UK-based observational study

Impact of clinical frailty on surgical and non-surgical complications after major emergency abdominal surgery

BACKGROUND

Major emergency abdominal surgery is associated with a high risk of morbidity and mortality. Given the ageing and increasingly frail population, understanding the impact of frailty on complication patterns after surgery is crucial. The aim of this study was to evaluate the association between clinical frailty and organ-specific postoperative complications after major emergency abdominal surgery.

METHODS

A prospective cohort study including all patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev, Denmark, from 1 October 2020 to 1 August 2022, was performed. Clinical frailty scale scores were determined for all patients upon admission and patients were then analysed according to clinical frailty scale groups (scores of 1-3, 4-6, or 7-9). Postoperative complications were registered until discharge.

RESULTS

A total of 520 patients were identified. Patients with a low clinical frailty scale score (1-3) experienced fewer total complications (120 complications per 100 patients) compared with patients with clinical frailty scale scores of 4-6 (250 complications per 100 patients) and 7-9 (277 complications per 100 patients) (P < 0.001). A high clinical frailty scale score was associated with a high risk of pneumonia (P = 0.009), delirium (P < 0.001), atrial fibrillation (P = 0.020), and infectious complications in general (P < 0.001). Patients with severe frailty (clinical frailty scale score of 7-9) suffered from more surgical complications (P = 0.001) compared with the rest of the cohort. Severe frailty was associated with a high risk of 30-day mortality (33% for patients with a clinical frailty scale score of 7-9 versus 3.6% for patients with a clinical frailty scale score of 1-3, P < 0.001). In a multivariate analysis, an increasing degree of clinical frailty was found to be significantly associated with developing at least one complication.

CONCLUSION

Patients with frailty have a significantly increased risk of postoperative complications after major emergency abdominal surgery, especially atrial fibrillation, delirium, and pneumonia. Likewise, patients with frailty have an increased risk of mortality within 90 days. Thus, frailty is a significant predictor for adverse events after major emergency abdominal surgery and should be considered in all patients undergoing major emergency abdominal surgery.

Longitudinal characterisation of cachexia in patients undergoing surgical resection for cancer

PURPOSE OF REVIEW

The complexity of the cancer cachexia phenotype has undoubtedly hindered researchers' understanding of this devastating syndrome. The presence and magnitude of host-tumour interactions are rarely considered during clinical decision-making within the current staging paradigm. Furthermore, treatment options for those patients who are identified as suffering from cancer cachexia remain extremely limited.

RECENT FINDINGS

Previous attempts to characterise cachexia have largely focussed on individual surrogate disease markers, often studied across a limited timeframe. While the adverse prognostic value of clinical and biochemical features is evident, the relationships between these are less clear. Investigation of patients with earlier-stage disease could allow researchers to identify markers of cachexia that precede the refractory stage of the wasting process. Appreciation of the cachectic phenotype within 'curative' populations may aid our understanding of the syndrome's genesis and provide potential routes for prevention, rather than treatment.

SUMMARY

Holistic, longitudinal characterisation of cancer cachexia, across all at-risk and affected populations, is of vital importance for future research in the field. This paper presents the protocol for an observational study aiming to create a robust and holistic characterisation of surgical patients with, or at risk of, cancer cachexia.

The risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury: a meta-analysis and meta-regression analysis

AIM

To determine the risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury.

METHODS

We performed a systematic review and meta-analysis in compliance with PRISMA statement standards (Registration Number: CRD42022328834). A search of electronic information sources was conducted to identify all studies reporting the risk of hepatic pseudoaneurysm after liver trauma. The JBI assessment tool was used to assess the risk of bias of the included studies. Random-effects models were applied to calculate pooled outcome data.

