Emergency Surgeons Research Articles

A rare cause of acute abdominal pain

Acute abdominal pain represents a challenge for the physician because it can hide a serious intra-abdominal pathology necessitating emergency intervention. A 65-year-old man presented to Emergency Department with sudden-onset abdominal pain. He underwent liver transplantation four years before. He complained tenderness on abdominal palpation. Blood chemistry and abdominal x-ray were normal. Contrast-enhanced computed tomography showed acute renal artery thrombosis. The patient underwent renal arterial thrombectomy and stent placement in less than two hours. Organ transplantation is a condition that makes patients at greater risk of life-threatening conditions. Renal artery thrombosis is a rare, severe and misdiagnosed condition which can benefit from a prompt cooperation among emergency physician, surgeon, and interventional radiologist. Transplant patients with acute abdominal pain should be considered at high risk of medical emergency. Acute renal artery thrombosis is a time dependent medical emergency in those patients with chronic drug-induced nephrotoxicity.

Saving lives by task sharing: The role of the non-doctor surgeon

Background: Ethiopia has serious shortages of obstetric and surgical specialists. A national Masters degree programme to train non-doctor mid-level health professionals in Emergency Surgery and Obstetrics started in 2009. Qualified professionals are known as integrated emergency surgical officers (IESOs). Aims: This study was carried out to evaluate graduated IESO's performances and the outcome of their work. Methods: Questionnaires were sent to all 135 registered members of the Professional Association of Emergency Surgical Officers of Ethiopia (PAESOE). Responses were received from 64 IESOs. Findings: Results showed that the IESOs had carried out a total of 20 176 caesarean sections since graduating. In the first 3 months of 2016, there were 3035 caesarean sections and 970 other laparotomies. Following caesarean section, the rate of neonatal deaths was 2.8%, and the rate of maternal deaths was 0.26%. The rate of maternal deaths following laparotomies was 0.61%. The rate of postoperative complications was 1.92%. Conclusions: Results showed that task-sharing with trained non-doctor emergency surgeons can improve access and outcomes for patients in need of essential surgical care. A similar programme could be a model for other developing countries.

Journal of Endovascular Resuscitation and Trauma Management: A Timely Endeavor

It is with great pleasure that the editorial staff of the Journal of Endovascular Resuscitation and Trauma Management (JEVTM) welcomes your review of – and participation in - our exciting new endeavor. This initial release of JEVTM represents the beginning of the first medical journal specifically dedicated to the examination of endovascular applications as tools for resuscitation, hemorrhage control and definitive trauma management. It is an ambitious undertaking, but one who’s time has come. Why is now the right time for the initiation of JEVTM? The answer to this question involves an examination of several key concepts. These include the emergence of new technologies, changing clinical practices and a growing body of multi-disciplinary innovators dedicated to the exploration and study of an expanding set of endovascular capabilities. Emerging Technologies
 The past several decades have born witness to an evolution in endovascular technologies. While many of these innovations were initially developed with the treatment of atherosclerotic and aneurysmal vascular disease pathologies in mind, the applications for hemorrhage control and vascular injury management were quickly appreciated. Endovascular balloons, known to potentially improve outcomes from ruptured abdominal aortic aneurysms, are now increasingly utilized as tools for bleeding control from non-compressible sites following trauma. Angio-embolization has become a mainstay of treatment capabilities for both pelvic and solid organ injury at most busy trauma centers. Endovascular stent grafts have emerged as the acute treatment of choice for blunt thoracic aortic injuries. Additionally, other endovascular adjuncts, including extra-corporeal membrane oxygenation (ECMO) and intra-aortic balloon pump devices, continue to evolve as tools of modern resuscitation. Initially, many of these advances were achieved using devices that were largely designed for the management of chronic vascular disease. Increasingly, however, devices and capabilities are being engineered to specifically optimize their utilization for victims of trauma and other patients in need of resuscitative salvage. Continued engineering advancements and efforts to define optimal clinical utilization of these devices will require a platform for reporting and critical review. It is our hope that JEVTM will serve as an effective vehicle for this study.Changing Practices
 With the increasing inclusion of endovascular capabilities in algorithms for hemorrhage control, resuscitation and trauma management other questions regarding practice have emerged. What provider is best suited to employ these technologies? How should they be trained? What expertise is required? The answer to these questions have not been well elucidated, even as the use of endovascular technologies continues to grow. Beyond the type of providers that should be involved, there also remain questions about the optimal care environment in which these technologies should be delivered. Is a hybrid-operating suite the optimal environment? How much imaging capability is really required? Can some of these capabilities safely be brought to the pre-hospital care environment? These questions are matters of active investigation that require a venue like JEVTM for examination.A multi-disciplinary collaboration
 The foundation for the creation of JEVTM can be traced to discussions that culminated in the February 2017 Endovascular Hybrid and Trauma Management Meeting in Orebro, Sweden. This gathering, sponsored by the University of Orebro, brought together thought leaders from nations throughout Europe, North America and Asia. Their diversity in geographic representation was second only to their diversity of training backgrounds. Interventional radiologists, emergency medicine physicians and surgeons (vascular, trauma and acute care) shared their clinical experiences with not only each other – but also a large group of translational scientists working diligently to provide important foundational data for next steps in endovascular applications. In the context of this excellent exchange, many of these multi-disciplinary participants discussed work that had been presented at prestigious meetings and had been published in a wide array of medical journals scattered across a variety of disciplines. It became apparent, however, that there was a need for a platform that might serve as a common ground for this diverse group of providers striving to advance the safe and effective use of endovascular technologies in resuscitation and trauma management. It is our hope that the Journal of Endovascular Resuscitation and Trauma Management serves as that needed platform.

