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Background The optimal nutritional therapy in the field of pancreatic surgery is still debated. Methods An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. Results The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. Conclusion The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes. [ABSTRACT FROM AUTHOR]

In recent years, as the high burden of surgical disease and poor access to surgical care in low- and middle-income countries have gained recognition as major public health problems, interest in global health has surged among surgical trainees and faculty. Traditionally, clinical volunteerism was at the forefront of the high-income country response to the significant burden of surgical disease in low- and middle-income countries. However, sustainable strategies for providing surgical care in low- and middle-income countries increasingly depend on bilateral clinical, research, and education collaborations to ensure effective resource allocation and contextual relevance. Academic global surgery creates avenues for interested surgeons to combine scholarship and education with their clinical global surgery passions through incorporation of basic/translational, education, clinical outcomes, or health services research with global surgery. Training in global health, either within residency or through advanced degrees, can provide the necessary skills to develop and sustain such initiatives. We further propose that creating cross-continental, bidirectional collaborations can maximize funding opportunities. Academic institutions are uniquely positioned to lead longitudinal and, importantly, sustainable global surgery efforts. However, for the individual global surgeon, the career path forward may be unclear. This paper reviews the development of academic global surgery, delineates the framework and factors critical to training global surgeons, and proposes models for establishing an academic career in this field. Overall, with determination, the academic global surgeon will not only carve out a niche of expertise but will define this critical field for future generations. [ABSTRACT FROM AUTHOR]

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]

Postoperative hyperamylasemia is a frequent finding after pancreatoduodenectomy, but its incidence and clinical implications have not yet been analyzed systematically. The aim of this review is to reappraise the concept of postoperative hyperamylasemia with postoperative acute pancreatitis, including its definition, interpretation, and correlation. Online databases were used to search all available relevant literature published through June 2019. The following search terms were used: "pancreaticoduodenectomy," "amylase," and "pancreatitis." Surgical series reporting data on postoperative hyperamylasemia or postoperative acute pancreatitis were selected and screened. Among 379 screened studies, 39 papers were included and comprised data from a total of 9,220 patients. Postoperative hyperamylasemia was rarely defined in most of these series, and serum amylase values were measured at different cutoff levels and reported on different postoperative days. The actual levels of serum amylase activity and the representative cutoff levels required to reach a diagnosis of postoperative acute pancreatitis were markedly greater on the first postoperative days and tended to decrease over time. Most studies analyzing postoperative hyperamylasemia focused on its correlation with postoperative pancreatic fistula and other postoperative morbidities. The incidence of postoperative acute pancreatitis varied markedly between studies, with its definition completely lacking in 40% of the analyzed papers. A soft pancreatic parenchyma, a small pancreatic duct, and pathology differing from cancer or chronic pancreatitis were all predisposing factors to the development of postoperative hyperamylasemia. Postoperative hyperamylasemia has been proposed as the biochemical expression of pancreatic parenchymal injury related to localized ischemia and inflammation of the pancreatic stump. Such phenomena, analogous to those associated with acute pancreatitis, could perhaps be renamed as postoperative acute pancreatitis from a clinical standpoint. Patients with postoperative acute pancreatitis experienced an increased rate of all postoperative complications, particularly postoperative pancreatic fistula. Taken together, the discrepancies among previous studies of postoperative hyperamylasemia and postoperative acute pancreatitis outlined in the present review may provide a basis for stronger evidence necessary for the development of universally accepted definitions for postoperative hyperamylasemia and postoperative 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]

