ATLANTA—Establishing a dedicated emergency general surgery service line may reduce complication rates, particularly among the common emergency general surgery procedures most prone to issues, according to new research.

More than 3 million people are admitted to U.S. hospitals every year with EGS diagnoses, nearly 30% of which require surgery. Although EGS patients comprise only 11% of all surgical admissions, they account for nearly 50% of surgical mortality, with up to an eightfold increase in the risk for postoperative death compared with patients undergoing comparable elective procedures.

“In fact, one study found EGS to be a risk factor for death independent of patients’ preoperative comorbid conditions and physiologic status,” said Morgan Roberts, MD, a general surgery resident at the University of South Alabama (USA) Medical Center, in Mobile, speaking at the 2021 Southeastern Surgical Congress.

According to a study by Scott et al, seven procedures make up the greatest burden of EGS cases: partial colectomy, cholecystectomy, appendectomy, small bowel resection, laparotomy, lysis of peritoneal adhesion and operative management of peptic ulcer disease (JAMA Surg 2016;151[6]:e160480).

“Together, these procedures account for not only 80% of EGS procedures but also 80% of postoperative complications, patient cost and death,” Dr. Roberts said, noting that this distinction allowed for a more quantifiable way to assess the functionality of EGS service.

Around the same time the Scott et al study was published, USA Medical Center established a comprehensive in-house EGS service led by a dedicated division director. They assigned call in five-day blocks with attending surgeons available in 12- to 24-hour stretches; this call included only acute care surgeons who were exempt from outpatient responsibilities.

To test their hypothesis that implementation of a dedicated EGS service would reduce morbidity and improve outcomes, Dr. Roberts and her colleagues used the subset of seven operations identified by Scott et al to compare their institution’s outcomes before and after establishing the EGS service.

In all, 718 patients who underwent one of the seven procedures between January 2013 and May 2019 met the inclusion criteria of being nontraumatic, nonelective cases performed primarily by a general surgeon within 48 hours of presentation. The patients were divided into two cohorts: 409 in the pre-EGS service group and 309 in the established EGS service group. The primary outcome was the overall complication rate following each of the seven types of procedures.

“We found that 19% of patients in the pre-EGS group experienced postoperative complications, while only 13% of patients in the post-EGS group experienced a postoperative complication, representing a statistically significant decrease,” Dr. Roberts said.

The primary driver of this decrease was the 10% to 3% reduction in complications after cholecystectomy, which made up about 54% of EGS procedures both before and after implementation of the EGS service; the remainder of operations demonstrated nonsignificant decreases in complications.

The researchers also evaluated a number of secondary end points, mainly postoperative mortality, time to operation from initial presentation, frequency of overnight operations and length of stay.

“We found a significant increase in overnight operations performed, from 7% in the pre-EGS group going to the OR between 6 p.m. and 6 a.m., to 16% in the post-EGS group undergoing overnight surgeries,” Dr. Roberts said. Changes in other secondary end points achieved statistical significance.

Katherine Kelley, MD, of Kelley Acute Care Surgery in Pocono Lake, Pa., noted that Dr. Roberts’ research is consistent with prior studies showing benefits from an acute care surgery model. “As an acute care surgeon, I appreciate the support,” Dr. Kelley said.

But she questioned why patients who went into surgery more than 48 hours after presentation were excluded from the study.

“I would expect that if you included these patients, you might see a more significant improvement in your time [in the] OR. Also, how many of each type of complication were seen? To me, there is a large clinical difference between my patients developing deep vein thrombosis as opposed to a cardiac arrest, sepsis or surgical site infection, and I would be interested to see this breakdown,” Dr. Kelley said.

Regarding the 48-hour cutoff, Dr. Roberts explained that their study was based on the Scott et al study, which used that same cutoff. “This was done largely to exclude nonoperative admissions and to look specifically at the quality of surgical intervention these patients were receiving.”

She acknowledged Dr. Kelley’s point about the difference between complications such as wound infection and respiratory failure. “But there was actually no difference in any of the individual complications, only in the overall complication rate; I suspect this has to do with power in that there were not a large number of individual complications,” Dr. Roberts said.