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The global imperative to expand prehospital emergency care in low and middle-income countries to reduce health disparities and improve outcomes for time-sensitive health conditions is well established in academic literature and public policy discussions. However, the governance and legal frameworks essential for the strategic development of prehospital systems remain understudied and inadequately addressed. This paper delves into the critical role of governance in prehospital systems, emphasizing its impact on equity, human rights, and the provision of timely, quality emergency care. Health system governance, defined as a complex interplay of mechanisms, processes, and institutions, is a neglected yet pivotal component of prehospital care. By highlighting previously described barriers, we underscore the opportunity to strengthen prehospital care through improved governance, particularly in leadership and legislative standards. Drawing on the World Health Organization's Health System Building Blocks and the Emergency Care System Framework, we elucidate the multifaceted nature of governance in the prehospital context, including the coordination of diverse stakeholders, the establishment of standards, and the creation of accountability mechanisms. We emphasize the importance of applying a human rights perspective to governance, ensuring non-discriminatory and timely access to emergency care. Through the application of an established governance framework of 10 principles to assess prehospital system governance, we offer policymakers and stakeholders a structured approach to identify weaknesses, propose solutions, and evaluate progress in the prehospital system. To provide practical insights, we present a contemporary case study of Ghana's National Ambulance Service Act and the Health Institutions and Facilities Act of 2011, which establish a structured approach to governance and oversight while reflecting Ghana's commitment to advancing emergency care yet faces common challenges to operationalizing the laws. We advocate for a renewed focus on governance as an essential building block for effective prehospital emergency care. By providing a comprehensive framework and case study analysis, the paper offers actionable insights to guide policymakers and stakeholders in developing and evaluating governance initiatives that improve the availability, accessibility, acceptability, and quality of prehospital care globally. [ABSTRACT FROM AUTHOR]

One-lung ventilation in infants is a high-risk procedure. Complications include endotracheal tube occlusion, with grave consequences. Although there are commercially available bronchoscopy simulators, there are no realistic models of infant patients. This limits access to training opportunities that would ensure safe and efficient lung isolation. To bridge this gap, we developesd a realistic infant bronchial tree model for single lung intubation and evaluated preliminary validity evidence of its features and clinicians' ability to perform critical skills associated with pediatric one-lung ventilation. Using computed tomography imaging, a stereolithography file of an infant airway was generated to 3D print a model. This model was inserted into a commercially available airway trainer to allow lung isolation using standard bronchoscopy techniques. Ten experienced pediatric anesthesiologists independently evaluated the simulator's physical attributes, realism, value, and relevance using a 29-item paper survey and rated using 4-point rating scales (4 = highest). Participants' ability to complete 5 critical tasks was self-reported using 5-point rating scales (5 = too easy). Item and domain mean ratings were calculated, and comments reviewed. Overall, reviews were positive, with mean scores indicating adequate realism and high value. Specific challenges were associated with right mainstem bronchus and upper lobe takeoff. Performance scores indicated that most tasks were "somewhat easy to perform," suggesting that the model's anatomy did not hinder physicians' ability to perform one-lung ventilation. Preliminary findings indicate that the novel simulator holds promise for training in lung isolation techniques after refinement. Future research will target refinement, expanding evaluation, and developing a comprehensive curriculum and competency assessment program. [ABSTRACT FROM AUTHOR]

Generative artificial intelligence is able to collect, extract, digest, and generate information in an understandable way for humans. As the first surgical applications of generative artificial intelligence are applied, this perspective paper aims to provide a comprehensive overview of current applications and future perspectives for the application of generative artificial intelligence in surgery, from preoperative planning to training. Generative artificial intelligence can be used before surgery for planning and decision support by extracting patient information and providing patients with information and simulation regarding the procedure. Intraoperatively, generative artificial intelligence can document data that is normally not captured as intraoperative adverse events or provide information to help decision-making. Postoperatively, GAIs can help with patient discharge and follow-up. The ability to provide real-time feedback and store it for later review is an important capability of GAIs. GAI applications are emerging as highly specialized, task-specific tools for tasks such as data extraction, synthesis, presentation, and communication within the realm of surgery. GAIs have the potential to play a pivotal role in facilitating interaction between surgeons and artificial intelligence. [ABSTRACT FROM AUTHOR]