Background The risk of port-site metastasis after laparoscopic removal of incidental gallbladder cancer was previously estimated to be 14–30%. The present study was designed to determine the incidence of port-site metastasis in incidental gallbladder cancer in the modern era (2000–2014) versus the historic era (1991–1999). We also investigated the site of port-site metastasis. Methods Using PRISMA, a systematic review was conducted to identify papers that addressed the development of port-site metastasis after laparoscopic resection of incidental gallbladder cancer. Studies that described cancer-specific outcomes in ≥5 patients were included. A validated quality appraisal tool was used, and a weighted estimate of the incidence of port-site metastasis was calculated. Results Based on data extracted from 27 papers that met inclusion criteria, the incidence of port-site metastasis in incidental gallbladder cancer has decreased from 18.6% prior to 2000 (95% confidence interval 15.3–21.9%, n = 7) to 10.3% since then (95% confidence interval 7.9–12.7%, n = 20) ( P < .001). The extraction site is at significantly higher risk than nonextraction sites. Conclusion The incidence of port-site metastasis in incidental gallbladder cancer has decreased but remains high relative to other primary tumors. Any preoperative finding that raises the suspicion of gallbladder cancer should prompt further investigation and referral to a hepato-pancreato-biliary specialist. [ABSTRACT FROM AUTHOR]

The Surgeon General oversees the Commissioned Corps of the U.S. Public Health Service (USPHS) and is viewed as the "Nation's Doctor," responsible for providing the public with information on living healthier and safer lives. The Surgeon General's influence is seen through public health initiatives such as warning labels on tobacco and alcohol products. The objectives of this paper are to describe the tradition of the Office of the Surgeon General as created by Dr John M. Woodworth and to describe the careers of Dr C. Everett Koop and Dr Richard H. Carmona—the only 2 surgeons by training to hold the role. This is a historical literature review using a combination of primary and secondary sources. Dr Woodworth set the priorities and responsibilities of the Surgeon General's Office: education, public service, sanitation, and public health. Dr Koop is widely regarded as the most influential Surgeon General of all time. He was both a pioneer in pediatric surgery and a highly influential public figure, issuing landmark reports on smoking, violence, and AIDS. Dr Carmona is a trauma surgeon by training and focused on the dangers of second-hand smoke as Surgeon General. Dr Carmona served in a more political role as Surgeon General, eventually running for Senate at the end of his term. This brief review of the history of the Surgeon General's Office highlights the contributions of the first Surgeon General and the only 2 surgeons who have held the position. [ABSTRACT FROM AUTHOR]

Subtotal cholecystectomy is recognized as a rescue procedure performed in grossly suboptimal circumstances that would deem a total cholecystectomy too risky to execute. An earlier systematic review based on 30 studies published between 1985 and 2013 concluded that subtotal cholecystectomy had a morbidity rate comparable to that of total cholecystectomy. This systematic review appraises 17 clinical outcomes in patients undergoing subtotal cholecystectomy. The study protocol was registered with the International Prospective Register for Systematic Reviews (CRD42020172808). MEDLINE, Embase, Cochrane bibliographic databases, and Google Scholar were used to identify papers published between 1985 and June 2020. Data related to the surgical setting, approach, intervention on the hepatic wall of the gallbladder, type of completion of subtotal cholecystectomy, year of study, and study design were collected. Seventeen clinical outcomes were considered. Meta-analyses were performed using a random-effects model, and the effect size was presented as risk ratios with 95% confidence intervals. From 1,017 records, 85 eligible studies were identified and included. These included 3,645 patients who underwent subtotal cholecystectomy. Laparoscopic (80.1%, n = 2,918) and reconstituting (74.6%, n = 2,719) approaches represented the majority of all subtotal cholecystectomy cases. Seven (0.2%) cases of injury to the bile duct were reported. Bile leak was reported in 506 (13.9%) patients. Reconstituting subtotal cholecystectomy was associated with a lower risk for 11 clinical outcomes. Open subtotal cholecystectomy was associated with an increased rate of 30-day mortality and wound infections. Subtotal cholecystectomy is associated with significant morbidity. Laparoscopic and reconstituting surgery may reduce the risks of some perioperative complications and long-term sequelae after subtotal cholecystectomy. [ABSTRACT FROM AUTHOR]

