Emergency General Surgery Research Articles

Current state of surgery and trauma in Mauritania: a Scoping Review

Introduction: Nearly one-third of the global burden of disease can be addressed through surgical care. Trauma forms a significant part of this burden, resulting in higher mortality than HIV, tuberculosis, and malaria combined. Mauritania, one of the largest countries in West Africa, lags significantly behind the sustainable development goals set by the World Health Organization (WHO). In this study, we reviewed the available literature on surgery and trauma in Mauritania. Methods: We conducted a literature review using the Embase database (from 1974) and Medline (from 1946) up to June 2024. All studies related to surgery and trauma in Mauritania were included. Studies focused solely on obstetrics, gynaecology and anaesthesia were excluded. Articles were screened for eligibility using Rayyan software. Results: The search strategy returned 449 abstracts. After manual de-duplication, 25 were removed. Following further screening, 411 articles were excluded. The final analysis included nine eligible full length articles and 2 conference abstracts. The 9 full length articles articles addressed a range of topics: emergency general surgery – ileal perforations (1), endocrine surgery specific to the thyroid gland (1), surgical expenditures (1), surgical availability (1), a surgical experience account in Mauritania (1), youth violence (1), causes of mortality and the burden of trauma (2), and an analysis of terrorist attacks (1). Both conference abstracts were related to emergency general surgery, covering the management of cholecystitis and malignant large bowel obstruction. Conclusion: The literature on surgery and trauma in Mauritania is extremely limited. More epidemiological data, as well as studies on interventions, are necessary to better inform the delivery of global surgical care in this country of approximately 5 million people.

Agile monitoring dashboard for clinical research studies

BackgroundClinical trial success hinges on efficient participant recruitment and retention. However, slow accrual and attrition frequently hinder progress. To address these challenges, a novel dashboard tool with control charts has been developed to provide investigators on the multi-site study of Delirium and Neuropsychological Recovery among Emergency General Surgery Survivors (DANE study) with timely information to improve trial recruitment.MethodsA quality monitoring Excel dashboard with control chart functionality developed by the principal investigator’s (PI) group and implemented in a department of a large hospital was re-engineered for research study recruitment purposes. The dashboard provides the PIs and other stakeholders with timely, actionable, and unbiased information on the count of participants who have completed each stage or action within the process, the rates of completion and trends, both for the current week and cumulatively.ResultsThe DANE dashboard was prototyped using Microsoft Excel for accessibility and rapid development. The tool integrates with a REDCap database, simplifying data import and analysis. By facilitating informed decision-making throughout the recruitment process, the DANE dashboard has significantly enhanced clinical trial efficiency and led to changes in the eligibility criteria and improvements in the approach and consent processes.ConclusionsThe DANE dashboard for monitoring participant recruitment and attrition in research studies represents a significant step towards enhancing study management and decision-making processes. It can be adapted to other clinical studies and other staged processes with attrition. The generic version, currently under development, holds promise for evolving into a valuable simulator by incorporating a spreadsheet for generating random data and accounting for resource constraints. This enhancement could further be augmented by integrating forecasting capabilities into the control charts.Trial registrationThe Delirium and Neuropsychological Recovery among Emergency General Surgery Survivors (DANE) study (NCT05373017, 1R01AG076489-01) is a multi-site, two-arm, single-blinded randomized controlled clinical trial to evaluate the efficacy of the Emergency General Surgery (EGS) Delirium Recovery Model to improve the cognitive, physical, and psychological recovery of EGS delirium survivors over 65. The DANE study received approval from the University of Wisconsin-Madison/University of Wisconsin Hospitals and Clinics Institutional Review Board (IRB, no. 2022–0545, approval date September 14, 2022), and Indiana University agreed to cede IRB review to University of Wisconsin-Madison/University of Wisconsin Hospital and Clinics (September 29, 2022).

Evidence-based, cost-effective management of acute cholecystitis: An algorithm of the Journal of Trauma and Acute Care Surgery emergency general surgery algorithms working group.

Evidence-based, cost-effective management of acute cholecystitis: An algorithm of the Journal of Trauma and Acute Care Surgery emergency general surgery algorithms working group.

Analysis of 73 Cases of Percutaneous Cholecystostomy for Acute Cholecystitis: Patient Selection is Key.

