Acute Care Surgery (ACS) has emerged as a structured solution to challenges in emergency general surgery (EGS), including subspecialisation, fragmented coverage, and delays in operative care. This narrative review outlines the global ACS evolution and examines Singapore’s experience over the past decade, focusing on implementation models, outcomes, and ongoing challenges. Since 2014, Singapore’s public hospitals have adopted variations of the ACS framework, ranging from consultant of the week rosters to dedicated full time ACS teams. These models have improved timeliness of care, efficiency, and surgical training. Innovations such as Emergency Laparotomy Pathways and abscess protocols reduced delays and improved perioperative coordination. Local outcomes demonstrate reduced time to intervention by 30–40

Quality-of-life is reduced in older patients surviving major blunt trauma. Pre-injury frailty, chronic illness, low falls, or head injury, increase the risk of unplanned healthcare utilization and post-discharge mortality. However, post-hospitalization needs and experiences of patients and caregivers from this high-risk group are not well-understood. This mixed-methods longitudinal study aims to understand participants’ perspectives on needs, prognosis, quality-of-life and end-of-life planning, during the post-injury trajectory. High-risk patients > 55-years-old, and their caregivers, were recruited from three hospitals after surviving blunt trauma. All participants allowed the study team access to medical records, including unplanned readmission and death, for 36 months. Participants who consented to longitudinal follow-up were assessed for quality-of-life and caregiver burden at regular intervals. If unplanned readmission or death occurred, the longitudinal group participants were contacted for a semi-structured interview. Out of 155 participants recruited, 71 patients experienced > = 1 unplanned readmission and 33 died. Twelve semi-structured interviews were conducted after unplanned readmission or death. Five unmet needs were extrapolated from qualitative interviews: uncertainty of prognosis; access to financial support; unaddressed social needs; inconsistent access to healthcare and inadequate structural support. Qualitative findings corroborated with and provided context for the quantitative analysis. Patients with high (> = 2) unplanned readmissions, higher co-morbidities or poorer function had lower quality-of-life. For caregiver burden, high-readmission caregivers experienced increasing financial stress over time, but other domain trajectories were similar between high- and low-readmission groups. The study was limited by recruitment and access difficulties caused by the COVID-19 pandemic, and over-representation of the ethnic majority. Older high-risk blunt trauma survivors and caregivers need better support to mitigate uncertainties in their disease trajectory. Future directions include a system-level prompt to identify at-risk patients at discharge, offering access to designated care teams at different time-points to support the patients and caregivers to navigate the many uncertainties in their healthcare journeys.

Choledocholithiasis is commonly managed using either endoscopic retrograde cholangiopancreatography (ERCP) or common bile duct exploration (CBDE). Although both approaches are widely used their comparative efficacy, safety and cost-effectiveness remain debated in the context of contemporary laparoscopic and endoscopic practice. A systematic review and meta-analysis was performed of randomised controlled trials and observational studies comparing ERCP with open or laparoscopic CBDE for the management of choledocholithiasis. PubMed, Embase and Scopus were searched for studies published from January 2013 to 25 March 2026. The primary outcome was procedural success. Secondary outcomes included: retained or recurrent stones, overall complications, severe complications, length of stay and hospitalisation cost. Meta-analysis was performed using pooled risk ratios or mean differences with 95

The coronavirus disease 2019 (COVID-19) pandemic drove many healthcare systems worldwide to postpone elective surgery to increase healthcare capacity, manpower, and reduce infection risk to staff. The aim of this study was to assess the impact of an elective surgery postponement policy in response to the COVID-19 pandemic on surgical volumes and patient outcomes for three emergency bellwether procedures. A retrospective cohort study of patients who underwent any of the three emergency procedures [Caesarean section (CS), emergency laparotomy (EL), and open fracture (OF) fixation] between 1 January 2018 and 31 December 2021 was conducted using clinical and surgical data from electronic medical records. The volumes and outcomes of each surgery were compared across four time periods: pre-COVID (January 2018-January 2020), elective postponement (February-May 2020), recovery (June-November 2020), and postrecovery (December 2020-December 2021) using Kruskal-Wallis test and segmented negative binomial regression. There was a total of 3886, 1396, and 299 EL, CS, and OF, respectively. There was no change in weekly volumes of CS and OF fixations across the four time periods. However, the volume of EL increased by 47% [95% confidence interval: 26-71%, P = 9.13 x 10-7) and 52% (95% confidence interval: 25-85%, P = 3.80 x 10-5) in the recovery and postrecovery period, respectively. Outcomes did not worsen throughout the four time periods for all three procedures and some actually improved for EL from elective postponement onwards. Elective surgery postponement in the early COVID-19 pandemic did not affect volumes of emergency CS and OF fixations but led to an increase in volume for EL after the postponement without any worsening of outcomes.

