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Frailty in Older Patients Undergoing Emergency Laparotomy

Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study

Parmar, Kat L. BSc, MB ChB, MSc, PGCE, FRCSEng*; Law, Jennifer BMBS, BMedSci, MSc; Carter, Ben PhD, MSc; Hewitt, Jonathan MB BS, MSc, FRCPGlas, PhD§; Boyle, Jemma M. MB ChB, PGCE, MRCS; Casey, Patrick MB ChB, MRCS||; Maitra, Ishaan BSc (Hons), MB ChB, MRCS**; Farrell, Ian S. MB ChB, MPharm, MRCS††; Pearce, Lyndsay BMedSci, BMBS, FRCSEng‡‡; Moug, Susan J. BSc (Hons), MB ChB, PhD, FRCS§§ on behalf of the ELF Study Group

doi: 10.1097/SLA.0000000000003402
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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.

*Manchester Cancer Research Centre, Manchester, UK

University of Liverpool, Liverpool, UK

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK

§Department of Population Medicine, Cardiff University, Cardiff, UK

Royal College of Surgeons of England, London, UK

||Health Education North West, Manchester, UK

**North West Deanery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK

††Manchester Royal Infirmary, Manchester, UK

‡‡Department of Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK

§§Department of Surgery, Royal Alexandra Hospital, Paisley, Scotland, UK.

susanmoug@nhs.net.

Authors’ contributions: LP and SJM conceived and designed the study in addition to obtaining funding. KLP, JL, JH, JMB, PC, IM, ISF, JH, and SJM coordinated the trial. KLP, JL, BC, and SJM prepared the first draft of the manuscript and were responsible for the final manuscript. KLP, LP, JL, JMB, PC, IM, ISF, JH, and SJM developed the protocol. Local investigators at each site recruited patients. BC authored the statistical analysis plan and carried out the analysis. KLP, JL, BC, JH, LP, and SJM interpreted the data. All authors revised manuscript drafts, approved the final manuscript, and contributed intellectually important content. SJM is the guarantor of the paper and takes responsibility for the integrity of the work as a whole, from inception to published article.

This study received funding from the Bowel Disease Research Foundation (BDRF) (December 2017). The BDRF were not involved in study design, data collection/analysis or interpretation of the data. Furthermore, they did not participate in the writing of this work and were not involved of the decision to submit the article for publication. All researchers were independent from the BDRF.

The authors report no conflicts of interest.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. All declare funding from the Bowel Disease Research Foundation (BDRF).

Transparency declaration: The corresponding author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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