Impact of Frailty on Outcomes Following Emergency Laparotomy: A Retrospective Analysis Across Diverse Clinical Conditions

Impact of Frailty on Outcomes Following Emergency Laparotomy: A Retrospective Analysis Across Diverse Clinical Conditions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Frailty on Outcomes Following Emergency Laparotomy: A Retrospective Analysis Across Diverse Clinical Conditions Karl Gunnar Isand, Shoaib Fahad Hussain, Maseh Sadiqi, Ülle Kirsimägi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4210153/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Aug, 2024 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose Emergency laparotomy (EL) encompasses procedures of varying complexity and urgency, undertaken in different clinical scenarios, leading to different risks of morbidity and mortality. We hypothesized that the increased mortality and longer postoperative length of stay (LoS) observed in frail patients are related to differences in indication for operation, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group. Methods This retrospective cohort study analysed patients entered into the National Emergency Laparotomy Audit database between January 1, 2018, and June 15, 2021, in Oxford. The primary outcome was 180-day survival analysed using multivariable Cox regression. The secondary outcomes, delay to surgery (DtS) and postoperative LoS, were analysed using logarithmically transformed multivariable linear regression. Results Of the 803 patients analysed, 396 (49.3%) were male. The median age was 66, and 337 (42%) were living with at least very mild frailty. Mortality hazard ratios for Clinical Frailty Scale grades 4 (3.93, 95% CI 1.89–8.20), 5 (5.86, 95% CI 2.87–11.97), and 6–7 (14.17, 95% CI 7.33–27.40) were not confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Frail patients experienced a 1.38-fold longer DtS and a 1.24-fold longer postoperative LoS, even after adjusting for indication, sepsis, intraperitoneal soiling, malignancy status, and DtS. Conclusion Our results indicate that frail patients have a poorer prognosis and longer postoperative LoS, independent of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. Patient frailty is also associated with longer DtS. frailty emergency laparotomy survival delay to surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The ageing population has sparked a growing interest in understanding patient frailty and its impact on treatment outcomes. The concept of diminished functional status leading to poor treatment outcomes is not novel, yet comprehensive quantification of frailty and its incorporation into clinical decision-making in emergency general surgery has only begun in the past decade[ 1 ]. While many reports have identified increased in-hospital or 30 to 90-day mortality associated with frailty in emergency laparotomy (EL)[ 2 – 4 ], long-term outcomes in this population have been less extensively studied, with only a few studies reporting on frailty-associated mortality beyond 90 days[ 5 ]. EL encompasses a multitude of procedures performed for various indications, with differing intraoperative findings that affect their urgency as well as outcome. The updated National Emergency Laparotomy Audit (NELA) risk calculator has defined categories for indication for operation (indication), intraperitoneal soiling, and malignancy status based on their effect on 30-day mortality[ 6 ]. To date, discrepancies in the distribution of these variables between fit and frail patients and whether they confound the effects of frailty on survival after EL have not been reported. It has been suggested that frail patients experience a longer delay to surgery (DtS) in EL[ 7 ], but this has not been extensively studied in the context of different indication, intraperitoneal soiling categories, or the presence of sepsis clinically that could influence the time from admission to surgery. Furthermore, the clinical relevance of such delay remains unclear[ 8 – 10 ]. The postoperative length of hospital stay (postoperative LoS) is associated with complications and decline in functional status post-surgery[ 11 ]. Although it has been shown that frail patients often have a longer postoperative LoS[ 5 ], this could also be confounded by indication, sepsis, and intraperitoneal soiling. We hypothesized that increased mortality and longer postoperative LoS in frail patients are directly related to differences in indication, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group. The primary aim of this retrospective study was to assess the effect of frailty, as measured by the Clinical Frailty Scale (CFS)[ 12 ], on 180-day survival after EL, considering indication, sepsis, intraperitoneal soiling, and malignancy status. Our secondary goal was to examine potential differences in DtS and postoperative LoS between fit and frail patients. Methods Ethics This study was approved by the Oxford University Hospitals NHS Trust (Approved Local Audit no. 7023) and was conducted in accordance with the ethical standards of the Helsinki Declaration of 1975. Setting The study was conducted at a single centre, Oxford University Hospitals NHS Foundation Trust, a large tertiary referral centre with a busy specialized Surgical Emergency Unit. Study Population In this retrospective cohort study, we utilized the NELA database to extract essential information on all patients recorded at Oxford University Hospitals with admission dates ranging from January 1, 2018, to June 15, 2021. The inclusion criteria for patients undergoing major emergency abdominal operations aligned with the NELA inclusion criteria during the same period[ 13 ]. The average estimated case ascertainment level for this timeframe was 85% at our institution. The NELA database is managed by the National Institute of Academic Anaesthesia's Health Services Research Centre (HSRC) on behalf of the Royal College of Anaesthetists (RCoA) in the United Kingdom. All patients were followed up for a minimum of 180 days, with the date of death acquired through the hospital’s Electronic Patient Records (EPR), linked to the national death register. We collected various data points from the NELA database for each patient, including the pre-morbid frailty measured by the CFS, age, sex, indication, sepsis, intraperitoneal soiling, and malignancy status. Indication and intraperitoneal soiling were grouped into categories based on the updated NELA risk calculator. CFS scores of one to three were categorized as "not frail," while grades four and above were analysed separately. For patients lacking CFS grade information in the NELA database, frailty was retrospectively evaluated based on doctors', nurses', occupational and physiotherapy notes, along with other relevant EPR notes. Patients without sufficient information in either the NELA database entry or EPR notes to assess CFS were excluded from the analysis. Statistical Analysis The normality of distribution of continuous variables was assessed using the Shapiro-Wilk test. Continuous variables with a non-normal distribution are represented as means and interquartile ranges (IQR). Categorical variables are represented as total numbers and percentages. The level of statistical significance (α) was set at 0.05 for all statistical tests. The Wilcoxon rank-sum test was used to determine the significance of differences in non-normally distributed continuous variables between categories. The chi-squared test or Fisher’s exact test was employed for differences in distributions of categorical variables. Survival for different CFS grades is represented as Kaplan-Meier curves, with the starting point set at the time of operation and the event time at the time of death. For multivariable analysis of survival, Cox regression was used with the same start and event times, and data are represented as hazard ratios (HR) and 95% confidence intervals (95% CI). For multivariable analysis of DtS and postoperative LoS, linear regression was used. Due to the positive skew of both DtS and postoperative LoS, both outcome variables were logarithmically transformed, and data are represented as the proportional increase and 95% CI for each independent variable. The validity of assumptions for all regression models was verified. All regression models were fitted using bi-directional stepwise elimination based on Akaike Information Criteria (AIC). The assumption of proportional hazards for Cox regression was checked using Schoenfeld’s residuals. Data analysis was performed using RStudio electronic software, Version 2023.03.0 (250 Northern Ave, Boston, MA 02210, USA). Results Following Institutional Review Board approval, data analysis was conducted on 823 patients entered into the National Emergency Laparotomy Audit (NELA) database between January 1, 2018, and June 15, 2021, at the Surgical Emergency Unit of the Oxford University Hospitals NHS Foundation Trust. The Clinical Frailty Scale (CFS) was available for 571 cases within the NELA database. However, in 95 instances where misclassification was evident, the CFS was reassessed based on the patient’s notes. Additionally, efforts were made to assess the CFS from the patient notes for 247 cases where this information was not recorded on the NELA database. Five patients were excluded due to being duplicates, and 15 were excluded because their frailty status could not be evaluated, leaving 803 cases for further statistical analysis. Baseline Characteristics Descriptive baseline characteristics are presented in Table 1 . Of the 803 included patients, 407 (50.7%) were female and 396 (49.3%) were male. The mean age was 63.2 years (range 18–94 years) with a median of 66.0 years (IQR 52–77 years). The distribution of age was not normal and was moderately left skewed. A total of 418 patients (52.1%) were aged 65 years or older. Table 1 Descriptive statistics of baseline characteristics CFS a 1…3 CFS 4 CFS 5 CFS 6 CFS 7 Number of patients (% of total) 466 (58.0) 131 (16.3) 111 (13.8) 73 (9.1) 22 (2.7) Median age in years (IQR b ) 59 (46–71) 70 (57–80) 77 (67–93) 77 (68–82) 76 (62–87) Sex ratio (M:F) 1.16 0.90 0.63 0.70 1.00 Presence of sepsis clinically 199 (44.1) 53 (41.7) 47 (43.1) 36 (50.7) 11 (52.4) Indication for operation Obstruction Other Sepsis Haemorrhage Ischaemia 254 (56.1) 8 (1.8) 146 (32.2) 6 (1.3) 39 (8.6) 69 (53.9) 4 (3.1) 44 (34.4) 4 (3.1) 7 (5.5) 65 (59.1) 0 (0) 33 (30) 2 (1.8) 10 (9.1) 46 (63) 0 (0) 21 (28.8) 3 (4.1) 3 (4.1) 12 (54.5) 0 (0) 8 (36.4) 