BACKGROUND & AIMS: Peritoneal metastasis (PM) in gastric cancer (GC) is associated with poor prognosis and significant morbidity. We sought to understand the genomic, transcriptomic, and tumor microenvironment (TME) features that contribute to peritoneal organotropism in GC. METHODS: We conducted a comprehensive multi-omic analysis of 548 samples from 326 patients, including primary tumors, matched normal tissues; peritoneal metastases, and adjacent-normal peritoneal tissues. We used whole exome sequencing, whole transcriptome sequencing, and digital spatial profiling to investigate molecular alterations, gene expression patterns, and TME characteristics associated with PM. RESULTS: Our analysis identified specific genomic alterations in primary tumors, including mutations in ELF3, CDH1, and PIGR, and TME signatures, such as stromal infiltration and M2 macrophage enrichment, associated with increased risk of PM. We observed distinct transcriptional programs and immune compositions in GCPM compared with liver metastases, highlighting the importance of the TME in transcoelomic metastasis. We found differential expression of therapeutic targets between primary tumors and PM, with lower CLDN18.2 and FGFR2b expression in PM. We unravel the roles of the TME in niche reprogramming within the peritoneum, and provide evidence of pre-metastatic niche conditioning even in early GC without clinical PM. These fi ndings were further validated using a humanized mouse model, which demonstrated niche remodeling in the peritoneum during transcoelomic metastasis. CONCLUSION: Our study provides a comprehensive molecular characterization of GCPM and unveils key biological principles underlying transcoelomic metastasis. The identified predictive markers, therapeutic targets, and TME alterations offer potential avenues for targeted interventions and improved patient outcomes.

BackgroundDiabetes mellitus (DM) is a worldwide pandemic affecting 500 million people. It is known to be associated with increased susceptibility to soft tissue infections (STI). Despite being a major public health burden, the literature relating the effects of DM and the presentation, severity and healing of STIs in general surgical patients remain limited.MethodWe conducted a retrospective review of all patients admitted with STI in a tertiary teaching hospital over a 12-month period. Patient demographics and surgical outcomes were collected and analysed.ResultsDuring the study period, 1059 patients were admitted for STIs (88% required surgery). DM was an independent risk factor for LOS. Diabetic patients presented with higher body-mass index (28 vs. 26), larger abscess size (24 vs. 14 cm2) and had a longer length of stay (4.4 days vs. 2.9 days). They also underwent a higher proportion of wide debridement and application of negative pressure wound therapy (42% vs. 35%). More diabetic patients underwent subsequent re-operation within the same sitting (8 vs. 4). Diabetic patients were two times more likely to present with carbuncles (p = 0.02).ConclusionThe incidence of STIs among DM patients represent a significant disease burden, surgeons should consider intensive patient counselling and partnering with primary care providers in order to help reduce the incidence of future STI admissions based upon lifestyle modification and glucose control.

