Traumatic injury is a significant global cause of mortality and disability with a particularly high burden in southern Ethiopia. Hawassa University Comprehensive Specialized Hospital (HUCSH) partnered with the American College of Surgeons Health Outreach Program for Equity in Global Surgery to improve access to surgical care, including trauma care. This study evaluates changes in trauma care capacity during the first 5 years of this collaboration. A comprehensive trauma capacity assessment was conducted at HUCSH in 2019 and repeated in 2024 using a 481-item tool designed for low-resource settings. The tool evaluates 5 major domains of trauma care: provider knowledge, infrastructure, human resources, supplies, and hospital processes, plus injury-specific and administrative categories. Each item was scored on a 0 to 3 ordinal scale during detailed hospital walkthroughs. Paired item-level comparisons were made with Wilcoxon signed-rank tests with Hodges-Lehmann estimates of change. Qualitative feedback was collected by direct observation and staff interviews. Scores improved in provider knowledge, infrastructure, supplies, and hospital processes, driven in part by the development of a prehospital system. Human resources showed no change and remained the lowest-scoring domain in 2024. Although administrative and process improvements were substantial, measured gains in clinical care for specific injury types were limited. Qualitative feedback aligned with these quantitative findings. Trauma care capacity at HUCSH, as measured by this assessment, improved during 5 years of a multi-institutional international partnership. Opportunities exist for investment in hospital infrastructure, workforce retention, and standardized clinical protocols. This model may guide capacity-building efforts in other low-resource settings, serve as a framework for iterative trauma capacity assessment, and monitor progression toward National Surgical, Obstetric, and Anesthesia Plans.
In 1955, twenty-five survivors of the Hiroshima atomic bombing traveled to Mount Sinai Hospital in New York to undergo a collective 170 plastic and reconstructive surgical operations. This research reconsiders the dominant historical narrative surrounding what came to be known as the "Hiroshima Maidens" project by examining the complex political, institutional, and social forces that shaped the care of these patients. Analysis draws on primary source documents from archival collections in Hiroshima and at Mount Sinai Hospital, personal papers of involved American and Japanese surgeons, related academic publications, unpublished communications between project organizers, interviews with former project stakeholders, and patient accounts. The project coalesced with a broader discourse in which atomic bomb survivors were leveraged as symbols of postwar reconciliation to aid a developing US-Japan Cold War alliance. Contrary to prevailing narratives that emphasized American medical superiority, Japanese surgeons possessed greater scientific and clinical knowledge of atomic-bomb related injuries than their American counterparts. A previously unreported finding is the use of experimental radiotherapy to reduce keloid recurrence-a protocol that raises ethical concerns about re-irradiating young atomic bomb survivors to prioritize visual restoration over long-term biological safety. The Hiroshima Maidens project illustrates how political context, unexamined clinical assumptions, and asymmetric knowledge structures can compromise patient care despite benevolent intent. For surgeons operating in humanitarian, global, or politically charged contexts, it underscores the importance of epistemic humility, multidisciplinary input, and rigorous informed consent-particularly when evidence is limited and natural history uncertain.
Tobacco exposure is the leading cause of lung cancer, with some surgeons and centers requiring smoking cessation before lung resection. The impact of continued smoking on outcomes remains uncertain. We evaluated morbidity and mortality after resection among patients who currently smoke compared with those who formerly smoked. We analyzed lung cancer resections (2018-2023) in the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database. Smoking status was defined using STS operational definitions as current (within 1 month of operation) or former (abstinence >1 month). Patients who never smoked were excluded. Primary outcomes were operative or 30-day mortality and postoperative pulmonary complications. Multivariable regression identified predictors of outcomes.This research was determined to be exempt research with a waiver of informed consent from Advarra Institutional Review Board (Mod01760092, Version 1.1, Approval date July 17, 2023). Of 85,124 patients, 28% (n=24,093) currently smoked and 72% (n=61,031) formerly smoked. Patients who currently smoked were younger (65.6 vs 69.6 years; p<0.001), had fewer comorbidities, and included higher proportions of patients who identify as Black (11.5% vs 7.5%; p<0.001). Pulmonary complications were more frequent among patients who currently smoke (34.6% vs 30.5%; p<0.001), but mortality did not differ by smoking status (1.0% vs 1.0%; p=0.52). Male sex, current smoking, greater pack-years, thoracotomy, and more extensive resection independently predicted pulmonary complications. Patients who currently smoke experienced higher pulmonary morbidity but no increase in mortality. Surgeons should not use smoking status alone when determining if a patient is a candidate for lung cancer resection. Risk assessment should integrate smoking status in combination with a comprehensive range of preoperative factors to guide shared decision-making and ensure access to lung cancer operation.