The modern surgical leader now requires many tools for successful leadership. One critical tool is developing an integrated strategic plan where team and culture are developed with a directed common mission. This mission or strategic plan must fit within certain constraints, such as the larger institutional goals and constrained resources. To help develop this strategic plan, the surgical leader has many resources to use. The most common strategic planning tool is the Strengths, Weaknesses, Opportunities, and Threats analysis. Here, both internal and external factors are evaluated. From here, the contribution will review the Political, Economic, Social, Technological, Legal, and Environmental analysis (ideal for external factors) and Mission, Objectives, Strategies and Tactics analysis (ideal for internal factors), along with the Blue Ocean Strategy, Scenario Planning, and Ansoff Matrix, all of which are excellent for future planning. Porter's Five Forces will review standard competing forces, whereas Six Sigma reviews measurable process development, and Balanced Scorecard provides the framework for measurable advancements. After the paper, the reader will better understand the various tools that can be used to develop an integrated strategic plan. [ABSTRACT FROM AUTHOR]

A majority of emergency response in low and middle-income countries (LMICs) without formal emergency medical services (EMS) rely on uncoordinated layperson first responders (LFRs) to respond to emergencies using readily available mobile phones and private transport. Although formally trained LFRs are an important foundation for nascent emergency medical services (EMS) development, without coordination by standardized emergency medical dispatch (EMD) systems, LFR response is limited to witnessed emergencies, which provides significant but incomplete coverage. After training and equipping LFRs, EMD implementation using telecommunications technologies is the next step in formal EMS development and is essential to coordinate response, given the impact of timely prehospital response, intervention, and transportation on reducing morbidity/mortality. In this paper, we describe the current state of dispatch technologies used for emergency response in LMICs, focusing on the role of communication technologies, current approaches, and challenges in communication, and offer potential strategies for future development. [ABSTRACT FROM AUTHOR]

Surgeons are traditionally categorized as working either in academic or private/community practice, but some transition between the two environments. Here, we profile current academic cardiothoracic surgeons who began their attending careers in private or community practice. We hypothesized that research activity may distinguish cardiothoracic surgeons who started in non-academic versus academic practice. Publicly available data regarding professional history and research productivity were collected for 992 academic cardiothoracic surgeons on faculty at the 77 cardiothoracic surgery training programs in the United States in 2018. Data are presented as medians analyzed with the Mann-Whitney test or proportions analyzed with Fisher exact test or the χ2 test. A total of 80 (8.1%) academic cardiothoracic surgery faculty started their careers in non-academic practice, and 912 (91.9%) started directly in academia. Those who started in non-academic practice spent a median 7.0 y in private/community practice and were more likely to be cardiac surgeons (68.8% vs 51.6%, P =.0132). They were equally likely to pursue a protected research fellowship (56.3% vs 57.0%, P =.9067) and publish research during training (92.5% vs 91.1%, P =.8374), but they published fewer total papers by the end of cardiothoracic surgery fellowship (3.0 vs 7.0, P =.0001) and fewer papers per year as an academic attending (0.8 vs 2.9, P <.0001). Nevertheless, the majority of cardiothoracic surgery faculty who started in non-academic practice are currently active in research (68.8%), and 2 such surgeons received National Institutes of Health R01 funding. Transitioning from non-academic to academic practice is an uncommon but feasible pathway for interested cardiothoracic surgeons. [ABSTRACT FROM AUTHOR]

Restorative proctocolectomy with ileal pouch–anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms. All consecutive eligible patients with ileal pouch–anal anastomosis and afferent limb stricture were identified from our institutional review board–approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study. Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch–anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repair site. All patients had their ileostomy closed 3.2 (2.99–3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6–5.8) years later. Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms. [ABSTRACT FROM AUTHOR]

Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions. pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature. Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation. Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons. [ABSTRACT FROM AUTHOR]

