Concerns persist within the surgical community that completion of an accredited surgical residency no longer consistently ensures that trainees are ready for independent practice. In response, the Independent Committee for Graduate Surgical Education (ICGSE) was established in January 2025 to address the unique requirements of surgical training. The committee's mandate was to recommend program standards that would potentially optimize education and training for surgical residents, with the goal of improving patient care. The ICGSE, consisting of 71 surgeons across 16 specialties, reviewed the history of surgical accreditation and relevant literature. Workgroup-led discussions identified strategies for improving trainee readiness and modernization of program accreditation standards. A literature review showed a "readiness gap" affecting 20%-30% of surgical trainees across multiple specialties. Key areas for improvement include:1. Designing curricula that increase clinical exposure, promote progressive autonomy, and facilitate transition to independent practice.2. Aligning training with the realities of surgical practice.3. Balancing accreditation requirements with efforts to reduce administrative burden and enhance faculty development.4. Emphasizing program evaluation beyond board passage rates and surveys to include real-time and longitudinal tracking of skill and clinical judgment acquisition.5. Supporting faculty education in teaching and assessment.6. Providing clear developmental roadmaps for lifelong learning. 1. Modernize accreditation through application of continuous quality improvement processes.2. Implement an outcomes-focused curriculum adaptable to each specialty that encourages innovation.3. Supplement case logs with an evidence-based framework for assuring procedural competency.4. Require standardized nontechnical skills training and assessment.5. Establish a longitudinal, competency-based assessment system.6. Mandate verifiable faculty development with institutional support. The ICGSE recommends that the graduate surgery education community, in collaboration with oversight organizations and professional associations, work to develop common surgery-focused accreditation standards that would drive the excellence required in surgical care.
To characterize short-term functional trajectories and identify risk factors for loss and recovery of independence among older surgical patients at a national level. As the surgical population ages, frailty increasingly influences outcomes beyond mortality. Short-term postoperative functional independence is a key patient-centered outcome with long-term implications, yet national data across surgical specialties remain limited. We conducted a retrospective cohort study using the 2022-2024 American College of Surgeons National Surgical Quality Improvement Program database, including all patients aged ≥75 years. Patients were categorized by functional trajectory from admission to 30 days postdischarge: maintenance of independence, loss of independence (LOI), maintenance of dependence, or gain of independence (GOI). Multivariable logistic regression identified independent factors associated with LOI among baseline-independent patients, and with GOI among baseline-dependent patients. Prespecified subgroup analyses assessed effect modification by dementia, age, frailty (mFI-5 score), surgical specialty, surgical approach, urgency, and setting. Among 436,471 patients, 28.2% of baseline-independent adults experienced LOI, while 5.6% of baseline-dependent patients experienced GOI. LOI rates increased stepwise with age and frailty and were strongly associated with frailty, recent falls, preoperative sepsis, higher American Society of Anesthesiologists class, urgent/emergent surgery, inpatient setting, and open surgical approaches. LOI was associated with markedly higher postoperative mortality, prolonged hospitalization, delirium, sepsis, ventilator dependence, and nonhome discharge. Dementia was independently associated with LOI risk and inversely with GOI risk across nearly all subgroups. Short-term LOI is common among adults aged ≥75 years and represents a powerful marker of adverse postoperative complications. Dementia and perioperative acuity are dominant associated factors of short-term functional trajectory, while short-term recovery of independence is rare. Findings suggest that short-term functional outcomes should be incorporated into preoperative risk stratification, shared decision-making, and perioperative care pathways for older adults.