Outcome-based quality metrics in surgery have limitations, including susceptibility to gaming and poor generalizability. American College of Surgeons (ACS) verification programs emphasize structural and process standards, but their multidomain impact on care quality has not been comprehensively evaluated. A systematic review and meta-analysis of studies comparing ACS-verified versus non-verified centers or pre/post verification outcomes was performed. Outcomes were categorized using the STEEEP framework (Safe, Timely, Effective, Efficient, Equity, Patient-centeredness). Due to heterogeneity, Stouffer's Z-score method aggregated p-values weighted by sample size to assess directional effects, with Holm adjustment for multiple comparisons. Thirty-one studies encompassing 131 outcomes were included. Overall, 61% of outcomes demonstrated improvement associated with verification, 34% showed no difference, and 5% suggested worse outcomes. Aggregated analysis demonstrated significant improvements in Safety (Z=3.03, p=0.0024), Effectiveness (Z=11.77, p<0.0001), Equity (Z=3.29, p=0.001), and Patient-centeredness (Z=5.36, p<0.0001). Timeliness showed no significant change (p=0.3735). Efficiency demonstrated mixed results and was not significant after Holm adjustment (p=0.0351). Findings reflect directional consistency across heterogeneous settings rather than pooled effect sizes. ACS verification is associated with consistent improvements in multiple domains of surgical quality, particularly safety and effectiveness. Benefits are not uniform across all domains, with limited evidence for efficiency, timeliness, and equity. These findings support verification as a structural approach to quality improvement while highlighting the need for standardized outcomes and stronger methodological designs.
Collaboration between surgeons and anesthesiologists is central to perioperative safety, yet interpersonal and systems barriers within this dyad remain poorly characterized. This qualitative study aimed to identify sources of conflict and practical strategies used by clinicians to improve collaboration during peri-operative care. A qualitative phenomenological study was conducted using semi-structured virtual interviews with practicing surgeons and anesthesiologists in the United States. Participants were recruited via respondent-driven snowball sampling to achieve geographic and practice diversity. Forty physicians (20 surgeons and 20 anesthesiologists) from 24 states, ages 31-81 years, were interviewed between February 2022 and June 2024. Transcripts were coded by multidisciplinary investigator teams using qualitative analysis software, with consensus coding and thematic analysis to identify patterns describing barriers to collaboration and strategies promoting effective teamwork. Seven themes describing conflicts and barriers to collaboration were identified: Systems and Professional Identity, Communication, Relationships, Personality Traits, Behaviors, Trainees, and Medical Management. Five themes describing strategies to enhance collaboration emerged: Communication across the pre-, intra-, and post-operative phases; Relationship Building; Team-Building Attitudes; Team-Building Actions; and Rebuilding Trust. Interviewees described practical tactics to strengthen collaboration, including fostering familiarity (eg, introductions and first-name communication), communicating thoroughly (eg, early case discussions, explaining clinical reasoning, announcing intra-operative status changes), and adopting a shared mentality emphasizing openness, respect for expertise, and assuming positive intent. These insights informed development of a clinician-level "toolkit" summarizing actionable behaviors to support effective peri-operative teamwork. Surgeons and anesthesiologists identified multiple interpersonal and systems factors that hinder collaboration but also described practical behaviors that can strengthen working relationships. Deliberate communication, relationship building, and shared team attitudes represent actionable strategies that may improve peri-operative teamwork and support safe, effective patient care.