Postpancreatectomy acute pancreatitis is challenging to diagnose and poorly characterized in its early phases. However, it represents the ideal target for novel therapeutic opportunities possibly gleaned from medical acute pancreatitis. This study aims to systematically investigate early radiologic, biochemical, and clinical features of postpancreatectomy acute pancreatitis. This was a prospective observational study of patients undergoing pancreatoduodenectomy from September 2019 to January 2021. Diffusion-weighted magnetic resonance imaging was performed on postoperative day 3. Serum pancreatic amylase and lipase were assessed daily until postoperative day 5. Postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis were defined based on the International Study Group for Pancreatic Surgery definition. A total of 65 patients were enrolled according to the sample size calculation. Patients with postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis had significantly lower apparent diffusion coefficient values at diffusion-weighted magnetic resonance imaging but no macroscopic features consistent with acute pancreatitis. Subsequently, 21 patients (32.3%) underwent computed tomography imaging for clinical worsening, and 6 had radiologic features of acute pancreatitis. All these latter patients had postoperative serum hyperamylasemia and worse outcomes, characterized by local (postoperative pancreatic fistula: 83%) and systemic morbidity (sepsis: 66.7%). The postoperative serum hyperamylasemia incidence was 21.5% (n = 14), and postpancreatectomy acute pancreatitis occurred in 6 patients (9.2%), with 4 grade B (6.1%) and 2 grade C (3%). Postpancreatectomy acute pancreatitis is characterized by early serum hyperamylasemia and hyperlipasemia. Although pancreatic changes may appear at postoperative day 3 diffusion-weighted magnetic resonance imaging, its standard use has no impact on postoperative management. Macroscopic radiologic features appear later and correlate with worse clinical scenarios. This paper paves the ground for including postpancreatectomy acute pancreatitis in the spectrum of acute pancreatitis, promoting the transfer of treatment strategies for acute pancreatitis into managing postpancreatectomy acute pancreatitis. [ABSTRACT FROM AUTHOR]

Vagus nerve-preserving gastrectomy is increasingly popular in treating gastric cancer in the early stage, however the long and short-term outcomes after gastrectomy while preserving the celiac branch of the vagus nerve are not well defined. We aimed to summarize and compare perioperative and longer-term outcomes after celiac branch vagus nerve-preserving gastrectomy (CBP, preserving both the celiac and hepatic branches of the vagus nerve), compared to those without CBP (non-CBP, only the hepatic branch of the vagus nerve is preserved). We searched the Embase, PubMed, Cochrane Library and Web of Science databases for papers published before October 2021. The primary results were evaluated by short-term and long-term postoperative complications, whereas the secondary outcomes included surgery-related parameters, recovery-related parameters and overall survival. Random-effects or fixed-effects model were used to estimate odds ratio, and weighted mean difference for the outcomes. The underlying publication bias was identified via funnel charts, Begg's test and Egger's test. Sensitivity analysis was conducted by removing the research one by one. A total of 9 studies consisting of 8 retrospective studies and one randomized control trial were included. The analysis included 1,109 patients, with 568 (51.2%) of patients receiving CBP and 541 (48.8%) patients who received non-CBP. The CBP group had a shorter time in terms of first flatus (weighted mean difference = -0.436, 95% confidence interval: -0.603 to -0.269; P < 0.001) and hospital stay (weighted mean difference = -0.456, 95% confidence interval: -0.874 to -0.037, P = 0.033) than the non-CBP group, but the time to the start of oral intake was comparable between the groups. Regarding short-term complications and surgery-related parameters, between CBP and non-CBP, no evident differences were observed in pancreatic complications, anastomotic leakage, postoperative bleeding, operation time, blood loss or lymph nodes examined. In terms of long-term complications, the incidence of gallstones in CBP was lower than that in non-CBP (odds ratio = 0.582, 95% confidence interval: 0.356–0.953, P = 0.031), and the incidence of bile reflux in CBP was lower than that in non-CBP (odds ratio = 0.473, 95% confidence interval: 0.280–0.800, P = 0.005). However, the prevalence rates of diarrhea, early dumping syndrome, esophageal reflux, and delayed gastric emptying were comparable between CBP and non-CBP. The present research showed that gastric cancer patients in the early stage under CBP were superior to those without CBP in terms of incidence of gallstones, bile reflux, time of first flatus and hospital stay. Furthermore, it is imperative to conduct randomized control studies with larger sample sizes to determine the oncological survival outcomes when preserving the celiac branch. [ABSTRACT FROM AUTHOR]