0 (0) 2 (9.1) Intraperitoneal soiling No contamination Pus Gastroduodenal or bile Small bowel Faeces or feculent fluid Blood 313 (69.1) 53 (11.7) 23 (5.1) 17 (3.8) 37 (8.2) 10 (2.2) 84 (65.6) 17 (13.3) 7 (5.5) 4 (3.1) 13 (10.2) 3 (2.3) 80 (72.7) 8 (7.3) 5 (4.5) 7 (6.4) 9 (8.2) 1 (0.9) 50 (68.5) 5 (6.8) 0 (0) 4 (5.5) 10 (13.7) 4 (5.5) 13 (59.1) 3 (13.6) 0 (0) 3 (13.6) 3 (13.6) 0 (0) Malignancy status at operation No malignancy Primary or locally spread Disseminated malignancy 342 (74) 72 (15.6) 48 (10.4) 98 (75.4) 17 (13.1) 15 (11.5) 73 (66.4) 19 (17.3) 18 (16.4) 52 (71.2) 11 (15.1) 10 (13.7) 19 (86.4) 1 (4.5) 2 (9.1) Median DtS c hours (IQR) 27 (11–67) 45 (16–100) 54 (18–112) 33 (14–76) 32 (10–177) Median LoS d days (IQR) 7.0 (4.0-13.8) 8.0 (5.0–16.0) 10.0 (5.0–16.0) 13.0 (6.0–23.0) 12.0 (6.0–17.0) In-hospital mortality 12 (2.6) 11 (8.4) 14 (12.6) 18 (24.7) 10 (45.5) 30-day mortality 11 (2.4) 10 (7.6) 12 (10.8) 18 (24.7) 10 (45.5) 90-day mortality 15 (3.2) 13 (9.9) 18 (16.2) 24 (32.9) 11 (50) 180-day mortality 19 (4.1) 19 (14.5) 24 (21.6) 29 (39.7) 12 (54.5) Values are reported as n (% within CFS grade), unless otherwise specified. a CFS – Clinical Frailty Scale, b IQR – interquartile range, c DtS – delay to surgery, d LoS – postoperative length of hospital stay 346 (42%) patients were assessed to be living with at least very mild frailty (CFS ≥ 4), while only 22 patients were assessed to be living with severe frailty (CFS = 7). The median age was 64 years for men and 67 years for women, but this difference was not found to be statistically significant (p = 0.059). The prevalence of frailty (CFS ≥ 4) was higher in female patients compared to men (46.9% vs 36.9%, p < 0.001). The prevalence of frailty increased with age (Fig. 2 ). 17.1% of patients under 50 were living with at least very mild frailty. For patients aged between 70 and 80, the prevalence of frailty was 48.9%, and for patients aged 80 years or older, the prevalence was 79.3%. However, it is important to note that 20.6% of patients over 80 were considered fit for their age. Sepsis was clinically present in 346 (44.4%) cases, and the status was unknown in 24 cases. In 17 cases data on both, indication and intraperitoneal soiling was missing. The most common indication was obstruction in 446 (56.7%) cases, followed by sepsis in 252 (32.1%) cases. Other indications were less common: ischaemia 61 (7.8%), haemorrhage 15 (1.9%), and other in 12 (1.5%) cases. In 540 (68.7%) cases, no peritoneal soiling was found during the operation. Pus, small bowel content, gastroduodenal content or bile, faeces or feculent fluid, or blood were present in 86 (10.9%), 35 (4.5%), 35 (4.5%), 72 (9.2%), and 18 (2.3) cases, respectively. In 584 (73.3%) cases, no malignancy was diagnosed before or in association with the operation. Information on malignancy status was unavailable for 6 cases. Malignancy was locally spread in 120 (15.1%) cases and disseminated in 93 (11.7%) cases. The exact time from admission to surgery was available for 621 patients. The median DtS was 33 hours (IQR 13–77 hours), with a mean of 67.6 hours. The median postoperative LoS was 8 days (IQR 5–15 days), with a mean of 13.2 days. The distributions of postoperative LoS and DtS were markedly right-skewed. The overall 30-day mortality was 61 patients (7.6%), and the 180-day mortality was 103 patients (12.8%). The odds of re-operation or return to the intensive treatment unit, whether planned or unplanned, were not statistically significantly different for patients across different CFS grades in our cohort. Indication, Sepsis, Intraperitoneal Soiling and Malignancy Status across Different CFS Grades Due to the limited number of patients living with severe frailty (CFS = 7), they were grouped together with those on CFS grade 6. For the same reason, intraperitoneal soiling with small bowel content was grouped together with contamination with gastroduodenal content or bile. The 'other' category within indication was merged with 'obstruction' in accordance with the NELA risk calculator guidelines. Additionally, due to the low incidence, surgical procedures indicated for bleeding were incorporated into this same category (Table 2 ). We found no statistically significant differences in the distribution of indication, sepsis, intraperitoneal soiling, and malignancy status across different CFS grades. Table 2 Distribution of operation parameters and clinical risk factors by Clinical Frailty Scale (CFS) grade. Values are reported as n (% within CFS grade). CFS 1…3 CFS 4 CFS 5 CFS 6...7 p-value Indication for operation Obstruction OR Other OR Bleeding Sepsis Ischaemia 268 (59.2) 146 (32.2) 39 (8.6) 77 (60.2) 44 (34.4) 7 (5.5) 67 (60.9) 33 (30) 10 (9.1) 61 (64.2) 29 (30.5) 5 (5.3) 0.799 Presence of sepsis clinically 199 (44.1) 53 (41.7) 47 (43.1) 47 (51.1) 0.548 Intraperitoneal soiling No contamination or blood Pus Free bowel content 323 (71.3) 53 (11.7) 77 (17) 87 (68) 17 (13.3) 24 (18.8) 81 (73.6) 8 (7.3) 21 (19.1) 67 (70.5) 8 (8.4) 20 (21.1) 0.688 Malignancy status No malignancy Primary or locally spread Disseminated 342 (74) 72 (15.6) 48 (10.4) 98 (75.4) 17 (13.1) 15 (11.5) 73 (66.4) 19 (17.3) 18 (16.4) 71 (74.7) 12 (12.6) 12 (12.6) 0.568 Survival after Operation Figure 1 depicts Kaplan-Meier curves stratified by CFS grade. A significant association between CFS grade and both 30-day and 180-day mortality was identified in univariable analysis (p < 0.001 for each grade). By 180 days post-operation, mortality reached 54.5% in CFS grade 7 patients, while it was only 4.1% in patients considered fit for their age. The HR for mortality for CFS grades 4, 5, and 6–7 were 3.73 (95% CI 1.98–7.06), 5.84 (95% CI 3.20-10.67), and 13.66 (95% CI 7.92–23.56), respectively, in univariable Cox regression analysis. Age was significantly correlated with both 30-day and 180-day mortality (p < 0.001). Only one patient under 50 died within 30 days after the operation (30-day mortality of 0.6%). For patients aged 50 and above, 30-day mortality rate was 60 patients (9.5%). The overall 180-day mortality was 5 patients (2.9%) for those under 50, and 98 (15.5%) for patients aged 50 and above. Figure 3 illustrates the distribution of 180-day mortality by age and CFS grade. Additional factors significantly affecting survival in univariable analysis included intraperitoneal soiling with free bowel content (HR 2.22, 95% CI 1.42–3.45), indication categories of sepsis or ischaemia (HR 1.87, 95% CI 1.22–2.86 and HR 2.27, 95% CI 1.20–4.31, respectively), disseminated malignancy at the time of operation (HR 1.73, 95% CI 1.03–2.91), and sepsis clinically (HR 2.42, 95% CI 1.60–3.68). The effect of intraperitoneal soiling with pus (HR 1.39, 95% CI 0.75–2.60), sex (HR 0.77 for female sex, 95% CI 0.52–1.14), and locally spread malignancy (HR 1.26, 95% CI 0.74–2.16) on survival was not statistically significant on univariable analysis. For multivariable analysis, CFS categories 6–7 were combined due to the small sample sizes. The indication category 'other' (n = 12) was grouped with operations performed for obstruction according to the updated NELA risk calculator. Due to the small number of patients in whom the indication was haemorrhage (n = 15), these cases were excluded from the final model to prevent overfitting. Local and disseminated malignancy were grouped together. A good model fit was achieved, with a concordance index of 0.838. After adjusting for age, sex, indication, sepsis, intraperitoneal soiling, and malignancy, patient frailty was found to be independently associated with poorer 180-day survival (Table 3 ). The HR for CFS grades 4, 5, and 6–7 were 3.93 (95% CI 1.89–8.20), 5.86 (95% CI 2.87–11.97), and 14.17 (95% CI 7.33–27.40), respectively. Table 3 Risk factors of mortality after operation. Risk factor Hazard Ratio (95% CI b ) Univariable regression Multivariable regression CFS a grade 1…3 4 5 6…7 1 3.74 (1.98–7.06) 5.74 (3.20-10.67) 13.66 (7.92–23.56) 1 3.93 (1.89–8.20) 5.86 (2.87–11.97) 14.17 (7.33–27.40) Age 1.04 (1.03–1.06) 1.02 (1.00-1.03) Male sex 1.29 (0.88–1.91) 1.50 (0.98–2.28) Indication for operation Obstruction or “other” Sepsis Ischaemia 1 1.84 (1.21–2.80) 2.24 (1.18–4.24) 1 0.93 (0.43–2.01) 3.30 (1.65–6.60) Presence of sepsis 2.42 (1.59–3.68) 1.80 (0.97–3.33) Intraperitoneal soiling with pus or free bowel content 1.90 (1.27–2.82) 2.17 (1.18-4.00) Any malignancy 1.47 (0.97–2.21) 1.62 (1.04–2.52) a CFS - Clinical Frailty Scale, b CI – Confidence Interval Delay to Surgery The median DtS was 27 hours for fit patients and 43.5 hours for patients living with at least very mild (CFS ≥ 4) (p = 0.003). We used logarithmically transformed linear regression for the multivariable analysis of DtS due to the positive skew in DtS distribution. Stepwise bi-directional elimination was used, with patient frailty, age, sex, intraperitoneal soiling, indication, and sepsis as input variables. The best model fit was achieved with patient frailty, intraperitoneal soiling, and sepsis included as independent variables (Table 4 ). In the adjusted model, patient frailty (CFS ≥ 4) was associated with a 1.38-fold increase of DtS. Table 4 Risk factors of prolonged delay to surgery after emergency laparotomy. Risk factor Delay to surgery multiplier (95% CI b ) Univariable regression Multivariable regression CFS a grade 1…3 ≥ 4 1 1.37 (1.12–1.67) 1 1.38 (1.14–1.67) Age 1.001 (0.995–1.006) n/a Male sex 0.87 (0.72–1.06) n/a Intraperitoneal soiling No intraperitoneal soiling Pus Free bowel content 1 1.41 (1.02–1.96) 0.53 (0.41–0.68) 1 2.06 (1.41–2.89) 0.72 (0.54–0.96) Indication for operation Obstruction or “other” Sepsis Ischaemia 1 0.76 (0.61–0.94) 0.92 (0.64–1.33) n/a n/a Presence of sepsis 0.65 (0.54–0.79) 0.63 (0.49–0.80) a CFS - Clinical Frailty Scale, b CI – Confidence Interval DtS was not associated with 30-day or 180-day mortality across our cohort (p = 0.981 and p = 0.632, respectively). Although there was a statistically significant difference in DtS across different intraperitoneal soiling categories, as well as between patients who had sepsis and those who did not, DtS did not significantly affect 30-day mortality within those subgroups. The correlation between DtS and postoperative LoS was negligible, with Pearson's correlation coefficient of 0.10. Length of Hospital Stay after Operation The median postoperative LoS was 7 days for fit patients and 10 days for patients living with at least very mild frailty (CFS ≥ 4) (p < 0.001). Overall, death during hospitalization