Emergency abdominal surgery is performed in every acute hospital in the United Kingdom, with the common aim to prevent death and minimize life-altering complications. The majority of these emergency laparotomies are performed on older adults (65 y and older) who, when compared with younger adults, have the highest postoperative mortality and morbidity, the highest utilization of intensive care resources, and subsequently, longer lengths of hospital stay.1–4 older adult population has a predisposition to more complex clinical needs than younger adults as a consequence of a higher prevalence of multimorbidity, cognitive impairment, polypharmacy, and frailty.5,6 older adult population undergoing emergency surgery with many widely used prognostic indicators and tools having been developed from younger, healthier, and often elective patient cohorts.7–15
Frailty is defined as an objective measure of increased vulnerability and decreased physiological reserve, resulting from the age-associated accumulation of physiological deficits in multiple systems.16 older adult admissions has been accompanied by interventions to modify frailty such as the Comprehensive Geriatric Assessment (CGA). The application of the CGA, that can include medical management, physiotherapy, nutrition, pharmacy, and occupational health, has led to improved patient survival and an ability to return to preadmission residence.17,18,19 20,21 22,23
The primary aims of the Emergency Laparotomy and Frailty (ELF) Study were to determine the prevalence and influence of frailty on 90-day mortality in older adults undergoing emergency laparotomy. The influence of frailty on postoperative outcomes, including 30-day mortality, morbidity, and length of hospital stay, was evaluated as secondary aims.
METHODS
From March 20 to June19, 2017, all older patients (defined as 65 y and older) undergoing emergency laparotomy at 49 registered sites across the United Kingdom were screened for inclusion into the ELF Study.13 www.nwresearch.org www.opsoc.eu
Ethical approval was obtained from National Health Service Research Ethics Committee (Black Country Research Committee: November 2016; 16/WM/0500). The study was registered centrally with the Health Research Authority (England), the NHS Research Scotland Permissions Co-coordinating Centre (Scotland), and the Health and Care Research Permissions Service (Wales). The ELF study was registered online at www.clinicaltrials.gov
Site Recruitment
Participation from sites across the United Kingdom was invited using a presentation at the National Research Collaborative meeting in 2016 (www.nationalresearch.org.uk
Patients
The full protocol was published in October 2017 according to STROBE Guidelines.24,25 www.nela.org.uk/criteria 1 https://links.lww.com/SLA/D28 26
Data Collection
Preoperatively, each older adult had the following recorded: age and sex; number of comorbidities (allowing calculation of Charlson Comorbidity Index, CCI)8,9 10 11,12
Postoperatively, each patient completed 90-day follow-up. For the first 30 postoperative days, mortality was also recorded in addition to postoperative complications; length of critical care stay (level 2 High Dependency Unit, HDU and level 3 Intensive Care Unit, ICU); overall length of hospital stay; and readmission to hospital.
Completed anonymous datasets were entered into a specifically designed online secure electronic database (REDCap, www.project-redcap.org www.nwstc.org.uk
Frailty Scoring
Each patient's surgical or nursing team assessed frailty preoperatively as part of standard care. The Clinical Frailty Score (CFS) developed by the Canadian Study of Health and Ageing (CSHA) was used (Supplemental Digital Content, Appendix 2, https://links.lww.com/SLA/D28 27 older adult population and is based on clinical judgment with a score of 1 to 4 being classified as nonfrail and 5 to 7 as frail. The CFS has been found to be a valid and reproducible score that is simple to understand and apply. OPSOC has used the CFS previously in the emergency surgical population to assess frailty.28
Data Completion and Validation
Regular emails to each registered site and Tweets were used to motivate data collection and update ELF Collaborators. To ensure accurate data collection, data validation was performed on 25% of data fields for 10% of cases at each site after study completion.
