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This cross-sectional study compares trends in use of robotic surgery for general surgical procedures among the Veterans Health Administration (VHA), community practice, and academic health centers from 2013 to 2021.

This cohort study compares the volume of performed surgical procedures classified as essential, urgent, and nonurgent before and after elective surgeries were restricted during the COVID-19 pandemic in the US.

This survey study investigates how local staff at a partner facility perceived the role of international visiting health care workers and the impact of hosting international workers on the facility and staff.

Importance Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

This cohort study uses gap decomposition analysis to ascertain the factors associated with postoperative mortality in patients with heart failure.

This cohort study identifies the primary indications for amputation among patients at a Cameroon hospital.

This study examines the rate of and investment in publication of randomized clinical trials in surgery in the United States and abroad.

Importance Surgical care is recognized as a growing component of global public health. Objective To assess self-reported barriers to access of surgical care in Sierra Leone, Rwanda, and Nepal using the validated Surgeons OverSeas Assessment of Surgical Need tool. Design, Setting, and Participants Data for this cross-sectional, cluster-based population survey were collected from households in Rwanda (October 2011), Sierra Leone (January 2012), and Nepal (May and June 2014) using the Surgeons OverSeas Assessment of Surgical Need tool. Main Outcomes and Measures Basic demographic information, cost and mode of transportation to health care facilities, and barriers to access to surgical care of persons dying within the past year were analyzed. Results A total of 4822 households were surveyed in Nepal, Rwanda, and Sierra Leone. Primary health care facilities were commonly reached rapidly by foot (>70%), transportation to secondary facilities differed by country, and public transportation was ubiquitously required for access to a tertiary care facility (46%-82% of respondents). Reasons for not seeking surgical care when needed included no money for health care (Sierra Leone: n = 103; 55%), a person dying before health care could be arranged (all countries: 32%-43%), no health care facility available (Nepal: n = 11; 42%), and a lack of trust in health care (Rwanda: n = 6; 26%). Conclusions and Relevance Self-reported determinants of access to surgical care vary widely among Sierra Leone, Rwanda, and Nepal, although commonalities exist. Understanding the epidemiology of barriers to surgical care is essential to effectively provide surgical service as a public health commodity in developing countries.

Importance Pneumonia is the third most common complication in postoperative patients and is associated with significant morbidity and high cost of care. Prevention has focused primarily on mechanically ventilated patients. This study outlines the results of the longest-running postoperative pneumonia prevention program for nonmechanically ventilated patients, to our knowledge. Objective To present long-term results (2008-2012) of a standardized postoperative ward-acquired pneumonia prevention program introduced in 2007 on the surgical ward of our hospital and compare our postintervention pneumonia rates with those captured in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). We also estimate the cost savings attributable to the pneumonia prevention program. Design, Setting, and Participants Retrospective cohort study at a university-affiliated Veterans Affairs hospital of all noncardiac surgical patients with ward-acquired postoperative pneumonia. Intervention A previously described standardized postoperative pneumonia prevention program for patients on the surgical ward. Main Outcome and Measure Ward-acquired postoperative pneumonia. Results Between 2008 and 2012, there were 18 cases of postoperative pneumonia among 4099 at-risk patients hospitalized on the surgical ward, yielding a case rate of 0.44%. This represents a 43.6% decrease from our preintervention rate (0.78%) ( P = .01). The pneumonia rates in all years were lower than the preintervention rate (0.25%, 0.50%, 0.58%, 0.68%, and 0.13% in 2008-2012, respectively). The overall pneumonia rate in ACS-NSQIP was 2.56% (14 033 cases of pneumonia among 547 571 at-risk patients), which is 582% higher than the postintervention rate at our ward. Using a national average of $46 400 in attributable health care cost of postoperative pneumonia and a benchmark of a 43.6% decrease in pneumonia rate achieved at our facility over the 5-year study period, a similar percentage of decrease in pneumonia occurrence at ACS-NSQIP hospitals would represent approximately 6118 prevented pneumonia cases and a cost savings of more than $280 million. Conclusions and Relevance The standardized pneumonia prevention program achieved substantial and sustained reduction in postoperative pneumonia incidence on our surgical ward; its wider adoption could improve postoperative outcomes and reduce overall health care costs.

