LAUSR

Dear Editor, We read with interest the manuscript by Hoehn et al. and we congratulate the authors on their attempt to clarify such a topical subject. Several recent studies have identified a Bweekend effect^ for surgical outcomes, but the underlying cause of such a potential effect remains unclear. Similarly, the Bnightshift effect^ is currently a matter of strong debate such that the safety of performing emergency surgery at night in stable patient is questioned. However, we have concerns regarding the statistical interpretation and accuracy of result reporting underpinning the manuscript. Firstly, there is a mismatch between the results and the reported data in Table 1. The text describes no significant difference in patients’ demographics between weekday and weekend cases, while in Table 1, all p values related to demographic data are statistically significant. Secondly, there is discrepancy in the data within Fig. 1a and the same value of weekday procedures as reported in Table 1. Figure 1b shows slight graphical differences in the rate of appendicectomy and PUD repair, whereas the values in Table 1 appear identical. Thirdly, the authors state that BFigure 1 is a graphical representation of noteworthy data from Tables 1 and 2^. However, Fig. 1 compares the percentages of procedures performed on weekdays vs weekends according to severity of illness (a) and postoperative mortality (b) and does not relate in any way to the hospital burden, as is the case with Table 2. Nonetheless, this study reports a potentially important Bweekend effect^ and seems to demonstrate its existence and its independency from patient characteristics (especially severity of illness). However, it is not clear if the multivariate analysis has been risk-adjusted according to the severity of illness and patient characteristics. In fact, not all patients requiring a specific surgical procedure are the same and we wonder if the Bweekend effect^ would persist taking this factor into consideration. For example, within the colonic resection group, there would be a spectrum of illness severity (obstruction, ischemia, perforation, for example). Would then a patient needing a colonic resection for an obstructing tumor have the same mortality risk if operated during the weekdays or during the weekend? Similarly, what would happen for a patient with a colonic perforation instead? We agree with the authors that Emergency General Surgery (EGS) service represents a high-volume and high-risk specialty, but it is still an under-resourced service in many countries. Therefore, as a surgical community, we must acknowledge that a poor EGS service with disappointing outcomes can be harmful to a large number of patients. This is a current and relevant issue within the United KingdomNational Health Service, where EGS services commonly admit a large number of patients each day. For this reason, EGS in the UK is still a potentially busy and stressful occupation. Since this issue was highlighted by the Royal College of Surgeons of England in 2011, the UK has gradually undertaken a change to its EGS services and EGS is progressively gaining importance, funding and resource. In other countries, EGS units are well-organized and more strictly dedicated to surgical patients and regulated in order to avoid work overload for general surgery staff. Where Acute * Salomone Di Saverio [email protected]