Statistical Analysis
Sample size justification from previous publication: to detect a 10% difference in 90-day postoperative mortality between frail and nonfrail patients (7.5% vs 17.5%), a sample size of 480 was required to maintain 80% power and 5% significance.28
The primary analysis was performed using a multilevel logistic regression of 90-day mortality by frailty, adjusted for age (65–74, and >75 y old) and sex. Each recruiting hospital was fitted as random effects to account for site variation. A secondary analysis of the primary outcome was carried out by presenting the crude odds ratio (OR) and adjusted OR (aOR), with associated 95% confidence intervals (Cis) and P values. Length of stay was analyzed with a zero-inflated negative binomial regression, and presented as the mean increased length of stay (in whole day integers) with associated 95% CI. We carried out an exploratory analysis to investigate the distribution of day 90 mortality, within age and frailty to determine if our findings could be explained in part by patient age. Statistical analyses were carried out using Stata 14 (StataCorp, www.stata.com
Patient and Public Involvement
There was no patient and public involvement in this study as it was an observational study in a novel research area.
RESULTS
Patients and Procedure
A total of 956 older adults undergoing emergency laparotomy were recruited to the study. Nineteen patients were excluded due to incomplete or incorrectly entered data, leaving 937 patients in the final analysis (Fig. 1 ).
FIGURE 1: ELF Study flow diagram.
Table 1 displays the preoperative patient characteristics by frailty score. Overall, frailty (CFS 5, 6, and 7) was present in 20% of older adults undergoing emergency surgery. The mean age of the patients was 76 years (SD 6.82; range 65–99) with over a third (38%) aged 80 or older. Eighty-nine percent of older adults had documented comorbidity; 54% polypharmacy, and the majority (83%) were admitted from home without carers. Two-thirds of patients (66%) were ASA 3 or more.
TABLE 1 -
Characteristics of Older Adults Undergoing Emergency Laparotomy, by Frailty Score
Clinical Frailty Score (CFS)
Very Fit
Well
Well, With Treated Comorbid Disease
Apparently Vulnerable
Mildly Frail
Moderately Frail
Severely Frail
Total (%) N = 937
1
2
3
4
5
6
7
55 (6%)
206 (22%)
287 (31%)
199 (21%)
126 (13%)
58 (6%)
6 (1%)
Country
England
37
142
191
143
84
37
3
637 (68)
Wales
10
31
34
14
18
10
117 (12)
Scotland
8
33
62
42
24
11
3
183 (19)
Age group, y
65–70
21
50
48
37
13
8
1
178 (19)
70–75
13
64
70
52
32
14
3
248 (26)
75–80
13
45
74
44
29
10
1
216 (23)
80–85
6
23
60
38
32
12
171 (18)
85–90
20
27
22
16
10
95 (10)
90+
2
4
8
6
4
4
1
29 (3)
Sex
Female
25
123
165
112
73
39
3
540 (57)
Male
30
83
122
87
53
19
3
397 (43)
Charlson Comorbidity Index
None
25
47
21
5
4
2
0
104 (11)
1–2 (mild)
7
48
101
54
32
16
1
259 (28)
3–4 (moderate)
21
102
123
92
48
22
4
412 (44)
≥5 (severe)
2
9
42
48
42
18
1
162 (17)
Polypharmacy
No
49
153
120
60
27
