Abstract
Emergency surgery is required for many patients suffering from trauma, acute (surgical) disease process, or surgical complications. However, not all emergencies are equal. Some need surgery as soon as possible, for example, patients with major intra-abdominal hemorrhage or vascular compromise associated with bowel ischemia. Patients with generalized peritonitis might benefit from a short period for stabilizing the physiology as long as antimicrobial treatment is promptly started, and the delay does not exceed a couple of hours.
The acceptable delay for patients where prolonged delay might lead to generalized peritonitis and poorer outcome (acute appendicitis) or more invasive surgical treatment and prolonged hospital stay (acute cholecystitis), respectively, is more controversial, and the trends seem to go in opposing directions. Nonoperative management with antibiotic treatment for acute uncomplicated appendicitis is gaining more favor (1, 2), whereas early (laparoscopic) cholecystectomy for acute cholecystitis or even symptomatic cholelithiasis is supported by several recent studies (3, 4).
Most surgeons would agree that patients with nonstrangulated small bowel obstructions or infected pancreatic necrosis (unless in septic shock) do not need to be operated on in the middle of the night, and the same is true for many other abdominal emergencies. Finally, there are many nonelective procedures that are performed by emergency surgery teams that are not true emergencies such as changing dressings in open abdomen patients or performing tracheostomies for patients from intensive care or acute neurology units.
Prioritizing emergency operations by urgency and using some form of categorization into different groups is becoming more common. The so-called traffic light color coding system has been used at the Helsinki University hospital for a decade. It consists of three categories coded red (surgery as soon as possible), orange (surgery within 24 h), and yellow (surgery within 48 h). Only patients with red code are operated on at nighttime. The majority of emergency surgery is performed during the daytime (three designated operation tables for emergency surgery) or during the evening shift ending at 22.00 hours
Several studies show that in most patients with a surgical emergency, an operation performed as soon as possible is beneficial from a medical point of view, as it reduces complications and length of hospital stay. It saves hospital resources (every day spent waiting in a surgical ward for an emergency operation is a wasted day), and patients appreciate not having to wait for surgery longer than necessary. However, nighttime surgery is expensive and might not be as safe as surgery performed during regular hours.
The solution to the dilemma could include the following components at least. Emergency surgery should be seen as an equal to elective surgery, thereby guaranteeing sufficient daytime operating room capacity, and should probably be separated to an independent “production line” not affected by unexpected delays in elective procedures requiring substitute personnel from the emergency surgery teams. Accumulation of patients waiting for emergency surgery should be minimized by a flexible system that permits adjustments to the inevitable day-to-day variation in patient numbers. Finally, more research is needed to validate the safe waiting times for emergency surgical conditions. For example, recent (unpublished) data from our institution show that, contrary to previous views, in-hospital delay for patients with acute appendicitis is associated with an increased risk of perforation.
Well-defined clinical pathways and timely and appropriate surgical interventions for emergency surgical problems lead to the best possible outcomes. Our patients deserve that, and it is our duty to provide it.
Key words: Emergency surgery; acute care surgery; prioritization; peritonitis; acute appendicitis; acute cholecystitis; operation theatre