LAUSR

In this Focus-on issue on emergency general surgery-EGS, several studies have addressed common problems and some controversies that are still too relevant to the practice of EGS. They cover aspects such as the increasing importance of an adequate management program for the specialty, the search for a better prediction score for those patients with the all too frequent condition of small bowel obstruction-SBO in need of timely surgical management, an ESTES ‘snapshot audit’ of practice in complicated acute biliary calculous disease, the results of omental patch repair of large-size perforations of gastroduodenal ulcers, the feasibility of routine avoidance of postoperative NG tube decompression after acute SBO surgery, and, finally, the most appropriate open abdomen closure methods for severe abdominal sepsis. Eaton et al. [1] from the Adams Cowley Shock Trauma Center, remind us that the evolution of EGS carries with it the need to acknowledge that quality outcomes, performance improvement and research are paramount in delivering the best care. They describe the maturation of their EGS quality program with the novel role of Service-Based Advanced Practice Providers (SB APP) who provide administrative oversight in the capacity of an EGS Program Manager. In 2009, they formalized the Division of Acute Care Emergency Surgery (ACES) as a separate and distinct clinical service. Any acute general surgery admission was accepted by the ACES service via the emergency department (ED), internal consultation or intra-hospital transfers, with some exceptions. In 2017, a separate ACES quality structure was formalized with primary focus on scheduled quality meetings, morbidity and mortality peer review, outcomes review and performance improvement (PI) initiatives. Theirs is probably the first medical center to describe an SB APP practicing in the role of a Program Manager within a dedicated EGS service. Their most substantial finding was that the ACES census was drastically underrepresented, giving the impression of a small service with a low yearly admission rate. This led to a prompt review of the way new admissions were coded within the hospital EMR system, and an enhanced logic was created. They state that the EGS population accounts for more than 3 million admissions a year in the US, has a higher mortality and complication rates than general surgery patients, and the potential impact of improving outcomes is substantial in both the economic and social sense. Their conclusion is that the quest to improve quality of care for the EGS patient requires timely review of highquality, accurate data by dedicated and trained personnel. Berge et al. [2] from the Centre Hospitalier Universitaire d'Angers, in France, have developed a Multi Detector Computed-Tomography (MDCT) score to predict single band adhesion (SBA) versus matted adhesions (MA) as as an etiology of SBO, thus leading to earlier surgical intervention in SBA, and with a more frequent and safer use of laparoscopy. Interestingly, they found that if the score was ≥ 7, the probability of the mechanism of SBO being SBA was of 100%. Theirs is a first step toward the improvement of SBO management through selecting SBA patients who would benefit from immediate, semi-emergent or elective surgery because of their risk of medical treatment failure, their probability of success from laparoscopy, and the lower risk of recurrence as compared to MA. Indeed, a very interesting study with beneficial potential implications for that frequent condition. Bass et al. and the ESTES Cohort Studies Collaborative Group [3] describe the results of a ‘snapshot audit’ performed across Europe in late autumn/winter 2018, to better define the epidemiology, management, and outcomes in patients with Acute Complicated Calculous Biliary Disease (ACCBD). Data were recorded contemporaneously and stored on a secure, user-encrypted online platform (REDCap®) without patient-identifiable information. The primary outcome measure was index admission surgical definitive treatment. The secondary outcome measures were length of stay, the postoperative major complication rate defined as Clavien–Dindo classification, the postoperative length of * Fernando Turégano [email protected]