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Social determinants of health (SDOH) are the societal conditions that influence an individual's experience of wellness, illness, life expectancy, and health outcomes, including conditions requiring surgery. We aim to define and contextualize the 10 SDOH defined by the World Health Organization, particularly with respect to their impact on surgical care. These include: (1) income and social protection; (2) education; (3) unemployment and job insecurity; (4) working life conditions; (5) food insecurity; (6) housing, basic amenities, and the environment; (7) early childhood development; (8) social inclusion and non-discrimination; (9) structural conflict; and (10) access to affordable health services of decent quality.
As the global population ages, more older adults undergo surgery, a group particularly vulnerable to postoperative complications. Malnutrition remains prevalent among geriatric patients and is strongly linked to increased morbidity, including infections and poor wound healing. Sarcopenia, the loss of muscle mass and function, frequently coexists with malnutrition, creating a detrimental cycle that worsens surgical outcomes. Early identification is essential, and validated screening tools such as the Mini Nutritional Assessment-Short Form and the Malnutrition Universal Screening Tool help detect patients at risk. Implementing routine preoperative nutritional assessment and targeted intervention can significantly improve recovery and reduce length of stay.
Nongovernmental organizations (NGOs) and faith-based organizations (FBOs) play a major role in decreasing the global burden of surgical disease. NGO and FBO assignments vary by their degree of permanence, cultural integration, locations, and scope of practice. Their efficacy may be impeded by pursuing efforts that are asynchronous with local needs or by developing maladaptive relationships with adjacent organizations, ministries of health, or the communities they serve. Both NGOs and FBOs harbor great potential to improve access to surgical care in low- and middle-income countries by expanding educational programs, technological advances, data accumulation, and the capacity of the public health sector.
Social determinants of health (SDOH) are often perceived as abstract, societal-level forces beyond the reach of surgical practice. This study reframes SDOH through the lens of health-related social needs (HRSNs)-discrete, patient-level manifestations that surgeons can identify, screen for, and address. This study focuses on the 5 HRSNs highlighted by the Center for Medicare and Medicaid Services and introduces financial hardship or "financial toxicity" as an emerging and equally important HRSN. By addressing HRSNs, surgeons can improve postoperative outcomes and mitigate health disparities of their patients.
Surgical disparities-differences in access, quality, and workforce representation-are deeply rooted in historical and structural inequities shaped by social hierarchies, racism, and exclusionary institutional practices. Early surgical advancements often exploited marginalized populations under pseudoscientific rationales, embedding mistrust and unequal care. These legacies persist, resulting in poorer outcomes and underrepresentation of women and minorities in the surgical field. Traditional training rarely addresses these origins, risking misattribution of disparities to patient behavior. Embracing a historical lens enables surgeons to identify structural barriers, integrate social determinants into care, and advocate for systemic reforms, ultimately promoting equity for both patients and providers.
A rectovaginal fistula is an epithelialized connection between the rectum and the vagina. These fistulae are stratified based on location, complexity, sphincter damage, and the status of the surrounding tissue. Multiple surgical treatments options are available and should be individualized based on the specific circumstances. Even in the most experienced hands recurrences are common. Recurrent fistulae often require the precise placement of well-vascularized transpositional flaps. Diversion is frequently required to control the symptoms of vaginal soilage and urinary tract infections, but it does not appear to definitively prevent recurrence. Almost all patients can eventually be successfully closed.
Humankind's historical footprint on the continent of Antarctica now spans nearly 130 years. Since the first expedition, surgical care has remained both a necessity and a challenge. Residence in Antarctica is made difficult by unforgiving terrain and a long, isolating winter season. Survival requires strategic allocation of resources and personnel. Surgical emergencies and consultations on residential bases arise in the forms of traumatic injuries and atraumatic illnesses. Medical evacuation is considered dangerous and therefore reserved for critical cases. As such, medical professionals (both surgeons and non-surgeons) must be prepared to provide life-saving surgical care.
Rural surgery plays a critical role in the health care system of the United States. Rural surgeons are the cornerstone of their communities and their hospitals, and the supply of rural surgeons is dwindling. This article explores the state of rural surgery in America, examining its historic development, current challenges, and innovative strategies to improve care delivery. By understanding these factors, stakeholders can work toward sustainable solutions that ensure equitable access to surgical services for rural populations.
Access to and quality of health care are fundamental determinants of surgical outcomes, yet disparities remain prevalent due to a mix of patient, provider, and systemic factors. Rural residents often face longer travel times and reduced hospital access, exacerbating inequities. Inhospital disparities are influenced by race, socioeconomic status, and insurance coverage, with Black patients, those of lower socioeconomic status, and the uninsured experiencing higher rates of surgical complications and mortality. Socioeconomic disadvantage further limits access to health-promoting resources. Family support programs are promising in improving perioperative outcomes and patient satisfaction, underscoring the need for comprehensive, equitable approaches to surgical care.