Frailty predicts poor outcomes after pancreatectomy, but whether excess mortality and readmission reflect more postoperative complications, worse rescue after complications, or broader recovery vulnerability remains unclear. We performed a retrospective study of the ACS-NSQIP Pancreatectomy database (2014-2023) including 71,104 patients undergoing pancreatic resection. Frailty was defined as modified 5-item frailty index score ≥2. Multivariable logistic regression evaluated associations between frailty and 30-day mortality and readmission. Causal mediation analysis quantified total, direct, and complication-mediated indirect effects. Interaction modeling compared failure-to-rescue and non-precedented deaths by frailty status. Of 71,104 patients, 15,779 (22.2%) were frail. Frailty was independently associated with 30-day mortality (aOR 1.29, 95% CI 1.13-1.46; p<0.001) and readmission (aOR 1.11, 95% CI 1.06-1.16; p<0.001). For mortality, the total effect of frailty was significant (RR 1.32, 95% CI 1.23-1.40; p<0.001), the indirect effect through complications was significant (RR 1.25, 95% CI 1.22-1.27; p<0.001), and the direct effect was not (RR 1.07, 95% CI 0.99-1.14; p=0.400); complications mediated 80.72% of the frailty-mortality association. The largest contributors were unplanned reintubation, bleeding requiring transfusion, septic shock, acute kidney injury requiring dialysis, myocardial infarction, and organ/space surgical site infection. Major complications increased mortality similarly in frail and non-frail patients, without meaningful frailty-related differences in failure-to-rescue. For readmission, complications explained only 17% of the frailty association. After pancreatectomy, frailty-associated mortality is largely explained by postoperative complications, whereas frailty-associated readmission is driven predominantly by vulnerability beyond complications. These findings support complication prevention, prehabilitation, and intensified post-discharge follow-up for frail patients.
Robotic liver surgery (RLS) provides technical advantages over laparoscopic liver surgery (LLS), but no validated robotic-specific difficulty scoring system (DSS) exists. We evaluated the applicability of the Southampton DSS to RLS and developed a dedicated RLS difficulty model. This multicenter retrospective cohort study included adults undergoing planned RLS across 24 international hepatobiliary centers. The Southampton DSS was assessed for calibration and discrimination in predicting intraoperative complications. Given limited performance, a robotic-specific model (International RoboLiver DSS) was developed using multivariable logistic regression with prolonged operative time (>280 minutes; 75th percentile) as a surrogate of technical difficulty. Model discrimination, calibration, and bootstrap internal validation were performed. Among 1,497 RLS patients, higher Southampton DSS categories were associated with increased intraoperative complications (p=0.003); however, discrimination was poor (AUC 0.571, 95% CI 0.530-0.612) with miscalibration (slope 0.43; intercept 0.06). Independent predictors of prolonged operative time included neoadjuvant chemotherapy, prior extrahepatic surgery, lesion >50 mm, multiple lesions, bilobar disease, and technically or anatomically major resection. The International RoboLiver DSS demonstrated moderate discrimination (AUC 0.719, 95% CI 0.686-0.751) with excellent calibration (intercept 0.00; slope 1.14). Bootstrap validation confirmed model stability (corrected AUC 0.719). Difficulty factors in RLS partially overlap with LLS but are not directly transferable. The International RoboLiver DSS provides a calibrated, robot-specific tool for preoperative complexity stratification and operative planning in RLS. External validation is required.
In times of rapidly evolving societal needs, perceptions, and expectations, collaboration is imperative. Although health professionals today must adapt quickly to new ways of thinking and working, which surgeons are well equipped to do, it is equally vital to uphold enduring shared values. Remembering our commonalities can be challenging, but they are rooted in the Hippocratic oath, a variation of which all physicians take in some form. Such oaths emphasize the importance of listening to patients, families, communities, and colleagues; remembering our own need for care and compassion; and practicing our profession with conscience and dignity. Doing so helps us achieve our shared goal "to heal all with skill and trust," which is both the American College of Surgeons' motto and a common goal for all in medicine.