RESULTS

A total of 2030 patients from six studies were included. Based on the American Association for the Surgery of Trauma classification system, 21% had grade I injury; 33% grade II injury; 28% grade III injury; 12% grade IV injury and 5% grade V injury. The pooled risk of hepatic pseudoaneurysm was 1.8% (95% CI 1.1-2.5%). The risk was 0.4% (0-1.2%) in patients with grade I injury, 0.7% (0-1.7%) in patients with grade II injury; 1.5% (0.4-2.7%) in patients with grade III injury; 4.6% (1.4-7.7%) in patients with grade IV injury and 10.6% (1.8-22.9%) in patients with grade V injury. The average time between liver injury and detection of hepatic pseudoaneurysm was 6 days (95% CI 1-10) CONCLUSIONS: The risk of hepatic pseudoaneurysm after liver trauma increases as the severity of liver injury increases. Hepatic pseudoaneurysms are rare after grade I or grade II injuries, and increasingly common after grades III, IV and V injuries. We recommend routine surveillance imaging in patients with grade III to V injuries.

Postoperative Complications and Outcome After Emergency Laparotomy: A Retrospective Study

BACKGROUND

Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL.

METHODS

This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications.

RESULTS

A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications.

CONCLUSIONS

This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.

Frailty and emergency abdominal surgery: A systematic review and meta-analysis

INTRODUCTION

Patients aged ≥65 years currently account for approximately 55% of all emergent operations. However, these patients account for 75% of post-operative mortality. Older age has long been associated with adverse outcomes from emergency surgery. However, old age is a heterogenous state. Recent studies have indicated that frailty may more accurately reflect true biological age and perioperative risk than chronological age alone in patients undergoing elective surgery. Few studies have evaluated the impact of frailty on post-operative outcomes in this setting.

METHODS

A systematic, electronic search for relevant publications was performed in November 2019 using Pubmed and Embase from 2009 to 2019. The latest search for articles was performed on February 16th, 2020. Articles were excluded if frailty was not measured using a frailty tool, or if patients did not undergo emergency general surgery (EGS).

RESULTS

The prevalence of frailty amongst patients undergoing emergency abdominal surgery was 30.8%. The all-cause mortality rate was 15.68%. The mortality rate amongst the frail undergoing EGS was 24.7%. Frailty was associated with an increased mortality rate compared with the non-frail (odds ratio (OR) 4.3, 95% CI 2.25-8.19%, p < 0.05, I² = 80%).

CONCLUSIONS

There is strong evidence to suggest that frailty in the older population predicts post-operative mortality, complications, prolonged length of stay and the loss of independence. Collaborative working with medicine for the elderly physicians to target modifiable aspects of the frailty syndrome in the perioperative pathway may improve outcomes. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

External Prospective Validation of the Modified CriSTAL Score for 30- and 90-day Mortality in Geriatric Urgent Surgical Patients

OBJECTIVE

This study aimed to determine the predictive accuracy of the modified clinical prognostic tool Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) to predict 30-day and 90-day mortality in older patients undergoing urgent abdominal surgery.

BACKGROUND

Anticipating the mid-term mortality of older patients undergoing urgent surgery is complex and flawed with uncertainty.

METHODS

A prospective study of consecutive ≥ 65 years old presenting at the emergency department who subsequently underwent urgent abdominal surgery. The modified CriSTAL score was calculated in the sample using the FRAIL scale instead of the Clinical Frailty Scale. Discrimination (area under the receiver-operating characteristic (AUROC)) and model calibration were used to test the predictive accuracy of the modified CriSTAL score for death within 30-day mortality as the primary outcome.

RESULTS

A total of 500 patients (median age 78 years) were enrolled. The observed 30-day and 90-day mortality rate were 11.6% and 13.6%. The modified CriSTAL tool AUROC curve to predict 30-day and 90-day mortality was 0.78 and 0.77. The model was well calibrated according to the Hosmer-Lemeshow test (p: 0.302) and the calibration plots to predict 30-day and 90-day mortality.

CONCLUSIONS

The modified CriSTAL tool (with FRAIL scale as frailty instrument) had good discriminant power and was well calibrated to predict 30-day and 90-day mortality in elderly patients undergoing urgent abdominal surgery. The modified CriSTAL tool is an easy preoperative tool that could assist in the prognosis of postoperative outcomes and decision-making discussions with patients before for urgent abdominal surgery.