To investigate the prevalence of tumor deposits in gastric cancer patients across different T and N stages as well as other pathologic parameters. Another goal of the study is to identify the potential impact of tumor deposit positivity on 5-year overall survival. Tumor deposits represent an increasingly recognized pathologic entity in resected surgical specimens of gastric adenocarcinoma patients. Their prevalence across different T and N stages and according to lymphovascular and perineural invasion, as well as across different grades remains largely unknown. We have undertaken a systematic literature review in the PubMed and Cochrane databases with meta-analysis of data from published studies. Raw data were extracted from studies to calculate the prevalence of tumor deposits across all T, N stages, positive/negative lymphovascular, and perineural invasion status, as well as according to tumor grade. Pooled prevalence for the calculated values was performed with a meta-analysis of extracted data. Pooled hazard ratios for 5-year overall survival hazard ratio were also compared among patients with and without tumor deposits, respectively. Fourteen studies (14) with a total of 18,056 patients were included in the meta-analysis. The calculated incidence of tumor deposits in gastric cancer patients undergoing surgical resection with curative intent was calculated at 17.9%. An increasing prevalence was noted while progressing from T1 to T4 and N0 to N3 stages, respectively. Patients with positive lymphovascular/perineural invasion status and patients with higher tumor grades were also noted to have increased tumor deposit prevalence compared with their negative counterparts. Patients with tumor deposits positive status were found to have an increased hazard ratio for death at the 5-year overall survival mark with a value of 1.308 (P value < 0.05). A significant degree of heterogeneity was noted across all studies, as well as a significant degree of bias, mainly because all included studies were retrospective in nature. Tumor deposits are a frequent clinical entity in resectable gastric cancer and should systematically be examined in surgical specimens. Their prevalence increases with increasing T, N stages and tumor grade, as well as with positive lymphovascular/perineural invasion status. Tumor deposit positive status appears to impose a worse prognosis for overall survival. Further research is required on the biologic properties of tumor deposits AND on standardization of their identification, especially in the current era of neoadjuvant treatments that are increasingly being utilized. Confirmation of our findings with high-quality prospective data should be another focus of further research.
The loss of Royal Mail Ship (RMS) Titanic has been examined extensively through the lenses of engineering failure, maritime law, and social history, yet little attention has been paid to the conduct and professional identity of her medical officers. This surgical history examines the lives and final hours of the ship's 2 surgeons, Dr. William Francis Norman O'Loughlin and Dr. John Edward "Jack" Simpson, situating their actions within the evolving practice of maritime medicine in the early 20th century. Drawing on contemporary newspaper accounts, official inquiries, archival records, personal correspondence, and genealogical sources, this article reconstructs their careers, responsibilities, and conduct during the disaster. O'Loughlin, a senior surgeon with decades of maritime experience, and Simpson, a younger assistant surgeon at the outset of his career, represented 2 generations united by a shared professional ethic. Both remained at their posts, assisting passengers and crew, maintaining calm, and declining opportunities for self-preservation. Their actions exemplify the unwritten code of the surgeon: composure under pressure, disciplined and methodical judgment, and a steadfast respect for the dignity of every human life. Beyond documenting individual bravery, this article demonstrates that their conduct reflects enduring principles of surgical professionalism that transcend era, technology, and setting. In a tragedy remembered primarily for its scale, the surgeons' story highlights how judgment, humanity, and moral responsibility remain central to the identity of the surgeon, whether practiced in a modern operating room or a rolling hospital at sea.
This study seeks to describe the lived experiences of self-identified introverts throughout a career in academic surgery. Surgeons and leaders are often perceived as extroverted, with the belief that introverts must project extroversion to succeed as surgeons or leaders. However, many surgical trainees entering academic surgery identify as introverted. Semi-structured interviews were conducted with self-identified introverted general surgery residents and attending surgeons at a tertiary academic medical center in the Northeast. Participants were purposively sampled to include junior and senior residents, early- and late-career attendings, and men and women participants. Interview transcripts were iteratively analyzed using inductive thematic analysis with a constructivist approach to develop a theoretical framework describing the experience of introverts in academic surgery. Nine surgical residents and 8 attending surgeons participated in interviews. Four overarching themes were identified: (1) the lived experiences and self-perceptions of introverts are highly individual; (2) introverts must reconcile their preferences with the necessity of extroverted behaviors in academic surgery; (3) introverted preferences for relationship-building often conflict with the interpersonal demands of a career in academic surgery; and (4) introverts evolve over a surgical career through both internally and externally motivated strategies. Introverts experience challenges surrounding the sociocultural conventions inherent to professional advancement in academic surgery. Over time, introspection, paired with support from role models and mentors, permits introverts to demonstrate their value and strengths. This study highlights opportunities for supporting the growth and development of introverts in hopes of fostering greater inclusivity within academic surgery.