Purpose: The consequences of severe traumatic injury extend beyond hospital admission and have the potential for long-term functional, psychological, and economic sequalae. This study investigated patient outcomes 6 months following major trauma.Methods: Using the National Trauma Registry, database of patients who were admitted between 2016-18 in a tertiary trauma hospital for major trauma [Injury Severity Score (ISS) ≥ 16] a review was performed on 6-month outcomes [including functional outcomes, self-reported state of health and outcome scores (EuroQol-5 Dimension score and Glasgow Outcome Scale Extended)].Result: There were 637 patients who were treated for major trauma (ISS ≥ 16); the median age was 64 years (range 16-100) and 435 (68.3%) patients were male. The most common injury mechanisms included falling from height (56.5%) and motor vehicle accident (27.0%). The median ISS was 24 (range 16-75). After 6 months, 87.6% of responders were living at home, 25.0% were back to work, and 55.1% were ambulating independently. The median self-rated state of health was 73 at baseline and 64 at 6 months. Age and length of stay were independent predictors of return to ambulation using multivariate analysis. Age, Abbreviated Injury Scale external, Glasgow Coma Scale on Emergency Department arrival, heart rate, and need for transfusion were independent predictors of failure to return to work at 6 months using multivariate analysis. Charlson Comorbidity Index, Glasgow Coma Scale on arrival, temperature, pain and need for inpatient rehabilitation were independent predictors of mortality at 6 months.Conclusion: Recovery from major trauma is multi-faceted and requires a team-based approach well beyond discharge.

Skin adhesives are an alternative method for closure of trocar-site incisions (TSI). This systematic review and meta-analysis aim to compare the outcomes of absorbable subcuticular sutures versus skin adhesives for the closure of TSI's. This PRISMA-compliant review was registered with PROSPERO (CRD42022325734). In April 2022, PubMed, Embase, and Web of Science were searched for peer-reviewed studies comparing the outcomes between skin adhesive and subcuticular absorbable sutures for skin closure of TSI's in adults. Primary outcomes included wound complication rate, wound cosmesis (HWES score), patient satisfaction and wound closure time. Odds ratio (OR) and mean differences (MD) were calculated with 95 % confidence intervals (95 % CI). Risk of bias was assessed with the Cochrane risk-of-bias tool. We included 10 studies and 7 were used for the meta-analysis. The wound complication rate was similar between groups (4 studies; OR: 1.39, 95 % CI: 0.74 to 2.61, p: 0.31). Wound cosmesis (4 studies; OR: 2.29, 95 % CI: 0.90 to 5.84, p: 0.08) and patient satisfaction (3 studies; OR: 1.59, 95 % CI: 0.58 to 4.38, p: 0.37) were also similar. However, wound closure time was shorter in the skin adhesives group (3 studies; MD: −22.78, 95 % CI: −40.68 to −4.89, p: 0.01). We conclude that wound complications, cosmetic outcome, and patient satisfaction were comparable between TSIs closed with tissue adhesives or sutures. While wound closure with tissue adhesives was significantly faster in the meta-analysis, it is unlikely to be clinically meaningful. Future high-quality studies with higher-risk patient cohorts are required.

According to the latest Utstein-style consensus, drowning is defined as the primary respiratory impairment resulting from submersion or immersion in a liquid medium.1 Patients may experience hypothermia, acute respiratory distress syndrome and shock.1 The pathophysiology is poorly understood, but could relate to physiological responses to temperature, water swallowing and electrolyte disturbances.2 Globally, more than 500,000 deaths from drowning are reported every year.3 Poor prognostic factors include low Glasgow Coma Scale (GCS) score and cardiorespiratory arrest. Treatment is largely supportive. Most preventative measures are centred on aquatic safety education and swimming lessons. Based on the National Sport Participation Survey 2018–2022, swimming has consistently ranked among the 5 most popular sports in Singapore.4 This study aimed to describe the outcomes of patients admitted for drowning.

INTRODUCTION:In December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus emerged and caused a worldwide pandemic, leading to measures being imposed by many countries to reduce its transmission. Singapore implemented the 'circuit breaker', which restricted all movements except for access to necessities and healthcare services. We aimed to investigate the impact of lockdown measures on the pattern of trauma and its effects. METHODS:An observational, retrospective, single-centre descriptive study was conducted using the trauma registry in Singapore General Hospital. It included patients above 18 years old who presented to the emergency department with trauma and were subsequently admitted. Patients admitted from 1 February 2020 to 31 July 2020 and those admitted during the same timeframe in 2019 were studied. Subgroup analyses were performed for patients aged ≥65 years and those <65 years. RESULTS:A total of 1,037 patients were included for analysis. A 17.6% increase in trauma presentations was seen from 2019 to 2020. Patients aged ≥65 years accounted for the rise in admissions. The predominant mechanism of injury was falls at home for older patients and vehicular accidents in patients <65 years. There were no significant differences in injury severity score, intensive care/high-dependency unit admission rates, length of stay, mortality rate, and subsequent need for inpatient rehabilitation. CONCLUSION:Our study provided information on differences in trauma presentations before and during the COVID-19 pandemic. Further studies are required to better inform on additional precautionary measures needed to reduce trauma and improve safety during future lockdowns and pandemics.

