Trauma/Critical Care| Volume 168, ISSUE 4, P676-683, October 2020

The CELIOtomy Risk Score: An effort to minimize futile surgery with analysis of early postoperative mortality after emergency laparotomy



      Emergency surgical services often encounter patients with generalized peritonitis. Difficult perioperative decisions impact morbidity, mortality, cost, and utilization of hospital resources. The ability to preoperatively predict patient nonsurvival despite surgical intervention using clinical physiologic indicators was the aim of this study and would be helpful in counseling patients/families.


      A retrospective cohort from an institutional database was queried for nontrauma patients with peritonitis undergoing emergency laparotomy from 2012 to 2016. Time to mortality after surgery was compared: early (≤72 hours) versus late (>72 hours) and no death.


      After 534 emergency laparotomies, there were 74 (13.9%) mortalities. Of these, death occurred early (≤72 hours) after surgery in 28 (37.8%) patients and late (>72 hours) in 46 (62.2%). Early death patients had a significantly more deranged physiology, as evidenced by higher Acute Physiology and Chronic Health Evaluation II scores (mean 28.1 ± 8.4 vs 22.9 ± 8.7, P = .01), worse acute kidney injury (preoperative creatinine 3.7 ± 3.2 vs 1.9 ± 1.4, P = .001), and greater level of acidosis (pH 7.19 ± 0.12 vs 7.27 ± 0.13, P = .017). Additionally, preoperative lactate was significantly increased in patients with early mortality (6.8 ± 4.1 vs 5.1 ± 4.0, P = .045). Using logarithmic regression, a nomogram was constructed using age, Glasgow Coma Scale, lactate, creatinine, and pH. This nomogram had an area under the curve of 0.908 on receiver operator curve analysis. A score of 13 equates to greater than 50% risk of early mortality after surgery.