Climate change is the biggest threat to human health. Paradoxically, the healthcare sector is a major contributor to climate change, and operating theaters are among the highest sources of emissions. Unsustainable practices are actions that compromise environmental, social, and financial sustainability, leading to unnecessary resource use, avoidable harm to the wider population, and reduced ability to provide effective healthcare in the future. Drivers of unsustainable practices and barriers to sustainability in practice (a top priority identified by the James Lind Alliance Priority Setting Partnership) are unexplored, hindering interventions that can help meet net-zero targets within healthcare. We conducted the first known ethnographic study to investigate behaviors related to sustainability in operating theaters, and their influences on those behaviors to inform the design of effective behavior change interventions. Nonparticipant ethnographic observations with opportunistic discussions in elective general surgical operating theaters were conducted between June and December 2023 at 2 university hospitals in Central London. Data were collected until saturation using a template developed during the initial observations. Inductive thematic analysis was conducted, with subthemes (influences) deductively mapped to the Theoretical Domains Framework. Twenty-six procedures were observed (42 hours). Unsustainable behaviors included: (1) unnecessary and inappropriate glove use, potentially compromising safety (average 8-10 pairs per operation), (2) incorrect waste disposal, (3) unnecessary package opening, and (4) energy waste. Thematic analysis generated 6 themes and 16 influences (mapped to 9 Theoretical Domains Framework domains). Key themes were that sustainable practices are "infrequent and inconsistent" due to limited awareness (Knowledge) and low environmental concerns (Memory, Attention, and Decision Processes). Unsustainable behaviors were "habitual" and performed automatically (Lack of Attention). Drivers of unsustainable practices were: "Precaution" (Emotions, Beliefs About Consequences); "Efficiency" (Goals); "Past experiences" (Emotions and Social influences); and the "Physical environment" (Environmental Context and Resources). "Leadership" (Social Influences) was a driver of sustainable practices. This study identified widespread unsustainable culture and practices in operating theaters that compromise patient safety, and financial and environmental sustainability. It provides a nuanced understanding of contextual factors and their drivers, such as the strong impact of habit, knowledge, and the striving for efficiency, highlighting the need for both bottom-up engagement and top-down prioritization. The study provides a foundation for designing targeted interventions that integrate education, leadership engagement, and environmental restructuring to embed sustainability into routine surgical practice while ensuring patient safety and operational efficiency.
Indeterminate pulmonary nodules are common in patients with colorectal liver metastases (CRLM), and can lead to treatment dilemmas. This study evaluates the clinical relevance of indeterminate pulmonary nodules in patients amenable for local treatment of CRLM. The incidence and prognosis of patients with CRLM and indeterminate pulmonary nodules is unknown. Only small retrospective studies have examined outcomes, and no consensus exists on the optimal management. It remains unknown if the presence of indeterminate pulmonary nodules impacts survival. All patients who underwent liver resection and/or thermal ablation for CRLM between 2000 and 2021 at a single tertiary centre, were included in the study. Patients with extra-hepatic disease were excluded. Patients were divided into 2 groups based on the absence or presence of indeterminate pulmonary nodules at the time of diagnosis of the CRLM. Indeterminate pulmonary nodules were defined as intrapulmonary nodules of which the nature could not be determined by the radiologist. The primary outcome measure was 5-year overall survival. The secondary outcome measures were disease-free survival and cumulative incidence of lung metastases. A total of 1008 patients were included, of whom 277 (27.5%) presented with indeterminate pulmonary nodules at time of first local treatment of CRLM. The 5-year overall survival in patients with or without indeterminate pulmonary nodules was 40.1% and 44.4%, respectively (P = 0.14). Corresponding 5-year disease-free survival was 19.0% and 20.4% and (P = 0.1). The 5-year cumulative incidence of lung metastases was 45.8% for patients with indeterminate pulmonary nodules and 37.6% for patients without (P = 0.001). More than a quarter of patients who were candidates for local treatment of CRLM presented with indeterminate pulmonary nodules. Although these patients were more likely to develop lung metastases, this did not significantly affect disease-free survival nor overall survival.