Background: Percutaneous cholecystostomy (PC) rates have substantially increased in England over the past two decades. However, its utilization and clinical outcomes at a local level are not well documented or understood. This study aimed to characterize the cohort of patients who underwent PC and resulting clinical outcomes at a tertiary center for hepatobiliary and emergency general surgery. Methods: This is a retrospective cohort study of patients treated between 2012 and 2020 at a single center. A subgroup analysis was conducted to compare outcomes between Tokyo grade 2 and Tokyo grade 3 patients. Results: In the 73-patient cohort, a 57.1% increase in PC was observed between 2012 and 2020. Compared to the gold-standard Tokyo guidelines, 36 patients (49.3%) met the criteria for PC. Postprocedural complications occurred in 50 patients (68.5%), including PC tube dysfunction (27.4%), intra-abdominal abscess (20.5%), external bile leak (8.2%), and biloma (5.5%). Recurrent biliary infection developed in 30 patients (41.1%). Twenty-seven patients (37%) underwent emergency reinterventions due to acute cholecystitis recurrence. Twenty patients (27.4%) required radiological reintervention. Seven patients (9.6%) required emergency cholecystectomy, and ten patients (13.7%) underwent an elective cholecystectomy. Overall, 36 patients (49.3%) died during the follow-up period. Five patients (6.8%) died during index admission. Subgroup analysis demonstrated a higher rate of complications in the Tokyo grade 3 subgroup of 82.8% vs. 59.1% (P = .04). Patients from this subgroup were also more likely to require emergency additional abscess drainage (17.2% vs. 2.3%, P = .034). There was no significant difference in the number of emergency cholecystectomies performed between groups. Patients from the Tokyo grade 2 subgroup were more likely to have an elective cholecystectomy in the future (20.5% vs. 3.4%, P = .044). Conclusions: PC was overperformed in our patient cohort, and was associated with high postprocedure morbidity and mortality. Clinicians should be discerning in patient selection criteria for PC.

Response to: Comment on: Nutritional support for the trauma and emergency general surgery patient: What you need to know.

Response to: Comment on: Nutritional support for the trauma and emergency general surgery patient: What you need to know.

Frailty and body composition predict adverse outcomes after emergency general surgery admission: a multicentre observational cohort study.

Emergency surgical admissions represent the most unwell patients admitted to any hospital. Frailty and body composition independently identify risk of adverse outcomes but are seldom combined to predict outcomes in emergency patients. We aim to determine the relationships between frailty, body composition analyses (BCA) and mortality in an undifferentiated emergency general surgical patient population. A prospective, multicentre observational cohort study of patients admitted with emergency surgical pathology was conducted in eight hospitals. BCA were performed at L3 vertebrae using computed tomography images to quantify sarcopenia and myosteatosis. Sex-specific BCA cut-off values were determined by our previous study. Reported Edmonton Frail Scale (REFS) values ≥8 identified frailty. The primary outcomes were all-cause 30-day and 1-year mortality. Multivariable logistic regression was utilised to explore predictive relationships between frailty, BCA, mortality and independent discharge. A total of 194 patients were included; 24% were frail, 25% were sarcopenic and 23% myosteatotic. Some 61% of patients underwent an emergency laparotomy. Frail patients were more likely to be sarcopenic (20.4% vs 40.4%; p = 0.011) and myosteatotic (27.2% vs 51.1%; p = 0.004). Thirty-day and 1-year mortality was 5.2% and 15.5%, respectively; 30-day mortality was two times higher in the frail group (4.1% vs 8.5%; p = 0.414), and three times higher at 1 year (10.2% vs 31.9%; p = 0.001). Age (odds ratio [OR] 1.06; p = 0.001), sarcopenia (OR 2.88; p = 0.047) and frailty (OR 4.13; p = 0.001) were associated with 1-year mortality. Only 55.3% of frail patients were discharged home independently compared with 88.4% non-frail patients (p < 0.001). One-year mortality was greater in those with frailty and/or BCA abnormalities than in those without (28.8% vs 9.6%; p = 0.003). Frailty, sarcopenia and myosteatosis contribute significantly to adverse outcomes. NCT03534765.

