Impact of frailty and physiological severity on early and medium-term surgical outcomes after open abdomen

Open abdomen (OA), mainly indicated for sepsis and second-look surgery, may entail severe complications that translate into high morbidity and mortality. Following the World Society of Emergency Surgery 2018 Guidelines leads to an improvement in surgical outcomes. However, how baseline status and fragility might determine patient´s morbidity and survival has not been described yet.

Retrospective analysis of a prospectively maintained registry of patients undergoing emergency laparotomy with temporary abdominal closure (January 2020-December 2022) and ≥12-month follow-up. Demographics, surgical features, surgical outcomes, and survival were compared across APACHE II and frailty strata. Frailty was assessed using both the Modified Frailty Index-5 and Modified Frailty Index-11 instruments. The APACHE II cutoff was derived by Youden Index; survival was analyzed with Kaplan-Meier/log-rank.

Of 3,103 emergency laparotomies, 115 patients (3.7%) required OA (69.6% males; median age: 62 y). The main indications were septic abdomen 44.3%, second-look 31.3%. All received negative-pressure therapy; 73.9%, in addition, underwent mesh-mediated fascial traction. Median time to definitive closure was three days (IQR: 2-4.75). Complication rates were 72% for surgical and 83.5% for systemic complications, Clavien-Dindo III-IV complications were present in 50 (43.5%) patients. In-hospital mortality was 47%; overall 49.6%, including 22.6% within 48 hours. APACHE II ≥16 (Youden cutoff) was associated with lower survival (log-rank p = 0.004) and higher mortality (22.84 ± 8.77 vs 17.98 ± 8.99; p = 0.003). Frailty indices showed no significant association with mortality or survival ( p = 0.11; p = 0.081).

Preoperative physiological status acts as a major determinant of systemic complications and mortality in patients requiring OA. The APACHE II score proved to be an independent prognostic factor and could be integrated into routine clinical decision-making.

Prognostic and Epidemiologic; Level IV.