Background Hybrid operating theatres (OT) allow for simultaneous interventional radiology and operative procedures, serving as a one-stop facility for the treatment of severely injured patients. Several countries have adopted the use of the hybrid OT however their clinical impact in improving efficiency and quality of care remains unclear. This study systematically reviews the clinical impact of the hybrid OT for treatment of the severely injured. Methods A literature review of the PubMed, Embase and Cochrane databases was performed to identify all published articles in English, from 1st January 2000 to 31st December 2020, reporting on the impact of a hybrid OT for severe trauma. Articles were also reviewed for references of interest. Results Five studies reporting the clinical impact of the hybrid OT, in a total of 951 patients, were shortlisted. All were cohort studies that compared patient outcomes in the hybrid OT versus a conventional group. Out of 3 studies that assessed timeliness to intervention, one reported shorter time associated with the hybrid OT, while the other two reported no difference. Mortality outcomes were reported in 4 studies and showed no significant difference associated with treatment in the hybrid OT. Two studies revealed shorter total procedure times associated with the hybrid OT. Two out of 3 studies that evaluated blood transfusion requirements reported decreased transfusion rates in the hybrid OT group. Only 1 study examined complication rates and demonstrated morbidity benefits associated with the hybrid OT. Conclusion Establishment of a hybrid OT requires a significant capital investment as well as a highly functioning multi-disciplinary team. The cost–benefit ratio remains unclear. Future studies, preferably in the form of clinical trials, are required to evaluate its usefulness in improving timeliness to definitive haemorrhage control and outcomes in severe trauma.

Background Lower gastrointestinal bleeding (LGIB) is a common presentation of surgical admissions, imposing a significant burden on healthcare costs and resources. There is a paucity of standardised clinical predictive tools available for the initial assessment and risk stratification of patients with LGIB. We propose a simple clinical scoring model to prognosticate patients at risk of severe LGIB and an algorithm to guide management of such patients. Methods A retrospective cohort study was conducted, identifying consecutive patients admitted to our institution for LGIB over a 1-year period. Baseline demographics, clinical parameters at initial presentation and treatment interventions were recorded. Multivariate logistic regression was performed to identify factors predictive of severe LGIB. A clinical management algorithm was developed to discriminate between patients requiring admission, and to guide endoscopic, angiographic and/or surgical intervention. Results 226/649 (34.8%) patients had severe LGIB. Six variables were entered into a clinical predictive model for risk stratification of LGIB: Tachycardia (HR ≥ 100), hypotension (SBP < 90 mmHg), anaemia (Hb < 9 g/dL), metabolic acidosis, use of antiplatelet/anticoagulants, and active per-rectal bleeding. The optimum cut-off score of ≥ 1 had a sensitivity of 91.9%, specificity of 39.8%, and positive and negative predictive Values of 45% and 90.2%, respectively, for predicting severe LGIB. The area under curve (AUC) was 0.77. Conclusion Early diagnosis and management of severe LGIB remains a challenge for the acute care surgeon. The predictive model described comprises objective clinical parameters routinely obtained at initial triage to guide risk stratification, disposition and inpatient management of patients.