A04 - EGS Evidenced competency in benign biliary surgery amongst UK general surgeons at certification: A JCST/ISCP study

Abstract Background Symptomatic gallstones are the most common reason for evaluation by an Emergency General Surgery (EGS) service, with laparoscopic cholecystectomy (LC) being performed by most general surgeons. Previous studies show that most LCs in the United Kingdom (UK) are performed by colorectal surgeons (CR). Emergency cholecystectomy requires advanced skills including intra-operative assessment of the bile ducts, and the ability to perform intra-operative cholangiogram (IOC) is part of the procedure-based assessment (PBA) that evidences competency for certificate of completion of training (CCT). This study aims to assess documented evidence of competency in benign biliary surgery amongst general surgeons in the UK. Method PBAs relating to LC and CBD exploration (CBDE) were retrieved for all UK general surgeons who received CCT between 2016 and 2021 from ISCP (702; 285 (41%) colorectal; 212 (30%) Upper GI (UGI)). All eLogbook entries relating to LC +/- IOC +/- CBDE were also retrieved. Subspecialty interest was determined from Part 2 of the FRCS examination. Competence (Level 4) as well as a granular assessment of IOC and CBDE was compared amongst trainees, taking into account their subspecialty interest. Results 11,733 LC and 553 CBDE assessments from 160,570 LC +/- IOC +/- CBDE procedures recorded on eLogbook were retrieved. Knowledge of IOC indication was assessed in 467 (94%) surgeons, but performance was only assessed in 380 (75%) surgeons. Median satisfactory IOC performance assessments was 3 (2-5). UGI were more likely to do this than colorectal (4 (2-7) vs 2 (1-4) P &amp;lt; 0.001). Satisfactory CBDE was achieved by 86 surgeons (12 CR and 74 UGI). 486 surgeons (97% CR; 94% UGI) received Level 4 (independence) despite never achieving satisfactory ability to perform IOC. Conclusion Competency in acute biliary surgery for general surgeons at certification is extensively assessed using PBAs. Cholecystectomy training and assessment in the UK does not seem to include intraoperative bile duct anatomy assessment or treatment of CBD stones. Assumed competency in cholecystectomy by trainers in the UK does not seem to include the need to do this, as 97% of CR and 94% of UGI trainees achieve documented competence without the ability to perform IOC. This may have an impact on EGS service delivery of acute and emergency gallbladder surgery including the ability to deal with difficult cases.

Value in acute care surgery, part 4: The economic value of an acute care surgery service to a hospital system

ABSTRACT The Healthcare Economics Committee of the American Association for the Surgery of Trauma has published a series of three articles on the topic of value in acute care surgery (ACS). In this series, the key elements of value, cost and outcomes, and the impact of stakeholder perspective on what constitutes high-value care are discussed. The fourth article in this series continues the discussion by focusing on the unique economic value that an ACS service brings to a hospital system and its patients. Characterized by the immediate 24-hour availability of surgeons trained in trauma management, emergency general surgery, and surgical critical care, acute care surgeons extend the benefits of surgical rescue and critical care to all hospitalized patients. As such, an ACS service acts as a vital part of a hospital's infrastructure to successfully care for complex and seriously ill patients, in addition to enabling the establishment of other, high revenue-generating services such as vascular, transplant, and complex oncologic surgery programs. The trauma service acts as intake for patients that lead to downstream revenue creation by other disciplines such as orthopedic and neurological surgery, while trauma center designation itself results in dedicated state funding to ensure trauma readiness in many states in the United States. The traditional “value equation” in health care of outcomes achieved per dollar spent is ill-suited to capture many of these unique aspects and benefits of ACS. This article provides the background to understand the economic value of an ACS service and future directions toward improving overall value of care. LEVEL OF EVIDENCE Economic &amp; Value-based Evaluations: Level IV.

EGS SO26 - Back Under the Knife: Unveiling the Fate of non-trauma Patients Returning to the Emergency Theatre

