Emergency surgery in Europe

JONATHAN TILSED

CONSULTANT COLORECTAL SURGEON HONORARY SENIOR LECTURER HULL YORK MEDICAL SCHOOL CHAIRMAN UEMS DIVISION OF EMERGENCY SURGERY VICE PRESIDENT EUROPEAN SOCIETY FOR TRAUMA AND EMERGENCY SURGERY

KORRESPONDANSE: JONATHAN TILSED – TILSED@DOCTORS.ORG.UK

JONATHAN TILSED

CONSULTANT COLORECTAL SURGEON HONORARY SENIOR LECTURER HULL YORK MEDICAL SCHOOL CHAIRMAN UEMS DIVISION OF EMERGENCY SURGERY VICE PRESIDENT EUROPEAN SOCIETY FOR TRAUMA AND EMERGENCY SURGERY

I recently met a man with a heavily ‘battle-scarred’ abdomen. It bore a midline incision which extended from xiphoid to pubis and had clearly healed by secondary intention in its lower third. In addition, there were about a dozen smaller healed wounds scattered across the rest of his anterior abdominal wall. The result of a frenzied knife attack or perhaps shrapnel from an improvised explosive device? No. This was the consequence of a misdiagnosed appendicitis: one of the seven common conditions that account for 85% of emergency general surgical procedures (1) and which in 2020 alone was the subject of 1,097 publications (2). Despite this familiarity, acute appendicitis is not always an easy diagnosis. Over recent decades the international surgical community has pursued a surgical paradox that has encouraged specialisation in all fields of care, in the belief that this gets better results, but has been reluctant to extend that paradigm to emergency surgery. Perhaps unsurprisingly, the care of these patients is inconsistent. The 2016 Nuffield report documented wide variations in outcomes for emergency general surgical cases in the UK (3). For example, mortality for emergency laparotomy ranged from 3.6% to 41.7%.

Emergency surgery is not simply elective surgery performed ‘out of hours’. Emergency surgical operations are high risk procedures with a disproportionately high rate of complications in comparison to elective surgery. In the USA, for example, they account for only 14% of operations, but 54% of the morbidity and mortality (4). These diseases are often time-dependent, requiring either an immediate life-saving operation with simultaneous resuscitation or surgery as soon as possible after resuscitation for good outcomes (5, 6). Training surgeons to recognise and manage the physiological challenges of acute surgical pathology is formally addressed in only a handful of European countries where surgical training includes time working on an intensive care unit.

Worldwide, the organisation and provision of healthcare has developed as a disorganised patchwork based not primarily on need, but as a result of political, historical and financial interests. This is mirrored by a similar variety in surgical training. While no two European countries have emergency surgical care organised in exactly the same way, there are two principal models that are currently followed. In a number of countries, it is still possible to find the generalist who deals with all surgical emergencies, but the predominant model is that of the super-specialist, where the working diagnosis is matched to the most appropriate surgical specialty (e.g. colorectal, oesophagogastric, hepaticopancreaticobiliary, vascular, urological, thoracic, plastic or orthopaedic). It is generally, but not always, a good fit. The specialist acute care surgeon is in the minority but growing in number.

Emergency surgery must be accessible 24/7, but to provide that level of service often requires compromise. It is rarely dealt with by surgeons who specialise in it and too often by those who have little interest in it. Emergency surgical care should always be provided at a consistently high quality. Anything less than that should be a powerful driver for change. It is difficult to achieve change in the face of established political and financial interests. Healthcare is big business with government expenditure on health in the EU amounting to €983 billion in 2019, and Norway spending the largest proportion of GDP of all (8.7%) (7). Even in the US, where a federal system has enabled the American Association for the Surgery of Trauma to develop a specialist training programme in Acute Care Surgery, this level of care is the exception rather than the rule (8). However, the American experience has shown that change is possible and a lot has been achieved in Europe in the past 10 years.

In 2015 the European Union of Medical Specialists (UEMS) introduced the European Board of Surgery Qualification in Emergency Surgery (EBSQ) (9), as a tool to be used to improve standards in emergency surgery. This exam is open to any individual who has completed their specialist surgical training and can demonstrate appropriate experience in emergency general surgery. It was developed by a multinational group which determined the knowledge and skills required of an emergency surgeon and is updated in the light of developments in the field. In addition to enabling individual surgeons to benchmark their skills to an international standard and receive the FEBS(EmSurg) diploma, the EBSQ was intended to facilitate the

development of Emergency Surgery at a national level.