Portal venous system thrombosis can develop after bariatric surgery. A systematic review and meta-analysis was conducted to evaluate the incidence of portal venous system thrombosis after bariatric surgery and clarify the role of anticoagulation for the prevention of portal venous system thrombosis after bariatric surgery. PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of portal venous system thrombosis after bariatric surgery was pooled by a random-effect model. Subgroup analyses were performed to explore the incidence of portal venous system thrombosis according to the average duration of prophylactic anticoagulation (extended versus short-term). Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity. Among 2,714 papers initially screened, 68 studies were included. Among 100,964 patients undergoing bariatric surgery, 300 developed portal venous system thrombosis. The pooled overall incidence of portal venous system thrombosis after bariatric surgery was 0.419% (95% confidence interval: 0.341%–0.505%). The pooled incidence of portal venous system thrombosis after bariatric surgery was numerically lower in patients who received extended prophylactic anticoagulation protocol after bariatric surgery than those who received short-term prophylactic anticoagulation protocol (0.184% vs 0.459%). Meta-regression analyses demonstrated that sample size (P =.006), type of surgery (P <.001), and average duration of prophylactic anticoagulation (P =.024) might be sources of heterogeneity, but not region, publication year, history of bariatric surgery, follow-up duration, or use of prophylactic anticoagulation. Sensitivity analyses could not identify any source of heterogeneity. The estimated mortality of portal venous system thrombosis after bariatric surgery was 1.33%. Portal venous system thrombosis after bariatric surgery is rare, but potentially lethal. Extended prophylactic anticoagulation protocol may be considered in patients at a high risk of developing portal venous system thrombosis after bariatric surgery. [ABSTRACT FROM AUTHOR]

A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic has raised several issues regarding the management of surgical patients. The aim of the current study was to clarify the management of oncologic and surgical patients during the pandemic. Relevant publications reporting on the epidemiology of the pandemic, the diagnosis of the severe acute respiratory syndrome coronavirus 2 infection, and the clinical management of cancer and surgical patients, as well as studies concerning health care workers' safety, were included. The last date of research for this study was April 4, 2020. We analyzed 28 papers. Real-time polymerase chain reaction was considered the gold standard for the diagnosis of COVID-19, and computed tomography scans were considered useful for cases of diagnostic uncertainty. Cancer patients and surgical patients were confirmed to be particularly at risk of infection and negative outcome. To guarantee adequate care to these patients, while minimizing the risk for infection, the early postponing of elective surgery, the creation of COVID-free facilities and the identification of COVID- dedicated operating theaters and teams have been proposed. The correct use of personal protective equipment was also strongly advocated, along with the institution of facilities for the psychologic support of health care workers. Clinicians should be aware of the importance of providing adequate care to patients with urgent and nondeferrable clinical issues, such as cancer. Every effort should be made to contain the virus spread in the hospital setting. Also, clinicians should value the importance of self-protection and mental health care. [ABSTRACT FROM AUTHOR]

Background: Surveys are important research tools that permit the accumulation of information from large samples that would otherwise be impractical to collect. Resident surveys have been used frequently to monitor the quality of postgraduate training. Low response rates threaten the utility of this research tool. The purpose of this study was to determine the standard response rate of surveys administered to surgery residents and identify characteristics associated with achieving greater response rates. Methods: A search of peer-reviewed literature published between September 2003 and June 2011 was performed with the use of PubMed with Medical Subject Headings: “internship and residency,” “surgery,” “data collection,” and “questionnaires.” For inclusion, articles must have described a survey given to active surgery residents within the United States. Surveys were evaluated based on the following criteria: population size, response rate, incentive use, follow-up use, survey format (online vs paper), and institution versus national. Results: Of 433 initial results, 47 met inclusion criteria with a mean response rate of 65.3%. Surveys administered in paper format had a greater response rate compared with those given electronically (mean 78.6% vs 36.4%, respectively, P < .001). Greatest mean response rates were seen for institutional surveys compared with those given nationally (83.1% vs 42% respectively, P < .001). Conclusion: Our review demonstrated that paper surveys administered at the institutional level and during assemblies integrated into residents’ schedules demonstrated enhanced response rates. The validity and generalizability of data collected through such surveys will improve as the aspects which dictate response rate are better understood and implemented. [Copyright &y& Elsevier]