was not associated with postoperative LoS (p = 0.093). However, death during hospitalization affected postoperative LoS differently in fit compared to frail patients (Fig. 4 ). Among fit patients, postoperative LoS tended to be slightly longer in those who died in hospital, although this difference was not statistically significant (p = 0.552). In frail patients, postoperative LoS was significantly shorter in patients who died in hospital (median of 6 vs. 10 days, p = 0.003). *LoS - postoperative length of stay. Boxes represent interquartile ranges (IQR), whiskers extend 1.5 times IQR. For multivariable analysis of postoperative LoS, we utilized logarithmically transformed linear regression. Stepwise bi-directional elimination was employed with patient frailty, age, sex, intraperitoneal soiling, indication, sepsis, and death during hospitalization as input variables. The best model fit was achieved with patient frailty, age, intraperitoneal soiling, sepsis, and death during hospitalization included as independent variables (Table 5 ). In the adjusted model, patient frailty (CFS ≥ 4) was associated with 1.24 times increase in postoperative LoS. Table 5 Risk factors of prolonged postoperative length of hospital stay after emergency laparotomy. Risk factor Postoperative length of stay multiplier (95% CI b ) Univariable regression Multivariable regression CFS a grade 1…3 ≥ 4 1 1.26 (1.10–1.43) 1 1.24 (1.08–1.42) Age (per one year) 1.007 (1.003–1.010) 1.006 (1.003–1.011) Male sex 0.99 (0.87–1.12) n/a Indication for operation Obstruction or “other” Sepsis Ischaemia 1 1.50 (1.30–1.72) 1.09 (0.86–1.39) n/a n/a n/a Presence of sepsis 1.59 (1.40–1.81) 1.43 (1.22–1.67) Intraperitoneal soiling with pus or free bowel content 1.52 (1.32–1.75) 1.27 (1.07–1.51) Died in hospital 0.77 (0.60–0.98) 0.55 (0.43–0.71) a CFS - Clinical Frailty Scale, b CI – Confidence Interval Discussion Frailty-associated increases in 30-day mortality following EL have been extensively documented. The integration of risk management strategies, such as those promoted by the National Emergency Laparotomy Audit (NELA), has been pivotal in reducing mortality rates associated with this high-risk procedure[ 14 ]. The importance of this topic is underscored by the fact that frailty assessment has now reached EL guidelines[ 1 ]. However, given that EL is an umbrella term for a wide range of procedures with varying degrees of complexity and urgency, it is critical to further investigate the impact of frailty across different clinical scenarios, such as different indication and intraperitoneal soiling categories. Our retrospective study confirms that patient frailty is associated with higher mortality rates following EL in both the short and long term. We found no evidence that differences in the distribution of indication, intraperitoneal soiling, or malignancy status categories explain this effect. While the mortality hazard after EL was 14 times higher in the moderately and severely frail patients, this effect appears not to be significantly confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Although reports often focus on increased prevalence of frailty in the elderly, it is crucial for clinicians to recognize that there are also fit people within this age group. In our cohort a fifth of patients over 80 were considered fit for their age and the outcome of their operation was more favourable accordingly. The observed prolongation of postoperative LoS in frail patients likely reflects a postoperative period marred by complications as well as functional decline[ 15 , 16 ], echoing previous findings on the increased cost of care for this group. Notably, our study revealed that death during hospitalization impacts postoperative LoS differently in fit versus frail patients. While it is reasonable to assume that a shorter postoperative LoS would be associated with a lower total cost of hospitalization, the decrease of postoperative LoS caused by death certainly cannot be regarded as a more favourable outcome. As with mortality, the effect of frailty on postoperative LoS seems to remain significant even adjusting for the other mentioned risk factors. The finding of a longer DtS for frail patients is consistent with previous research. However, the clinical implication of such delay is less clear. We found no evidence that a longer DtS correlates with worse survival or an extended postoperative LoS in our cohort. It is conceivable that this additional waiting period allowed for the involvement of more senior staff in the decision-making process, as well as elderly care specialists to achieve better physiological optimization before surgery. While it could be hypothesized that such efficient use of time could offset the intrinsic risks associated with frailty, our study lacked specific data on this aspect. Further research is needed to explore and substantiate this hypothesis. Limitations The retrospective nature of our study introduces inherent limitations. While the CFS can be effectively assessed from patient records, the accuracy of such evaluations is dependent on the detail of these notes. In cases where CFS data were missing from the NELA database, occupational and physiotherapy records were invaluable. However, the absence of detailed records may lead to misclassification, skewing patients towards a "not frail" designation and potentially introducing information bias, especially for patients on CFS grade 4. Although the number of patients included in the study was relatively large, the lower proportion of patients with higher Clinical Frailty Scale (CFS) grades and the number of categories analysed in our regression model necessitated the grouping of certain variables to prevent overfitting. Consequently, a larger cohort could yield more precise estimates of effect sizes. Additionally, as the study was conducted at a single institution, its generalizability may be limited. Conclusion Our findings underscore the adverse impact of frailty on prognosis and postoperative LoS following EL, regardless of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. The association between frailty and extended DtS highlights the need for larger, multicentre studies to further elucidate the effects of frailty across different EL procedures and to assess the role of DtS in frail patient populations. Declarations Author Contribution K.G.I. was responsible for conseptualization, methodology, project administration, writing he original draftK.G.I., S.F.H and M.S were responsible for data curation, investigation and reviewing the draftK.G.I. and Ü.K. were responsible for data analysis, methodology, preparing the figures and reviewing the draft.G.B-S., H.K., S.S., U.L. and P.T. were responsible for conseptualization, methodology, resources, supervision and reviewing the draft. Data availability: not publically available References Tian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E et al. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg [Internet]. 2023 [cited 2024 Feb 22];18:38. https://doi.org/10.1186/s13017-023-00506-7 . Parmar KL, Law J, Carter B, Hewitt J, Boyle JM, Casey P, et al. Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study. Ann Surg. 2021;273:709–18. Kennedy CA, Shipway D, Barry K. Frailty and emergency abdominal surgery: A systematic review and meta-analysis. Surg J R Coll Surg Edinb Irel. 2022;20:e307–14. Joseph B, Zangbar B, Pandit V, Fain M, Mohler MJ, Kulvatunyou N et al. Emergency General Surgery in the Elderly: Too Old or Too Frail? J Am Coll Surg [Internet]. 2016 [cited 2023 Feb 15];222:805. https://journals.lww.com/journalacs/Abstract/2016/05000/Emergency_General_Surgery_in_the_Elderly__Too_Old.9.aspx . Vilches-Moraga A, Rowley M, Fox J, Khan H, Paracha A, Price A et al. Emergency laparotomy in the older patient: factors predictive of 12-month mortality—Salford-POPS-GS. An observational study. Aging Clin Exp Res [Internet]. 2020 [cited 2024 Feb 21];32:2367–73. https://doi.org/10.1007/s40520-020-01578-0 . NELA parsimonious risk score for adult patients. undergoing laparotomy after an emergency admission (Parsimonious Risk Score (PRS)) [Internet]. https://data.nela.org.uk/getmedia/62232ae6-1294-456d-bf9d-c34013d1d9bb/Technical-Document-NELA_PRS_Overview_Coefficients-April-2023-(1).aspx . Ramsay EA, Carter B, Soiza RL, Duffy S, Moug SJ, Myint PK. Frailty is associated with increased waiting time for relevant process-of-care measures; findings from the Emergency Laparoscopic and Laparotomy Scottish audit (ELLSA). Br J Surg [Internet]. 2022 [cited 2024 Jan 5];109:172–5. https://doi.org/10.1093/bjs/znab371 . Vester-Andersen M, Lundstrøm LH, Buck DL, Møller MH. Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study. Scand J Gastroenterol. 2016;51:121–8. Coimbra R, Barrientos R, Allison-Aipa T, Zakhary B, Firek M. The unequal impact of interhospital transfers on emergency general surgery patients: Procedure risk and time to surgery matter. J Trauma Acute Care Surg [Internet]. 2022 [cited 2024 Feb 22];92:296. https://journals.lww.com/jtrauma/abstract/2022/02000/the_unequal_impact_of_interhospital_transfers_on.8.aspx . Ong M, Guang TY, Yang TK. Impact of surgical delay on outcomes in elderly patients undergoing emergency surgery: A single center experience. World J Gastrointest Surg [Internet]. 2015 [cited 2024 Feb 22];7:208–13. https://www.wjgnet.com/1948-9366/full/v7/i9/208.htm . Howes TE, Cook TM, Corrigan LJ, Dalton SJ, Richards SK, Peden CJ. Postoperative morbidity survey, mortality and length of stay following emergency laparotomy. Anaesthesia [Internet]. 2015 [cited 2024 Feb 22];70:1020–7. https://onlinelibrary.wiley.com/doi/abs/ 10.1111/anae.12991 . Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ Can Med Assoc J J Assoc Medicale Can. 2005;173:489–95. Audit Inclusion & Exclusion Criteria. - National Emergency Laparotomy Audit [Internet]. [cited 2023 Feb 20]. https://www.nela.org.uk/Criteria#pt . Reports - The National Institute of Academic Anaesthesia [Internet]. [cited 2023 Feb 15]. https://www.nela.org.uk/reports . Tan HL, Chia STX, Nadkarni NV, Ang SY, Seow DCC, Wong TH. Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study. World J Emerg Surg [Internet]. 2019 [cited 2024 Feb 21];14:62. https://doi.org/10.1186/s13017-019-0280-z . Carter B, Law J, Hewitt J, Parmar KL, Boyle JM, Casey P, et al. Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy. Br J Surg. 2020;107:218–26. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Aug, 2024 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 23 Jul, 2024 Reviews received at journal 18 Jul, 2024 Reviewers agreed at journal 18 Jul, 2024 Reviews received at journal 18 Jul, 2024 Reviewers agreed at journal 09 Jul, 2024 Reviewers agreed at journal 19 Apr, 2024 Reviewers invited by journal 04 Apr, 2024 Editor assigned by journal 04 Apr, 2024 Submission checks completed at journal 03 Apr, 2024 First submitted to journal 03 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4210153","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288264879,"identity":"72864ab1-dcb0-4769-a6c4-b058127d8993","order_by":0,"name":"Karl Gunnar Isand","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACNhDBc4CBgY+9AcgysCBBCxuIYDCQINIqsBaJBBCTCC18/IefPXhzxi6fTfL51Q0/CiQY+Nu7E/A7TCLN3HDOjWTLNumcsps9QIdJnDm7gYAWBjNpng/MBmzSOWk3eIBaDCRyCWjhP/4NqKXegE3yTNrNP0RpYcgB2nLjsAGbBPux28TZIpFTJjnnzHEDNp4cttsyBhI8BP0i3398m8SbY9UG/OzHn91888dGjr+9F78WJMBjACaJVQ4C7A9IUT0KRsEoGAUjCAAAUK1AEBBLtE0AAAAASUVORK5CYII=","orcid":"","institution":"North Estonia Medical Centre","correspondingAuthor":true,"prefix":"","firstName":"Karl","middleName":"Gunnar","lastName":"Isand","suffix":""},{"id":288264881,"identity":"68250ff4-fda4-4ecc-9718-9736baacd8a2","order_by":1,"name":"Shoaib Fahad Hussain","email":"","orcid":"","institution":"Oxford University Hospitals NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Shoaib","middleName":"Fahad","lastName":"Hussain","suffix":""},{"id":288264882,"identity":"2e87a0dd-e917-47d9-8fc6-e47c96c2b244","order_by":2,"name":"Maseh Sadiqi","email":"","orcid":"","institution":"Oxford University Hospitals NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Maseh","middleName":"","lastName":"Sadiqi","suffix":""},{"id":288264884,"identity":"2eaf3b99-9385-4217-8f17-80a4de00b7c1","order_by":3,"name":"Ülle Kirsimägi","email":"","orcid":"","institution":"Tartu University","correspondingAuthor":false,"prefix":"","firstName":"Ülle","middleName":"","lastName":"Kirsimägi","suffix":""},{"id":288264886,"identity":"c0d1cef8-9c02-41bc-bc3e-77dc5ec4468c","order_by":4,"name":"Giles Bond-Smith","email":"","orcid":"","institution":"Oxford University Hospitals NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Giles","middleName":"","lastName":"Bond-Smith","suffix":""},{"id":288264888,"identity":"b60f03c9-a503-4c7d-ad3d-fa7cab04cec5","order_by":5,"name":"Helgi Kolk","email":"","orcid":"","institution":"Tartu University","correspondingAuthor":false,"prefix":"","firstName":"Helgi","middleName":"","lastName":"Kolk","suffix":""},{"id":288264889,"identity":"21fff87f-a5c0-4a87-b8f0-be1414652243","order_by":6,"name":"Sten Saar","email":"","orcid":"","institution":"North Estonia Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Sten","middleName":"","lastName":"Saar","suffix":""},{"id":288264890,"identity":"41dcb33b-50ea-4ff9-a612-07a9af2f943a","order_by":7,"name":"Urmas Lepner","email":"","orcid":"","institution":"Tartu University","correspondingAuthor":false,"prefix":"","firstName":"Urmas","middleName":"","lastName":"Lepner","suffix":""},{"id":288264894,"identity":"7dc3b79f-cadd-4313-bfd1-4643066b18fe","order_by":8,"name":"Peep Talving","email":"","orcid":"","institution":"North Estonia Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Peep","middleName":"","lastName":"Talving","suffix":""}],"badges":[],"createdAt":"2024-04-03 05:45:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4210153/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4210153/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-024-02632-6","type":"published","date":"2024-08-21T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54393869,"identity":"4c3a85aa-f340-4537-97bb-6dda41edfbdc","added_by":"auto","created_at":"2024-04-09 21:09:28","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":106228,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of Clnical Frailty Scale (CFS) Categories by Age Groups\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4210153/v1/360e956ef182568b01848b1c.jpg"},{"id":54393868,"identity":"c559e609-53a7-4cd4-83cb-2f1c5b342f7e","added_by":"auto","created_at":"2024-04-09 21:09:28","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130867,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves for different Clinical Frailty Scale (CFS) grades\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4210153/v1/35b863f02e581108c476c8bf.jpg"},{"id":54393866,"identity":"c35e03dd-842b-4fc0-95dd-353946c5bf3d","added_by":"auto","created_at":"2024-04-09 21:09:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":122013,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of 180-day mortality by age and Clinical Frailty Scale (CFS) grade\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4210153/v1/868f493edc3161bc47833edb.jpg"},{"id":54393867,"identity":"4c2d6c84-9b49-4805-a6a5-126dee94a122","added_by":"auto","created_at":"2024-04-09 21:09:28","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":72103,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplots of Postoperative Length of Stay for Fit and Frail Patients\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4210153/v1/7b01e61629ac2f6b2b9f1cf5.jpg"},{"id":63299927,"identity":"b1135e7c-c08d-4774-a559-9ff7078e7bbd","added_by":"auto","created_at":"2024-08-26 16:04:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1063977,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4210153/v1/16b3b0c2-af0f-4d4f-a37c-ef6c3cb05159.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Frailty on Outcomes Following Emergency Laparotomy: A Retrospective Analysis Across Diverse Clinical Conditions","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe ageing population has sparked a growing interest in understanding patient frailty and its impact on treatment outcomes. The concept of diminished functional status leading to poor treatment outcomes is not novel, yet comprehensive quantification of frailty and its incorporation into clinical decision-making in emergency general surgery has only begun in the past decade[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While many reports have identified increased in-hospital or 30 to 90-day mortality associated with frailty in emergency laparotomy (EL)[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], long-term outcomes in this population have been less extensively studied, with only a few studies reporting on frailty-associated mortality beyond 90 days[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEL encompasses a multitude of procedures performed for various indications, with differing intraoperative findings that affect their urgency as well as outcome. The updated National Emergency Laparotomy Audit (NELA) risk calculator has defined categories for indication for operation (indication), intraperitoneal soiling, and malignancy status based on their effect on 30-day mortality[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To date, discrepancies in the distribution of these variables between fit and frail patients and whether they confound the effects of frailty on survival after EL have not been reported.\u003c/p\u003e \u003cp\u003eIt has been suggested that frail patients experience a longer delay to surgery (DtS) in EL[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], but this has not been extensively studied in the context of different indication, intraperitoneal soiling categories, or the presence of sepsis clinically that could influence the time from admission to surgery. Furthermore, the clinical relevance of such delay remains unclear[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe postoperative length of hospital stay (postoperative LoS) is associated with complications and decline in functional status post-surgery[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although it has been shown that frail patients often have a longer postoperative LoS[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], this could also be confounded by indication, sepsis, and intraperitoneal soiling.\u003c/p\u003e \u003cp\u003eWe hypothesized that increased mortality and longer postoperative LoS in frail patients are directly related to differences in indication, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group.\u003c/p\u003e \u003cp\u003eThe primary aim of this retrospective study was to assess the effect of frailty, as measured by the Clinical Frailty Scale (CFS)[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], on 180-day survival after EL, considering indication, sepsis, intraperitoneal soiling, and malignancy status. Our secondary goal was to examine potential differences in DtS and postoperative LoS between fit and frail patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003eThis study was approved by the Oxford University Hospitals NHS Trust (Approved Local Audit no. 7023) and was conducted in accordance with the ethical standards of the Helsinki Declaration of 1975.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe study was conducted at a single centre, Oxford University Hospitals NHS Foundation Trust, a large tertiary referral centre with a busy specialized Surgical Emergency Unit.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eIn this retrospective cohort study, we utilized the NELA database to extract essential information on all patients recorded at Oxford University Hospitals with admission dates ranging from January 1, 2018, to June 15, 2021. The inclusion criteria for patients undergoing major emergency abdominal operations aligned with the NELA inclusion criteria during the same period[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The average estimated case ascertainment level for this timeframe was 85% at our institution. The NELA database is managed by the National Institute of Academic Anaesthesia's Health Services Research Centre (HSRC) on behalf of the Royal College of Anaesthetists (RCoA) in the United Kingdom.