Abstract Background Offering a planned or unplanned second operation in emergency general surgery is not uncommon. However, there is a scarcity of data in this context. This study aims to evaluate the outcomes of patients who were offered two emergency operations to those who required one operation, focusing on complications, increased level of care at discharge and mortality rates. Method We identified those patients who underwent planned and unplanned revisits to the emergency theatre between July 2020 and July 2023. Inclusion criteria were consistent with the established UK National Emergency Laparotomy Audit (NELA at our centre over three years.. We examined demographics, ASA (American Society of Anesthesiologists) classification, indications and outcomes in terms of complications, increased post-operative care levels and mortality rates. Results 390 patients (89.3%) required one operation (1OP) and 47 (10.7%)patients underwent two operations (2OP) . The median age was 70 years for 1OP and 71 years for 2OP, with a male-to-female ratio of 192:198 in 1OPG and 22:25 in 2OP. The median ASA score (2 vs. 3), median frailty score (3 vs. 4) and the median Clavien-Dindo classification (2 vs. 4), and length of stay in days (12 vs. 21) were significantly higher for the 2OP. The increase in the level of care at discharge (30.6% vs. 59%) and the mortality (7.4% vs. 32%) were higher in the 2OP. Conclusion Our study shows that non-trauma patients requiring a second emergency operation face significantly worse outcomes compared to those undergoing only one surgery. Specifically, the group needing two operations experienced higher rates of complications, increased levels of post-operative care, and significantly higher mortality rates. These findings underscore the critical need for close monitoring and a multidisciplinary approach perioperatively. Moreover, these insights can help provide patients and their families with informed decision-making regarding the potential risks and benefits of additional surgical interventions. A prospective multicentre study would be valuable in providing further insights into this subgroup of patients.

Open abdomen versus primary closure in nontrauma patients: A weighted analysis of a single-center experience

INTRODUCTION The open abdomen (OA) technique is nowadays a worldwide strategy both for trauma and emergency general surgery. Despite the attempt at conducting prospective studies, a high level of evidence is far from established. The aim of this study was to investigate if we overused this strategy and if it improved the postoperative course of our patients. METHODS Emergency laparotomies from 2017 and 2023 were reviewed and stratified according to OA and closed abdomen (CA). Differences were balanced by inverse probability weighting, and the 90-day mortality was estimated. Subgroup analysis was carried out for patients with a Mannheim Peritonitis Index (MPI) of &gt;26, bowel obstruction, bowel ischemia (BI) and gastrointestinal perforation. RESULTS Of the 320 patients, 167 were CA and 153 were OA. Groups were different for American Society of Anesthesiologists, comorbidities, transfusion rate, Physiologic and Operative Severity Score for the Study of Mortality and Morbidity score, MPI, Clinical Frailty Scale score, diagnosis, and resection. Two balanced pseudo-populations were created. The 90-day survival rate was 50.8% for CA and 60.8% for OA (hazard ratio [HR], 0.79; confidence interval [CI], 0.40–1.55; p = 0.502). At the Cox regression, the Clinical Frailty Scale score (HR, 1.125; 95% CI, 1.01–1.25; p = 0.033) and BI (HR, 5.531; 95% CI, 2.37–12.89; p &lt; 0.001) were independent risk factors for mortality. Transfusion rate (odds ratio [OR], 3.44; 95% CI, 1.44–8.23; p &lt; 0.006) and length of stay in the intensive care unit (OR, 1.13; 95% CI, 1.07–1.20; p &lt; 0.001) were associated with major complications. Open abdomen did not modify mortality in the case of bowel obstruction, MPI &gt;26, or gastrointestinal perforation. Finally, OA (HR, 0.056; 95% CI, 0.01–0.22; p = 0.001) and large bowel resection (HR, 6.442; 95% CI, 1.28–32.31; p = 0.040) were predictors of longer survival in the subgroup of patients with BI. CONCLUSION Open abdomen was not associated with a higher complication rate or higher mortality but did result in a longer in-hospital stay. The only setting where OA seemed to be advantageous was in the BI population. LEVEL OF EVIDENCE Epidemiological and Prognostic Study; Level III.

HPB SO58 - Reporting outcomes on the management of complex benign biliary pathology referred into a tertiary Hepatobiliary centre

