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During the last few years the landscape of surgical practice and training has changed dramatically and several, at times contradicting trends shape the way surgery is practiced today and tomorrow. In elective surgery, minimally invasive procedures are expanding while at the same time more radical methods, especially in cancer surgery are becoming the standard. Increasing demands favor super-specialization into one-organ surgery and specialized centers that can guarantee sufficient institutional and individual case loads to produce the impressive results seen already now. To produce these super-specialists the surgical education systems have been adapted accordingly, but sometimes at the expense of more widely-based general surgical knowledge and skills.
Organizing emergency surgical services in this world of surgical super-specialization is challenging. Especially in trauma the single patient can suffer from multiple organ and organ system injuries, require multiple surgical and non-surgical interventions, and suffer from sequelae and complications affecting any part of the body. Obviously, there can be no extensive organ-based coverage of surgical emergencies in most, if any parts of the world. Some degree of more general knowledge is needed, if not more than to coordinate the efforts of several subspecialists (including nonsurgical specialists such as endoscopists or interventional radiologists) to look after the whole patient, prioritize invasive procedures and correlate the physiological state of the patient to the extent of planned interventions.
There are two basic options to organize emergency surgical services; either rely heavily on the specialized elective services or aim for expertise in emergency surgery as such. While the first option might be superior in providing the specialized knowledge and skills from the surgical anatomical aspect of an organ, the overall effects of the acutely injured or diseased organ to the overall physiological state of the patient might be underappreciated. However, it is also unrealistic to assume that any single surgeon could master the acute problems of all organ and organ systems in the body [1]. One attempt to solve this problem is to create a specialty and training program for surgeons to specialize in (almost) all life-threatening surgical problems, whether caused by trauma or acute disease process, especially in areas of the torso and neck, essentially combining trauma surgery with emergency general surgery, such as the Acute Care Surgery program in the United States [2].
Pancreatic surgery is a case in point. While there is little doubt that surgeons specialized in pancreatic surgery achieve good results in managing pancreatic cancer, surgical problems of chronic pancreatitis and other elective pancreatic surgery, their expertise might not be always available and most appropriate in emergency surgical conditions involving the pancreas. While some of the acute complications of chronic pancreatitis, such as the management of bleeding pancreatic pseudoaneurysms and infected pseudocysts can be managed with interventional radiological or endoscopic interventions [3,4], the management of pancreatic injuries and surgical emergencies of severe acute pancreatitis require prompt surgical decisionmaking, skills and knowledge available around the clock.
In this issue of the European Journal of Trauma and Emergency Surgery, trauma surgeons, emergency surgeons and surgical intensivists explore the indications and management principles of pancreatic emergencies. While the acute surgical management of pancreatic trauma naturally falls into the domain of trauma and emergency surgeons, the principles of the management of surgical complications of severe acute pancreatitis are less well defined. The indications and management of infected pancreatic necrosis are wellestablished [5], but the management of a new ‘‘pancreatic emergency’’, the abdominal compartment syndrome associated with severe acute pancreatitis, is less clear. The indications for decompressive surgery, and the techniques and management of the ensuing open abdomen are challenging issues explored in this Focus on-issue that hopefully stimulates the discussion for future options and trends, and helps the readers in updating their knowledge in trauma and emergency surgery of the pancreas. I wish to express my gratitude to Dr. Subramanian [6], Dr. Feliciano [6], and Dr. De Waele [7] for their excellent contributions and thank for their support over the years.
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