Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model. We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate. The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied. Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.

Ultrasonography (US) is the mainstay of biliary tract imaging, but few recent studies have tested its ability to diagnose acute cholecystitis (AC). Our objective was to determine how well a US diagnosis of AC correlates with the intraoperative diagnosis. We hypothesize that US underestimates this diagnosis, potentially leading to unexpected findings in the operating room (OR). This retrospective review included all patients admitted to the acute care surgical service of a tertiary hospital in 2011 with suspected biliary pathology who underwent US and subsequent cholecystectomy. We determined the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US using the intraoperative diagnosis as the gold standard. Further analysis identified which US findings were most predictive of an intraoperative diagnosis of AC. We used a recursive partitioning method with random forests to identify unique combinations of US findings that, together, are most predictive of AC. In total, 254 patients underwent US for biliary symptoms; 152 had AC diagnosed, and 143 (94%) of them underwent emergency surgery (median time to OR 23.03 hr). Ultrasonography predicted intraoperative findings with a sensitivity of 73.2%, specificity of 85.5% and PPV of 93.7%. The NPV (52.0%) was quite low. The US indicators most predictive of AC were a thick wall, a positive sonographic Murphy sign and cholelithiasis. Recursive partitioning demonstrated that a positive sonographic Murphy sign is highly predictive of intraoperative AC. Ultrasonography is highly sensitive and specific for diagnosing AC. The poor NPV confirms our hypothesis that US can underestimate AC.

Prophylactic cholecystectomy following endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-S) remains the gold standard management of choledocholithiasis. Some clinicians propose ERCP-S alone as the definitive management in the elderly, given perioperative complication risks. This retrospective cohort study aimed to assess the long-term efficacy and safety of non-operative management of choledocholithiasis in adults aged ≥70. A total of 252 patients aged ≥70 underwent ERCP from 2004 to 2014 at a single institution. The rates of cholecystectomy, ERCP, complications, and mortality were gathered. Data were linked to a provincial health database to capture follow-up visits to alternate hospitals. Predictors of operation, recurrence, and mortality were analyzed using multivariable regression. Following ERCP, of the 252 patients, 33 (13.1%) underwent prophylactic cholecystectomy within three months, while 219 (86.9%) were initially managed conservatively. Of the 219 patients, 147 (67.1%) experienced no further choledocholithiasis after conservative management, while 23 (10.5%) patients underwent cholecystectomy. The mean follow-up was 2.9 years. Delayed operative patients were younger (mean age: 77.56 vs. 82.90; p < 0.001) and had lower Charlson Comorbidity Index (CCI) (1.04 vs. 1.84; p = 0.030). When adjusted for age, CCI score, and sex, cholecystectomy was associated with increased survival, with an odds ratio of 0.48 (95% confidence interval = 0.26-0.90; p = 0.021). Perioperative complications occurred in 7/56 (12.5%) patients. Recurrent choledocholithiasis is common in elderly patients. Despite recurrent symptoms, these patients are unlikely to undergo cholecystectomy. Surgeons operate on patients with greater life expectancy and fewer comorbidities with high success despite advanced patient age. Future prospective studies should examine objective criteria for prophylactic cholecystectomy in this population, given purported safety and benefits.

Background: There is an important disconnect between surgical programs and primary care physicians (PCP) in the delivery of bariatric care. The objective of this study is to assess PCP knowledge and perception of a provincial bariatric surgery program. Methods: A 32-question, IRB approved, survey was developed by bariatric surgery experts and vetted by local PCPs. A single round of paper surveys was administered to 1,000 PCPs between July and September 2015. Continuous variables were assessed by t-test and categorical variables by Chi-square test. Results: There were 131 survey responses (13.1%). Half (54.2%) of respondents did not feel equipped to counsel their patients on operative management strategies. PCPs counselled on average 11.6%+/- 17.0% of their obese patients on bariatric surgery. Many respondents (58.3%) thought excess weight loss from gastric bypass was less than 40% and most believed there was less than 50% resolution of diabetes (62.4%), hypertension (72.3%), dyslipidemia (77.8%) and obstructive sleep apnea (60.6%). PCPs who referred patients to the bariatric program (71.8%) were more comfortable counselling their patients on bariatric surgery options (56.8% vs. 17.1%, P<0.001) and were more comfortable with post-operative care (67.4% vs. 38.2%, P=0.004). Additionally, these PCPs estimated higher rates of diabetes and hypertension resolution post-bariatric surgery. The predominant perceived barrier to accessing bariatric surgery was wait times (33.3%). Conclusions: PCPs appear to underestimate the efficacy of bariatric surgery in the treatment of obesity and feel ill-equipped to counsel patients. Further education related to bariatric surgery may improve PCP comfort in counselling and long-term follow-up.