The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: a multicentre retrospective cohort study

OBJECTIVES

This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy.

METHODS

In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan-Meier survival statistics.

RESULTS

A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82-3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50-2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07-2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36-3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011).

CONCLUSIONS

Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.

Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study

OBJECTIVE

This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality.

SUMMARY BACKGROUND DATA

The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions.

METHODS

An observational multicenter (n=49) UK study was performed (March-June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5-7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay.

RESULTS

A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24-8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26-16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay.

CONCLUSIONS

A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

Causes of death after emergency general surgical admission: population cohort study of mortality

Background

A substantial number of patients treated in emergency general surgery (EGS) services die within a year of discharge. The aim of this study was to analyse causes of death and their relationship to discharge diagnoses, in patients who died within 1 year of discharge from an EGS service in Scotland.

Methods

This was a population cohort study of all patients with an EGS admission in Scotland, UK, in the year before death. Patients admitted to EGS services between January 2008 and December 2017 were included. Data regarding patient admissions were obtained from the Information Services Division in Scotland, and cross-referenced to death certificate data, obtained from the National Records of Scotland.

Results

Of 507 308 patients admitted to EGS services, 7917 died while in hospital, and 52 094 within 1 year of discharge. For the latter, the median survival time was 67 (i.q.r. 21–168) days after EGS discharge. Malignancy accounted for 48 per cent of deaths and was the predominant cause of death in patients aged over 35 years. The cause of death was directly related to the discharge diagnosis in 56.5 per cent of patients. Symptom-based discharge diagnoses were often associated with a malignancy not diagnosed on admission.

Conclusion

When analysed by subsequent cause of death, EGS is a cancer-based specialty. Adequate follow-up and close links with oncology and palliative care services merit development.

Safety of Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly: A Multivariate Analysis of Risk Factors for Intra and Postoperative Complications

Background and Objectives: This study investigates the impact of age upon the safety and outcomes of laparoscopic cholecystectomy performed for acute cholecystitis, by a multivariate approach. Materials and Methods: A 2-year retrospective study was performed on 333 patients admitted for acute cholecystitis who underwent emergency cholecystectomy. The patients included in the study group were divided into four age subgroups: A ≤49 years; B: 50-64 years; C: 65-79 years; D ≥80 years. Results: Surgery after 72 h from onset (p = 0.007), severe forms, and higher American Society of Anesthesiologists Physical Status Classification and Charlson comorbidity index scores (p < 0.001) are well correlated with older age. Both cardiovascular and surgical related complications were significantly higher in patients over 50 years (p = 0.045), which also proved to be a turning point for increasing the rate of conversion and open surgery. However, the comparative incidence did not differ significantly between patients aged from 50-64 years, 65-79 years and over 80 years (6.03%, 9.09% and 5.8%, respectively). Laparoscopic cholecystectomy (LC) was the most frequently used surgical approach in the treatment of acute cholecystitis in all age groups, with better outcomes than open cholecystectomy in terms of decreased overall and postoperative hospital stay, reduced surgery related complications, and the incidence of acute cardiovascular events in the early postoperative period (p < 0.001). Conclusions: The degree of systemic inflammation was the main factor that influenced the adverse outcome of LC in the elderly. Among comorbidities, diabetes was associated with increased surgical and systemic postoperative morbidity, while stroke and chronic renal insufficiency were correlated with a high risk of cardiovascular complications. With adequate perioperative care, the elderly has much to gain from the benefits of a minimally invasive approach, which allows a decreased rate of postoperative complications and a reduced hospital stay.

Meta-analysis of mortality risk in octogenarians undergoing emergency general surgery operations

BACKGROUND

This study aimed to quantify the risk of perioperative mortality in octogenarians undergoing emergency general surgical operations and to compare such risk between octogenarians and nonoctogenarians.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards to identify studies reporting the mortality risk in patients aged over 80 years undergoing emergency general surgery operations. The primary outcome measure was 30-day mortality, which was stratified based on American Society of Anesthesiologists (ASA) status and procedure type. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Random-effects models were applied to calculate pooled outcome data.