Robotic surgery may mitigate technical challenges associated with patient obesity. However, prevalence of robotic cholecystectomy and impact on outcomes in patients with obesity are unclear. We evaluated trends in robotic cholecystectomy, factors contributing to robot use, and outcomes based on BMI. We analyzed data from a statewide, 69-hospital member clinical registry and identified patients who underwent elective robotic or laparoscopic cholecystectomy from 2020 to 2024. Patients were stratified by BMI (lower than 35 kg/m2, 35 to 49.9 kg/m2, greater than or equal to 50 kg/m2) and outcomes were compared. Multivariable logistic regression was used to evaluate the association between patient characteristics, surgical approach, and outcomes. An interaction term was used to evaluate the impact of BMI category on the risk associated with the surgical approach. A total of 27,006 patients underwent laparoscopic (18,610; 68.9%) or robotic (8,396; 31.1%) cholecystectomy. Robotic approach increased over time, with the greatest increase in patients with BMI greater than or equal to 50 kg/m2 (23.1% in 2020 vs 55.8% in 2024, p < 0.001). Compared with patients who underwent laparoscopic surgery, those who underwent robotic surgery were more likely to have a higher BMI (BMI 35 to 49.9 kg/m2: odds ratio [OR] 1.15, 95% CI 1.08 to 1.23, p < 0.001; BMI greater than equal to 50 kg/m2: OR 1.34, 95% CI 1.14 to 1.57, p < 0.001). BMI did not modify the effect of surgical approach on postoperative complication risk (BMI 35 to 49.9 kg/m2 with robotic approach: OR 0.97, 95% CI 0.60 to 1.56, p = 0.887; BMI greater than or equal to 50 kg/m2 with robotic approach OR 1.55, 95% CI 0.50 to 4.86, p = 0.451). Robotic approach is increasingly used in elective minimally invasive cholecystectomy, especially for patients with the highest BMI. Postoperative outcomes did not differ across BMI groups between robotic and laparoscopic cholecystectomy, indicating that BMI did not alter the relationship between surgical approach and outcomes.
Older adults undergoing surgery are at increased risk for postoperative complications, functional decline, and death, yet factors associated with new perioperative do not resuscitate (DNR) orders and the timing of these orders relative to clinical events remain incompletely defined. Retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Program (2015-2019). Patients aged 65 years and older undergoing surgery at participating hospitals were included. The primary outcome was new perioperative DNR order within 30 days of surgery. Multivariable logistic regression accounting for hospital-level clustering identified predictors of new DNR placement. Timing analyses evaluated DNR placement relative to surgery, mortality, major morbidity, and palliative care consultation (PCC). Among 47,564 cases from 27 sites, 1,108 (2.3%) had a new perioperative DNR order. Independent predictors included ASA IV/V (OR 2.6, 95% CI 1.9-3.6), disseminated cancer (OR 3.3, 95% CI 2.5-4.3), emergent surgery (OR 3.5, 95% CI 1.8-6.7), malnutrition (OR 2.3, 95% CI 1.6-3.1), and postoperative delirium (OR 2.3, 95% CI 1.8-2.9). PCC was associated with new DNR placement in cases with non-missing PCC data (OR 10.8, 95% CI 6.9-17.0). New DNR orders were placed a mean 3.8 (±7.0) days after surgery; 32.5% occurred within 24 hours of surgery. Among patients who died, DNR orders were placed a mean 5.2 (±6.6) days before death, with 43.3% occurring within 24 hours of death. Among 239 cases with both PCC and DNR dates, 46.4% occurred on the same day. New perioperative DNR orders in older adults cluster early after surgery and near death. These patterns, together with low overall specialty PCC use, identify potential opportunities for earlier structured multidisciplinary goals-of-care discussions in high-risk surgical patients.