Contemporary surgical training programs rely on the repetition of selected surgical motor tasks. Such methodology is inherently open ended with no control on the time taken to attain a set level of proficiency, given the trainees' intrinsic differences in initial skill levels and learning abilities. Hence, an efficient training program should aim at tailoring the surgical training protocols to each trainee. In this regard, a predictive model using information from the initial learning stage to predict learning curve characteristics should facilitate the whole surgical training process. This paper analyzes learning curve data to train a multivariate supervised machine learning model. One factor is extracted to define the trainees' learning ability. An unsupervised machine learning model is also utilized for trainee classification. When established, the model can predict robustly the learning curve characteristics based on the first few trials. We show that the information present in the first 10 trials of surgical tasks can be utilized to predict the number of trials required to achieve proficiency ( R 2 = 0.72) and the final performance level ( R 2 = 0.89). Furthermore, only a single factor, learning index, is required to describe the learning process and to classify learners with unique learning characteristics. Using machine learning models, we show, for the first time, that the first few trials contain sufficient information to predict learning curve characteristics and that a single factor can capture the complex learning behavior. Using such models holds the potential for personalization of training regimens, leading to greater efficiency and lower costs. [ABSTRACT FROM AUTHOR]

Background Pancreatic neuroendocrine neoplasms are a heterogenous group of rare tumors whose natural history remains poorly defined. Accurate prognostication of pancreatic neuroendocrine neoplasms is essential for guiding clinical decisions. This paper aims to summarize all the commonly utilized and recently proposed prognostication systems for pancreatic neuroendocrine neoplasms published in the literature to date. Methods A systematic review of Pubmed, Scopus, and Embase databases, of the period from January 1, 2000–November 29, 2016, was conducted to identify all published articles reporting on prognostication systems of pancreatic neuroendocrine neoplasms. Results A total of 23 articles were included in our review, and a total of 25 classification systems were identified. There were 2 modifications of the World Health Organization 2004 criteria, 4 modifications of the World Health Organization 2010 criteria, 2 modifications of the American Joint Committee on Cancer 2010 staging system, 3 modifications of the European Neuroendocrine Tumor Society 2006 tumor, node, metastasis staging system, 7 novel categorial classification systems, and 2 novel proposed continuous classifications. The most commonly included variables included age, size of tumor, presence of distant and lymph node metastases, Ki-67 index, and mitotic count. Conclusion Numerous prognostication systems have been proposed for pancreatic neuroendocrine neoplasms, of which the most commonly used systems presently include the World Health Organization 2010 criteria and the two tumor, node, metastasis staging systems by the European Neuroendocrine Tumor Society and the American Joint Commission on Cancer. However, prognostication systems for pancreatic neuroendocrine neoplasms continue to evolve with time as more prognostication factors are identified. More validation and comparative studies are needed to identify the most effective prognostication system. [ABSTRACT FROM AUTHOR]

Background: A prior study revealed a paucity of surgical research in the 5 top-rated general surgery journals for 1998. The hypothesis of the current study was that a large amount of surgical research was published in other journals. Methods: In all, 15 research journals and 9 surgery specialty journals were reviewed for basic research, funded clinical studies, randomized clinical trials, and drug trials. The funding sources and the surgeon''s role were recorded. The findings were compared with research published in the previously studied 5 journals in 1998 and 2005. Results: Of 6,016 papers in the research and surgery specialty journals, 19% were research, of which 76% were basic research. Funding from 1,101 sources was provided to 825 studies (70%). Seventy-four percent of funded studies were basic research. Government was the source for 46% of grants, private for 41%, and industry for 13%. A surgeon was the sole or senior author in 72% of studies. A total of 1,172 research articles were published in the research and surgery specialty journals in 1998. In comparison, 369 research papers were published in the general surgery journals in 1998 and 306 papers were published in 2005. With respect to the type of research, there were 896 basic research papers in the research and specialty journals in 1998, 200 such papers in the general surgery journals in 1998, and 164 in 2005. There were 87 randomized trials in the research and the surgery specialty journals in 1998, 46 such papers in the general surgery journals in 1998, and 29 in 2005. Conclusion: A 3-fold greater volume of surgical research and more than a 4-fold greater volume of basic research was found in the research and the surgical specialty journals than in the general surgical journals in 1998, and this margin is increased when compared with the data for 2005. Consideration of only the general surgical journals greatly underestimates the surgical research being conducted. [Copyright &y& Elsevier]

