Patients presenting to hospital with emergency general surgery (EGS) conditions such as appendicitis, biliary disease, bowel obstructions, and intestinal perforations represent 11% of all annual hospital admissions in Canada. Compared to their elective surgical counterparts, EGS patients have significantly higher morbidity and more than five times the rate of mortality. The advent of the Acute Care Surgery (ACS) service model in Canada recognizes that patients with EGS conditions require dedicated and coordinated systems of care to optimize outcomes, and has been associated with greater access to timely operative intervention, which in turn, has translated into better outcomes for many EGS conditions. In this relatively new field, research supporting the ideal structure and function of ACS services and modern clinical guidelines for management of common pathologies has lagged behind. As a result, there is a noticeable absence of high-quality clinical trials to guide evidence-based clinical practice in ACS. The significant shift from individual-surgeon focused EGS care to this new model – with admission of EGS patients to a single ACS service at most medium-large community hospitals and all academic hospitals in Canada –is a significant structural improvement in our ability to identify and conduct research on ACS patients.
Surgical research has historically been conducted using primarily observational methodologies. While there is an important role for observational studies – indeed, the majority of our early work has been observational in nature – evidence from large well-conducted clinical trials is needed to truly change practice. Despite an exponential increase in the number of ACS publications (from just 4 in 2005 to over 800 in 2023), the number of randomized controlled trials (RCTs) has not changed substantially. Given the diversity in EGS patients and conditions, collaboration with multiple centers is imperative to ensure trials are both adequately powered and representative of the target population to which we aim to extrapolate the results. Compared to our counterparts across the world, the collaborative nature and long-standing relationships amongst the ACS leaders in Canada affords us a significant advantaged in idea generation, trial conduct, and knowledge translation.
As in the rest of the world, the leaders in ACS in Canada have emerged from leaders in trauma surgery as the clinical specialties have merged. Indeed, we have much to learn from the parallels drawn to the advent of trauma systems in the 1970s, where a recognition of the need to coordinate care, as well as measure and report on epidemiology and outcomes, has led to a significant decrease in morbidity and mortality after injury throughout the world. Although EGS care has been practiced since the advent of modern medicine, ACS is just now reaching a place of system-level organization where we are able to entertain a similar level of commitment to data and inquiry. It was, in fact, a natural evolution from the key contributing EGS and trauma surgeons representing both the Canadian Association of General Surgeons (CAGS) Acute Care Surgery Committee, and the Trauma Association of Canada (TAC) Research Committee, that led to the creation of the Canadian Collaborative on Urgent Care Surgery (CANUCS) in 2019. CANUCS represents a grass roots alliance amongst surgeons who were already regularly collaborating on research and educational initiatives relating to the growing field of ACS. Since inception, members of CANUCS have collaborated on over 20 research projects, including two pilot RCTs. To our knowledge, there are currently no similar networks completing research in the ACS space in Canada. Given the large number of patients presenting with EGS conditions, and the morbidity associated with these common but complex problems, there is an urgent need to support research that can translate to improved care and outcomes for ACS patients.
