Outcomes and Decision Making in High-Risk Lap and NoLap Patients: Clinical Frailty Score vs NELA Score

Introduction: High-risk emergency laparotomy patients are characterised as having a National Emergency Laparotomy Audit (NELA) mortality prediction of ≥5%, but this often underestimates risk. Frailty has been reported as an important factor in decision-making for laparotomy. Outcomes for patients who do not proceed to laparotomy (NoLap) are less-reported, as are the reasons why this decision is made. Our aim was to explore the decision-making process for high-risk patients eligible for laparotomy and to investigate which factors heavily influenced the decision. We then analysed outcomes in those were managed with a laparotomy (Lap), vs NoLap. Methods: A prospective study over 6 months was conducted across two hospitals. Patients with NELA ≥5% and aged ≥65 warranting laparotomy were included. Fisher's and Mann-Whitney U testing was used to compare Lap and NoLap outcomes. Multivariable regression analysis was used to determine which factors were associated with the decision for or against laparotomy. Results: A total of 62 patients were eligible for inclusion. NoLap patients had significantly higher NELA (p=<0.001), American Society of Anaesthesiologists (ASA) classification (p=0.008) CFS (p=<0.001), and higher mortalities (<0.001). ASA was the only predictor of mortality (p=0.04). Only 32% of all cases had a full multidisciplinary team (intensivist, anaesthesiologist and surgeon) involved in decision-making. CFS was the most specific and sensitive factor influencing decision-making (p=<0.001), but only NELA predicted morbidity (p=0.03). Conclusions: High-risk NoLap patients have worse outcomes than their Lap counterparts. Although CFS is not currently included in the NELA calculation, it is a crucial variable used in laparotomy decision making in high-risk patients.