Postoperative intensive care use after gastrointestinal cancer surgery may reflect evolving perioperative triage, yet national patterns of intensive care unit admission and life-support intervention use remain poorly defined. Adults undergoing gastrointestinal cancer surgery in Epic Cosmos between 2016 and 2025 were identified. Intensive care unit admission and postoperative life-support intervention use, defined as invasive mechanical ventilation for ≥24 consecutive hours and/or continuous vasopressor infusion during the index hospitalization, were assessed over time. Multivariable logistic regression evaluated predictors of life-support use and associations with short-term outcomes, adjusting for sociodemographic and clinical factors. Among 376,503 patients, 21.8% (n=82,076) underwent postoperative intensive care unit admission; 88.6% (n=72,702) of these received life-support interventions. From 2016 to 2025, intensive care unit admissions declined by 8.4% (95% CI 6.7-10.1), whereas life-support intervention use increased by 24.2% (95% CI 22.8-25.6) (both p<0.001). Life-support intervention use was more frequent among males (59.3% vs 56.9%), patients with comorbidity (53.7% vs 44.8%), and emergency presentations (24.7% vs 17.8%) (all p<0.001). Compared with colorectal cancer, esophageal cancer surgery had the highest odds of life-support intervention use (aOR 2.42, 95% CI 2.16-2.72). Life-support intervention use was associated with prolonged hospitalization (aOR 2.89, 95% CI 2.66-3.14), complications (aOR 1.94, 95% CI 1.85-2.04), 30-day mortality (aOR 2.82, 95% CI 2.50-3.19), and lower odds of discharge home (aOR 0.25, 95% CI 0.23-0.27) (all p<0.001). After gastrointestinal cancer surgery, intensive care unit use declined while life-support intervention use increased, indicating more selective concentration of higher-acuity postoperative care. Life-support intervention use was strongly associated with adverse short-term outcomes and may serve as a marker of postoperative severity to inform perioperative risk stratification and critical-care resource planning.
Prehospital whole blood (PHWB) transfusion improves outcomes in trauma patients, but blood products are a scarce and costly resource. We hypothesized that massive transfusion protocol (MTP) activation could be an indicator for trauma patients who might benefit from PHWB, and we used geo-mapping to identify high need zones. We retrospectively analyzed trauma registry data from five trauma centers in Omaha and Lincoln, Nebraska, including all patients who had MTP activated in the trauma bay from 6/1/2019-3/31/2025. Assault and motor vehicle crash (MVC) data was collected from the Nebraska Department of Transportation and local police databases. Incidence of MTP, assaults, and MVCs was mapped to identify the highest need zones. Chi-square tests of independence and Pearson and Spearman correlations compared MTP incidence by ZIP Code Tabulated Areas (ZCTA's) with known trauma events. A total of 338 MTP patients from Omaha and 89 from Lincoln were included. Geo-mapping revealed a greater need for PHWB in the downtown centers of both cities. Tests of independence showed significant associations between MTP incidence (Omaha: χ² = 741.22, df = 28, p < 0.001; Lincoln: χ² = 43.75, df = 13, p < 0.001). Spearman and Pearson correlations showed a positive linear correlation between MTP incidence and trauma incidence. Geo-mapping MTP data strongly correlated with known traumas, supporting MTP activation as a surrogate marker for PHWB need. This offers a novel method for cities to plan PHWB programs by determining high need zones and ensuring equitable and cost-effective distribution of scarce resources.