Background: This study was performed to identify factors that impact student performance on a web-based objective structured clinical evaluation (OSCE) that was developed to improve the evaluation process of students who complete a fourth-year surgical clerkship in trauma-critical care. Methods: We created a multiple-choice OSCE with commercially available software. Clinical cases were developed for incorporation into 7 quizzes that were assembled to appear as 1 examination. Students used intensive care unit flow sheets to review data, to develop a systems-based problem list and differential diagnoses, and to produce treatment recommendations. Results: No difference was noted in a comparison of the mean scores that were achieved by students on a previous paper (essay format) OSCE and the new web OSCE. There was a correlation of student performance on the web OSCE to the National Board of Medical Examiners (NBME) subject examination that had been completed the previous year (r = 0.60; P < .0001). Performance on the NBME subject examination was the only independent factor that affected reporter, interpreter, and manager skills that were assessed by the OSCE (P < .01). Conclusion: Implementation of a web OSCE resulted in similar performance of the class as compared with performance on the previous paper OSCE. Correlation of student achievement on the web OSCE to the NBME subject examination supported the construct validity of this institutional examination beyond the areas of face and content validity in which OSCEs may excel. [Copyright &y& Elsevier]

Owing to increasing external pressures on both faculty and learners, the practice of bedside teaching is declining. The objective of this paper is to provide an overview of educational strategies to foster bedside teaching in the current clinical practice environment for surgical educators. General strategies include building a culture within the program that promotes the atmosphere of a learning community, and providing scaffolding for trainees that fosters gradual progression to autonomous practice. Specific techniques for bedside teaching include CAMEO, the "one-minute preceptor", and mini-presentations or peer-teaching. The intentional and proactive implementation of these strategies alongside others can assist educators in capturing the "redeemable moments" that occur in the course of routine clinical care at the patient's bedside. [ABSTRACT FROM AUTHOR]

Background Few details are known about open-access surgery journals that solicit manuscripts via E-mail. The objectives of this cross-sectional study are to compare solicitant surgery journals with established journals and to characterize the academic credentials and reasons for publication of their authorship. Methods We identified publishers who contacted the senior author and compared their surgery journals with 10 top-tier surgical journals and open-access medical journals. We assessed the senior authorship of articles published January 2017–March 2017 and utilized a blinded survey to determine motivations for publication. Results Throughout a 6-week period, 110 E-mails were received from 29 publishers distributing 113 surgery journals. Compared with established journals, these journals offered lesser publication fees, but also had lesser PubMed indexing rates and impact factors (all P < .002). Professors, division chiefs, and department chairs were the senior authors of nearly half of US-published papers and spent ≈$83,000 to publish 117 articles in journals with a median impact factor of 0.12 and a 33% PubMed indexing rate. Survey responses revealed a dichotomy as 43% and 57% of authors published in these journals with and without knowledge of their solicitant nature, respectively. The most commonly reported reasons for submission included waived publication fees (50%), invitation (38%), and difficulty publishing elsewhere (12%). Conclusion Despite their sparse PubMed indexing and low impact factors, many senior academic faculty publish in solicitant surgery journals. This study highlights the importance for the academic surgical community to be cognizant of the quality of a journal when reviewing the literature for research and evidence-based practice. [ABSTRACT FROM AUTHOR]