\u003c/p\u003e \u003cp\u003eAll patients were followed up for a minimum of 180 days, with the date of death acquired through the hospital\u0026rsquo;s Electronic Patient Records (EPR), linked to the national death register. We collected various data points from the NELA database for each patient, including the pre-morbid frailty measured by the CFS, age, sex, indication, sepsis, intraperitoneal soiling, and malignancy status. Indication and intraperitoneal soiling were grouped into categories based on the updated NELA risk calculator. CFS scores of one to three were categorized as \"not frail,\" while grades four and above were analysed separately. For patients lacking CFS grade information in the NELA database, frailty was retrospectively evaluated based on doctors', nurses', occupational and physiotherapy notes, along with other relevant EPR notes. Patients without sufficient information in either the NELA database entry or EPR notes to assess CFS were excluded from the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe normality of distribution of continuous variables was assessed using the Shapiro-Wilk test. Continuous variables with a non-normal distribution are represented as means and interquartile ranges (IQR). Categorical variables are represented as total numbers and percentages. The level of statistical significance (α) was set at 0.05 for all statistical tests. The Wilcoxon rank-sum test was used to determine the significance of differences in non-normally distributed continuous variables between categories. The chi-squared test or Fisher\u0026rsquo;s exact test was employed for differences in distributions of categorical variables. Survival for different CFS grades is represented as Kaplan-Meier curves, with the starting point set at the time of operation and the event time at the time of death. For multivariable analysis of survival, Cox regression was used with the same start and event times, and data are represented as hazard ratios (HR) and 95% confidence intervals (95% CI). For multivariable analysis of DtS and postoperative LoS, linear regression was used. Due to the positive skew of both DtS and postoperative LoS, both outcome variables were logarithmically transformed, and data are represented as the proportional increase and 95% CI for each independent variable. The validity of assumptions for all regression models was verified. All regression models were fitted using bi-directional stepwise elimination based on Akaike Information Criteria (AIC). The assumption of proportional hazards for Cox regression was checked using Schoenfeld\u0026rsquo;s residuals.\u003c/p\u003e \u003cp\u003eData analysis was performed using RStudio electronic software, Version 2023.03.0 (250 Northern Ave, Boston, MA 02210, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFollowing Institutional Review Board approval, data analysis was conducted on 823 patients entered into the National Emergency Laparotomy Audit (NELA) database between January 1, 2018, and June 15, 2021, at the Surgical Emergency Unit of the Oxford University Hospitals NHS Foundation Trust.\u003c/p\u003e \u003cp\u003eThe Clinical Frailty Scale (CFS) was available for 571 cases within the NELA database. However, in 95 instances where misclassification was evident, the CFS was reassessed based on the patient\u0026rsquo;s notes. Additionally, efforts were made to assess the CFS from the patient notes for 247 cases where this information was not recorded on the NELA database. Five patients were excluded due to being duplicates, and 15 were excluded because their frailty status could not be evaluated, leaving 803 cases for further statistical analysis.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Characteristics\u003c/h2\u003e \u003cp\u003eDescriptive baseline characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 803 included patients, 407 (50.7%) were female and 396 (49.3%) were male. The mean age was 63.2 years (range 18\u0026ndash;94 years) with a median of 66.0 years (IQR 52\u0026ndash;77 years). The distribution of age was not normal and was moderately left skewed. A total of 418 patients (52.1%) were aged 65 years or older.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of baseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCFS\u003csup\u003ea\u003c/sup\u003e 1\u0026hellip;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCFS 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCFS 5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCFS 6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCFS 7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients (% of total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e466 (58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian age in years (IQR\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (46\u0026ndash;71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (57\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77 (67\u0026ndash;93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77 (68\u0026ndash;82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76 (62\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex ratio (M:F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of sepsis clinically\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (43.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (52.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for operation\u003c/p\u003e \u003cp\u003eObstruction\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003eHaemorrhage\u003c/p\u003e \u003cp\u003eIschaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254\u0026nbsp;(56.1)\u003c/p\u003e \u003cp\u003e8\u0026nbsp;(1.8)\u003c/p\u003e \u003cp\u003e146\u0026nbsp;(32.2)\u003c/p\u003e \u003cp\u003e6\u0026nbsp;(1.3)\u003c/p\u003e \u003cp\u003e39\u0026nbsp;(8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u0026nbsp;(53.9)\u003c/p\u003e \u003cp\u003e4\u0026nbsp;(3.1)\u003c/p\u003e \u003cp\u003e44\u0026nbsp;(34.4)\u003c/p\u003e \u003cp\u003e4\u0026nbsp;(3.1)\u003c/p\u003e \u003cp\u003e7\u0026nbsp;(5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u0026nbsp;(59.1)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003cp\u003e33\u0026nbsp;(30)\u003c/p\u003e \u003cp\u003e2\u0026nbsp;(1.8)\u003c/p\u003e \u003cp\u003e10\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u0026nbsp;(63)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003cp\u003e21\u0026nbsp;(28.8)\u003c/p\u003e \u003cp\u003e3\u0026nbsp;(4.1)\u003c/p\u003e \u003cp\u003e3\u0026nbsp;(4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u0026nbsp;(54.5)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003cp\u003e8\u0026nbsp;(36.4)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003cp\u003e2\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraperitoneal soiling\u003c/p\u003e \u003cp\u003eNo\u0026nbsp;contamination\u003c/p\u003e \u003cp\u003ePus\u003c/p\u003e \u003cp\u003eGastroduodenal\u0026nbsp;or\u0026nbsp;bile\u003c/p\u003e \u003cp\u003eSmall\u0026nbsp;bowel\u003c/p\u003e \u003cp\u003eFaeces\u0026nbsp;or\u0026nbsp;feculent\u0026nbsp;fluid\u003c/p\u003e \u003cp\u003eBlood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e313\u0026nbsp;(69.1)\u003c/p\u003e \u003cp\u003e53\u0026nbsp;(11.7)\u003c/p\u003e \u003cp\u003e23\u0026nbsp;(5.1)\u003c/p\u003e \u003cp\u003e17\u0026nbsp;(3.8)\u003c/p\u003e \u003cp\u003e37\u0026nbsp;(8.2)\u003c/p\u003e \u003cp\u003e10\u0026nbsp;(2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u0026nbsp;(65.6)\u003c/p\u003e \u003cp\u003e17\u0026nbsp;(13.3)\u003c/p\u003e \u003cp\u003e7\u0026nbsp;(5.5)\u003c/p\u003e \u003cp\u003e4\u0026nbsp;(3.1)\u003c/p\u003e \u003cp\u003e13\u0026nbsp;(10.2)\u003c/p\u003e \u003cp\u003e3\u0026nbsp;(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u0026nbsp;(72.7)\u003c/p\u003e \u003cp\u003e8\u0026nbsp;(7.3)\u003c/p\u003e \u003cp\u003e5\u0026nbsp;(4.5)\u003c/p\u003e \u003cp\u003e7\u0026nbsp;(6.4)\u003c/p\u003e \u003cp\u003e9\u0026nbsp;(8.2)\u003c/p\u003e \u003cp\u003e1\u0026nbsp;(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u0026nbsp;(68.5)\u003c/p\u003e \u003cp\u003e5\u0026nbsp;(6.8)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003cp\u003e4\u0026nbsp;(5.5)\u003c/p\u003e \u003cp\u003e10\u0026nbsp;(13.7)\u003c/p\u003e \u003cp\u003e4\u0026nbsp;(5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u0026nbsp;(59.1)\u003c/p\u003e \u003cp\u003e3\u0026nbsp;(13.6)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003cp\u003e3\u0026nbsp;(13.6)\u003c/p\u003e \u003cp\u003e3\u0026nbsp;(13.6)\u003c/p\u003e \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy status at operation\u003c/p\u003e \u003cp\u003eNo\u0026nbsp;malignancy\u003c/p\u003e \u003cp\u003ePrimary or locally spread\u003c/p\u003e \u003cp\u003eDisseminated malignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e342\u0026nbsp;(74)\u003c/p\u003e \u003cp\u003e72\u0026nbsp;(15.6)\u003c/p\u003e \u003cp\u003e48\u0026nbsp;(10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98\u0026nbsp;(75.4)\u003c/p\u003e \u003cp\u003e17\u0026nbsp;(13.1)\u003c/p\u003e \u003cp\u003e15\u0026nbsp;(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u0026nbsp;(66.4)\u003c/p\u003e \u003cp\u003e19\u0026nbsp;(17.3)\u003c/p\u003e \u003cp\u003e18\u0026nbsp;(16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u0026nbsp;(71.2)\u003c/p\u003e \u003cp\u003e11\u0026nbsp;(15.1)\u003c/p\u003e \u003cp\u003e10\u0026nbsp;(13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19\u0026nbsp;(86.4)\u003c/p\u003e \u003cp\u003e1\u0026nbsp;(4.5)\u003c/p\u003e \u003cp\u003e2\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian DtS\u003csup\u003ec\u003c/sup\u003e hours (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (11\u0026ndash;67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (16\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (18\u0026ndash;112)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (14\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (10\u0026ndash;177)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian LoS\u003csup\u003ed\u003c/sup\u003e days (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 (4.0-13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0 (5.0\u0026ndash;16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.0 (5.0\u0026ndash;16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.0 (6.0\u0026ndash;23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.0 (6.0\u0026ndash;17.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u0026nbsp;(2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026nbsp;(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u0026nbsp;(12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u0026nbsp;(24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u0026nbsp;(45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026nbsp;(2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026nbsp;(7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u0026nbsp;(10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u0026nbsp;(24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e180-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u0026nbsp;(4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u0026nbsp;(14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u0026nbsp;(21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u0026nbsp;(39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (54.