This prospective, single-center study aimed to characterise and report clinical outcomes for a consecutive cohort of patients eligible for major emergent abdominal surgery including patients who did not proceed to major emergent abdominal surgery (No-LAP population) in a Danish center with an established care pathway.
The study revealed that 8.3% of our total patient cohort did not proceed to surgery. This in comparison to the 32% reported by McIlveen et al. In our cohort, all but one No-LAP patient (95%) died within a month after admission while approximately 37% of the No-LAP patients in the study by McIlveen et al. were alive 30 days after admission The 30-day mortality rate for the LAP-cohort was 9% in our cohort vs. 12.6% in the study by McIlveen et al. However, the 30-day mortality rate for the whole cohort was 16% in our study versus 29% in the data reported previously by McIlveen et al .
Current literature is scarce with only one prospective study reporting outcomes for this patient population [8, 12]. In our study, the No-Lap population was predominantly characterised by elderly patients with poor performance status, severe comorbidities, hypoalbuminemia, elevated lactate, and creatinine levels, and those likely to have bowel ischemia at admission. These features also appeared to be common in the study by McIlveen et al  and have also been described in patients who had undergone futile surgery despite extreme preoperative risk [5, 18, 19]. While all No-Lap patients but one died within 30-days after admission, early mortality within the first 30 days was also observed in the LAP cohort, however, to a lesser extent. A continuous increase in mortality was observed in the LAP cohort until 90 days after admission where the mortality seems to reach a steady state (Fig. 2). This may indicate potential variation in patient related characteristics and physiological adaptation to surgical stress response in late survivors vs. non-survivors.
The results of our study, and the results presented by McIlveen et al indicate potential large differences in the complex procedure of pre-operative decision-making which may have an immense effect on patient outcomes . Decision-making in emergency abdominal surgery is challenging due to a large heterogeneity in patient-related factors i.e. surgical pathology and physiology (perforation vs. intestinal obstruction, presence of frailty, comorbidities, and age). Other well-established factors affecting decision making include surgeons' clinical and operative experience, perception of risks and benefits of operative and non-operative treatment, external pressure to operate i.e. from patients or their relatives, and culture [1, 7, 9, 20, 21].
The potential variation in pre-operative decision-making between our study and the study presented by McIlveen et al seems to be large and raises several issues. Firstly, from an ethical point of view, if patients suitable for major emergency surgery are deselected from surgery due to cultural variations in health care systems, unnecessary excessive mortality can be expected. Secondly, these variations may hamper the development of evidence-based guidelines, as the comparison of research outcomes and evaluation of different patient care pathways are based on the operated patients, thus making it challenging to establish objective criteria to define surgical futility. Thirdly excessive surgery to patients with low life expectancy is futile and causes both unnecessary suffering and waste scarce surgical resources.
While the main strength of the current study is the prospective design with the inclusion of a high number of consecutive patients some limitations need to be addressed. Firstly, we conducted a single-center study which may limit the extrapolation of our findings, as different centers may have different demographic characteristics, center volume, and triage. Secondly, it is reasonable that the conduction of the study may have led to increased awareness about the No-LAP patients which may have led to different decision-making during the study period.
Moreover, the COVID-19 pandemic and the associated lockdowns have affected surgical health care services globally and should be considered as a potential limitation when interpreting the results of our study 
COVID-19 may have had an impact on the incidence of patients presenting with major abdominal pathology- as some patients may have died at home/nursing home facilities instead of admission to surgical wards potentially biasing mortality outcomes. During the study period, there was a period with lockdown and cancellation of elective non-cancer surgery which may have led to fewer reoperations for complications during the study period. The average number of patients undergoing AHA surgery at our institution was 23,1 during the study period versus 26,4 during the same monthly period pre-Covid dates (15th October 2018- 15th August2019), indicating a 14% decrease. While this decrease could be due to reduced patient intake secondary to Covid-19 restrictions, it could also be due to fewer complications secondary to elective surgery. However, it should be noted that complications secondary to elective surgery have been shown to have lower mortality than primary emergency surgery. During the COVID-19 pandemic the hospital resources (Operating theathers for emergency surgery and Intensive care resources including bed availability) for AHA-patients were not affected. Finally, the lower number of patients undergoing surgery in the inclusion period could be due to an increase in the number of NoLap patients secondary to the present study, thus decreasing the number of patients presenting for surgery.
In the era of shared decision-making, proper identification of the frail surgical patient and early evaluation of whether surgical intervention is deemed futile, is of paramount importance, to avoid futile care which seems to be common. Nevertheless, a complex clinical and ethical dilemma that every surgeon and anesthesiologist will face regularly, and probably face more frequently, as life expectancy and the need for emergency surgery is on the rise globally. Preoperative decision-making must be a multidisciplinary assessment process where the surgeon and the anaesthesiologists address the morbidity and mortality risks associated with care concerning the patient’s pathology, comorbidities, functional status, and wishes adequately to avoid futile care .
There is an obvious need for prospective multi-center studies to characterise the whole population of patients in whom surgery is indicated including the No-LAP population, and to establish a standardized report form for these decisions allowing comparisons to be made, and evidence-based guidelines for futility to be established, hopefully increasing quality of care for the patients.
Final results from an ongoing large multicenter, UK-based prospective cohort study aiming to characterize the No-LAP patients are awaited . While this study may show potential regional and cultural differences between the centers in the UK it will not show potential cultural differences compared to other countries. This can be assessed by a prospective international multicenter cohort study in the future although it will require a standardization of cohort definitions and outcome measures.
Results from the UK-based multicenter study may however raise questions about which departments should manage these complex surgical patients if potential variation in decision making and mortality-related outcomes between low-volume and high volume surgical centers are found. . Future studies should focus on objective assessment tools to identify patients in whom surgery may not be beneficial.
Moreover, reporting of study outcomes including reporting outcomes for the No-LAP population should be standardized to make comparison feasible in future research.