14
1
424 (45)
Yes
6
53
166
138
97
43
5
508 (54)
Missing
5 (1)
ASA I
17
11
3
31 (3)
ASA II
24
109
91
32
19
8
283 (30)
ASA Grade
ASA III
9
59
146
112
67
25
4
422 (45)
ASA IV
4
25
40
46
36
24
2
177 (19)
ASA V
1
2
6
8
4
1
22 (2)
Missing
1
1
2 (0)
Care level before admission
Home without carer
55
198
270
173
65
14
1
776 (83)
Home with carer
4
13
20
51
27
3
118 (13)
Residential home
3
1
4
3
6
17 (2)
Nursing home
1
1
3
7
1
13 (1)
Intermediate care
2
2 (0)
Other
3
1
4
2
1
11 (1)
The most common indication for surgery was intestinal obstruction (54%). The commonest surgical procedure performed was adhesiolysis (25%) with the majority of surgery performed by an open approach (87%) (Table 2 ). These findings are in keeping with the NELA 4th report.1
TABLE 2 -
Indication and Type of Surgical Procedure Performed on Older Adults Undergoing Emergency Laparotomy
90-d Mortality
Yes
No
Missing
N (%)
183 (20)
747 (80)
7 (1)
937 (100)
Indication for surgery
Intestinal obstruction
83
419
1
503 (54)
Perforation
47
107
2
156 (17)
Peritonitis
16
58
1
75 (8)
Ischemia
11
46
1
58 (6)
Other
7
38
1
46 (5)
Hemorrhage
7
16
23 (2)
Abdominal abscess
4
14
18 (2)
Anastomotic leak
2
13
15 (2)
Sepsis (other)
1
11
1
13 (1)
Intestinal fistula
1
8
9 (1)
Colitis
1
7
8 (1)
Abdominal wound dehiscence
1
3
4 (0)
Planned relook
1
1 (0)
Missing
2
6
8 (0)
Procedure performed ∗
Adhesiolysis
31
207
1
239 (25)
Small bowel resection
37
161
2
200 (21)
Stoma formation
39
119
158 (17)
Colectomy (right)
29
116
1
146 (16)
Hartmann's procedure
23
117
1
141 (15)
Colorectal resection (other)
13
48
2
63 (7)
Abdominal wall closure
11
46
57 (6)
Enterotomy
8
39
47 (5)
Peptic ulcer (suture or repair)
15
27
42 (4)
Drainage of abscess/collection
6
30
1
37 (4)
Colectomy (left)
8
25
1
34 (4)
Washout only
5
17
22 (2)
Gastric surgery
6
12
18 (2)
Repair of intestinal perforation
7
11
18 (2)
Laparostomy formation
7
8
15 (2)
Stoma revision
5
9
14 (1)
Intestinal bypass
2
11
13 (1)
Hemostasis
1
10
11 (1)
Reduction of volvulus
10
10 (1)
Peptic ulcer (oversew of bleed)
3
4
7 (1)
Surgical approach
Open
163
645
7
815 (87)
Lap converted to open
11
47
58 (6)
Laparoscopic
7
49
56 (6)
Laparoscopic assisted
6
6 (1)
Missing
2
2 (0)
∗ Total number of procedures exceeds 937 as some patients had more than one procedure performed at the same laparotomy.
Frailty and 90-day Postoperative Mortality
Overall, 90-day mortality for all patients was 19.5% (183/930). As the frailty score increased, the risk of 90-day mortality increased: patients scoring CFS 6 and 7 had the highest risk of 90-day mortality (OR 5·89, 95% CI, 2.19–15.86; P = 0·001) compared with patients scoring CFS 1 (Table 3 and Fig. 2 ). After accounting for patient age and sex, increasing frailty was still associated with increased risk of 90-day mortality: aOR for patients who were mildly frail (CFS 5) and moderately/severely frail (CFS 6/7) was 3.18 (95% CI, 1.24– 8.14; P = 0.016) and 6.10 (95% CI, 2.26–16.45; P < 0.001), respectively, compared with CFS 1 (very fit).