The surgical learning curve is an observable and measurable phenomenon. Operative experience targets are well established as a proxy measure for operative competence in surgical training across jurisdictions. The aim of this study was to critique the available evidence regarding the relationship between operative experience in surgical training and trainee competence. A systematic review of the PubMed, Embase, Web of Science, and Cochrane library databases was conducted in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses guidelines. Articles were sought that defined the relationship between procedural volume in surgical training and trainee competence, proficiency, or mastery. The educational impact of included studies was evaluated using a modified Kirkpatrick model. Of 3,672 records identified on database searching, 30 papers were ultimately included. Fourteen studies defined operative experience thresholds using operative time as a surrogate measure of competence, whereas another 8 used trainer assessments of operative performance (Kirkpatrick level 3). A further 5 studies were able to determine the relationship between trainee case volumes and subsequent patient outcomes (Kirkpatrick level 4b). Many studies have recorded competent trainee performance in key index procedures after reaching experience threshold numbers in excess of currently mandated targets across jurisdictions. The evidence relating current operative experience targets to patient outcomes across a range of surgical subspecialties of surgical subspecialties is lacking. This review supports a move toward criterion-based referencing of operative performance targets in surgical training. [ABSTRACT FROM AUTHOR]

The adipose stromal vascular fraction contains abundant mesenchymal stem cells and is utilized for cell therapy of male stress urinary incontinence. The purpose of this paper was to explore the effect of local transplantation of the stromal vascular fraction on improvement of damaged anal sphincter function. A rat model of vaginal distension was used as a model of damaged anal sphincter function. The adipose stromal vascular fraction was separated from the inguinal fat of syngeneic green fluorescent protein transgenic rats and delivered into the internal anal sphincter of vaginal distension rats. The maximum resting pressure was evaluated during insertion and withdrawal of the catheter at 4 or 10 days after vaginal distension treatment to estimate anal sphincter function. Green fluorescent protein-transfected human-adipose–derived mesenchymal stem cells were transplanted into the internal anal sphincter of nude rats. Hematoxylin-eosin and Masson trichrome staining were performed to evaluate tissue damage and collagen synthesis. Transplanted cells were identified using a green fluorescent protein antibody and a human-specific antibody. Activation of the transplanted human-ADSC was evaluated by quantitative RT-PCR The mean maximum resting pressure (during catheter withdrawal) of vaginal distension rats was significantly lower than that of control rats, and stromal vascular fraction injection normalized it 4 days after treatment (control: 5.66 ± 0.98, vaginal distension: 4.04 ± 1.28, vaginal distension + stromal vascular fraction: 5.92 ± 1.28 [mmHg, control versus vaginal distension: P =.039; vaginal distension versus vaginal distension + stromal vascular fraction: P =.007]). Histological examination showed that vaginal distension disrupted the internal anal sphincter, and the transplanted syngeneic stromal vascular fraction survived for 10 days. Transplanted xenogeneic human-adipose–derived mesenchymal stem cells survived in the internal anal sphincter of nude rats for 4 and 10 days. Genes related to extracellular remodeling were up-regulated in the transplanted human-adipose–derived mesenchymal stem cells Syngeneic and heterotopic transplanted adipose-derived mesenchymal stem cells engrafted in the internal anal sphincter and ameliorated damaged anal sphincter function in a rat model of vaginal distension. [ABSTRACT FROM AUTHOR]

Climate change is a significant public health threat. Health care comprises 10% of greenhouse gas emissions in the United States, where surgery is especially resource intensive. We did a systematic review to assess and summarize the published evidence of the environmental impact of surgery. We searched Medline, Embase, Web of Science, and GreenFILE databases for publications that report any environmental impact measure by all surgical subspecialties, including anesthesia. Inclusion criteria were published in English, original research, and passed peer review. Because data were heterogeneous and the aim was broad, we conducted a qualitative summary of data. Where possible, we compare impact measures. In the study, 167 articles were identified by our search strategy and reviewed, of which 55 studies met criteria. Eight were about anesthesia, 27 about operating room waste, and 6 were life cycle assessments. Other topics include carbon footprint and greenhouse gas emissions. Nine papers fell into 2 or more categories. Overall, the operating room is a significant source of emissions and waste. Using anesthetic gases with low global warming potential reduces operating room emissions without compromising patient safety. Operating room waste is often disposed of improperly, often due to convenience or knowledge gaps. There are environmental benefits to replacing disposable materials with reusable equivalents, and to proper recycling. Surgeons can help implement these changes at their institution. Although there is a clear need to lower the carbon footprint of surgery, the quality of research with which to inform protocol changes is deficient overall. Our attempt to quantify surgery's carbon footprint yielded heterogeneous data and few standardized, actionable recommendations. However, this data serves as a starting point for important future initiatives to decrease the environmental impact of surgery. [ABSTRACT FROM AUTHOR]