Editorial: Surgical outcomes in acute care surgery: should we introduce the concept of time-critical condition?

Abstract

Patients undergoing Emergency Gastrointestinal Surgery (EGS) are so heterogeneous in terms of procedures they receive, comorbidities and physiologic derangement at the time of diagnosis and treatment that perioperative risk stratification, surgical planning and risk mitigation may be exceedingly cumbersome. Nonetheless, EGS, while representing about 15% of the whole surgical burden worldwide, still accounts for more than 50% of global surgical morbidity and mortality (2).Thus, a structured decision-making process, with accurate risk stratification and patients' priority addressing (3)(4)(5), seems even more crucial in the emergency than in the elective setting. On one hand, we need to better assess EGS patients' needs and improve surgical outcomes in the emergency setting.How? First, perioperative risk stratification is crucial to improve shared decision-making among the care team and the patient, perioperative planning, and risk mitigation (5,7). As suggested by Yun Il, several factors are thought to be related to the postoperative outcome, but frailty has recently gained increased attention and its preoperative screening has been advocated as a critical tool in predicting length of stay, operative risk, and surgical outcomes in the elderly (1). Second, as reported by Eydivandi N, a thorough attention in intraoperative care items, such as levels of carbon dioxide insufflation, analgesia, i.v. fluid load, has a pivotal role in preventing post-operative surgical complications. In this respect, the so called "Enhanced recovery after emergency surgery" concept may represent the new frontier of perioperative care for EGS patients (6). Finally, as reported by Ali M et all, the Clavien-Dindo classification still plays a crucial role in assessing postoperative complications and predicting the impact of surgery on quality of life (7). On the other hand, the new emerging concept of EGS as a time dependent condition can help achieving early diagnosis and treatment, thus improving outcomes and reducing health care costs (8). During the COVID19 pandemic, we have witnessed a dramatic decrease in surgical emergencies but also an increase in the severity of acute diseases, as patients, frightened by the risk of contagion, went late to the ED.Definitive treatment was often postponed in favour of a non-operative treatment (NOM), both due to concomitant Sars-Cov-2 infection in these patients as well as to shortage of resources (such as ICU beds and surgical rooms) engaged with COVID-19 patients (9). If we look at a single disease such as acute appendicitis, several studies have shown that a conservative approach may further increase the risk of recurrence: more than one third of the patients treated by antibiotics only have been re-admitted for a recurrent episode of appendicitis. (10)(11)(12)(13)(14). Moreover, a systematic review and metanalysis by Podda M. et al showed that appendectomy remains the most effective treatment for patients with uncomplicated acute appendicitis and that antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. (14) Coming to the general landscape of EGS, it is well known that a prolonged waiting time from the onset of symptoms to surgical treatment is directly related to an increased risk of major bowel resection and postoperative complications. (15)(16)(17) Peritonitis due to gastric perforation is associated with an increasing risk of mortality of 2% for each hour of delay in surgical treatment after the diagnosis (18)(19)(20)(21). Patients with acute cholecystitis should undergo surgery within a time lapse of less than 10 days, such as stated in modern guidelines (22)(23)(24)(25)(26). Femur fractures should receive a definitive surgical treatment within 48 hours from diagnosis, as this time cut-off is directly linked to better outcomes. (28) Delay in the treatment of acute diseases is not only of ethical interest in terms of harm for