Simulation has become an integral part of physician education, and abundant evidence confirms that simulation-based education improves learners' skills and behaviors and is associated with improved patient outcomes. The resources required to implement simulation-based education, however, have led some stakeholders to question the overall value proposition of simulation-based education. This paper summarizes the information from a special panel on this topic and defines research priorities for the field. Future work should focus on both outcomes and costs, with robust measurement of resource investments, provider performance (in both simulation and real settings), patient outcomes, and impact on the health care organization. Increased attention to training practicing clinicians and health care teams is also essential. Clarifying the value proposition of simulation-based education will require a major national effort with funding from multiple sponsors and active engagement of a variety of stakeholders. [ABSTRACT FROM AUTHOR]

Global surgery is an emerging academic discipline that is developing in tandem with numerous policy and advocacy initiatives. In this regard, academic global surgery will be crucial for measuring the progress toward improving surgical care worldwide. However, as a nascent academic discipline, there must be rigorous standards for the quality of work that emerges from this field. In this white paper, which reflects the opinion of the Global Academic Surgery Committee of the Society for University Surgeons, we discuss the importance of research in global surgery, the methodologies that can be used in such research, and the challenges and benefits associated with carrying out this research. In each of these topics, we draw on existing examples from the literature to demonstrate our points. We conclude with a call for continued, high-quality research that will strengthen the discipline's academic standing and help us move toward improved access to and quality of surgical care worldwide. [ABSTRACT FROM AUTHOR]

Background We systematically reviewed the literature concerning simulation-based teaching and assessment of the Accreditation Council for Graduate Medical Education professionalism competencies to elucidate best practices and facilitate further research. Methods A systematic review of English literature for “professionalism” and “simulation(s)” yielded 697 abstracts. Two independent raters chose abstracts that (1) focused on graduate medical education, (2) described the simulation method, and (3) used simulation to train or assess professionalism. Fifty abstracts met the criteria, and seven were excluded for lack of relevant information. The raters, 6 professionals with medical education, simulation, and clinical experience, discussed 5 of these articles as a group; they calibrated coding and applied further refinements, resulting in a final, iteratively developed evaluation form. The raters then divided into 2 teams to read and assess the remaining articles. Overall, 15 articles were eliminated, and 28 articles underwent final analysis. Results Papers addressed a heterogeneous range of professionalism content via multiple methods. Common specialties represented were surgery (46.4%), pediatrics (17.9%), and emergency medicine (14.3%). Sixteen articles (57%) referenced a professionalism framework; 14 (50%) incorporated an assessment tool; and 17 (60.7%) reported debriefing participants, though in limited detail. Twenty-three (82.1%) articles evaluated programs, mostly using subjective trainee reports. Conclusion Despite early innovation, reporting of simulation-based professionalism training and assessment is nonstandardized in methods and terminology and lacks the details required for replication. We offer minimum standards for reporting of future professionalism-focused simulation training and assessment as well as a basic framework for better mapping proper simulation methods to the targeted domain of professionalism. [ABSTRACT FROM AUTHOR]

Background It is vital for clinicians to understand and interpret correctly medical statistics as used in clinical studies. In this review, we address current issues and focus on delivering a simple, yet comprehensive, explanation of common research methodology involving receiver operating characteristic (ROC) curves. ROC curves are used most commonly in medicine as a means of evaluating diagnostic tests. Methods Sample data from a plasma test for the diagnosis of colorectal cancer were used to generate a prediction model. These are actual, unpublished data that have been used to describe the calculation of sensitivity, specificity, positive predictive and negative predictive values, and accuracy. The ROC curves were generated to determine the accuracy of this plasma test. These curves are generated by plotting the sensitivity (true-positive rate) on the y axis and 1 − specificity (false-positive rate) on the x axis. Results Curves that approach closest to the coordinate ( x = 0, y = 1) are more highly predictive, whereas ROC curves that lie close to the line of equality indicate that the result is no better than that obtained by chance. The optimum sensitivity and specificity can be determined from the graph as the point where the minimum distance line crosses the ROC curve. This point corresponds to the Youden index ( J ), a function of sensitivity and specificity used commonly to rate diagnostic tests. The area under the curve is used to quantify the overall ability of a test to discriminate between 2 outcomes. Conclusion By following these simple guidelines, interpretation of ROC curves will be less difficult and they can then be interpreted more reliably when writing, reviewing, or analyzing scientific papers. [ABSTRACT FROM AUTHOR]