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eValues are reported as n (% within CFS grade), unless otherwise specified. \u003csup\u003ea\u003c/sup\u003eCFS \u0026ndash; Clinical Frailty Scale, \u003csup\u003eb\u003c/sup\u003eIQR \u0026ndash; interquartile range, \u003csup\u003ec\u003c/sup\u003eDtS \u0026ndash; delay to surgery, \u003csup\u003ed\u003c/sup\u003eLoS \u0026ndash; postoperative length of hospital stay\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e346 (42%) patients were assessed to be living with at least very mild frailty (CFS\u0026thinsp;\u0026ge;\u0026thinsp;4), while only 22 patients were assessed to be living with severe frailty (CFS\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e \u003cp\u003eThe median age was 64 years for men and 67 years for women, but this difference was not found to be statistically significant (p\u0026thinsp;=\u0026thinsp;0.059). The prevalence of frailty (CFS\u0026thinsp;\u0026ge;\u0026thinsp;4) was higher in female patients compared to men (46.9% vs 36.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe prevalence of frailty increased with age (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 17.1% of patients under 50 were living with at least very mild frailty. For patients aged between 70 and 80, the prevalence of frailty was 48.9%, and for patients aged 80 years or older, the prevalence was 79.3%. However, it is important to note that 20.6% of patients over 80 were considered fit for their age.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSepsis was clinically present in 346 (44.4%) cases, and the status was unknown in 24 cases. In 17 cases data on both, indication and intraperitoneal soiling was missing. The most common indication was obstruction in 446 (56.7%) cases, followed by sepsis in 252 (32.1%) cases. Other indications were less common: ischaemia 61 (7.8%), haemorrhage 15 (1.9%), and other in 12 (1.5%) cases. In 540 (68.7%) cases, no peritoneal soiling was found during the operation. Pus, small bowel content, gastroduodenal content or bile, faeces or feculent fluid, or blood were present in 86 (10.9%), 35 (4.5%), 35 (4.5%), 72 (9.2%), and 18 (2.3) cases, respectively. In 584 (73.3%) cases, no malignancy was diagnosed before or in association with the operation. Information on malignancy status was unavailable for 6 cases. Malignancy was locally spread in 120 (15.1%) cases and disseminated in 93 (11.7%) cases.\u003c/p\u003e \u003cp\u003eThe exact time from admission to surgery was available for 621 patients. The median DtS was 33 hours (IQR 13\u0026ndash;77 hours), with a mean of 67.6 hours.\u003c/p\u003e \u003cp\u003eThe median postoperative LoS was 8 days (IQR 5\u0026ndash;15 days), with a mean of 13.2 days. The distributions of postoperative LoS and DtS were markedly right-skewed.\u003c/p\u003e \u003cp\u003eThe overall 30-day mortality was 61 patients (7.6%), and the 180-day mortality was 103 patients (12.8%).\u003c/p\u003e \u003cp\u003eThe odds of re-operation or return to the intensive treatment unit, whether planned or unplanned, were not statistically significantly different for patients across different CFS grades in our cohort.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eIndication, Sepsis, Intraperitoneal Soiling and Malignancy Status across Different CFS Grades\u003c/h2\u003e \u003cp\u003eDue to the limited number of patients living with severe frailty (CFS\u0026thinsp;=\u0026thinsp;7), they were grouped together with those on CFS grade 6. For the same reason, intraperitoneal soiling with small bowel content was grouped together with contamination with gastroduodenal content or bile. The 'other' category within indication was merged with 'obstruction' in accordance with the NELA risk calculator guidelines. Additionally, due to the low incidence, surgical procedures indicated for bleeding were incorporated into this same category (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). We found no statistically significant differences in the distribution of indication, sepsis, intraperitoneal soiling, and malignancy status across different CFS grades.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of operation parameters and clinical risk factors by Clinical Frailty Scale (CFS) grade. Values are reported as n (% within CFS grade).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCFS 1\u0026hellip;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCFS 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCFS 5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCFS 6...7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for operation\u003c/p\u003e \u003cp\u003eObstruction OR Other OR Bleeding\u003c/p\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003eIschaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268\u0026nbsp;(59.2)\u003c/p\u003e \u003cp\u003e146\u0026nbsp;(32.2)\u003c/p\u003e \u003cp\u003e39\u0026nbsp;(8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u0026nbsp;(60.2)\u003c/p\u003e \u003cp\u003e44\u0026nbsp;(34.4)\u003c/p\u003e \u003cp\u003e7\u0026nbsp;(5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67\u0026nbsp;(60.9)\u003c/p\u003e \u003cp\u003e33\u0026nbsp;(30)\u003c/p\u003e \u003cp\u003e10\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61\u0026nbsp;(64.2)\u003c/p\u003e \u003cp\u003e29\u0026nbsp;(30.5)\u003c/p\u003e \u003cp\u003e5\u0026nbsp;(5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.799\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of sepsis clinically\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e199\u0026nbsp;(44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u0026nbsp;(41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u0026nbsp;(43.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47\u0026nbsp;(51.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.548\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraperitoneal soiling\u003c/p\u003e \u003cp\u003eNo contamination or blood\u003c/p\u003e \u003cp\u003ePus\u003c/p\u003e \u003cp\u003eFree bowel content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e323\u0026nbsp;(71.3)\u003c/p\u003e \u003cp\u003e53\u0026nbsp;(11.7)\u003c/p\u003e \u003cp\u003e77\u0026nbsp;(17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87\u0026nbsp;(68)\u003c/p\u003e \u003cp\u003e17\u0026nbsp;(13.3)\u003c/p\u003e \u003cp\u003e24\u0026nbsp;(18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u0026nbsp;(73.6)\u003c/p\u003e \u003cp\u003e8\u0026nbsp;(7.3)\u003c/p\u003e \u003cp\u003e21\u0026nbsp;(19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67\u0026nbsp;(70.5)\u003c/p\u003e \u003cp\u003e8\u0026nbsp;(8.4)\u003c/p\u003e \u003cp\u003e20\u0026nbsp;(21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy status\u003c/p\u003e \u003cp\u003eNo malignancy\u003c/p\u003e \u003cp\u003ePrimary or locally spread\u003c/p\u003e \u003cp\u003eDisseminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e342\u0026nbsp;(74)\u003c/p\u003e \u003cp\u003e72\u0026nbsp;(15.6)\u003c/p\u003e \u003cp\u003e48\u0026nbsp;(10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98\u0026nbsp;(75.4)\u003c/p\u003e \u003cp\u003e17\u0026nbsp;(13.1)\u003c/p\u003e \u003cp\u003e15\u0026nbsp;(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u0026nbsp;(66.4)\u003c/p\u003e \u003cp\u003e19\u0026nbsp;(17.3)\u003c/p\u003e \u003cp\u003e18\u0026nbsp;(16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71\u0026nbsp;(74.7)\u003c/p\u003e \u003cp\u003e12\u0026nbsp;(12.6)\u003c/p\u003e \u003cp\u003e12\u0026nbsp;(12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSurvival after Operation\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts Kaplan-Meier curves stratified by CFS grade. A significant association between CFS grade and both 30-day and 180-day mortality was identified in univariable analysis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for each grade). By 180 days post-operation, mortality reached 54.5% in CFS grade 7 patients, while it was only 4.1% in patients considered fit for their age. The HR for mortality for CFS grades 4, 5, and 6\u0026ndash;7 were 3.73 (95% CI 1.98\u0026ndash;7.06), 5.84 (95% CI 3.20-10.67), and 13.66 (95% CI 7.92\u0026ndash;23.56), respectively, in univariable Cox regression analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAge was significantly correlated with both 30-day and 180-day mortality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Only one patient under 50 died within 30 days after the operation (30-day mortality of 0.6%). For patients aged 50 and above, 30-day mortality rate was 60 patients (9.5%). The overall 180-day mortality was 5 patients (2.9%) for those under 50, and 98 (15.5%) for patients aged 50 and above. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates the distribution of 180-day mortality by age and CFS grade.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAdditional factors significantly affecting survival in univariable analysis included intraperitoneal soiling with free bowel content (HR 2.22, 95% CI 1.42\u0026ndash;3.45), indication categories of sepsis or ischaemia (HR 1.87, 95% CI 1.22\u0026ndash;2.86 and HR 2.27, 95% CI 1.20\u0026ndash;4.31, respectively), disseminated malignancy at the time of operation (HR 1.73, 95% CI 1.03\u0026ndash;2.91), and sepsis clinically (HR 2.42, 95% CI 1.60\u0026ndash;3.68). The effect of intraperitoneal soiling with pus (HR 1.39, 95% CI 0.75\u0026ndash;2.60), sex (HR 0.77 for female sex, 95% CI 0.52\u0026ndash;1.14), and locally spread malignancy (HR 1.26, 95% CI 0.74\u0026ndash;2.16) on survival was not statistically significant on univariable analysis.