      Early mortality (≤72 hours after emergency laparotomy) is associated with decreased pH, elevated creatinine, and elevated lactate. These factors combined into the nomogram constructed may assist surgical teams with patient and family discussions to prevent futile surgical interventions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Shafi S.
        • Aboutanos M.B.
        • Agarwal Jr., S.
        • et al.
        • and the AAST Committee on Severity Assessment and Patient Outcomes
        Emergency general surgery: definition and estimated burden of disease.
        J Trauma Acute Care Surg. 2013; 74: 1092-1097
        • Gale S.C.
        • Shafi S.
        • Dombrovskiy V.Y.
        • Arumugam D.
        • Crystal J.S.
        The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample--2001 to 2010.
        J Trauma Acute Care Surg. 2014; 77: 202-208
        • Havens J.M.
        • Olufajo O.A.
        • Cooper Z.R.
        • Haider A.H.
        • Shah A.A.
        • Salim A.
        Defining rates and risk factors for readmissions following emergency general surgery.
        JAMA Surg. 2016; 151: 330-336
        • Shah A.A.
        • Haider A.H.
        • Zogg C.K.
        • et al.
        National estimates of predictors of outcomes for emergency general surgery.
        J Trauma Acute Care Surg. 2015; 78 (discussion 490-491): 482-490
        • Scott J.W.
        • Olufajo O.A.
        • Brat G.A.
        • et al.
        Use of national burden to define operative emergency general surgery.
        JAMA Surg. 2016; 151e160480
        • Ogola G.O.
        • Gale S.C.
        • Haider A.
        • Shafi S.
        The financial burden of emergency general surgery: National estimates 2010 to 2060.
        J Trauma Acute Care Surg. 2015; 79: 444-448
        • Ogola G.O.
        • Shafi S.
        Cost of specific emergency general surgery diseases and factors associated with high-cost patients.
        J Trauma Acute Care Surg. 2016; 80: 265-271
        • Al-Temimi M.H.
        • Griffee M.
        • Enniss T.M.
        • et al.
        When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database.
        J Am Coll Surg. 2012; 215: 503-511
        • Saunders D.I.
        • Murray D.
        • Pichel A.C.
        • Varley S.
        • Peden C.J.
        • UK Emergency Laparotomy Network
        Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network.
        Br J Anaesth. 2012; 109: 368-375
        • Cooper Z.
        • Scott J.W.
        • Rosenthal R.A.
        • Mitchell S.L.
        Emergency major abdominal surgical procedures in older adults: A systematic review of mortality and functional outcomes.
        J Am Geriatr Soc. 2015; 63: 2563-2571
        • Berlin A.
        • Hwang F.
        • Singh R.
        • et al.
        Outcomes and palliative care utilization in patients with dementia and acute abdominal emergency: opportunities for surgical quality improvement.
        Surgery. 2018; 163: 444-449
        • Cauley C.E.
        • Panizales M.T.
        • Reznor G.
        • et al.
        Outcomes after emergency abdominal surgery in patients with advanced cancer: Opportunities to reduce complications and improve palliative care.
        J Trauma Acute Care Surg. 2015; 79: 399-406
        • Singh R.
        • Hwang F.
        • Berlin A.
        • et al.
        Patients with end-stage renal disease and acute surgical abdomen: Opportunities for palliative care.
        J Palliat Med. 2019; 22: 635-643
        • Rix T.E.
        • Bates T.
        Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery.
        World J Emerg Surg. 2007; 2: 16
        • Stonelake S.
        • Thomson P.
        • Suggett N.
        Identification of the high risk emergency surgical patient: Which risk prediction model should be used?.
        Ann Med Surg (Lond). 2015; 4: 240-247
        • Regenbogen S.E.
        • Lancaster R.T.
        • Lipsitz S.R.
        • Greenberg C.C.
        • Hutter M.M.
        • Gawande A.A.
        Does the Surgical Apgar Score measure intraoperative performance?.
        Ann Surg. 2008; 248: 320-328
        • Mohil R.S.
        • Bhatnagar D.
        • Bahadur L.
        • Rajneesh
        • Dev D.K.
        • Magan M.
        POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy.
        Br J Surg. 2004; 91: 500-503
        • Bertsimas D.
        • Dunn J.
        • Velmahos G.C.
        • Kaafarani H.M.A.
        Surgical risk is not linear: Derivation and validation of a novel, user-friendly, and machine-learning-based Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) calculator.
        Ann Surg. 2018; 268: 574-583
        • Vaid S.
        • Bell T.
        • Grim R.
        • Ahuja V.
        Predicting risk of death in general surgery patients on the basis of preoperative variables using American College of Surgeons National Surgical Quality Improvement Program data.
        Perm J. 2012; 16: 10-17
        • DeWane M.P.
        • Davis K.A.
        • Schuster K.M.
        • Maung A.A.
        • Becher R.D.
        Rethinking our definition of operative success: predicting early mortality after emergency general surgery colon resection.
        Trauma Surg Acute Care Open. 2019; 4e000244
        • Chiu A.S.
        • Jean R.A.
        • Resio B.
        • Pei K.Y.
        Early postoperative death in extreme-risk patients: A perspective on surgical futility.
        Surgery. 2019; 166: 380-385
        • Muralidhar V.A.
        • Madhu C.P.
        • Sudhir S.
        • Srinivasarangan M.
        Efficacy of Mannheim peritonitis index (MPI) score in patients with secondary peritonitis.
        J Clin Diagn Res. 2014; 8: NC01-NC3
        • Viehl C.T.
        • Kraus R.
        • Zurcher M.
        • Ernst T.
        • Oertli D.
        • Kettelhack C.
        The Acute Physiology and Chronic Health Evaluation II score is helpful in predicting the need of relaparotomies in patients with secondary peritonitis of colorectal origin.
        Swiss Med Wkly. 2012; 142: w13640
        • Peng Y.
        • Qi X.
        • Guo X.
        Child-Pugh Versus MELD score for the assessment of prognosis in liver cirrhosis: A systematic review and meta-analysis of observational studies.
        Medicine (Baltimore). 2016; 95: e2877
        • Aoki N.
        • Wall M.J.
        • Demsar J.
        • et al.
        Predictive model for survival at the conclusion of a damage control laparotomy.
        Am J Surg. 2000; 180 (discussion 544-545): 540-544
        • Asensio J.A.
        • McDuffie L.
        • Petrone P.
        • et al.
        Reliable variables in the exsanguinated patient which indicate damage control and predict outcome.
        Am J Surg. 2001; 182: 743-751
        • Kairinos N.
        • Hayes P.M.
        • Nicol A.J.
        • Kahn D.
        Avoiding futile damage control laparotomy.
        Injury. 2010; 41: 64-68
      1. The Royal College of Anaesthetists. National emergency laparotomy audit.
        (Accessed January 14, 2020.)
        • Becher R.D.
        • Hoth J.J.
        • Miller P.R.
        • Meredith J.W.
        • Chang M.C.
        Systemic inflammation worsens outcomes in emergency surgical patients.
        J Trauma Acute Care Surg. 2012; 72: 1140-1149
        • Becher R.D.
        • Peitzman A.B.
        • Sperry J.L.
        • et al.
        Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery.
        World J Emerg Surg. 2016; 11: 10
        • Huynh T.N.
        • Kleerup E.C.
        • Wiley J.F.
        • et al.
        The frequency and cost of treatment perceived to be futile in critical care.
        JAMA Intern Med. 2013; 173: 1887-1894
        • Meltzer L.S.
        • Huckabay L.M.
        Critical care nurses' perceptions of futile care and its effect on burnout.
        Am J Crit Care. 2004; 13: 202-208
        • Niederman M.S.
        • Berger J.T.
        The delivery of futile care is harmful to other patients.
        Crit Care Med. 2010; 38: S518-S522
        • Cooper Z.
        • Corso K.
        • Bernacki R.
        • Bader A.
        • Gawande A.
        • Block S.
        Conversations about treatment preferences before high-risk surgery: a pilot study in the preoperative testing center.
        J Palliat Med. 2014; 17: 701-707
        • Cooper Z.
        • Koritsanszky L.A.
        • Cauley C.E.
        • et al.
        Recommendations for best communication practices to facilitate goal-concordant care for seriously ill older patients with emergency surgical conditions.
        Ann Surg. 2016; 263: 1-6
        • Kruser J.M.
        • Nabozny M.J.
        • Steffens N.M.
        • et al.
        “Best Case/Worst Case”: Qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions.
        J Am Geriatr Soc. 2015; 63: 1805-1811