Opioids are routinely prescribed after ambulatory breast surgery despite low reported pain, increasing risk of misuse and diversion. We conducted a randomized clinical trial to determine whether a patient opt-in prescribing strategy reduces opioid prescription, consumption, and excess without worsening postoperative pain or quality of life. Adults undergoing ambulatory breast surgery at a single tertiary center (2022-2024) were randomized 1:1 to Postoperative Opt-In Opioid Treatment (POINT) or routine opioid prescription. POINT patients received education and were prescribed opioids only upon request. Primary outcome was peak pain scores (0-10 NRS) on postoperative days (POD) 1-7 (noninferiority margin 2 points). Secondary outcomes included opioids prescribed, consumed, excess (prescribed minus consumed), PROMIS-29 quality-of-life change, and predictors of opioid use. Of 107 patients, 56 were randomized to POINT and 51 to control. In the POINT, 37 (66%) opted out and 19 (34%) opted in. Prescription rates were 35% in POINT vs 100% in controls (absolute reduction 65%). 9% were consumers vs 24% (absolute reduction 15%). A total of 111 pills were prescribed in POINT vs 362 in controls vs (median 0 [IQR 0-5] vs. median 6 [IQR 5-7], p<0.0001), with excess of 95 vs 293 pills (median 0 [IQR 0-5] vs 6 [IQR 5-7], p<0.0001). Total pills consumed were 63 vs 16, though most patients used none (median 0 [IQR 0] in both groups, p=0.04). Peak pain scores and quality-of-life scores did not differ. Pain scores independently predicted opioid use (OR 2.14, 95% CI 1.41-3.26; p=0.00037). A patient opt-in strategy reduced opioid prescribing, consumption, and excess without worsening pain or quality of life after ambulatory breast surgery.
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Substance use is a modifiable risk factor that may adversely affect surgical outcomes, yet its prevalence using surgical risk-specific thresholds remains incompletely characterized in preoperative populations. We performed a cross-sectional analysis of preoperative screening data from a clinical trial (NCT05783635) at a large Midwestern health system. Between February 2024 and February 2025, 2,688 adults aged 21-75 years undergoing elective surgery completed validated self-report assessments of alcohol, nicotine, cannabis, and other drug use. High-risk use was defined as Alcohol Use Disorders Identification Test-Consumption scores ≥5 or weekly/daily use of other substances. Polysubstance use was defined as high-risk use of more than one substance. Multivariable logistic regression evaluated associations between patient and surgical factors and high-risk use. Overall, 27.6% (n=743) of patients reported high-risk substance use and 6.6% (n=177) reported polysubstance use. Cannabis was the most prevalent high-risk substance (15.0%), followed by alcohol (11.1%), nicotine (8.5%), and other drugs (0.4%). Younger age, male sex, and poorer self-reported health were associated with increased odds of high-risk use. Prevalence varied across surgical services, with the highest rates in neurosurgery (27.1% high-risk; 11.4% polysubstance) and lowest in endocrine surgery (15.1%; 3.3%). More than one in four elective surgical patients report high-risk substance use prior to surgery. These findings support universal preoperative substance use screening to identify patients at elevated risk for adverse perioperative outcomes and enable targeted risk mitigation.
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Allocation of acute lower gastrointestinal surgical conditions between acute care surgeons and colorectal surgeons remains inconsistent, with no consensus guidelines to inform service assignment in teaching hospitals where both specialties share call. A two-round modified Delphi study of expert surgeons was conducted with a predefined 70% consensus threshold. In round 1, participants (n=16) assigned 20 conditions to acute care surgery, colorectal surgery, or either service. Conditions without consensus were discussed in round 2 (n=13). Qualitative data were analyzed using directed content analysis. Consensus was achieved for 10 of 20 conditions (50%) after round 1. The remaining conditions required contextual adjudication in round 2, with no uniform specialty assignment. Qualitative analysis identified three determinants of service allocation: practice model differences, including capacity for longitudinal care; specialty-specific training, with acute care surgeons emphasizing emergency management and colorectal surgeons emphasizing pelvic, rectal, and minimally invasive expertise; and patient clinical status, wherein hemodynamic instability prioritized surgeon availability over specialty-specific expertise. In the absence of universal agreement, service allocation for acute lower gastrointestinal conditions depends on clinical context, surgeon expertise, and institutional resources. This Delphi-derived framework provides a structured approach to guide triage and care pathways in systems with dual acute care and colorectal surgical coverage.
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