Background Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools. Methods A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria. Results Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission. Conclusion Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs. Study Design: We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article. Principal Findings: Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent. Conclusion: Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States. [Copyright &y& Elsevier]

Background: The h-index is used as an objective measure of research impact. Its validity, however, is not known in the context of general surgery and comparisons with other bibliometric indices are lacking. We sought to evaluate the h-index as a reliable and valid measure of research performance in general surgery across 6 universities in the province of Ontario, Canada. Methods: Bibliometric indices for 219 faculty members in general surgery were calculated using the Scopus and Web of Science online databases. We investigated agreement between the databases. A 2-way analysis of variance was used to compare the h-index of surgeons grouped by institutional affiliation and academic rank and to identify the relative impact of these factors on different bibliometric indices. Results: The agreement on h-indices between the Scopus and Web of Science was problematic. The h-index was associated more strongly with academic rank (academic rank accounted for 33.3% of researcher’s h-index) than of the number of publications (12.5%) or the number of citations per author (10.2%). The number of citations per paper was not associated with academic rank. The institutional affiliation affected bibliometric indices to a similar degree to academic rank. Conclusion: Our data suggest better construct validity for the h-index than for other bibliometrics, although the agreement of h-index values between databases can be problematic for some researchers. The use of the h-index as a criterion-based assessment across different universities is problematic and that it should be used as a normative assessment tool, with comparisons with a specified population of interest. [ABSTRACT FROM AUTHOR]

Background: Approximately 300 cases of leiomyosarcoma of the inferior vena cava (IVC) have been reported in the literature to date. In this study, we combined the experience from 2 institutions to provide additional clinical outcomes data. Methods: We performed a retrospective analysis from 1984 to 2009 that included 17 patients treated between the 2 institutions. Clinicopathologic data, surgical and adjuvant therapy, and survival outcomes were obtained. Results: The median age of patients in the study was 48 years. The tumor location was infrarenal in 8 patients, juxtarenal in 6, and suprahepatic in 2 patients; 7 patients had high-grade tumors. All patients underwent complete resection; the IVC was repaired primarily in 5 patients, ligated in 5, and reconstructed with a prosthetic tube graft in 7 patients. There was no perioperative mortality; 6 patients had complications. Median follow-up was 49 months; median survival had not been reached when this paper was written. The 5-year overall and disease -free survival were 56% and 37%, respectively. Of the 17 patients, 10 experienced disease recurrence and underwent numerous treatment modalities for these recurrences. Conclusion: Aggressive resection of primary leiomyosarcoma of the IVC can be performed safely and result in long-term survival, irrespective of IVC management. Despite high recurrence rates, no consensus yet exists regarding adjuvant treatment. [ABSTRACT FROM AUTHOR]

Background: Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice. Methods: Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP. Results: A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] −3.92 to −1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36–0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14–1.43) when compared with patients undergoing traditional care. Conclusion: Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures. [ABSTRACT FROM AUTHOR]