The discipline of burn care has been challenged by a declining professional workforce, resulting from changes in general surgery residency training, simultaneous with a multidisciplinary but siloed approach to care. Secondary effects on children's burn care include decreased awareness of where children receive care outside of the American Burn Association (ABA)-verified burn centers, loss of bidirectional education and communication inherent to patient and family-centered care, and good outcome measures. These factors affect disaster planning. A system of care must be capable of addressing "everyday" pediatric burn care availability before the nation can manage multiple burn victims in a disaster. Pediatric burn care is delivered by a variety of clinicians with complementary skill levels, knowledge, and resources at several types of centers, including verified burn centers caring for children and adults or only children and nonverified children's or acute care hospitals providing pediatric burn care. The current ABA verification process is rigorous but not tiered, making it difficult for many children's hospitals to satisfy these standards. The current landscape of children's burn care has strengths and opportunities in terms of access to care, care delivery, workforce and training, education, data and quality, and research. A national pediatric burn system will: (1) improve the understanding of "everyday" and expert burn care for children, (2) define gaps in children's burn care, including preparedness of the emergency care system where children initially receive care, and (3) anticipate action and implementation strategies to address these gaps.
To compare perioperative outcomes of minimally invasive pancreatoduodenectomy (MIPD) to open pancreatoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs). The wider adoption of MIPD has largely been fueled by observational studies rather than high-level evidence. We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Web of Science for RCTs comparing MIPD with OPD in adult patients with benign or malignant conditions requiring elective pancreatoduodenectomy. The primary outcomes were 90-day mortality, the comprehensive complication index, Clavien-Dindo grade ≥III complications, and hospital length of stay (LOS). Secondary outcomes included postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood loss, reoperation, operative time, and oncologic outcomes. Data were pooled as odds ratios or mean differences using a random-effects model. Risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach (PROSPERO ID: CRD42024592919). Ten RCTs with a total of 1794 patients were included. Meta-analysis showed there were no significant differences regarding 90-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, reoperation, readmission, or oncologic outcomes between MIPD and OPD. LOS was reduced for MIPD. No clinically relevant differences were found in the subgroup analyses of laparoscopic and robotic pancreatoduodenectomy. Certainty of evidence was moderate to low. MIPD showed no clinically relevant advantages over OPD. These findings were consistent both for the robotic and laparoscopic approach.
This review aims to analyze robotic surgery training prior to clinical operation. In the interest of patient safety, preprocedural simulation-based training is imperative on a new medical technology prior to in vivo operation. A study protocol was developed in accordance with Preferred Items for the Reporting of Systematic Reviews and Meta-Analyses guidelines. A search of the Pubmed, Embase, and Cochrane databases was conducted. Title and abstract screening were performed. Full texts were appraised for eligibility. Data regarding platform utilized, speciality and grade of intended target training population, duration and delivery method of curriculum, and outcome measures were determined. A meta-analysis was precluded given the heterogeneity of extracted data, therefore, a meta-synthesis was performed. After removal of duplicates 734 records were screened. Of these, 290 full texts were sought for retrieval and assessed for eligibility. In total, 87 records fulfilled the inclusion criteria: describing, validating, reviewing, or proposing guidelines for preprocedural curricula in robotic surgery. Almost half (47%) of records were published between 2018 and 2024. While not universal, the common components of preprocedural curricula for robotic surgery involve participants acquiring canonical (context independent) knowledge and skills. Didactic modules and bedside education of the system are typically followed by high fidelity simulation training using virtual reality, dry, and wet laboratory rudimentary platform and procedural training. The exponential increase in recent publications in this field highlights the evolving awareness of preprocedural training when adopting new technologies including robotic surgery, and the need for consistent standards. Though challenging to implement, a standardized framework for preprocedural curriculum will aid all stakeholders, regardless of variations in resources and service demands.