TABLE 3 -
Frailty and Primary and Secondary Outcomes in Older Adults Undergoing Emergency Laparotomy
Primary Outcome
90-d Mortality
Crude OR (95% CI)
P
aOR∗ (95% CI)
P
CFS compared with patients very fit
(Very fit)
Reference
Reference
Well
0.82 (0.31–2.17)
0.69
0.84 (0.32–2.22)
0.72
Well with treated disease
1.36 (0.54–3.40)
0.51
1.38 (0.55–3.46)
0.49
Vulnerable
3.12 (1.25–7.75)
0.014
3.15 (1.27–7.84)
0.014
Mildly frail
3.12 (1.24–7.99)
0.017
3.18 (1.24–8.14)
0.016
Moderately and severely frail
5.89 (2.19–15.86)
0.001
6.10 (2.26–16.45)
<0.001
Secondary outcomes
30-d Mortality
CFS compared with patients very fit
Well
1.99 (0.43–9.07)
0.38
2.05 (0.45–9.37)
0.36
Well with treated disease
3.08 (0.71–13.40)
0.13
3.11 (0.71–13.57)
0.13
Vulnerable
7.41 (1.72–31.99)
0.007
7.49 (1.73–32.40)
0.007
Mildly frail
9.67 (2.22–42.23)
0.003
9.79 (2.23–42.91)
0.002
Moderately and severely frail
10.04 (2.17–46.34)
0.003
10.40 (2.24–48.18)
0.003
Postoperative complications
CFS compared with patients very fit
Well
1.82 (0.91–3.63)
0.09
1.85 (0.92–3.71)
0.08
Well with treated disease
2.14 (1.09–4.21)
0.03
2.20 (1.11–4.34)
0.02
Vulnerable
3.95 (1.95–8.01)
<0.001
4.06 (1.99–8.22)
<0.001
Mildly frail
4.42 (2.11–9.24)
<0.001
4.56 (2.17–9.60)
0.001
Moderately and severely frail
3.78 (1.64–8.73)
0.002
3.92 (1.69–9.10)
0.001
HDU length of stay‡
CFS compared with patients very fit
Well
1.29 (0.69–2.42)
0.42
1.34 (0.71–2.51)
0.36
Well with treated disease
1.22 (0.66–2.24)
0.52
1.26 (0.68–2.32)
0.46
Vulnerable
0.94 (0.50–1.78)
0.85
0.97 (0.51–1.83)
0.92
Mildly frail
1.07 (0.54–2.09)
0.85
1.11 (0.56–2.19)
0.76
Moderately and severely frail
0.80 (0.36–1.79)
0.60
0.86 (0.38–1.93)
0.71
ICU length of stay‡
CFS compared with patients very fit
Well
1.45 (0.82–2.59)
0.21
1.50 (0.84–2.66)
0.17
Well with treated disease
1.79 (1.02–3.13)
0.04
1.89 (1.08–3.29)
0.03
Vulnerable
2.21 (1.24–3.95)
0.008
2.31 (1.30–4.11)
0.005
Mildly frail
2.11 (1.14–3.89)
0.02
2.15 (1.15–3.96)
0.02
Moderately and severely frail
4.00 (2.00–7.98)
<0.001
4.18 (2.11–8.03)
<0.001
Postoperative length of stay‡
CFS compared with patients very fit
Well
1.22 (0.95–1.58)
0.12
1.21 (0.94–1.56)
0.14
Well with treated disease
1.28 (1.00–1.63)
0.05
1.26 (0.99–1.63)
0.06
Vulnerable
1.49 (1.16–1.92)
0.002
1.48 (1.15–1.91)
0.002
Mildly frail
1.46 (1.11–1.91)
0.006
1.44 (1.10–1.89)
0.008
Moderately and severely frail
1.64 (1.21–2.23)
0.002
1.62 (1.19–2.20)
0.002
30-d readmission†
CFS compared with patients very fit
Well
0.76 (0.28–2.05)
0.58
0.76 (0.28–2.07)
0.59
Well with treated disease
1.11 (0.43–2.82)
0.83
1.25 (0.48–3.24)
0.64
Vulnerable
1.72 (0.70–4.42)
0.26
1.93 (0.74–5.04)
0.18
Mildly frail
1.01 (0.35–2.89)
0.98
1.16 (0.40–3.37)
0.78
Moderately and severely frail
1.08 (0.32–3.62)
0.91
1.22 (0.35–4.19)
0.75
The odds ratio of the chance of 90- and 30-day mortality, readmission, operative complications, and length of stay, comparing increasing frailty versus an older adult patient defined as very fit prior to emergency laparotomy.
∗ Adjusted by age (65–74 vs 75+) and sex (male, female).
† 185 cases removed, as were still in postoperative care at 30 days following surgery.
‡ Analyzed using a zero-inflated negative binomial regression, modeling the increased rate of length of stay in mean days, compared with those very fit.CFS indicates Clinical Frailty Score.
