Source control is now the major operative role of the acute care surgeon

Authors:
Ryan Desrochers, Francesca Bragg, Andrew Stephen, Daithi Heffernan

Body of Abstract:
BACKGROUND: Emergency general surgery (EGS) conditions requiring urgent operative source control, including acute intra-abdominal sepsis and necrotizing soft-tissue infections, demand timely surgical intervention to prevent progression of infection and septic deterioration. The Acute Care Surgery (ACS) model was developed to provide dedicated, around-the-clock access to surgeons capable of managing these urgent and emergent presentations. The degree to which ACS implementation has replaced Non-ACS surgeons in delivery of urgent operations for surgical infection, particularly after-hours, remains incompletely defined.

METHODS: A retrospective cohort study of operatively managed EGS infectious presentations at a tertiary academic center from 2015 to 2025. Within this cohort, we specifically addressed acute surgical infectious processes that could traditionally be managed by surgeons without specialized trauma or critical care fellowship training. Thus, we focused on emergent cases including necrotizing soft tissue infections, complex soft tissue abscesses with sepsis, and laparotomy for source control for intra-abdominal sepsis, as well as urgent cases including operatively managed appendicitis and cholecystitis. Surgeon type (ACS vs Non-ACS), operative timing, and weekend/holiday (W&H) status were recorded. Temporal changes in case distribution over time were evaluated using linear regression for annual volumes and trend analysis for W&H proportions, with segmented regression assessing pandemic-associated effects.

RESULTS: A total of 14,410 emergency operations for infectious surgical processes were performed, 9,812 (68%) by ACS surgeons and 4,598 (32%) by Non-ACS surgeons. Non-ACS annual case volume declined 49% over the decade (438 to 225 cases), showing a significant negative temporal trend (slope -28.3 cases/year; R²=0.70; p<0.001), whereas ACS volume increased by 29% (from 886 to 1,140 cases; slope +18.1 cases/year; p=0.20). Redistribution of off-hours workload was more pronounced. Non-ACS surgeons performed 68 W&H cases in 2015 versus only 2 in 2025 (-97%), while ACS coverage increased from 193 to 295 W&H cases. The ACS share of all W&H cases rose from 74% to 99% (slope +2.0%/year; R²=0.37; p=0.02). Segmented regression revealed a significant operational inflection during the COVID-19 period. Pre-pandemic Non-ACS volume was stable (slope +20.5/year; p>0.05), whereas post-2020 volume decreased sharply (-51/year; p<0.01); ACS volume demonstrated the reverse pattern, transitioning from a flat trajectory pre-pandemic (-33/year; p>0.05) to significant growth post-2020 (+105/year; p=0.03).

CONCLUSIONS: ACS surgeons have become the primary workforce for urgent operative source control. Health systems need to be very cognizant about the impact of expanded ACS programs upon surgical training and the role of possible regional emergency surgery networks to safeguard timely care for acutely infected patients.