Postdischarge transitions from the hospital to home in older (≥65 years) colorectal surgery patients have a high risk of medication errors, complications, and worsening of existing conditions. Up to 14% are readmitted within 30 days, costing ~$180 million annually. The anticipated 50% increase in colorectal cancer surgeries in older adults by 2040 necessitates an improvement in care transitions and outcomes. We conducted semi-structured qualitative interviews with 10 surgeons from 8 US health systems to inform the design of a multicomponent care transition model. We selected participants through stratified purposive sampling based on experience with older surgical patients and/or leadership roles. Consolidated Criteria for Reporting Qualitative Studies guidelines were followed, and a detailed line-by-line editing and organizing style was used to analyze transcripts. The interviews identified challenges in care transitions and potential solutions, and 4 themes emerged: (1) Discharge planning should start before surgery and incorporate preoperative geriatrics evaluation and planning; (2) Coordinated communication and collaboration among multidisciplinary care teams are necessary but often lacking; (3) Educating older surgical patients and their care partners and involving them in care decisions is needed for successful management of care responsibilities after discharge; and (4) The complex and fragmented healthcare system creates care challenges postdischarge. Discharge planning that begins preoperatively, integrates geriatrics domains, ensures timely and coordinated interdisciplinary communication postdischarge, and emphasizes patient and family education is essential to improve care transitions in older colorectal surgery patients. A multilevel care transition model incorporating these elements may enhance outcomes and reduce readmissions.
To evaluate current practices and attitudes of general surgeons in Switzerland regarding perioperative code status discussions (CSD) and the management of surgical patients. CSDs are a critical component of perioperative care. Although guidelines recommend addressing code status with all surgical patients, implementation remains inconsistent and influenced by institutional and clinical barriers. A national web-based survey was conducted among surgeons in Switzerland. The primary outcome was the proportion of participants routinely conducting CSD in patients classified as American Society of Anesthesiologists 3 to 4 (ASA 3-4) according to the ASA classification system. Secondary outcomes included the proportion of preoperative CSD in patients classified as ASA 1 to 2 and ASA 5, as well as preoperative discussions of therapy limitations and management of patients with do-not-resuscitate (DNR) orders. Of 266 participants, 243 were included in the analysis (mean age 45.7 years ±12.5; 40.3% female). 71.2% reported routinely conduct CSDs with patients classified as ASA 3 to 4. Factors independently associated with routine discussions included prior exposure to more than 10 perioperative resuscitations [27.2% (47/173) vs 12.9% (9/70), adjusted odds ratio (AOR) 2.9 (95% confidence interval CI: 1.28-6.56), P = 0.011, assessment of advance directives before surgery [81.2% (125/154) vs 47.5% (29/61), AOR 4.91 (95% CI: 2.56-9.43), P < 0.001] and presence of institutional training [25.3% (39/154) vs 11.5% (7/61), AOR 2.94 (95% CI: 1.2-7.23), P = 0.019]. Half of surgeons (50.0%, 107/214) reported discussing code status with patients with preexisting DNR order, which was associated with fewer conflicts concerning postoperative therapy limitations and stronger endorsement of interdisciplinary collaboration between surgical and anesthesiology teams. While 63.8% (n = 132) of surgeons supported statements upholding DNR orders perioperatively, 32.5% (n = 67) believed they should not apply. Most surgeons reported conducting CSDs in patients classified as ASA 3 to 4 and generally supported respecting DNR orders perioperatively. However, institutional training remains limited. Expanding structured education, improving guideline implementation, and fostering interdisciplinary collaboration may improve the consistency and quality of perioperative communication.
To evaluate the current state of healthcare disparities within the Military Health System, comparing Department of Defense facilities to treatment outsourced to the civilian sector. Racial disparities in healthcare outcomes remain a critical concern in the US, even in the setting of universal insurance provisions. Despite prior studies suggesting reduced disparities within the Military Health System, challenges such as reduced surgical volume, staffing shortages, and the COVID-19 pandemic may have exacerbated inequalities, particularly among racial and ethnic minorities. We performed a retrospective cohort study of healthcare claims data evaluating 90-day readmission in adult TRICARE beneficiaries undergoing surgical procedures between 2020 and 2023. The outcome of interest was readmission to an inpatient facility within 90-days of the index surgery, irrespective of the original site of service. Multivariable logistic regression and interaction analyses assessed the association of race, surgical care settings, Charlson Comorbidity Index (CCI) score, and patient characteristics with 90-day readmission. A total of 262,344 surgeries among 244,008 beneficiaries were identified for inclusion. Black patients with CCI of 0 were more likely to experience 90-day readmissions to private sector hospitals (adjusted odds ratio [AOR] = 1.19; 95% confidence interval [CI] = 1.17-1.22) and direct care facilities (AOR = 1.08; 95% CI = 1.05-1.11). Readmission in direct care was appreciated for Hispanic patients with a CCI of 1 (AOR = 1.14; 95% CI = 1.13-1.15). We found significant increases in 90-day readmissions among Black and Hispanic patients based on CCI score within the direct care setting. We believe this reflects recent challenges that have impacted both staffing and surgical volume within these facilities.
