Abstract
The “General Surgery” we have known for decades is rapidly dying, at least in the developed countries. A major paradigm shift has occurred, yielding an increasing number of narrowly and subspecialty focused surgical graduates and practicing surgeons, leading to organ- or procedure-specific practices (1). Concomitantly, the proportion of our populations who are elderly and more likely than the younger age group to require surgery has increased. The demand for care has outstripped the supply of general surgeons willing and able to provide the care for these patients (2–4).
Acute Care Surgery (ACS), as it is called in the United States, and Emergency Surgery, as titled in Europe and elsewhere, has developed to address this public need. Trauma surgeons in the United States and the “visceral” trauma and emergency general surgeons of Europe have embraced this specialty. Although the terminology is new, the practice of ACS is not. The majority of us, in fact, have been “Acute Care Surgeons” for years.
As originally described in the United States, ACS consists of Trauma, Emergency Surgery, and Surgical Critical Care. Ten of the 29 most common hospital discharge diagnosis in the United States are those seen daily on any inpatient list of the ACS team, including but not limited to pancreatitis, appendicitis, colitis, soft-tissue infection, cholecystitis, injury, and bowel obstruction (2–4). It is this disease process of the ACS patient that distinguishes the acute care surgeon, from the general surgeon and elective surgical pathology. Elective surgery focuses on full understanding of the anatomy and pathology of the disease. Although equally fundamental for ACS, there is the additional critical need to address the abnormal physiology in the emergency surgery or trauma patient. This involves prompt source control, whether from a perforated duodenal ulcer or gunshot wound to the duodenum. The primary disease is a hole in a hollow viscus, and the physiologic response and need for immediate surgical intervention are the same.
It has become clear to us that patients who have developed complications of medical or surgical care may be the most vulnerable of all patients. Referring again to US hospital discharge data (2), Complication of Medical or Surgical Care is as frequent as appendicitis, acute cholecystitis, and small bowel obstruction combined. These patients comprise approximately 20% of our inpatient General Surgery service at the Pittsburgh Medical Center, where, on average, a patient a day is “surgically rescued.” Immediate intervention is essential to retrieve these patients from these major complications.
Recent publications have shown that the incidence of major complications does not differ as much as one would expect, comparing high-performing to low-performing hospitals. What separates them is failure-to-rescue (5). The high-performing hospital rescues the patient from the complication; the low-performing hospital does not. This is Surgical Rescue, as a resource intensive component of an ACS or emergency surgery service. Over 80% of these patients require an operation; 50% of the patients require multiple operations. More than one-half of these patients are admitted to the Intensive Care Unit. The other resources essential for the care of these patients are those already available in a trauma or emergency surgery center; interventional radiology, angiography/embolization, nutritional support, and surgical subspecialties. The expertise, immediate availability, and established resources make the Acute Care Surgeon essential to Surgical Rescue.
The skill set to deal with many of these complex complications and critically ill patients requires a team, which includes experienced, truly master surgeons. To fully understand and appropriately treat these major complications requires a surgeon with a good understanding of the initial elective operation, thus the essential need for an elective surgery component within ACS. As ACS moves forward, it is clear that the immediate care provided by the Acute Care Surgeon to extricate a patient from a major complication of his medical or surgical care is an essential component of ACS. The five pillars of ACS should now be defined as Trauma, Emergency Surgery, Critical Care, Elective General Surgery, and Surgical Rescue (6).