Introduction Workload in oncology during a pandemic is expected to increase as manpower is shunted to other areas of need in combating the pandemic. This increased workload, coupled with the high care needs of cancer patients, can have negative effects on both healthcare providers and their patients. Methods This study aims to quantify the workload of medical oncologists compared to internal medicine physicians and general surgeons during the current COVID-19 pandemic, as well as the previous H1N1 pandemic in 2009. Results Our data showed decrease in inpatient and outpatient workload across all three specialties, but the decrease was least in medical oncology (medical oncology −18.5% inpatient and −3.8% outpatient, internal medicine −5.7% inpatient and −24.4% outpatient, general surgery −17.6% inpatient, and −39.1% outpatient). The decrease in general surgery workload was statistically significant. The proportion of emergency department admissions to medical oncology increased during the COVID-19 pandemic. Furthermore, the study compared the workload during COVID-19 with the prior H1N1 pandemic in 2009 and showed a more drastic decrease in patient numbers across all three specialties during COVID-19. Discussion We conclude that inpatient and outpatient workload in medical oncology remains high despite an ongoing COVID-19 pandemic. The inpatient medical oncology workload is largely contributed by the stable number of emergency department admissions, as patients who require urgent care will present to a healthcare facility, pandemic or not. Healthcare systems should maintain manpower in medical oncology to manage this vulnerable group of patients in light of the prolonged COVID-19 pandemic.

Background The aim of this study is to use classification methods to predict future onset of Alzheimer's disease in cognitively normal subjects through automated linguistic analysis. Methods To study linguistic performance as an early biomarker of AD, we performed predictive modeling of future diagnosis of AD from a cognitively normal baseline of Framingham Heart Study participants. The linguistic variables were derived from written responses to the cookie-theft picture-description task. We compared the predictive performance of linguistic variables with clinical and neuropsychological variables. The study included 703 samples from 270 participants out of which a dataset consisting of a single sample from 80 participants was held out for testing. Half of the participants in the test set developed AD symptoms before 85 years old, while the other half did not. All samples in the test set were collected during the cognitively normal period (before MCI). The mean time to diagnosis of mild AD was 7.59 years. Findings Significant predictive power was obtained, with AUC of 0.74 and accuracy of 0.70 when using linguistic variables. The linguistic variables most relevant for predicting onset of AD have been identified in the literature as associated with cognitive decline in dementia. Interpretation The results suggest that language performance in naturalistic probes expose subtle early signs of progression to AD in advance of clinical diagnosis of impairment. Funding Pfizer, Inc. provided funding to obtain data from the Framingham Heart Study Consortium, and to support the involvement of IBM Research in the initial phase of the study. The data used in this study was supported by Framingham Heart Study's National Heart, Lung, and Blood Institute contract (N01-HC-25195), and by grants from the National Institute on Aging grants (R01-AG016495, R01-AG008122) and the National Institute of Neurological Disorders and Stroke (R01-NS017950).

BackgroundAs the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, Acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions. MethodsAn extended ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed.ResultsThere were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 minutes) and time from surgery to discharge (2.4-hours). Mortality was decreased during this time. The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised.ConclusionIn healthcare systems affected by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.

Introduction The traditional 24-h call model faces pressure from competing needs between emergency and elective services. Recognizing this, a dedicated ESAT service was developed in Khoo Teck Puat Hospital in Singapore, with improved clinical outcomes. It was initially led by a single consultant (SC) in 2014, and subsequently evolved to a weekly consultant rotation (WC) roster in 2017 to achieve sustainability. Methods Each consultant led the ESAT WC service for a week and maintained ownership of their patients thereafter. All emergency surgical admissions between two distinct 6-month periods were reviewed, from May to October 2014 (pre-ESAT) and January to June 2017 (ESAT WC). Patient demographics, diagnoses, and operations were compared. Efficiency and clinical outcomes were evaluated. Results There were 1248 and 1284 patients in the pre-ESAT and ESAT WC group, respectively. Majority were males and in their 50s. Acute appendicitis, gallstone conditions, and soft-tissue infections made up half of the admissions. Trauma workload was comparable (7.8% pre-ESAT vs 9.5% ESAT WC). Cholecystectomies doubled during the ESAT period, 14.2% vs 7.2%, (p = 0.01). More consultants were involved in major cases (95.9% vs 86%), (p = 0.01) and more operations were performed during the day (52.1% vs 47.9%), (p = 0.01). Average time to OT was shorter and there were less major surgical complications (p = 0.02). Mortality (p = 0.08) and length of stay were reduced (4 vs 4.5 days), (p = 0.01). Conclusion The ESAT WC service has sustained improved outcomes in our institution.