Trauma activation fees (TAF) are intended to offset the costs of trauma readiness yet remain unregulated. Prior studies have explored TAF variations across American College of Surgeons Committee on Trauma (ACS-COT)-verified centers, which represent a minority of US trauma centers. We aimed to characterize TAF variations across all US trauma centers, accounting for previously underexplored characteristics that may be associated with TAFs. This cross-sectional study evaluated all level I-III designated US trauma centers and their TAFs. We delineated each trauma center's hospital [hospital ownership (for-profit or nonprofit), designation level (I/II or III), ACS-COT verification, and safety-net hospital status] and county-level characteristics (per capita income, Area Deprivation Index, years-of-potential-life-lost from fatal injury). Multivariable lasso regression evaluated the association between median TAFs and hospital ownership status, with trauma center designation level as an effect modifier. Study cohort comprised 1014 trauma centers [N = 166 (16.4%) for-profit]. Across all designation levels and ACS-COT verification status, for-profit trauma centers had higher median TAFs compared with nonprofit counterparts. We did not find a statistically significant difference in TAFs over safety-net or ACS-COT-verified status. Multivariable lasso regression did not find a statistically significant association between hospital ownership status and TAFs [β = 4540 (-722 to 9810); P = 0.091], but a statistically significant interaction between hospital ownership status and trauma center designation level [β = 9090 (1270-16900); P = 0.003]. Nationwide analysis of over 1000 designated US trauma centers found wide heterogeneity in TAFs and an association between for-profit ownership status and higher TAF among level I and II trauma centers. Whether observed nationwide TAF heterogeneity characteristics warrant evaluating the role of TAF regulation deserves discussion.
Examine the role of low health literacy in surgical cancer care. Disparities exist in surgical cancer care in the Deep South, focused here on the states of Alabama and Mississippi. Low health literacy is prevalent in this region and is associated with worse surgical outcomes. We conducted semi-structured interviews with gastrointestinal cancer patients and providers to explore the influence of health literacy on the surgical journey. Participants were recruited using a purposeful sampling with a snowball-recruitment approach. Verbatim interview transcripts were coded with NVivo 12.6 Plus using inductive thematic analysis to develop a codebook, followed by content analysis of the coded data. A constant comparative method was employed to ensure that saturation in the data was achieved. The inter-coder agreement was established at the recommended 90%. Thirty-six patients and 32 providers were interviewed, including 15 surgeons. In the preoperative phase, low health literacy contributed to patients' difficulty in understanding diagnosis, facilitating their own care, understanding costs/insurance, and delays in care. In the perioperative phase, low health literacy increased difficulty understanding treatment plans and created barriers to compliance with staged treatments. In the postoperative phase, low health literacy led to difficulty understanding complications and the need for more follow-up. Common subthemes included difficulty following instructions and the usefulness of visual aids and teach-back methods. Cancer providers and patients highlighted the role of health literacy in all phases of the surgical journey, particularly in creating barriers to understanding key components of cancer care. Interventions to address these barriers will be critical to improve care for low health literacy patients.