Abstract Background Gallstone disease represents a significant portion of acute general surgery workload. Complex biliary pathology is a common cause of referrals to tertiary hepatobiliary (HPB) centres, however, there is a paucity in the literature regarding criteria for referrals and the outcomes from the management of these cases. The aim of this study was to report the outcomes of patients referred to a tertiary HPB centre in an acute setting from secondary care hospitals for management of benign biliary pathology. Method Patients who were transferred to the HPB unit at Manchester Royal Infirmary from secondary care hospitals in the North West of England between September 2022 and May 2024 for benign biliary pathology were included. Patients were identified from the electronic emergency transfer centre. Data was collected on the reason for referral and management at the HPB unit. Outcomes were reported as: admission to intensive care (ITU), length of stay in hospital, in-hospital mortality, Clavien-Dindo grading of surgical complications and re-admission to hospital. Data was retrospectively collected from electronic patient records. Results Twenty-three patients were included. The most common reasons for transfer included: biliary drainage for choledocholithiasis where endoscopic retrograde cholangiopancreatography (ERCP) was not feasible at the referring hospital (8/23); Mirizzi syndrome (4/23); emergency general surgery not offered at the referring hospital (3/23) and perforated gallbladder (2/23). Ten patients were managed surgically, five patients had ERCPs, four patients had radiological interventions and four were managed conservatively. Two patients were admitted to ITU, one patient died within admission and a second patient managed conservatively was re-admitted within 30 days. Post-operative morbidity rate was 30%. The median hospital stay was 12 days (2, 50). Conclusion Our data demonstrates that complex biliary pathology that has been referred into a tertiary HPB unit from secondary care hospitals has been managed safely, with low rates of morbidity and mortality. Patients who underwent cholecystectomies that were deemed to be high risk had a 0% mortality rate. This study adds to the body of evidence that centralisation of specialist services with a multi-disciplinary approach has led to better patient outcomes.

HPB SO75 - Burden and Pattern of Gallstone-Related Acute Surgical Admissions

Abstract Background Gallstone disease accounts for nearly one-third of emergency general surgery admissions, with a considerable number resulting from recurrent episodes. Laparoscopic cholecystectomy (LC) is the only definitive treatment for gallstones. This study aimed to examine the burden and patterns of acute biliary admissions. Method This prospective cohort study was conducted over a continuous 12-week period in 2022 within a single surgical unit, focusing on all gallstone-related admissions. The total number of admissions for various surgical pathologies was documented, and the proportion due to biliary disease was determined. The analysis encompassed patient demographics, reasons for biliary admission, prior gallstone history, and any planned laparoscopic cholecystectomies (LC). Results There were 532 acute admissions, 98 (18.4%) were gallstones related. Median age was 62 years (IQR 47-72) and 58 (59.2%) were female. 40 (40.8%) had acute cholecystitis, 24 (24.5%) had gallstone pancreatitis, 16 (16.3%) had bile duct stones, 10 (10.2%) had biliary colic and 8 (8.2%) had ascending cholangitis. 43 (43.9%) patients were known to have gallstones and 26 (26.5%) patients had prior admission related to gallstones. 35.7% patients had outpatient LC, 23.5% had no documentation, 19.4% had inpatient LC, 18.4% were not fit candidates and 3.1% patients declined LC. Median total length of stay was 6 days (IQR 4-11). Conclusion In our study, the rate of biliary-related admissions was lower than previously reported in the literature. This reduction may be attributed to our semi-aggressive management approach for gallstone disease. To further improve patient outcomes, we suggest implementing more aggressive management strategies for gallstones during the initial admission for patients who are deemed fit for surgery. Such an approach could potentially reduce the recurrence of biliary admissions and enhance overall treatment efficacy.

EGS SO01 - A retrospective study on understanding the dangers of delaying emergency laparoscopic cholecystectomies in patients with acute cholecystitis

Abstract Background Gallstone related diseases account for approximately one-third of emergency general surgery admissions and referrals. Acute cholecystitis (AC), a major complication of gallstones, is typically treated with laparoscopic cholecystectomies (LC), the gold standard for treating symptomatic gallstone disease. According to NICE guidelines patients with AC should preferably undergo a LC within 72 hours. Similarly, SAGES recommends that patients who can tolerate the procedure should have a LC within 24-72 hours of diagnosis. This study aimed to determine if surgical outcomes differ among patients managed within 24 hours, between 25-72 hours, and more than 72 hours from onset of symptoms. Method This retrospective analysis evaluates wait times between onset of symptoms and surgery, as well as subsequent surgical outcomes for patients booked for emergency LC over a twelve-month period from September 2022 to September 2023. The data assessed included demographics, indications, imaging results, alkaline phosphate (ALP) levels, alanine transaminase (ALT) levels, total bilirubin levels, C-reactive protein (CRP) levels, white cell count levels, american society of anaesthesiologists (ASA) grade, type of intraoperative complications, time of day operated, length of hospital stay, duration of symptoms prior to decision for surgery and wait until surgery. This data was compared against NICE and SAGES standards. Results Sixty-one patients underwent emergency LC in the twelve-month period reviewed, mean age was 49.7 years. The sample was approximately 70% (n=43) female and 28% (n=17) male. 62% (n=38) of patients were booked for a LC within 72 hours of symptom onset. 5% (n=3) of patients had their surgery within 24 hours of presenting to hospital with symptoms, 41% (n=25) had their surgery within 24-72 hours and 54% (n=33) waited more than 72 hours for their LC. 84% (n=51) of the total patients had no adverse intraoperative findings. The 16% (n=10) patients who had complications were part of all three groups. Conclusion This study found that 46% of the patients presenting with symptoms of AC undergo emergency LC within 72 hours as per NICE and SAGES guidelines. Intraoperative complications were found in all groups of patients, waiting from 0 to 72 hours for their surgery. 80% of the complications seen were in patients waiting more than 24 hours for their LC. Increasing local awareness on the importance of not delaying emergency LC by creating pathways, such as dedicated LC lists, to allow same-admission LC will enable us to adhere more closely to current guidelines and reduce morbidity from gallstone disease.