Gallstone obstructing the duodenum. Report of two cases of Bouveret’s syndrome

Bouveret’s syndrome is the obstruction of the duodenum due to a gallstone. It is a rare condition, known for over a century that continues to confound emergency room physicians and surgeons to this day. We present two cases of Bouveret’s syndrome. The first is a 63-year-old female patient with a 4 cm gallstone obstructing the third part of the duodenum. The patient underwent prompt surgery and the gallstone was removed through the jejunum. The other patient’s course, an 88–year-old male, was more complicated. After fluid resuscitation and an attempt at endoscopic removal, a gallstone obstructing the first part of the duodenum was surgically removed through a gastrotomy. Both patients recovered fully and were discharged. Both cases presented many dilemmas and challenges from the diagnosis to the final management.

The Future of Emergency Surgery.

A survey on ES was developed by the Educational Committee of the European Society for Trauma and Emergency Surgery (ESTES) and sent to all ESTES members with 102 responses received. Results: Of the responses, 93.1% had completed training. 75.3% of respondents report that ES should be a recognised subspecialty and 79% report that ES is capable of offering a rewarding career. 90% report that ES should have dedicated post-graduate training programme with 69.8% in agreement that dedicated emergency surgeons have improved outcomes following ES. Developing ES as a subspecialty in Europe would improve patient outcomes and facilitate resource allocation. This advancement is, however, still in its infancy and its evolution would require overhaul of our current European system, training methods and understanding of the role of emergency surgeons in ES.

Acute Acalculous Cholecystitis in Dengue Fever: An Alert for Emergency Surgeons

ABSTRACT Dengue fever is an acute viral disease, typical of tropical countries and endemic in Brazil, which can present abdominal symptoms and complications. One of its atypical presentations is acute acalculous cholecystitis (AAC), present in 6% of the severe cases. It is usually self-limited, and generally improves with nonoperative treatment. This is a case report of a patient transferred to a tertiary hospital for surgical evaluation of acute abdomen. She presented with significant abdominal findings (pain, nausea, and vomits), suggestive of acute cholecystitis. After initial assessment and examinations, the patient was diagnosed with severe dengue fever and AAC. The patient was treated conservatively and improved within 3 days. Physicians must be aware of ACC in patients with suspicious presentations in endemic areas for dengue fever. Surgery should be avoided once it is associated with significant postoperative complications and death. How to cite this article Becker MJ, Scherer JR, de Oliveira CS, Netto FS. Acute Acalculous Cholecystitis in Dengue Fever: An Alert for Emergency Surgeons. Panam J Trauma Crit Care Emerg Surg 2017;6(2):124-126.