FIGURE 2: Scatterplot displaying the relationship between frailty and 90-day mortality in older adults undergoing emergency laparotomy.
Frailty and Secondary Outcomes
Overall, 30-day mortality for all patients was 14.6% (137/937) and a similar association with frailty was seen for 30-day mortality as for 90-day mortality: CFS 5 aOR 9.79 (95% CI, 2.23–42.91; P = 0.002) and for CFS 6/7 aOR 10.40 (95% CI, 2.24–48.18; P = 0.003) (Table 3 ). Increasing frailty score was associated with increased risk of postoperative complications: aOR for CFS 5 was 4.56 (95% CI, 2.17–9.60; P = 0.001) and 3.92 (95% CI, 0.35–4.19; P = 0·001) for CFS 6/7 compared with those older adults scoring CFS 1.
There was increased length of postoperative hospital stay and stay in ICU in frail patients (Table 3 ). For hospital stay: aOR for CFS 5 was 1.44 (95% CI, 1.10–1.89; P = 0·008) and 1.62 (1.19–2.20; P = 0.002) for CFS 6/7compared with adults scoring CFS 1. For ICU length of stay: CFS 5 aOR of 2.15 (95% CI, 1.15–3.96; P = 0·02) and CFS 6/7 aOR 4.18 (95% CI, 2.11–8.03; P < 0.001) compared with CFS 1. Frail patients stayed in ICU for 2 days (IQR 1–4) versus 1 day (IQR 0–3) for nonfrail. There was no association with frailty to the length of time in HDU or to 30-day readmission.
Frailty, by Age Mortality Distribution
Tables 4 and 5 show that frailty is distributed throughout the range of ages and not restricted to the very old age patient groups (85+). Observation of this distribution shows that patients with a higher frailty score had a higher mortality rate. The marginal 90-day mortality rates were increased from 11.1% to 50% for CFS of 1 to 7 and the marginal mortality rate for increased patient age was 15.9% to 25.3% for patients aged 65 to 70, compared with those aged 85 to 90 (Table 4 ). Similar results were found for the 30-day mortality showing that frailty results in a wider distribution of predicted mortality than age (Table 5 ). In addition, when compared with P-POSSUM, it can be seen that frailty stratifies the older adult into a greater number of prognostic groups and also allows risk-prediction of 30-day morbidity through the range of scoring, whereas P-POSSUM does not (Table 6 ).
TABLE 4 -
The Distribution of 90-day Mortality Within Frailty by Age in Older Adults Undergoing Emergency Laparotomy
Clinical Frailty Score (CFS)
Very Fit
Well
Well, With Treated Comorbid Disease
Apparently Vulnerable
Mildly Frail
Moderately Frail
Severely Frail
Total∗
1
2
3
4
5
6
7
Age group
65–70
9.5 (2/21)
8.0 (4/50)
17.0 (8/47)
22.2 (8/36)
7.7 (1/13)
50.0 (4/8)
100 (1/1)
15.9 (28/176)
70–75
25.0 (3/12)
7.8 (5/64)
17.6 (12/68)
25.0 (13/52)
34.4 (11/32)
35.7 (5/14)
33.3 (1/3)
20.4 (50/245)
75–80
7.7 (1/13)
8.9 (4/45)
12.2 (9/74)
27.3 (12/44)
31.0 (9/29)
50.0 (5/10)
100 (1/1)
19.0 (41/216)
80–85
0 (0/6)
8.7 (2/23)
13.6 (8/59)
28.9 (11/38)
22.6 (7/31)
50.0 (6/12)
20.1 (34/169)
85–90
15.0 (3/20)
11.1 (3/27)
40.9 (9/22)
37.5 (6/16)
30.0 (3/10)
25.3 (24/95)
90+
0 (0/2)
25.0 (1/4)
12.5 (1/8)
33.3 (2/6)
25.0 (1/4)
25.0 (1/4)
0 (0/1)
20.7 (6/29)
Subtotal†
11.1 (6/54)
9.2 (19/206)
14.5 (41/283)
27.8 (55/198)
27.8 (35/125)
41.4 (24/58)
50.0 (3/6)
19.5 (183/930)
∗ Note that 7 patients’ 90-day mortality was not recorded.