To develop a machine learning model that predicts surgical case length and benchmark its performance against an embedded electronic health record (EHR) model. Surgical care accounts for one-third of U.S. healthcare expenditure. Current case length prediction models are generally overly simplistic and inaccurate or too specialized to have a broad impact, contributing to operating room (OR) inefficiency and dissatisfaction for patients and providers. Retrospective analysis of 55,495 surgical cases performed by 299 surgeons between January 2022 and April 2024 at a metropolitan, quaternary care hospital. The dataset was split temporally for training (46,767 cases) and holdout validation (8728 cases). Three separate machine learning models predicted preprocedure, operative, and postprocedure times using patient and provider characteristics, operation details, and hospital features available at least 1 day before surgery. Approximately 22% of cases lacked historical time averages and relied on procedural time heuristics. The machine learning model significantly outperformed the embedded EHR model, achieving lower root mean squared error (61.0 vs 91.0 minutes; P < 0.01), lower mean average error (39.6 vs 51.8 minutes; P < 0.01), and higher R 2 (0.78 vs 0.50; P < 0.01). The model predicted 213 more cases within ±30 minutes of actual duration. In cases without historical time averages, the model increased cases within ±30 minutes of actual duration (35% vs 29%; P < 0.01). A machine learning model leveraging comprehensive preoperative data significantly improved surgical case length prediction compared to an embedded EHR model. Future implementation has the potential to improve OR efficiency and patient and provider satisfaction.
The goal of this study was to assess 2 analytic strategies for comparing hospital outcomes among those with emergency general surgery (EGS) conditions, comparing a conventional risk stratification method with a less utilized, but equally informative strategy. EGS is a complex set of heterogeneous, time-sensitive conditions that require expeditious treatment. Patients need a mechanism to evaluate how hospitals perform for similar populations treated within the hospital and a reliable metric that benchmarks outcomes across institutions. We performed a retrospective cohort study assessing hospital outcomes for EGS Medicare beneficiaries from July 1, 2015, to June 30, 2018. Using direct standardization with balancing weights and indirect standardization with logistic regression, we compare hospital performance on a risk-adjusted composite adverse event rate. Performance based on each standardization modality was correlated using the Spearman rank coefficient. There were 536,284 patients with a median (interquartile interval) age of 74.2 (72.9, 75.6) years treated at 1866 study hospitals. Direct and indirect standardization showed agreement on 92 low- and 76 high-performing hospitals. Adverse event rates for hospital rankings were strongly correlated between the 2 methods of standardization (0.83, P < 0.001). Rankings based on operative (0.75) and nonoperative (0.77) groups were also highly correlated (all P < 0.001). Significant variation exists in EGS outcomes. Hospital performance is inconsistent between operative and nonoperative treatment. A small number of hospitals can be distinguished based on risk-adjusted outcomes regardless of analytic technique, suggesting opportunities for optimized care standardization and quality improvement.
To evaluate the feasibility of Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening among surgical inpatients following hospital-wide implementation of a quality improvement initiative. Risky alcohol use increases postoperative complications, yet alcohol screening for surgery remains inconsistently applied. As a brief, validated screening tool, the AUDIT-C may improve risk assessment and guide timely intervention, but its adoption in surgical settings is understudied. We retrospectively analyzed electronic health record data from inpatient surgical admissions between April 2021 and September 2023. The primary outcome was completion of a valid AUDIT-C score during admission. Scores were categorized as no use (0), low-risk (1-4), moderate-risk (5-8), and high-risk (9-12). Multivariable logistic regression assessed independent associations with AUDIT-C screening completion. Among 30,714 encounters, 9540 (31.1%) had a completed AUDIT-C score. Screening completion varied by surgical service (15.2%-52.4%) and was higher in emergent (51.7%) and urgent (48.4%) cases than elective (29.1%) cases. The 3 most frequently performed procedures screened 53.8% (cesarean), 42.8% (free flap), and 11.6% (aortic valve) of patients. In multivariable models, emergent case status [marginal effect (ME): 0.14], urgent case status (ME: 0.09), and Medicare insurance (ME: 0.03) were independently associated with higher odds of screening completion. Among those screened, 6.5% were classified as moderate- or high-risk. Perioperative alcohol screening using AUDIT-C is feasible but inconsistently implemented. System-wide integration could support identification of at-risk patients and improve perioperative outcomes.