Impact of an Acute Care Surgery Clinical Pathway on Patient Outcomes in Acute Appendicitis.

Objectives: Acute care surgery (ACS) encompasses surgical critical care, emergency general surgery, and the surgical management of trauma. Following ACS implementation at our institution, we developed a perioperative clinical pathway for acute appendicitis (AA) to improve efficiency and standardize post-operative care. The purpose of our study is to assess patient outcomes utilizing our ACS clinical pathway for patients with AA. Methods: This is a retrospective cohort study involving patients admitted to our tertiary care facility with AA who underwent appendectomy. Patients were classified by pre-implementation (January 1, 2016-July 31, 2018) and post-implementation (August 1, 2018-December 31, 2020) of our ACS clinical pathway. The primary outcome was hospital length of stay (LOS). Statistical analysis was performed using SAS with a p-value <0.05 determined as significant. Results: Of the 492 patients included, 225 were in the pre- and 267 were in the post-implementation cohorts. Hospital LOS was substantially decreased in the post-implementation cohort (31.2 vs. 50.4 h, p < 0.001). The post-implementation group had a substantial decrease in computed tomography (CT) to operating room (OR) start time (6.81 vs. 11.4 h, p < 0.001), CT to antibiotic agents' administration (2.20 vs. 3.37 h, p < 0.001), inpatient opioid utilization (125 morphine equivalents [ME] vs. 172 ME, p < 0.001), and discharge antibiotic agents' prescription rates (23.6% vs. 30.7%, p = 0.077). Recovery unit discharges (20 vs. 9%, p < 0.001) were increased in the post-implementation cohort. Conclusion: Our ACS clinical pathway for AA resulted in earlier surgical intervention, enhanced opioid and antimicrobial stewardship, and gains in surgical care efficiencies.

Preparing the future combat surgeon: a survey of the military general surgery trainee GME experience

IntroductionGraduate medical education (GME) lacks a standardized military training program for general surgery residents, and concern exists that they may not be prepared to serve as combat surgeons on training...

Validation of Artificial Intelligence-Based POTTER Calculator in Emergency General Surgery Patients Undergoing Laparotomy: Prospective, Bi-Institutional Study.

The POTTER calculator, a widely used interpretable artificial intelligence (AI) risk calculator, has been validated in population-based studies and shown to predict outcomes in emergency general surgery (EGS) patients better than surgeons. We sought to prospectively validate POTTER. Patients undergoing an emergency exploratory laparotomy for non-trauma indications at two Academic Medical Centers between June 2020 and March 2022 were included. POTTER preoperative risk calculations and postoperative outcomes were systematically recorded. POTTER's performance in predicting 30-day postoperative mortality, septic shock, respiratory failure, bleeding, and pneumonia was assessed using the c-statistic methodology. A total of 361 patients were included. The median age was 63 years (IQR: 51-72), 45.4% were females, and the overall mortality and morbidity were 24.1% and 51.4%, respectively. POTTER predicted mortality accurately with a c-statistic of 0.90. POTTER also accurately predicted the occurrence of individual postoperative complications, with c-statistics ranging between 0.80 and 0.89. This is the first prospective validation of the AI-enabled POTTER calculator. The superior accuracy, user-friendliness, and interpretability of POTTER make it a useful bedside tool for preoperative patient and family counseling.

Demonstrating the Electronic Consent Process for Emergency Surgical Patients.