Denmark was the first country to adopt it in 2017 where emergency surgery was launched as a surgical specialty on a par with hepaticopancreaticobiliary or paediatric surgery and the EBSQ exam formed an integral part of this. In Sweden it has led to the ongoing development of an emergency surgery training curriculum and the introduction of a three year rolling programme of emergency surgery courses for surgical residents.

The Danish specialty of emergency surgery encompasses trauma surgery and acute care surgery, as well as elements of general gastrointestinal surgery (i.e. hernias, cholecystectomies and endoscopies). This fellowship training programme takes a minimum of two years. It is undertaken after completion of specialist surgical training and is entirely competency driven with training plans structured to meet the needs of the individual surgeon enabling them to take the examination and gain the UEMS certification.

In the UK and Ireland, the recently published curriculum for general surgery highlighted the importance of emergency surgery as a specific integral part of the training programme in surgery (10). The aim of this new syllabus, produced by the respective Royal Surgical Colleges and endorsed by their national Medical Councils, is to produce “general surgeons able to manage patients presenting with the full range of emergency general surgery conditions and elective conditions in the generality of General Surgery”. Emergency general surgery is a compulsory part of the first four years of specialist surgical training and has become an optional special interest component of the final two years.

While the training of future surgeons to manage emergency surgical cases to the highest standard is essential, it is not sufficient to meet the challenge of delivering emergency surgical care. That must be provided in a unit with adequate facilities and underpinned by audit, continuing education and professional development. In 2018 the Asociación Española de Cirujanos (Spanish Association of Surgeons) established an accreditation committee to define the minimum standards required of a trauma and emergency surgery unit. These encompassed the facilities, the number of surgeons dealing exclusively with emergency surgery, treatment protocols and algorithms, surgical trainers, audit data, and a review and reaccreditation procedure. It also included caseload and set targets for emergency laparoscopic surgery and conversion rates, and maximum acceptable rates of morbidity and mortality for common acute surgical conditions together with an overall mortality rate (<10%).

The UK National Emergency Laparotomy Audit (NELA) was launched in 2012 led by the Royal College of Anaesthetists, the Clinical Effectiveness Unit of the Royal College of Surgeons of England and the Intensive Care National Audit and Research Team. It set standards for emergency laparotomy, monitored compliance and measured outcomes. Since the start, overall mortality has fallen (11.8% to 9.3%) length of hospital stay has reduced (19.2 to 15.4 days) and a greater proportion (85%) of highrisk patients are admitted to critical care units. However, in the most recent report (11), almost 80% of patients with sepsis failed to receive antibiotics within an hour and more than a quarter of patients requiring urgent surgery did not get to the operating room within the target time. These deficiencies highlight the importance of the extended multi-disciplinary team in ensuring good patient care as it is rarely the senior surgeon who administers the antibiotics or wheels the patient to the operating room.

Moreover, there are many studies which have shown that surgeons working in specialised high-volume centres get better results than those with lower throughput (12). There are also several studies which show little difference in outcomes when the operating surgeon is a consultant or trainee (13, 14). This apparent contradiction suggests that it is the unit rather than the individual that actually makes the difference.

Being human we will all make mistakes, and these can have catastrophic consequences particularly when dealing with a physiologically challenged patient. Outcomes depend on the team, not just the individual. A well-functioning and experienced team will mitigate the mistakes of an individual. Conversely a poor team is likely to have poor outcomes.

Is the solution to the challenge of emergency surgery the development of specialist units? Possibly, but a more immediate, pragmatic and cost-effective solution would be the development of specialist emergency surgery teams. This will provide plenty of points for discussion at the European Congress of Trauma and Emergency Surgery in Oslo on 24th-26th April 2022.

REFERANSER: På grunn av tidsskriftets omfang har vi besluttet å ikke trykke referanselisten i papirutgaven. Den finner du i nettutgaven av artikkelen på kirurgen.no

Mediplast AS Tollbugata 115, 3041 Drammen Tlf kundeservice: 32 88 11 00 mediplast@mediplast.no

Mediplast-Compass-A5-NO.indd 1

Compass for måling av kompartmenttrykk

• Designet for tidlig, nøyaktig måling av kompartmenttrykk. • Forhindrer feildiagnose og langvarige komplikasjoner på grunn av forsinket diagnose. • Raskere, enklere å bruke og billigere enn eksisterende metoder.

