TPTh 3.02 Perioperative Risk Prediction in Emergency Laparotomy: Evolution, Current Tools and Future Directions

Importance Emergency laparotomy (EL) is a high-risk general surgical procedure, increasingly performed in frail, comorbid populations. Over the past seven decades, multiple risk stratification tools have emerged to quantify perioperative risk, incorporating physiological parameters, comorbidities, and, in some cases, anticipated operative findings. This review synthesises the historical evolution and current utility of these tools in EL, highlighting their roles in shared decision-making, consent, and quality improvement. Observations Risk prediction in EL has progressed from early physiological scores (ASA, APACHE) to audit-derived models (POSSUM, P-POSSUM), large database-driven calculators (ACS-NSQIP), and EL-specific tools such as NELA, ESAS/PESAS, ESS and CORES. Disease-specific indices (e.g., Mannheim Peritonitis Index) and emerging prognostic markers, including frailty measures and CT-derived body-composition metrics, address limitations of traditional physiological models, particularly in elderly or physiologically vulnerable patients. Tools based solely on preoperative variables support rapid assessment when operative data are unavailable, whereas newer early-mortality scores (e.g., CELIO) may aid proportionality and goals-of-care discussions but require further validation. A chronological table summarises each scoring system’s variables and development timeline. Conclusions and Relevance Risk-adjusted outcomes should replace crude mortality as the benchmark for surgical quality, consent, and institutional comparison. Integrating validated scoring systems with frailty, physiological variables and body composition assessment offers a pragmatic framework for individualised care, especially in older, comorbid patients. This approach supports standardisation, reduces unwarranted variation, and guides future research toward improved calibration and external validation. Clinically, these tools enhance transparency, facilitate multidisciplinary communication, and align surgical decision-making with patient-centred and evidence-based principles.