To evaluate the long-term impact of the Trauma and Disaster Team Response (TDTR) course-supported by McGill University's Center for Global Surgery (CGS) and endorsed by the United Nations Institute for Training and Research's Surgical Hub-on Tanzanian clinicians' self-assessed confidence in trauma care skills taught in 2023. Locally led, context-specific team training, such as the TDTR course, is essential in resource-limited settings to strengthen trauma care systems, prepare for unforeseeable natural or man-made disasters, and reduce preventable injury-related harm. In 2023, a 3-day, simulation-based, multidisciplinary TDTR course was conducted to equip Tanzanian clinicians with essential trauma management skills. This longitudinal cohort study tracked participants of the 2023 TDTR course. That year, in collaboration with the CGS, faculty from Tanzania's Muhimbili Orthopedic Institute trained 22 clinicians, including surgeons, residents, anesthetists, general physicians, and nurses. Participants completed self-assessments before and immediately after the course, evaluating their confidence in general skills (leadership, teamwork, and communication) and trauma-specific competencies. In 2025, the same questionnaires were emailed to all 22 trainees for a 2-year follow-up. Additionally, a separate questionnaire was sent to the 8 course instructors, inviting them to provide feedback on the course's long-term impact. Reminders were sent to nonresponders after 3 weeks. Instructor feedback was collected through structured surveys and open-ended questions, and was analyzed thematically to assess perceptions of participant progress, team dynamics, and areas for improvement. Changes in trainee confidence scores across the 3 time points (precourse, postcourse, and 2-year follow-up) were analyzed using mean comparisons and mixed-effects models. Participants demonstrated short-term improvements in self-assessed trauma skills, with partial retention at 2 years. The surgical team retained gains (general skills: 3.93-4.69; specific skills: 38-57, P < 0.002). Anesthesia providers showed improvement (general: 3.40-4.21; specific: 32.33-52, P < 0.04). Physicians improved the most (general: 3.67-4.20; specific: 33.57-51.29, P < 0.003), while nurses showed moderate gains (general: 3.25-3.82; specific: 32-46, P < 0.05). Participants perceived a 4.5% reduction in trauma-related deaths, which was corroborated by supervising instructors, who also highlighted observed improvements in care quality, teamwork, and outcomes. While the perceived reduction in trauma-related mortality is notable, it is based on subjective assessment and cannot be solely attributed to the training without further controlled analysis. Furthermore, trainees and instructors emphasized the need for regular refresher sessions. The TDTR course was associated with sustained improvements in self-assessed trauma care confidence and perceived enhancements in clinical outcomes over 2 years. These findings underscore the value of ongoing, team-based training in resource-limited settings. However, regular refresher courses and future studies using objective performance measures are essential to confirm and quantify the long-term clinical impact.
This study investigates the relationship between clinical center operative volume and perioperative outcomes for elective hiatal hernia repairs. Patients receiving an elective hiatal hernia repair within the Society of Thoracic Surgeons-General Thoracic Surgery Database (2018-2023) were included. Patients with a cancer diagnosis or achalasia were excluded. Participant centers were categorized into low-, medium-, and high-volume tertiles based on annual elective hiatal hernia operative volume. Primary outcomes were 30-day morbidity and reoperation. Secondary outcomes included mortality and 30-day readmission. Multivariable regressions were performed to adjust for covariates, including sociodemographics, comorbidities, and hernia characteristics. Among 174 centers, 13,658 elective hiatal hernia repairs were performed. A total of 295 (2.2%), 1714 (12.5%), and 11,649 (85.3%) repairs were performed at low-, medium-, and high-volume centers, respectively. Mortality within 30 days was <0.5% and did not differ by center volume. There was a stepwise decrease in 30-day morbidity (22.4% vs 18.4% vs 14.0%; P < 0.001), reoperation (4.7% vs. 2.7% vs 1.7%; P <0.001), and readmission (7.8% vs 7.3% vs. 5.8%; P < 0.001) when comparing low-, medium-, and high-volume centers. Minimally invasive approaches were more common at high-volume centers (94.4% vs 81.5% vs 82.1%; P < 0.001), and length of stay was shorter (2 days vs 3 days vs 3 days; P < 0.001). These differences remained significant for 30-day morbidity and 30-day reoperation in multivariable analysis. Perioperative outcomes after hiatal hernia repair were significantly improved when treatment occurred at high-volume centers. Referral to high-volume centers is encouraged for elective repairs.