Evaluation of care for traffic accidents victims made by on duty emergency physicians and surgeons in the emergency room

to evaluate the care for victims of traffic accidents by on call emergency physicians and/or surgeons in the emergency room. we conducted a retrospective, descriptive and exploratory study on the care for traffic accidents victims in the urban area of ​​Maringá-PR, between July 2013 and July 2014 in reference hospitals. We assessed demographics and vocational training through a questionnaire sent to the attending physicians. of the 688 records evaluated, 99% of patients had a prehospital Revised Trauma Score of 12. Statistical analysis showed that in the cases conducted by the emergency physicians (n​=187), the recording of the Glasgow Coma Scale and the performance of surgical procedures were less common, whereas the recording of blood pressure values ​​was performed in greater numbers when compared with cases led by surgeons (n=501). There was a statistically significant relationship (p<0.01) between the length of hospital stay and surgical specialty, with a greater chance (crude OR=28) in the period from one to six hours for the group treated by emergency doctors. Most physicians participating in the study were young, with emergency room time of up to one to two years, and with ATLS training. Among those who had attended the ATLS course, 60% did so in the last four years. Surgeons performed 73% of hospital treatments. in the care of traffic victims with minor injuries, the Glasgow Coma Scale, the blood pressure levels, the type of treatment in the emergency room and hospital stay had different approaches between emergency physicians and surgeons.

Upaya Pencegahan Perbedaan Diagnosis Klinis Dan Diagnosis Asuransi Dengan Diberlakukan Program Jaminan Kesehatan Nasional (JKN) Dalam Pelayanan Bpjs Kesehatan Studi Di Rsud Kota Semarang

Percentage of clinical and insurance diagnosis differences at Semarang City Public Hospital tended to increase. If this condition remained, it would lead to upcoding (fraud). The aim of this study was to explain a process of clinical and insurance diagnosis at a hospital in the implementation of Healthcare and Social Security Agency (Health BPJS). This was a qualitative study. Main informants consisted of doctors at an emergency room, surgeons, and internists. Informants for triangulation purpose consisted of a Hospital Director, a hospital verifier, and a head of Medical Record Unit. Data were analysed using content analysis.The results of this research showed that there were any differences in clinical and insurance diagnosis at Semarang City Public Hospital. The cause of these differences was due to differences in diagnosis and medical treatment between medical service standard of doctors at the hospital and a standard of INA-CBGs. To prevent the differences of clinical and insurance diagnosis, the Semarang City Public Hospital had formed an internal verifier team of the hospital and a Clinical Micro System team. A medical committee had a role to minimise the occurrence of upcoding by multiplying kinds of Clinical Pathway as a reference for doctors in diagnosing and determining kinds of treatments for patients.The differences of clinical and insurance diagnosis must be equated to prevent the occurrence of upcoding and disadvantage of the hospital. Efforts to prevent these differences are by adding officers, training coding, making and multiplying algorithm of clinical pathway, forming a team of Clinical Micro System, and monitoring and evaluating medical services.

Guidelines for Imaging and Transfusion in Trauma

Sponsoring Organization: U.K.'s National Institute for Health and Care Excellence (NICE) Target Population: Emergency physicians, surgeons, and other clinicians who care for patients with trauma Background and Objective An expert panel commissioned by the U.K.'s National Health Service reported recommendations for assessment and resuscitation of major trauma in the context of a system of care organized by regional trauma networks. Key Recommendations

Acute colonic diverticulitis: an update on clinical classification and management with MDCT correlation.

Currently, the most commonly used classification of acute colonic diverticulitis (ACD) is the modified Hinchey classification, which corresponds to a slightly more complex classification by comparison with the original description. This modified classification allows to categorize patients with ACD into four major categories (I, II, III, IV) and two additional subcategories (Ia and Ib), depending on the severity of the disease. Several studies have clearly demonstrated the impact of this classification for determining the best therapeutic approach and predicting perioperative complications for patients who need surgery. This review provides an update on the classification of ACD along with a special emphasis on the corresponding MDCT features of the different categories and subcategories. This modified Hinchey classification should be known by emergency physicians, radiologists, and surgeons in order to improve patient care and management because each category has a specific therapeutic approach.

