General surgery's game changer and the unanswered question

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In 1975, McArthur et al.1 published a trial of early versus interval cholecystectomy for acute cholecystitis. Although it was the open cholecystectomy era, they showed a small improvement in hospital stay and complication rates with early operation. Fast forward to 1998 and Lai et al.2 demonstrated clear advantages in complication rate, hospital stay and other parameters for patients undergoing early laparoscopic cholecystectomy for acute cholecystitis. These findings established a new standard of care. What was not appreciated at the time was how much of a change this was.
Historically, acute general surgery was fitted around elective work. Surgeons and their registrars simply added acute commitments to their usual daily workload of elective operating, teaching and clinic work. The requirement to offer acute cholecystectomy exposed a tenuous acute service infrastructure to potentially complex patients requiring what could be a demanding operation, both in terms of skill and intraoperative decision‐making, with the risk of significant complications. In addition, the case numbers were large. My own institution performs at least two cholecystectomies per day, every day of the year. It was no longer advisable to leave a remotely supervised junior registrar to manage these cases intraoperatively and so the acute surgical unit was born.3 Here, surgeons divested of elective commitments, were rostered to focus on acute patients and their surgery often with dedicated acute theatre resource and junior staff support. However, there were catches. It required a critical patient volume to function so was suited to larger metropolitan centres rather than provincial centres and it required that an electively subspecialized surgical workforce, increasingly common in large metropolitan centres, maintains a broad general surgical competency. This latter requirement was often easier for surgeons working within the abdomen on a regular basis than those who did not.
In the current issue of the journal, Tran et al.4 and Maloney et al.5 report two other ways of dealing with this issue. Tran et al.4 describe a service led by hepatobiliary subspecialists, serving a local population of 400 000, who performed 486 laparoscopic cholecystectomies out of 700 patients presenting with acute cholecystitis over a 6‐year period (on average 71 procedures annually). As expected, the quality metrics are good with cholangiography performed in 84%, a conversion rate of 1.6% and a 4.4‐day hospital stay. In comparison, Maloney et al.5 describe a general surgeon led service in a provincial hospital serving a population of 160 000. A total of 259 cholecystectomies were performed over a 12‐month period with cholangiography performed in 83%, a conversion rate of 3.5% and a 7‐day hospital stay.
For the subspecialty service reported by Tran et al.,4 the overall caseload is quite low – no more than two acute cholecystectomies per week (although as it is a subspecialty service, it must be acknowledged that they may have been at the trickier end of the spectrum) and the majority of these were performed by surgical fellows. The degree of consultant supervision (whether in theatre, in house or remote) is not clear. Many of the procedures were carried out after hours and the low numbers, ironically, might be seen to lessen the need for a dedicated acute surgical theatre during daylight hours. Maloney et al.5 highlight the significant acute caseload of many provincial hospitals and both investigators show satisfactory patient outcomes. However, neither investigator reports on some important surgeon outcomes. Was the consultant in house/in theatre/remote? How many operations were carried out in daylight hours? Were the surgeons compensated for their acute service?
In 2010, General Surgery Australia released a 12‐point plan for acute general surgery services.
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