\u003c/p\u003e \u003cp\u003eFor multivariable analysis, CFS categories 6\u0026ndash;7 were combined due to the small sample sizes. The indication category 'other' (n\u0026thinsp;=\u0026thinsp;12) was grouped with operations performed for obstruction according to the updated NELA risk calculator. Due to the small number of patients in whom the indication was haemorrhage (n\u0026thinsp;=\u0026thinsp;15), these cases were excluded from the final model to prevent overfitting. Local and disseminated malignancy were grouped together. A good model fit was achieved, with a concordance index of 0.838. After adjusting for age, sex, indication, sepsis, intraperitoneal soiling, and malignancy, patient frailty was found to be independently associated with poorer 180-day survival (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The HR for CFS grades 4, 5, and 6\u0026ndash;7 were 3.93 (95% CI 1.89\u0026ndash;8.20), 5.86 (95% CI 2.87\u0026ndash;11.97), and 14.17 (95% CI 7.33\u0026ndash;27.40), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors of mortality after operation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRisk factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eHazard Ratio (95% CI\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariable regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultivariable regression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFS\u003csup\u003ea\u003c/sup\u003e grade\u003c/p\u003e \u003cp\u003e1\u0026hellip;3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e6\u0026hellip;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e3.74 (1.98\u0026ndash;7.06)\u003c/p\u003e \u003cp\u003e5.74 (3.20-10.67)\u003c/p\u003e \u003cp\u003e13.66 (7.92\u0026ndash;23.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e3.93 (1.89\u0026ndash;8.20)\u003c/p\u003e \u003cp\u003e5.86 (2.87\u0026ndash;11.97)\u003c/p\u003e \u003cp\u003e14.17 (7.33\u0026ndash;27.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.04 (1.03\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02 (1.00-1.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.29 (0.88\u0026ndash;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.50 (0.98\u0026ndash;2.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for operation\u003c/p\u003e \u003cp\u003eObstruction or \u0026ldquo;other\u0026rdquo;\u003c/p\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003eIschaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.84 (1.21\u0026ndash;2.80)\u003c/p\u003e \u003cp\u003e2.24 (1.18\u0026ndash;4.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.93 (0.43\u0026ndash;2.01)\u003c/p\u003e \u003cp\u003e3.30 (1.65\u0026ndash;6.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.42 (1.59\u0026ndash;3.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.80 (0.97\u0026ndash;3.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraperitoneal soiling with pus or free bowel content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.90 (1.27\u0026ndash;2.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.17 (1.18-4.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny malignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.47 (0.97\u0026ndash;2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.62\u0026nbsp;(1.04\u0026ndash;2.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003eCFS - Clinical Frailty Scale, \u003csup\u003eb\u003c/sup\u003eCI \u0026ndash; Confidence Interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDelay to Surgery\u003c/h2\u003e \u003cp\u003eThe median DtS was 27 hours for fit patients and 43.5 hours for patients living with at least very mild (CFS\u0026thinsp;\u0026ge;\u0026thinsp;4) (p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003eWe used logarithmically transformed linear regression for the multivariable analysis of DtS due to the positive skew in DtS distribution. Stepwise bi-directional elimination was used, with patient frailty, age, sex, intraperitoneal soiling, indication, and sepsis as input variables. The best model fit was achieved with patient frailty, intraperitoneal soiling, and sepsis included as independent variables (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In the adjusted model, patient frailty (CFS\u0026thinsp;\u0026ge;\u0026thinsp;4) was associated with a 1.38-fold increase of DtS.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors of prolonged delay to surgery after emergency laparotomy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRisk factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDelay to surgery multiplier (95% CI\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariable regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultivariable regression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFS\u003csup\u003ea\u003c/sup\u003e grade\u003c/p\u003e \u003cp\u003e1\u0026hellip;3\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.37 (1.12\u0026ndash;1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.38 (1.14\u0026ndash;1.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.001 (0.995\u0026ndash;1.006)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.87 (0.72\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraperitoneal soiling\u003c/p\u003e \u003cp\u003eNo intraperitoneal soiling\u003c/p\u003e \u003cp\u003ePus\u003c/p\u003e \u003cp\u003eFree bowel content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.41 (1.02\u0026ndash;1.96)\u003c/p\u003e \u003cp\u003e0.53 (0.41\u0026ndash;0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2.06 (1.41\u0026ndash;2.89)\u003c/p\u003e \u003cp\u003e0.72 (0.54\u0026ndash;0.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for operation\u003c/p\u003e \u003cp\u003eObstruction or \u0026ldquo;other\u0026rdquo;\u003c/p\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003eIschaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.76 (0.61\u0026ndash;0.94)\u003c/p\u003e \u003cp\u003e0.92 (0.64\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.65 (0.54\u0026ndash;0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.63 (0.49\u0026ndash;0.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003eCFS - Clinical Frailty Scale, \u003csup\u003eb\u003c/sup\u003eCI \u0026ndash; Confidence Interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDtS was not associated with 30-day or 180-day mortality across our cohort (p\u0026thinsp;=\u0026thinsp;0.981 and p\u0026thinsp;=\u0026thinsp;0.632, respectively). Although there was a statistically significant difference in DtS across different intraperitoneal soiling categories, as well as between patients who had sepsis and those who did not, DtS did not significantly affect 30-day mortality within those subgroups. The correlation between DtS and postoperative LoS was negligible, with Pearson's correlation coefficient of 0.10.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLength of Hospital Stay after Operation\u003c/h2\u003e \u003cp\u003eThe median postoperative LoS was 7 days for fit patients and 10 days for patients living with at least very mild frailty (CFS\u0026thinsp;\u0026ge;\u0026thinsp;4) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eOverall, death during hospitalization was not associated with postoperative LoS (p\u0026thinsp;=\u0026thinsp;0.093). However, death during hospitalization affected postoperative LoS differently in fit compared to frail patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Among fit patients, postoperative LoS tended to be slightly longer in those who died in hospital, although this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.552). In frail patients, postoperative LoS was significantly shorter in patients who died in hospital (median of 6 vs. 10 days, p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e*LoS - postoperative length of stay. Boxes represent interquartile ranges (IQR), whiskers extend 1.5 times IQR.\u003c/p\u003e \u003cp\u003eFor multivariable analysis of postoperative LoS, we utilized logarithmically transformed linear regression. Stepwise bi-directional elimination was employed with patient frailty, age, sex, intraperitoneal soiling, indication, sepsis, and death during hospitalization as input variables. The best model fit was achieved with patient frailty, age, intraperitoneal soiling, sepsis, and death during hospitalization included as independent variables (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In the adjusted model, patient frailty (CFS\u0026thinsp;\u0026ge;\u0026thinsp;4) was associated with 1.24 times increase in postoperative LoS.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors of prolonged postoperative length of hospital stay after emergency laparotomy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRisk factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePostoperative length of stay multiplier (95% CI\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariable regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultivariable regression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFS\u003csup\u003ea\u003c/sup\u003e grade\u003c/p\u003e \u003cp\u003e1\u0026hellip;3\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.26 (1.10\u0026ndash;1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.24 (1.08\u0026ndash;1.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (per one year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.007 (1.003\u0026ndash;1.010)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.006 (1.003\u0026ndash;1.011)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.99 (0.87\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for operation\u003c/p\u003e \u003cp\u003eObstruction or \u0026ldquo;other\u0026rdquo;\u003c/p\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003eIschaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.50 (1.30\u0026ndash;1.72)\u003c/p\u003e \u003cp\u003e1.09 (0.86\u0026ndash;1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003cp\u003en/a\u003c/p\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.59 (1.40\u0026ndash;1.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43 (1.22\u0026ndash;1.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraperitoneal soiling with pus or free bowel content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.52 (1.32\u0026ndash;1.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27 (1.07\u0026ndash;1.51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied in hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.77 (0.60\u0026ndash;0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55 (0.43\u0026ndash;0.