COMPASS UNIVERSAL Mål kompartment trykk presist på kun et par sekunder. COMPASS PLEURATAPPING Mål pleuratrykk umiddelbart. COMPASS SPINALPUNKSJON Mål nøyaktig CSF-trykk på sekunder.

Har du spørsmål eller vil vite mer om våre produker, kontakt vår kundeservice på tlf: 32881100, eller besøk vår hjemmeside www.mediplast.com.

mediplast.com

2021-09-29 14:28:39

Er 1000 mg jern alltid nok?

Tilpasser du den intravenøse jernbehandlingen etter pasientens behov?

Monofer® kan administreres som en engangsinfusjon opp til 20 mg jern/kg kroppsvekt

ALLE PASIENTER SOM KAN BEHANDLES MED Monofer®

og med kroppsvekt over 50 kg, kan få en enkelt dose som overstiger 1000 mg – med maksdose 2000 mg EN REKKE pasienter kan dermed få dekket hele sitt individuelle jernbehov ved en enkelt infusjon med Monofer®

UTVALGT SIKKERHETSINFORMASJON

Skal ikke brukes ved: kjent overfølsomhet, anemi uten at det foreligger jernmangel, for høyt jernnivå eller forstyrrelser i kroppens utnyttelse av jern, dekompensert leversykdom. Brukes med forsiktighet ved akutt eller kronisk infeksjon. Bør ikke gis til pasienter med aktiv bakteriemi. Gis kun etter en grundig nytte-/risikovurdering ved nedsatt leverfunksjon. Skal ikke brukes under graviditet hvis ikke absolutt nødvendig. Behandlingen bør begrenses til 2. og 3. trimester. Føtal bradykardi kan oppstå. Vanlige bivirkninger: Kvalme, utslett, reaksjoner på injeksjonsstedet. Pasienten skal overvåkes nøye for tegn og symptomer på overfølsomhetsreaksjoner under og i minst 30 minutter etter hver administrering av Monofer.

UTVALGT PRODUKTINFORMASJON

Infusjons-/injeksjonsvæske, oppløsning 100 mg/ml. Indikasjoner: Behandling av jernmangel ved følgende indikasjoner: Ved klinisk behov for hurtig tilførsel av jern. Når orale jernpreparater ikke kan benyttes pga. manglende effekt eller ikke kan brukes av andre årsaker. Diagnosen må baseres på laboratorieprøver. Dosering: Doseringen gjøres trinnvis: [1] bestemmelse av det individuelle jernbehovet, og [2] utregning og administrasjon av jerndosen(e). Trinnene kan gjentas etter [3] vurdering av jernoppfylling etter jerntilskudd. Jernbehovet er uttrykt i mg elementært jern. Jernbehovet kan bestemmes enten ved en forenklet tabell basert på Hb-verdi og kroppsvekt eller ved Ganzoni-formelen (se preparatomtalen). For å vurdere effekten av Monofer skal Hb-nivået revurderes tidligst 4 uker etter siste administrering. Ved ytterligere behov for jern, må dette utregnes på nytt. Ytterligere sikkerhetsinformasjon: Bør ikke brukes til barn og ungdom <18 år. Kan gi overfølsomhetsreaksjoner, inkl. alvorlige og potensielt dødelige anafylaktiske/anafylaktoide reaksjoner. Overfølsomhetsreaksjoner som har utviklet seg til Kounis syndrom er sett. Risikoen er økt ved kjente allergier og ved autoimmune eller inflammatoriske tilstander. Behandlingen må stoppes umiddelbart ved overfølsomhetsreaksjoner eller tegn på intoleranse under administrering. Pakninger og priser: Hetteglass: 5x1 ml kr 1532,40. 5x5 ml kr 7203,10. 2x10 ml kr 5770,60. Reseptgruppe C. Basert på SPC godkjent 26.05.2020. For ytterligere informasjon om Monofer, se SPC. Pharmacosmos A/S, Rørvangsvej 30, 4300 Holbæk, Denmark. www.pharmacosmos.com/nordic