Enhanced Recovery After Surgery in Emergency Laparotomy in Older Patients - A Streamlined Approach

3499
Rebecca Taljaard, Clare Hughes, Nick Newton
University Hospitals Birmingham
Clinical Quality
CQ - Clinical Effectiveness

Abstract

Introduction:
Enhanced Recovery After Surgery (ERAS) protocols have significantly improved outcomes in elective surgery, but their application in emergency settings—particularly for elderly patients—remains limited. Although ERAS guidelines for emergency laparotomy exist, uptake in clinical practice is inconsistent. Data from the National Emergency Laparotomy Audit (NELA) show that patients aged ≥65 experience significantly worse outcomes than younger cohorts, with a 30-day mortality of 15.3% compared to 4.9%, and longer hospital stays (15.2 vs. 11.3 days)1.

Our aim was to develop a modified, concise ERAS protocol tailored for elderly patients (≥65 years) undergoing emergency laparotomy, addressing frailty, multimorbidity, cognitive impairment, and reduced physiological reserve.

Methods:
Current ERAS guidelines for emergency laparotomy were reviewed and categorised into preoperative, perioperative, and postoperative phases. Three key components per phase were selected for their relevance to older adults, guided by recommendations from the British Geriatrics Society (BGS), NELA and our local Health Care of Older People (HCOP) consultant team.  This process informed the development of a modified ERAS protocol specifically tailored to improve outcomes in the elderly population undergoing emergency laparotomy.

Results:
A modified ERAS in emergency laparotomy protocol for elderly patients was developed.  Preoperative recommendations focus on frailty assessment with clinical frailty score, early geriatrician input for comprehensive geriatric assessment, and risk stratification. Perioperatively the focus is on goal-directed fluid therapy, intraoperative monitoring and a minimally invasive approach where possible. Postoperatively: Early mobilisation, delirium prevention and nutritional support.

Conclusion:
A shortened, elderly-focused ERAS protocol for emergency laparotomy is both feasible and potentially beneficial. Given the limited uptake of full ERAS guidelines in emergency surgery, such pragmatic adaptations may bridge the gap between evidence and practice while improving outcomes. Prospective studies are needed to validate these findings and refine emergency ERAS pathways for geriatric populations.

References

  1. Peden CJ et al. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 45, 1272–1290 (2021).
  2. Scott MJ et al. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 47, 1850–1880 (2023).
  3. Aitken RM et al. Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1-4. Age Ageing. 2020 Jul 1;49(4):656-663.