† The mortality percentage is presented followed by (deaths/total included participants).
TABLE 5 -
The Distribution of 30-day Mortality Within Frailty by Age in Older Adults Undergoing Emergency Laparotomy
Clinical Frailty Score (CFS)
Very Fit
Well
Well, With Treated Comorbid Disease
Apparently Vulnerable
Mildly Frail
Moderately Frail
Severely Frail
Total
1
2
3
4
5
6
7
Age Group
65–70
4.7 (1/21)
8.0 (4/50)
12.5 (6/48)
16.2 (6/37)
100 (1/1)
37.5 (3/8)
100 (1/1)
12.4 (22/178)
70–75
7.7 (1/13)
7.8 (5/64)
8.6 (6/70)
17.3 (9/52)
31.3 (10/32)
21.4 (3/14)
0 (0/3)
13.7 (34/248)
75–80
0 (0/13)
4.4 (2/45)
9.5 (7/74)
25.0 (11/44)
24.1 (7/29)
30.0 (3/10)
0 (0/1)
13.9 (30/216)
80–85
0 (0/6)
4.3 (1/23)
13.3 (8/60)
18.4 (7/38)
28.1 (9/32)
41.7 (5/12)
17.5 (30/171)
85–90
10.0 (2/20)
7.4 (2/27)
31.8 (7/22)
31.3 (5/16)
20.0 (2/10)
18.9 (18/95)
90+
0 (0/2)
0 (0/4)
0 (0/8)
33.3 (2/6)
25.0 (1/4)
0 (0/4)
0 (0/1)
10.3 (3/29)
Subtotal∗
3.6 (2/55)
6.7 (14/206)
10.1 (29/287)
21.1 (42/199)
26.2 (33/126)
27.6 (16/58)
16.7 (1/6)
14.6 (137/937)
∗ The mortality percentage is presented followed by (deaths/total included participants).
TABLE 6 -
Comparison of Frailty Status to P-Possum by Actual 30-day Mortality and Morbidity
Actual 30-d Mortality
Actual 30-d Morbidity
Total %
Total %
Clinical Frailty Score (CFS)∗
1
Very fit
3.6
31.5
2
Well
6.8
40.6
3
Well, with treated comorbid disease
10.1
49.1
4
Apparently vulnerable
21.1
57.6
5
Mildly frail
26.2
61.3
6
Moderately frail
27.6
63.2
7
Severely frail
16.7
16.7
P-Possum†
Predicted %
<5%
5.6
38.8
5%–10%
12.6
50.0
10%–20%
12.9
53.9
20%–50%
23.1
58.9
≥50%
38.1
69.8
† Six cases were missing P-POSSUM scores.
∗ CFS 6 and 7 are presented separately in this table—previous analyses have combined these 2 groups.
DISCUSSION
This study is the first to prospectively document the prevalence of frailty in older adults undergoing emergency laparotomy. Frailty was present in a fifth of patients preoperatively placing them at significantly greater risk of 30- and 90-day mortality. In addition, as the frailty score increased, so did the risk of postoperative complications, and the length of stay in intensive care and in hospital overall. With frailty found to be independent of age, this work supports integration of frailty scoring to all older adults admitted as a surgical emergency to guide perioperative strategies for this high-risk complex population.
There are several strengths to this work. First, it focused solely on a large population of older patients undergoing emergency laparotomy improving understanding of this overlooked group that carry the highest risk for postoperative death. Second, the data were collected prospectively and was multicentered minimizing geographical bias that could occur with local or regional studies. Third, validation of a proportion of each site's data optimized data completion. Finally, the CFS seems to be a simple tool to use with only a small percentage of frailty scores not entered despite the substantial overrecruitment.