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003eCFS - Clinical Frailty Scale, \u003csup\u003eb\u003c/sup\u003eCI \u0026ndash; Confidence Interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrailty-associated increases in 30-day mortality following EL have been extensively documented. The integration of risk management strategies, such as those promoted by the National Emergency Laparotomy Audit (NELA), has been pivotal in reducing mortality rates associated with this high-risk procedure[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The importance of this topic is underscored by the fact that frailty assessment has now reached EL guidelines[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, given that EL is an umbrella term for a wide range of procedures with varying degrees of complexity and urgency, it is critical to further investigate the impact of frailty across different clinical scenarios, such as different indication and intraperitoneal soiling categories.\u003c/p\u003e \u003cp\u003eOur retrospective study confirms that patient frailty is associated with higher mortality rates following EL in both the short and long term. We found no evidence that differences in the distribution of indication, intraperitoneal soiling, or malignancy status categories explain this effect. While the mortality hazard after EL was 14 times higher in the moderately and severely frail patients, this effect appears not to be significantly confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Although reports often focus on increased prevalence of frailty in the elderly, it is crucial for clinicians to recognize that there are also fit people within this age group. In our cohort a fifth of patients over 80 were considered fit for their age and the outcome of their operation was more favourable accordingly.\u003c/p\u003e \u003cp\u003eThe observed prolongation of postoperative LoS in frail patients likely reflects a postoperative period marred by complications as well as functional decline[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], echoing previous findings on the increased cost of care for this group. Notably, our study revealed that death during hospitalization impacts postoperative LoS differently in fit versus frail patients. While it is reasonable to assume that a shorter postoperative LoS would be associated with a lower total cost of hospitalization, the decrease of postoperative LoS caused by death certainly cannot be regarded as a more favourable outcome. As with mortality, the effect of frailty on postoperative LoS seems to remain significant even adjusting for the other mentioned risk factors.\u003c/p\u003e \u003cp\u003eThe finding of a longer DtS for frail patients is consistent with previous research. However, the clinical implication of such delay is less clear. We found no evidence that a longer DtS correlates with worse survival or an extended postoperative LoS in our cohort. It is conceivable that this additional waiting period allowed for the involvement of more senior staff in the decision-making process, as well as elderly care specialists to achieve better physiological optimization before surgery. While it could be hypothesized that such efficient use of time could offset the intrinsic risks associated with frailty, our study lacked specific data on this aspect. Further research is needed to explore and substantiate this hypothesis.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe retrospective nature of our study introduces inherent limitations. While the CFS can be effectively assessed from patient records, the accuracy of such evaluations is dependent on the detail of these notes. In cases where CFS data were missing from the NELA database, occupational and physiotherapy records were invaluable. However, the absence of detailed records may lead to misclassification, skewing patients towards a \"not frail\" designation and potentially introducing information bias, especially for patients on CFS grade 4.\u003c/p\u003e \u003cp\u003e Although the number of patients included in the study was relatively large, the lower proportion of patients with higher Clinical Frailty Scale (CFS) grades and the number of categories analysed in our regression model necessitated the grouping of certain variables to prevent overfitting. Consequently, a larger cohort could yield more precise estimates of effect sizes.\u003c/p\u003e \u003cp\u003eAdditionally, as the study was conducted at a single institution, its generalizability may be limited.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings underscore the adverse impact of frailty on prognosis and postoperative LoS following EL, regardless of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. The association between frailty and extended DtS highlights the need for larger, multicentre studies to further elucidate the effects of frailty across different EL procedures and to assess the role of DtS in frail patient populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.G.I. was responsible for conseptualization, methodology, project administration, writing he original draftK.G.I., S.F.H and M.S were responsible for data curation, investigation and reviewing the draftK.G.I. and \u0026Uuml;.K. were responsible for data analysis, methodology, preparing the figures and reviewing the draft.G.B-S., H.K., S.S., U.L. and P.T. were responsible for conseptualization, methodology, resources, supervision and reviewing the draft.\u003c/p\u003e\u003ch2\u003eData availability:\u003c/h2\u003e \u003cp\u003enot publically available\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E et al. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg [Internet]. 2023 [cited 2024 Feb 22];18:38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13017-023-00506-7\u003c/span\u003e\u003cspan address=\"10.1186/s13017-023-00506-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParmar KL, Law J, Carter B, Hewitt J, Boyle JM, Casey P, et al. Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study. Ann Surg. 2021;273:709\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy CA, Shipway D, Barry K. Frailty and emergency abdominal surgery: A systematic review and meta-analysis. Surg J R Coll Surg Edinb Irel. 2022;20:e307\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph B, Zangbar B, Pandit V, Fain M, Mohler MJ, Kulvatunyou N et al. Emergency General Surgery in the Elderly: Too Old or Too Frail? J Am Coll Surg [Internet]. 2016 [cited 2023 Feb 15];222:805. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.lww.com/journalacs/Abstract/2016/05000/Emergency_General_Surgery_in_the_Elderly__Too_Old.9.aspx\u003c/span\u003e\u003cspan address=\"https://journals.lww.com/journalacs/Abstract/2016/05000/Emergency_General_Surgery_in_the_Elderly__Too_Old.9.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVilches-Moraga A, Rowley M, Fox J, Khan H, Paracha A, Price A et al. Emergency laparotomy in the older patient: factors predictive of 12-month mortality\u0026mdash;Salford-POPS-GS. An observational study. 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Br J Surg. 2020;107:218\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"frailty, emergency laparotomy, survival, delay to surgery","lastPublishedDoi":"10.21203/rs.3.rs-4210153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4210153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eEmergency laparotomy (EL) encompasses procedures of varying complexity and urgency, undertaken in different clinical scenarios, leading to different risks of morbidity and mortality. We hypothesized that the increased mortality and longer postoperative length of stay (LoS) observed in frail patients are related to differences in indication for operation, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study analysed patients entered into the National Emergency Laparotomy Audit database between January 1, 2018, and June 15, 2021, in Oxford. The primary outcome was 180-day survival analysed using multivariable Cox regression. The secondary outcomes, delay to surgery (DtS) and postoperative LoS, were analysed using logarithmically transformed multivariable linear regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 803 patients analysed, 396 (49.3%) were male. The median age was 66, and 337 (42%) were living with at least very mild frailty. Mortality hazard ratios for Clinical Frailty Scale grades 4 (3.93, 95% CI 1.89\u0026ndash;8.20), 5 (5.86, 95% CI 2.87\u0026ndash;11.97), and 6\u0026ndash;7 (14.17, 95% CI 7.33\u0026ndash;27.40) were not confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Frail patients experienced a 1.38-fold longer DtS and a 1.24-fold longer postoperative LoS, even after adjusting for indication, sepsis, intraperitoneal soiling, malignancy status, and DtS.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur results indicate that frail patients have a poorer prognosis and longer postoperative LoS, independent of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. Patient frailty is also associated with longer DtS.\u003c/p\u003e","manuscriptTitle":"Impact of Frailty on Outcomes Following Emergency Laparotomy: A Retrospective Analysis Across Diverse Clinical Conditions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-09 21:09:23","doi":"10.21203/rs.3.rs-4210153/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-24T00:42:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T21:27:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162841069548210460240032990763049646456","date":"2024-07-18T21:19:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T18:32:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6832839801281433154121587362716563424","date":"2024-07-09T22:43:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"06ef7c03-f45b-4431-929c-61c0175905e4","date":"2024-04-19T21:36:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-04T15:44:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-04T13:36:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-04T03:52:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-04-03T05:43:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"19bd6713-093f-491a-ab8a-e9f23139d9f9","owner":[],"postedDate":"April 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-26T15:58:22+00:00","versionOfRecord":{"articleIdentity":"rs-4210153","link":"https://doi.org/10.1007/s00068-024-02632-6","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2024-08-21 15:56:51","publishedOnDateReadable":"August 21st, 2024"},"versionCreatedAt":"2024-04-09 21:09:23","video":"","vorDoi":"10.1007/s00068-024-02632-6","vorDoiUrl":"https://doi.org/10.1007/s00068-024-02632-6","workflowStages":[]},"version":"v1","identity":"rs-4210153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4210153","identity":"rs-4210153","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}