Modern surgery’s heritage has been based on the introduction of innovative approaches to the way surgery was practiced, all in an attempt to improve patient outcomes. Innovations ranged widely from purely technical advances to simple changes in practice norms that resulted in safer surgery. These innovations in surgical safety had a profound impact on patient mortality and would transform the manner in which surgery, and medicine, would hence be approached. In 1867, for example, Joseph Lister introduced the use of a preoperative antibacterial preparation, at a time when surgical site and deep soft-tissue infections were common and often the cause of postoperative patient morbidity and mortality. 1 In the United States, William Stewart Halsted insisted on universal operative hand scrubbing as a patient safety maneuver to decrease postoperative infections. 2 These innovations were simple and are common sense by today’s standards, yet they effectively transformed the practice of surgery; they made it safer and allowed for the complexity of procedures to increase. The public’s perception of the surgeon changed as well, evolving from the experimental anatomist and radical thinker exemplified by John Hunter in the 18th century to the effective healer and possessor of special skill of modern times. 3

Importance Telehealth encounters can safely substitute for routine postoperative clinic visits in selected ambulatory surgical procedures. Objective To examine whether an allied health professional telephone visit could safely substitute for an in-person clinic visit. Design Prospective case series during a 10-month study period from October 2011 to October 2012 (excluding July and August 2012). Setting University-affiliated veterans hospital. Patients Ambulatory surgery patients who underwent elective open hernia repair or laparoscopic cholecystectomy during the 10-month study period. Interventions Patients were called 2 weeks after surgery by a physician assistant and assessed using a scripted template. Assessment variables included overall health, pain, fever, incision appearance, activity level, and any patient concerns. If the telephone assessment was consistent with absence of infection and return to baseline activities, the patient was discharged from follow-up. Patients who preferred a clinic visit were seen accordingly. Main Outcomes and Measures Percentage of patients who accepted telehealth follow-up and complications that presented in telehealth patients within 30 days of surgery. Results One hundred fifteen open herniorrhaphy and 26 laparoscopic cholecystectomy patients had attempted telehealth follow-up. Seventy-eight percent (110) of all patients were successfully contacted; of those, 70.8% (63) of hernia patients and 90.5% (19) of cholecystectomy patients accepted telehealth as the sole means of follow-up. Complications in the telehealth patients were zero for cholecystectomy and 4.8% (3) for herniorrhaphy. Nearly all patients expressed great satisfaction with the telephone follow-up method. Conclusions Telehealth can be safely used in selected ambulatory patients as a substitute for the standard postoperative clinic visit with a high degree of patient satisfaction. Time and expense for travel (7-866 miles) were reduced and the freed clinic time was used to schedule new patients.

OBJECTIVE To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country. DESIGN A randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012. SETTING Sierra Leone, Africa. PARTICIPANTS Three thousand seven hundred fifty randomly selected participants throughout Sierra Leone. MAIN OUTCOME MEASURES Mechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures. RESULTS Data were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries). CONCLUSIONS This study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the world's poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas. Language: en

Importance Because of the similarity in clinical outcomes after elective open and endovascular repair of abdominal aortic aneurysm (AAA), cost may be an important factor in choosing a procedure. Objective To compare total and AAA-related use of health care services, costs, and cost-effectiveness between groups randomized to open or endovascular repair. Design, Setting, and Participants This unblinded randomized clinical trial enrolled 881 patients undergoing planned elective repair of AAA who were candidates for open and endovascular repair procedures. Patients were randomized from October 15, 2002, to April 15, 2008, at 42 Veterans Affairs medical centers. Follow-up was completed on October 15, 2011, and data were analyzed from April 15, 2013, to April 15, 2016, based on intention to treat. Main Outcomes and Measures Mean total and AAA-related health care cost per life-year and per quality-adjusted life-year (QALY). Results A total of 881 patients (876 men [99.4%]; 5 women [0.6%]; mean [SD] age, 70 [7.8] years) were included in the analysis. After a mean of 5.2 years of follow-up, mean life-years were 4.89 in the endovascular group and 4.84 in the open repair group ( P = .68), and mean QALYs were 3.72 in the endovascular group and 3.70 in the open repair group ( P = .82). Total mean health care costs did not differ significantly between the 2 groups (endovascular group, $142 745; open repair group, $153 533; difference, −$10 788; 95% CI, −$29 796 to $5825; P = .25). Costs related to AAA, including the initial repair, constituted nearly 40% of total costs and did not differ significantly between the 2 groups (endovascular group, $57 501; open repair group, $57 893; difference, −$393; 95% CI, −$12 071 to $7928; P = .94). Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies. The probability of endovascular repair being less costly and more effective was 56.8% when effectiveness was measured in life-years and 55.4% when effectiveness was measured in QALYs for total costs and 31.3% and 34.3%, respectively, for AAA-related costs. Conclusions and Relevance In this multicenter randomized clinical trial with follow-up to 9 years, survival, quality of life, costs, and cost-effectiveness did not differ between elective open and endovascular repair of AAA. Trial Registration clinicaltrials.gov Identifier:NCT00094575