P040: Development of a categorization tool for delayed hemothoraces in patients with closed minor thoracic trauma

Introduction: Thoracic trauma is, depending on severity, a frequent cause of mortality, morbidity, hospitalization and incapacity. Minor closed thoracic injuries are often discharged from Emergency Departments (ED) and treated on an outpatient basis. One potential complication is the development of a delayed hemothorax (DHx). Currently, there exists no consensus on the best method for classifying DHx. The goal of this study is to evaluate the level of interrater and intrarater agreement with respect to three classification schemes for DHx. Methods: This was a secondary analysis drawn from a prospective multicenter cohort study of consecutive patients presenting to one of four Canadian ED for minor closed thoracic trauma over a four-year period. Using intraclass correlation (ICC), chest radiographs of 50 patients previously diagnosed with new DHx within 2 weeks of discharge were randomly selected and subjected to analysis by emergency physicians, radiologists, surgeons and family physicians using three different methods of classification to study their reliability, both between raters and for the same rater on two separate evaluations, at determining hemothorax severity. Results: Analysis of ICC values demonstrates poor interrater agreement (Global ICC 0.44, 0.35-0.52) for the current classification method, based on professional experience and opinion. The second method, based on hemothorax / total thorax ratio calculation, showed good Global ICC (0.58, 0.49-0.67) on lateral films. The third method, based on presence / absence of overflow from the costo-phrenic angle, showed equally good Global ICC (0.56, 0.47-0.64) on postero-anterior films and was more homogenous across the four different groups of physicians. Conclusion: Our results demonstrate that the current method used to classify DHx, based on gestalt, shows poor interrater agreement. Two innovative classification methods achieved good interrater agreement. Future studies, analyzing possible correlation of this more reliable classification method to objective, clinical measures would be of value to management decisions.

Frailty and cognitive impairment: Unique challenges in the older emergency surgical patient.

Older patients (>65 years of age) admitted as general surgical emergencies increasingly require improved recognition of their specific needs relative to younger patients. Two such needs are frailty and cognitive impairment. These are evolving research areas that the emergency surgeon increasingly requires knowledge of to improve short- and long-term patient outcomes. This paper reviews the evidence for frailty and cognitive impairment in the acute surgical setting by defining frailty and cognitive impairment, introducing methods of diagnosis, discussing the influence on prognosis and proposing strategies to improve older patient outcomes. Frailty is present in 25% of the older surgical population. Using frailty-scoring tools, frailty was associated with a significantly longer hospital stay and higher mortality at 30 and 90 days after admission to an acute surgical unit. Cognitive impairment is present in a high number of older acute surgical patients (approximately 70%), whilst acute onset cognitive impairment, termed delirium, is documented in 18%. However, patients with delirium had significantly longer hospital stays and higher in-hospital mortality than those with cognitive impairment. Improved knowledge of frailty and delirium by the emergency surgeon allows the specialised needs of older surgical patients to be taken into account. Early recognition, and consideration of minimally invasive surgery or radiological intervention alongside potentially transferable successful elective interventions such as comprehensive geriatric assessment, may help to improve short- and long-term patient outcomes in this vulnerable population.

How to diagnose acute appendicitis: ultrasound first.

Acute appendicitis (AA) is a common abdominal emergency with a lifetime prevalence of about 7 %. As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging modalities have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low. Introduced in 1986, graded-compression ultrasound (US) has well-established direct and indirect signs for diagnosing AA. In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent specificity both in the paediatric and adult patient populations. As US sensitivity is limited, and non-diagnostic US examinations with non-visualization of the appendix are more a rule than an exception, diagnostic strategies and algorithms after non-diagnostic US should focus on clinical reassessment and complementary imaging with MRI/CT if indicated. Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates.Main Messages• Ultrasound (US) should be the first imaging modality for diagnosing acute appendicitis (AA).• Primary US for AA diagnosis will decrease ionizing radiation and cost.• Sensitivity of US to diagnose AA is lower than of CT/MRI.• Non-visualization of the appendix should lead to clinical reassessment.• Complementary MRI or CT may be performed if diagnosis remains unclear.