RESULTS

Analysis of 66,701 octogenarians from 22 studies showed that the risk of 30-day mortality was 26% (95% confidence interval 18%-34%) for all operations: 29% (95% confidence interval 25%-33%) for emergency laparotomy; 9% (95% confidence interval 1%-23%) for nonlaparotomy emergency operations; 21% (95% confidence interval 13%-30%) for colon resection; 17% (95% confidence interval 11%-25%) for small bowel resection; 9% (95% confidence interval 7%-11%) for adhesiolysis; 6% (95% confidence interval 5.9%-6.8%) for perforated ulcer repair; 3% (95% confidence interval 2.6%-4%) for appendicectomy; 3% (95% confidence interval 2.8%-3.3%) for cholecystectomy; and 5% (95% confidence interval 0.2%-14%) for hernia repair. When stratified based on the patient's ASA status, the risk was 11% (95% confidence interval 4%-20%) for ASA 2 status, 22% (95% confidence interval 10%-36%) for ASA 3 status, 39% (95% confidence interval 29%-48%) for ASA 4 status, and 94% (95% confidence interval 77%-100%) for ASA 5 status. The risk was higher in octogenarians compared with nonoctogenarians (odds ratio: 4.07, 95% confidence interval 2.40-6.89), patients aged 70 to 79 (odds ratio: 1.21, 95% confidence interval 1.13-1.31), and patients aged 50 to 79 (odds ratio: 2.03, 95% confidence interval 1.68-2.45).

CONCLUSION

The risk of perioperative mortality in octogenarians undergoing emergency general surgical operations is high. The risk of perioperative death in this group is higher than in younger patients. Laparotomy, bowel resection, and ASA status above 3 carry the highest risk.

Evaluating and improving current risk prediction tools in emergency laparotomy

PURPOSE

Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL.

METHODOLOGY

We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools.

RESULTS

A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively).

CONCLUSION

We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool.

LEVEL OF EVIDENCE

Level IV; Retrospective observational cohort study.

The influence of social media on recruitment to surgical trials

BACKGROUND

Social media has changed the way surgeons communicate worldwide, particularly in dissemination of trial results. However, it is unclear if social media could be used in recruitment to surgical trials. This study aimed to investigate the influence of Twitter in promoting surgical recruitment in The Emergency Laparotomy and Frailty (ELF) Study.

METHODS

The ELF Study was a UK-based, prospective, observational cohort that aimed to assess the influence of frailty on 90-day mortality in older adults undergoing emergency surgery. A power calculation required 500 patients to be recruited to detect a 10% change in mortality associated with frailty. A 12-week recruitment period was selected, calculated from information submitted by participating hospitals and the numbers of emergency surgeries performed in adults aged > 65 years. A Twitter handle was designed (@ELFStudy) with eye-catching logos to encourage enrolment and inform the public and clinicians involved in the study. Twitter Analytics and Twitonomy (Digonomy Pty Ltd) were used to analyse user engagement in relation to patient recruitment.

RESULTS

After 90 days of data collection, 49 sites from Scotland, England and Wales recruited 952 consecutive patients undergoing emergency laparotomy, with data logged into a database created on REDCap. Target recruitment (n = 500) was achieved by week 11. A total of 591 tweets were published by @ELFStudy since its conception, making 218,136 impressions at time of writing. The number of impressions (number of times users see a particular tweet) prior to March 20th 2017 (study commencement date) was 23,335 (343.2 per tweet), compared to the recruitment period with 114,314 impressions (256.3 per tweet), ending June 20th 2017. Each additional tweet was associated with an increase in recruitment of 1.66 (95%CI 1.36 to 1.97; p < 0.001).