The authors cannot exclude selection bias where a local recruiter may have not contributed a consecutive series of older patients undergoing emergency laparotomy. This is likely to reflect the pragmatic nature of this work. In addition, only a small proportion of patients undergoing surgery had the highest frailty score (CFS 7), perhaps as a consequence of being unfit for surgery. To overcome this, CFS 6 was combined with CFS 7 for statistical analysis where appropriate.
Previous work in the emergency surgical setting has found frailty to be associated with a greater risk of mortality and longer hospital stays.28,29,30,31 older adult patients and/ or small patient numbers. In a recently published prospective multicentered UK study (n = 2279) assessing all patients admitted to an acute surgical unit, frailty was found to exist in all age groups and was not exclusive to the older adult population.32
Clinicians have long been interested in prognostic scores resulting in many being available. All have their limitations in the older adult emergency laparotomy setting, including predicting mortality only (APACHE II, ASA); multiple variables making calculation labor intensive (APACHE II); not validated in older adult populations (Charlson, ASA); being based on diagnosed comorbidity with no attempt to differentiate well-controlled morbidity from severe functionally limiting morbidity (Charlson); or requiring intraoperative details to complete score (P-POSSUM).7–12 1,15 older adult surgical populations, and can be determined preoperatively.
Implications for Clinicians and Policymakers
Frailty scoring should be performed preoperatively on all older adults undergoing an emergency laparotomy to aid with the complex decision-making and perioperative care. Few of the already established prognostic scores are easy for the patient and their family to understand, which is potentially detrimental to shared decision-making.33,34
Once the decision for surgery is made, the frailty score could lead targeted perioperative pathways. For example, patients with CFS 4 to 7 have the highest risk of mortality where early involvement and assessment by critical care would optimize postoperative planning. Treatment over the first few days postoperatively is focused on continuing treatment for the initial pathology (eg, sepsis, renal support, ventilator support, wound management) led by critical care and surgeons. This could be improved by working alongside geriatricians and the CGA with the key aim of minimizing any complications from frailty,1,6,15,35 6,36
CONCLUSIONS
Frailty is present in 20% of older adults undergoing emergency laparotomy and is independent of age. As frailty increases, the older adult is at greater risk of postoperative mortality and morbidity. These findings support the integration of preoperative frailty assessment and identify the urgent need to develop novel postoperative strategies to improve outcomes for this complex high-risk group of health service users.
ACKNOWLEDGMENTS
The authors gratefully acknowledge support from the North West Surgical Trials Centre (www.nwstc.org.uk
THE ELF STUDY GROUP:
Addenbrooke's Hospital: Bryony Ross, Julia Oleksiewicz, Nicola Fearnhead.
Blackpool Victoria Hospital: Christopher Jump, Jemma Boyle, Alex Shaw, Jonathan Barker.
Bristol Royal Infirmary: Jane Hughes, Jonathan Randall, Isileli Tonga, James Kynaston, Matthew Boal.
Countess of Chester Hospital: Nicola Eardley, Elizabeth Kane, Harriet Reader, Sunanda Roy Mahapatra, Michael Garner-Jones.
Croydon University Hospital: Jessica Juliana Tan, Said Mohamed.
Doncaster Royal Infirmary: Rina George, Ed Whiteman.
East Cheshire NHS Trust: Kamran Malik, Christopher J. Smart, Monica Bogdan.
East Lancashire Hospitals (Blackburn): Madhu Parna Chaudhury, Videha Sharma, Daren Subar.
Furness General Hospital (Barrow): Panna Patel, Sok-Moi Chok, Evelyn Lim.
Glan Clywd Hospital: Vedamurthy Adhiyaman, Glesni Davies.
Glasgow Royal Infirmary: Ellen Ross, Rudra Maitra, Colin W. Steele, Campbell Roxburgh.
Gloucestershire Royal Hospital: Shelly Griffiths, Natalie S. Blencowe, Emily N. Kirkham.
Lorn and Islands Hospital (Oban): John S. Abraham, Kirsty Griffiths.
Maidstone and Tunbridge Wells NHS Trust: Yasser Abdulaal, Muhammad Rafaih Iqbal, Munir Tarazi.