Emergency Surgery for Colorectal Cancer in Patients Aged Over 90 Years: Review of the Recent Literature

The aging of the world population is leading to an increase in the number of patients aged over ninety needing for a surgical treatment in emergency setting. Colorectal cancer in people over 90 years of age represents an ethical dilemma for surgeons and oncologists, above all when the neoplastic disease is advanced and complicated by obstruction and/or perforation. The emergency surgeon often has the crucial role of selecting which patients to submit to surgery, balancing the benefits and the high surgical risk associated with frailty, polipharmacy and comorbidities.We decided to review the recent literature to discuss the latest strate-gies in the management of colorectal cancer in emergency situations, for patients aged over ninety.

Disaster Victim Care by Emergency Surgeons One Year after the Great East Japan Earthquake

Purpose: This study examines patterns of diseases that were treated at the Iwate Prefectural Hanaizumi Regional Clinic after the Great East Japan Earthquake, which occurred on March 11, 2011, and caused serious damage in Japan. Methods: Data on patients’ address, age, sex, and medical conditions, obtained from medical records of 583 (178 men, 405 women) patients who visited the clinic during that time period were analyzed. Results: The diseases for which the clinic provided care were the same as those listed in a textbook of emergency medicine and previous reports. Conclusions: It is important that emergency surgeons understand these common post-disaster disease patterns in order to provide disaster victims with appropriate care.

The effects of distress and the dimensions of coping strategies on physicians' satisfaction with competence.

Objectives:The purposes of this study were to (1) articulate the dimensions of Coping strategies used by physicians, and (2) determine whether Coping strategies alleviated Distress and enhanced Satisfaction with Competence.Methods:Comprehensive questionnaires on factors associated with Satisfaction with Competence were sent to a stratified sample of 5300 physicians across Canada. The response rate was 57% with negligible bias. Factor analysis was used to articulate the dimensions of Coping strategies. The classic Baron and Kenny regression series was used to establish whether Coping mediates the effects of Distress on Satisfaction with Competence. Years in Practice, Self-Reported Health, and Duties of Physicians were control factors.Results:A reliable 15-item measure of Coping was confirmed (α = .76) with four reasonably reliable dimensions: Collegiality (α = .80), Attitude (α = .63), Managing Work (α = .60), and Self-Care (α = .62). Physicians reported a mean Satisfaction with Competence of (M = 4.26 out of 6.0, standard deviation (SD) = 0.64) with General practitioners reporting slightly lower levels of Satisfaction with Competence than average. Conversely, chronic disease, clinical, and procedural specialists reported higher levels of Satisfaction with Competence. The mean Distress level for all physicians was (M = 3.66 out of 7.0, SD = 0.93). The highest levels of distress were reported by emergency physicians, general practitioners, and surgeons. Clinical specialists, anesthesiologists, and psychiatrists reported the lowest levels of distress. Physicians reported (M = 4.48 out of 7.0, SD = 0.78) as the mean level of Coping ability with clinical specialists and general practitioners reporting lower than average abilities to cope. Laboratory and chronic care specialists reported greater than average coping abilities. Regression analyses established Coping as a mediator of Distress which predicted physicians’ Satisfaction with Competence.Conclusion:Four groups of coping strategies were significant in relieving the pressures of work: (1) Collegiality, (2) Self-Care, (3) Managing Work, and (4) Positive Attitude.

PWE-405 Emergency general surgery; are trainers and trainees perspectives in line with population needs?

<h3>Introduction</h3> More consultant surgeon posts (around 20%) are being advertised for general and emergency surgeons, but is this in line with the expectations of trainees and consultants? <h3>Method</h3> An online tool was used to design, collect and analyse 2 online surveys (www.surveymonkey.net) to determine UK experience and attitudes towards Emergency General Surgery (EGS). One online link was distributed to Consultant members of the ASGBI excluding those appointed as EGS Consultant and a different link to all UK trainees in numbered training posts. <h3>Results</h3> 229 (28%) Consultants and 309 (22%) trainees responded. Whilst 16% of consultants surveyed already work in institutions with Emergency Surgeons, most trainees are seeking appointments in city teaching hospitals and have no interest in EGS beyond normal rota provision with only 8.2% declaring a long term career interest in EGS. Nearly half of consultants expect EGS to become a subspecialty but a similar proportion of trainees said they would not consider an EGS consultant post under any circumstances. Reasons included perception of a sub-consultant specialty, poor work life balance, lack of operating, risk of de-skilling and earning potential. More recently appointed consultants (50%) felt a dedicated period of EGS training would have better prepared them for EGS when compared with those in post for ten years or more (17%, p = 0.022). EGS aspects cited as ‘unexpected’ by consultants in post included poorly trained registrars and management of trauma patients. Most trainees (72%) favour a 6 month dedicated training period in EGS. <h3>Conclusion</h3> Increasing advertisements for EGS posts reflects public and societal need for EGS service provision but training programmes and trainee aspirations may not be meeting this need. A dedicated period of EGS for trainees may address this problem. Trainees with an interest in EGS should be encouraged to pursue a career in this developing specialty. <h3>Disclosure of interest</h3> None Declared.