CONCLUSION

The ELF Study over-recruited by nearly 100%, reaching over 200,000 people across the U.K. Branding enhanced tweet aesthetics and helped increase tweet engagement to stimulate discussion and healthy competition amongst clinicians to aid trial recruitment. Other studies may draw from the social media experiences of the ELF Study to optimise collaboration amongst researchers.

TRIAL REGISTRATION

This study is registered online at www.clinicaltrials.gov (registration number NCT02952430 ) and has been approved by the National Health Service Research Ethics Committee.

Early Postoperative Death in Patients Undergoing Emergency High-Risk Surgery: Towards a Better Understanding of Patients for Whom Surgery May Not Be Beneficial

The timing, causes, and quality of care for patients who die after emergency laparotomy have not been extensively reported. A large database of 13,953 patients undergoing emergency laparotomy, between July 2014 and March 2017, from 28 hospitals in England was studied. Anonymized data was extracted on day of death, patient demographics, operative details, compliance with standards of care, and 30-day and in-patient mortality. Thirty-day mortality was 8.9%, and overall inpatient mortality was 9.8%. Almost 40% of postoperative deaths occurred within three days of surgery, and 70% of these early deaths occurred on the day of surgery or the first postoperative day. Such early deaths could be considered nonbeneficial surgery. Patients who died within three days of surgery had a significantly higher preoperative lactate, American Society of Anesthesiologists Physical Status (ASA-PS) grade, and Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM). Compliance with perioperative standards of care based on the Emergency Laparotomy Collaborative care bundle was high overall and better for those patients who died within three days of surgery. Multidisciplinary team involvement from intensive care, care of the elderly physicians, and palliative care may help both the communication and the burden of responsibility in deciding on the risk–benefit of operative versus nonoperative approaches to care.

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

The North East Multispecialty Delphi Project - Collaboration Between Trainee Research Networks

Trainee research collaborative networks have revolutionized how trainees participate in clinical research. Three North East of England trainee-led research groups, the Intensive Care and Anesthesia Research Network of North East Trainees (INCARNNET), the Northern Surgical Trainees Research Association (NOSTRA) in General Surgery and the Collaborative Orthopedic Research Network (CORNET) in Trauma and Orthopedics have joined, creating a multispecialty collaborative. This multispecialty collaborative undertook a two-phase research Delphi, between November 2017 and June 2018, to identify key research questions. This Delphi identified three high priority research questions common to the three specialties: what is the impact of diabetes control on perioperative outcomes, what factors affect theater efficiency, and how to prevent postoperative chest infection following emergency surgery? These research questions will be developed into collaborative projects. The Delphi also identified specialty-specific questions to be taken forward as research projects by each network.

Emergency laparotomy research methodology: A systematic review

BACKGROUND

Emergency abdominal surgery is associated with poorer clinical outcomes than similar procedures in the elective setting. Research into emergency laparotomy (EL) care is moving from observational studies which simply measure EL outcomes to interventional research evaluating the implementation of care strategies designed to improve the quality and outcomes from EL care. There is no consensus as to the optimal approach to conducting research in this sphere. The primary objective of this review was to examine how mortality and other outcome measures were reported in previous EL research and to identify what might be the most appropriate methods in future outcome research.

METHODS

A systematic review was performed in accordance with the PRISMA principles. Electronic databases were interrogated with a pre-specified search strategy to identify English language studies addressing outcomes from EL care. Retrieved papers were screened and assessed according to pre-defined eligibility criteria. The mortality and other outcomes reported in each paper were extracted and examined.

RESULTS

16 studies were included. They demonstrated significant heterogeneity in case definition, outcome reporting and data processing. A wide range of mortality and other outcome measures were applied and reported. Only few studies included on patient-reported outcomes measures.

CONCLUSION

The heterogeneity in EL research, demonstrated by this review must be considered when EL outcomes are compared. A standardized approach with respect to case definition, outcome measurement, and data analysis would provide for more valid and comparable evaluation of EL outcomes. Future EL research should include more patient centred outcomes.