The false dichotomy of surgical futility in the emergency laparotomy setting: scoping review

BACKGROUND: Futile is defined as ‘the fact of having no effect or of achieving nothing’. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This scoping review aimed to identify key concepts around surgical futility as it relates to emergency laparotomy. METHODS: Using the Arksey and O’Malley framework, a scoping review was conducted. A search of the Cochrane Library, Google Scholar, MEDLINE, and Embase was performed up until 1 November 2021 to identify literature relevant to the topic of futility in emergency laparotomy. RESULTS: Three cohort studies were included in the analysis. A total of 105 157 patients were included, with 1114 patients reported as futile. All studies were recent (2019 to 2020) and focused on the principle of quantitative futility (assessment of the probability of death after surgery) within a timeline after surgery: two defining futility as death within 48 hours of surgery and one as death within 72 hours. In all cases this was derived from a survival histogram. Predictors of defined futile procedures included age, level of independence prior to admission, surgical pathology, serum creatinine, arterial lactate, and pH. CONCLUSION: There remains a paucity of research defining, exploring, and analysing futile surgery in patients undergoing emergency laparotomy. With limited published work focusing on quantitative futility and the binary outcome of death, research is urgently needed to explore all principles of futility, including the wishes of patients and their families.