Introduction Patient consent for surgery is a vital part of the surgical pathway from both a patient safety and medicolegal point of view. Improvement in documenting the full consent process in the electronic patient record (EPR), alongside the standard completion of the paper consent form in a surgical emergency unit (SEU), to comply with the Montgomery ruling of informed consent, has become of paramount importance. The aim of this project was to improve the documentation of the full consent processby creating an electronic template that was easy for the consenting clinician to use and provided a robust record of the bespoke consent process for the individual patient. Methods In July 2020, clinicians in the SEU were asked to begin documenting the patient's consent process in the EPR. The number of documented electronic consent processes (ECPs) of patients who underwent emergency general surgery during a two-week period was then captured between October and November 2020. The second cycle involved creating a single consent template, allowing the ECP to be easily documented in one template for all the common emergency surgery operations. All clinicians who were responsible for surgical consenting were asked to use the electronic template as part of the consent process. The rate of electronic consent was recorded over a second two-week period, six months later, in May 2021. Results From the first cycle, 78 patients were identified as undergoing emergency surgery, of which 13% (N=10) had an electronic entry regarding the consent process fully documented and personalised to the patient. From the second cycle, 64 patients were identified. The rate of documented ECPs increased to 77% (N=49). Conclusion This project has successfully improved the electronic demonstration of a consent process, bespoke to the individual, in accordance with the Montgomery ruling, by implementing an easy-to-use template on EPR. This is a significant step towards full digital consent in the future.

Primary care follow-up improves outcomes in older adults following emergency general surgery admission

BACKGROUND While preoperative optimization improves outcomes for older adults undergoing major elective surgery, no such optimization is possible in the emergent setting. Surgeons must identify postoperative interventions to improve outcomes among older emergency general surgery (EGS) patients. The objective of this cohort study was to examine the association between early follow-up with a primary care physician (PCP) and the risk of nursing home acceptance or death in the year following EGS admission among older adults. METHODS Using population-based administrative health data in Ontario, Canada (2006–2016), we followed all older adults (65 years or older) for 1 year after hospital admission for EGS conditions. A multivariable Cox model was used to identify the association between early postdischarge follow-up with a patient's PCP and the time to nursing home acceptance or death while adjusting for confounders. RESULTS Among 76,568 older EGS patients, 32,087 (41.9%) were seen by their usual PCP within 14 days of discharge, and 9,571 (12.5%) were accepted to a nursing home or died within 1 year. Primary care physician follow-up was associated with a 13% reduced risk of nursing home acceptance or death compared with no follow-up (hazard ratio 0.87; 95% confidence interval 0.84–0.91). This effect was consistent across age and frailty strata, patients managed operatively and nonoperatively, and patients who had both high and low baseline continuity of care with their PCP. CONCLUSION Early follow-up with a familiar PCP was associated with a reduced risk of nursing home acceptance or death among older adults following EGS admission. Structures and processes of care are needed to ensure that such follow-up is routinely arranged at discharge. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.

An integrated model of care between general surgery and general medicine rationalizes and enhances the care of older surgical patients.

There is growing evidence on the benefits of integrated models of care between surgeons and physicians in non-orthopaedic surgery. We implemented a new General Surgery/General Medicine care model, for all emergency General Surgery patients aged 75 years and older. We compared rates of goals of care (GOC) documentation, hospital-acquired complications (HAC), mortality, and hospital length of stay (LOS). This is a non-randomized trial, with data collected prospectively in phase 1 (2021-2022), where patients received the traditional standard of care (case-by-case referral to a General Physician), and in phase 2 (2022-2023) where patients received integrated care. Variables were compared between phase 1 and phase 2 using Generalized Linear Models (GLMs). Five hundred and forty-nine patients, 188 in phase 1 and 361 in phase 2, participated in the study. On univariate analysis, there was a significant increase in patients treated non-surgically in phase 2 (58.5% vs. 69.0%). Patients treated non-surgically had significantly shorter LOS, experienced less HACs (P < 0.001). Other variables did not significantly differ after implementation of the service. The multivariate GLM revealed a significant reduction in admissions with undocumented GOC in phase 2 (P = 0.037). This study showed that an integrated care model resulted in a greater proportion of patients being treated non-surgically with a comparable rate of HAC and mortality, as well as better documentation of patients' GOC. As the number of older surgical patients will continue to rise, the call for such service to become standard of care in non-orthopaedic surgery is pressing.

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.