Background: Previous studies using simulation-based curricula have focused largely on technical skills. We developed a set of simulation-based modules that focus on intraoperative decision making. The objective of this study was to conduct a faculty evaluation of: (1) the usefulness of 4 newly developed, simulation-based modules; (2) the curricular need to train and assess intraoperative decision making skills of the residents; and (3) potential for resident benefit. Methods: Simulation-based modules were developed using a cognitive task analysis (CTA) framework. The CTA framework involved faculty interviews focusing on 4 operative tasks that span a range of complexity: (1) creation of small and large bowel stoma, (2) laparoscopic ventral hernia repair, (3) pancreaticojejunostomy, and (4) lymph node biopsy during a mediastinoscopy. An experienced psychologist conducted task-specific, one-on-one interviews with fellowship-trained specialists who perform these operations in their practice. Two faculty were interviewed for each procedure. The interviews lasted a minimum of 1 hour and focused on critical decisions, error prevention, error recognition, and error rescue strategies. The coded interview summaries were used as development guides for the simulation-based learning modules. Each module included locally developed physical models for the simulated operative tasks combined with oral and paper-based questions. The physical models were fabricated in such a way that simulated operative tasks could be performed using standard surgical instruments. To assess the newly developed simulation-based modules, 8 volunteer faculty (50% overlap with the interview pool) participated in a simulation-based exercise during a one-on-one session and then completed an 8-item survey cast on a 5-point Likert agreement scale (1 = strongly disagree, 5 = strongly agree). One of the items was worded negatively to ensure internal consistency. An independent observer recorded faculty session times and assessed faculty engagement in the task (1 = not engaged, 5 = extremely engaged). Results: On average, faculty spent 60 minutes completing each simulation-based exercise. Over 80% of this time was spent performing the operative tasks as they would during a real-life procedure. Mean engagement rating was 4.9 (maximum 5.0, SD = 0.3). Survey results show strong agreement on the importance of training and assessing intraoperative decision making, and that residents would likely benefit from the simulation-based modules. Conclusion: We developed 4 high-fidelity simulation-based modules to assess intraoperative decision making. Faculty agree strongly on the importance and need for additional modules. [Copyright &y& Elsevier]

Background: Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR. Methods: A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance). Results: The mean age of this cohort was 52 years (range, 18–85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified. Conclusion: Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection. [ABSTRACT FROM AUTHOR]

Background: This paper describes our experience with a novel method of temporary abdominal closure that permits frequent reassessment of the abdominal contents and progressive reapproximation of the fascial edges without compromising definitive fascial closure outcomes. Methods: We developed a novel method of temporary abdominal closure, which we have named the frequent assessment temporary abdominal closure (FASTAC). The records of patients who underwent planned relaparotomy during 5 years were reviewed. The data collected included patient demographics, indication for operation, number of operations, duration of temporary abdominal closure placement, hospital duration of stay, method of definitive abdominal closure, and subsequent ventral hernia repair. Results: One hundred and thirty-three patients underwent 308 temporary abdominal closure placements, including 16 patients who had a FASTAC placed for open abdomen management. FASTAC remained in place for a significantly greater time with more frequent reassessment. Fascial closure techniques were not different in FASTAC patients. FASTAC patients had a significantly greater duration of stay, which suggests selective placement in a more complicated patient population. The materials for frequent assessment temporary abdominal closure cost only $38 compared with $350 for a large piece of Silastic. Conclusion: FASTAC is a novel, cost-effective method of temporary abdominal closure that allows for frequent bedside intra-abdominal surveillance, maintains abdominal domain, and does not compromise abdominal closure outcomes in the management of the open abdomen. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive liver surgery is a rapidly advancing field with demonstrated applicability to living donation. In this paper, we compare the safety and efficacy of laparoscopy-assisted donor right hepatectomy (LADRH) to open donor right hepatectomy (ODRH). Methods: We performed a retrospective, comparative analysis of 33 LADRH to the most recent 33 ODRH performed at our institution, evaluating donor complications, costs, and recipient outcomes. Results: Donor demographics including age, gender, body mass index (BMI), and vascular and biliary anomalies were comparable. Donor complication rates were equivalent for LADRH and ODRH. Donor operative times were shorter for LADRH (LADRH 265 minutes, ODRH 316; P < .001) even after adjusting for BMI. Blood loss and length of stay were comparable. Additionally, total hospitalization costs were equivalent (LADRH $1.11, ODRH $1.00; P = .19). Higher operative supply costs for LADRH were balanced by higher time-based operative costs for ODRH resulting in no significant differences in total operative costs. Finally, there were no differences in graft size, recipient patient or graft survival, or recipient vascular or biliary complications. Conclusion: Our experience suggests that LADRH compares favorably with ODRH with equivalent safety, resource utilization, and effectiveness. We believe that LADRH provides potential physical and psychological benefits without an adverse effect on outcomes. [Copyright &y& Elsevier]