Manchester Royal Infirmary: James Hill, Azam Khan, Ian Farrell.
Mid Essex/Broomfield: Gemma Conn, Jugal Patel, Hyder Reddy.
Mid Yorkshire NHS Hospitals: Janahan Sarveswaran, Lakshmanan Arunachalam, Afaq Malik.
Milton Keynes University Hospital NHS Foundation Trust: Luca Ponchietti, Krystian Pawelec, Yan Mei Goh, Parveen Vitish-Sharma, Ahmed Saad.
Musgrove Park (Taunton): Edward Smyth, Amy Crees, Louise Merker, Nahida Bashir.
Newport: Gethin Williams, Jennifer Hayes, Kelly Walters, Rhiannon Harries, Rahulpreet Singh.
Ninewells Hospital (Dundee): Nikola A. Henderson, Francesco M. Polignano.
Queen Alexandra Hospital (Portsmouth): Ben Knight, Louise Alder, Alexandra Kenchington.
Queen Elizabeth Hospital (Birmingham): Yan Li Goh, Ilaria Dicurzio, Ewen Griffiths.
Queen Elizabeth University Hospital (Glasgow): Ahmed Alani, Katrina Knight, Patrick MacGoey, Guat Shi Ng.
Royal Albert Edward Infirmary (Wigan): Naomi Mackenzie, Ishaan Maitra.
Royal Alexandra Hospital (Paisley): Susan Moug, Kelly Ong.
Royal Berkshire Hospital (Reading): Daniel McGrath, Emanuele Gammeri, Guillame Lafaurie.
Royal Bolton Hospital: Gemma Faulkner, Gabriele Di Benedetto, Julia McGovern, Bharathi Subramanian.
Royal Devon and Exeter Hospital NHS: Sunil Kumar Narang, Jennifer Nowers, Neil J. Smart, Ian R. Daniels.
Royal Free Hospital (Hampstead site): Massimo Varcada, Tanzeela Gala.
Royal Glamorgan Hospital: Julie Cornish, Zoe Barber.
Royal Infirmary of Edinburgh: Stephen O’Neill, Richard McGregor, Andrew G. Robertson, Simon Paterson-Brown.
Royal Lancaster Infirmary: Thomas Raymond.
Royal London Hospital: Mohamed A. Thaha, William J. English, Cillian T. Forde, Heidi Paine, Alpa Morawala.
Royal Preston Hospital: Ravindra Date, Patrick Casey, Thomas Bolton, Xuan Gleaves, Joshua Fasuyi.
Royal Surrey County Hospital, Guildford: Sanja Durakovic, Matt Dunstan, Sophie Allen, Angela Riga.
Salford Royal NHS Foundation Trust: Jonathan Epstein, Lyndsay Pearce, Emily Gaines, Anthony Howe, Halima Choonara.
Southmead (North Bristol): Ffion Dewi, Joanne Bennett, Emile King, Kathryn McCarthy.
Swansea: Greg Taylor, Dean Harris, Hari Nageswaran, Amy Stimpson.
Tameside Hospital: Kamran Siddiqui, Lay In Lim.
University Hospital Crosshouse, Kilmarnock: Christopher Ray, Laura Smith, Gillian McColl.
University Hospital of South Manchester: Mohammed Rahman, Aaron Kler, Abhi Sharma, Kat Parmar.
University Hospital of Wales (Cardiff): Neil Patel, Perry Crofts, Claudio Baldari, Rhys Thomas, Michael Stechman.
Western General Hospital (Edinburgh): Roland Aldridge, James O’Kelly, Graeme Wilson.
Weston General Hospital: Nicholas Gallegos.
Whiston: Ramya Kalaiselvan, Rajasundaram Rajaganeshan.
William Harvey Hospital (East Kent): Aliya Mackenzie, Prashant Naik, Kaushiki Singh, Harinath Gandraspulli.
Wirral University Teaching Hospital: Jeremy Wilson, Kate Hancorn, Amir Khawaja, Felix Nicholas, Thomas Marks.
Wrexham: Cameron Abbott, Susan Chandler.
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