The Japanese Surgical Reimbursement System Fails to Reflect Resource Utilization.

The goal of this study was to examine the current Japanese surgical payment system from the viewpoint of resource utilization. We collected data from surgical records in Teikyo University's electronic medical record system from April 1 through September 30, 2013. We defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as: 1) the number of medical doctors who assisted surgery and 2) the time of operation from skin incision to closure. An output was defined as the surgical fee. We calculated each surgeon's efficiency score using the output-oriented Banker-Charnes-Cooper model of data envelopment analysis. We compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and Steel methods. We analyzed 2,825 surgical procedures performed by 103 surgeons. The difference in efficiency scores was significant (P = 0.0001). The thoracic surgeons were the most efficient and were more efficient than plastic, obstetric and gynecologic, urologic, otorhinolaryngologic, orthopedic, general, and emergency surgeons (P < 0.05). We demonstrated that surgeons' efficiency in operating rooms was significantly different among surgical specialties. This suggests that the Japanese surgical reimbursement scales fails to reflect resource utilization.

Assessment of the Pittsburgh Sleep Quality Index among Physician's Speciality Who Work Night Shifts

Objective: As with other people, sleep quality has an impact on a physician's work safety. Aim of this study is determine the sleep quality among medical specialists whose working night shifts, and detect other independent factors that affect their sleep quality. This is essential for improving the physician health and their daily performance for patient care. Methods: A qualitative study was design with a cross-sectional method. Sampling was con- ducted with stratification among night shift physicians who work in the emergency, internal medicine and surgical departments at an education and research hospital. Scores on the Pitts- burgh Sleep Quality Index (PSQI) and the Swedish Demand-Control-Support Questionnaire (DCSQ) were assessed. Results: One hundred eight physicians who worked night shifts responded to the questionnaire. The average age of the physicians was 31.3±5.9, and 40.7% were women. The average PSQI score in male participants was significantly higher (8.1±3.7 vs. female 7.6±3.9; p=0.014). The majority of physicians (83.3%) had high PSQI values, i.e., scores of 5 or more. No significant difference was found in the average PSQI values between the emergency and internal medicine physicians and surgeons (p>0.05). The most important factors that affected physicians' sleep quality were the number of night shifts per month, age, gender and the existence of a chronic disease.

Implementation of a novel emergency surgical unit significantly improves the management of gallstone pancreatitis.

Emergency surgery is changing rapidly with a greater workload, early subspecialisation and centralisation of emergency care. We describe the impact of a novel emergency surgical unit (ESU) on the definitive management of patients with gallstone pancreatitis (GSP). A comparative audit was undertaken for all admissions with GSP before and after the introduction of the ESU over a six-month period. The impact on compliance with British Society of Gastroenterology (BSG) guidelines was assessed. Thirty-five patients were treated for GSP between December 2013 and May 2014, after the introduction of the ESU. This was twice the nationally reported average for a UK trust over a six-month period. All patients received definitive management for their GSP and 100% of all suitable patients received treatment during the index admission or within two weeks of discharge. This was a significantly greater proportion than that prior to the introduction of the ESU (57%, p=0.0001) as well as the recently reported national average (34%). The mean length of total inpatient stay was reduced significantly after the ESU was introduced from 13.7 ± 4.7 days to 7.8 ± 2.1 days (p=0.03). The mean length of postoperative stay also fell significantly from 6.7 ± 2.6 days to 1.8 ± 0.8 days (p=0.001). A dedicated ESU following national recommendations for emergency surgery care by way of using dedicated emergency surgeons and a streamlined protocol for common presentations has been shown by audit of current practice to significantly improve the management of patients presenting to a busy district general hospital with GSP.