Many factors play a role in disparities across the spectrum of care, including patient, clinician, hospital, and community level factors. These factors are often interrelated and while categorized as belonging to one category or another, they invariably overlap, stretch across categories, and interact with each other. Importantly, many factors contributing to surgical disparities remain unstudied or understudied, with a clear need to improve data collection, build inclusive research teams, and develop trust with communities to grow our understanding of how all these factors impact surgical outcomes.
The global shortage of surgeons threatens health care systems, especially in resource-limited areas. This synopsis explores modernizing surgical education by shifting from traditional apprenticeship models to competency-based training supported by technology. Key innovations include telementoring, simulation-based training with virtual reality and artificial intelligence and scalable online learning platforms. Faculty development is enhanced through virtual networks and global collaboration. Policy strategies such as national surgical plans, task-sharing, accreditation reforms, and public-private partnerships are vital. Scaling these innovations and addressing workforce retention challenges can rapidly expand the surgical workforce, ultimately improving health care outcomes for underserved populations worldwide.
The intestinal microbiota is composed of diverse microbial species that interact with the host, playing a vital role in immune regulation and maintaining homeostasis. Colorectal surgery has been shown to alter the gut microbiota, contributing to post-operative complications. Emerging evidence suggests that these microbial shifts influence the incidence of anastomotic leaks. In this review, we examine how the gut microbiota composition is altered in patients undergoing colon surgery, leading to anastomotic leaks, the role of collagenolytic bacteria in tissue breakdown at the anastomotic site, the connection between anastomotic leaks and cancer recurrence, and microbially based therapeutic approaches to prevent leaks.
Young-onset colorectal cancer (YOCRC) is increasingly common in the Western world. This has been attributed to changes in diet, lifestyle, and other environmental factors which all influence the gut microbiome. This review summarizes a small number of studies that have demonstrated differences in the microbiome of YOCRC, assessed in the stool and tumoral compartment. These populations are distinct from LOCRC and are prognostically important. Further research may reveal their role in the pathogenesis of this epidemic, and microbiological interventions can alter or augment existing treatment responses.
Anorectal abscesses and fistulas are common surgical conditions. Most often these are idiopathic and caused by cryptoglandular infections. Diagnosis relies on focused history and physical examination findings as well as imaging studies to determine the extent of sphincter involvement and exact location. Treatment of an abscess is prompt surgical drainage. Surgical management of a fistula is focused on preservation of continence while achieving healing. Optimal surgical treatment is based on anatomy of the fistula tract. Surgical options include fistulotomy, seton placement, advancement flap, LIFT, and VAAFT. Emerging therapies, such as mesenchymal stem cell injections, show promise but require further study.
Outcomes in surgical patients after hospital discharge are influenced by many factors. Social drivers of health play a critical role in recovery, complication rates, readmissions, and long-term functional outcomes. These include food security, access to care, health literacy, housing stability, and transportation. Solutions to improve outcomes involve identifying at-risk patients and providing targeted support. Examples include transitional programs focused on communication and coordination of follow up, or interventions for specific at-risk populations such as those injured by violence. Enhanced recovery after surgery protocols offer another opportunity to improve health equity throughout the continuum of surgical care.
The concept that a "one-size-fits-all" approach can be universally applied to all patients undergoing colorectal surgery is waning in enthusiasm especially given the variation in risk perception among patients and surgeons. In this review, we discuss the scientific rationale in generating a microbiome readout that will inform how to selectively eliminate problematic pathogens while preserving those beneficial bacterial strains that may enhance recovery from surgery. We also provide the reader with practical decision points with which to contemplate the need for a bowel preparation with your patient.
Crohn'sdisease (CD) is a chronic inflammatory bowel disease characterized by relapsing and remitting episodes of inflammation that can affect the entire gastrointestinal tract. The prevalence of CD is increasing and affects a vast range of patients, encompassing adolescents to the geriatric population. Medical pharmacologic management aims to obtain steroid-free endoscopic and clinical remission. However, many patients ultimately progress to requiring surgical interventions to alleviate symptoms, improve quality of life, and prevent further disease-specific and life-threatening complications. Surgical intervention is variable based on disease phenotype and location.
The current missions to Low Earth Orbit do not require surgical intervention or training owing to fast evacuation times to Earth. Long mission durations to the Moon, Mars, and beyond will require increased surgical training and capabilities for the crew. This review article summarizes the history, challenges, and potential of bringing surgical capabilities to space, including discussion of the specific physiologic, environmental, and practical concerns regarding surgery in space.
Our approach to the diagnosis and treatment of diverticulitis has evolved over the past 20 y. Routine use of antibiotics has decreased with recent studies suggesting simple cases of diverticulitis can be selectively managed without antibiotics. The criteria necessitating surgical intervention have also been amended as our understanding of the natural history of diverticulitis has grown. We favor selective use of antibiotics, percutaneous drainage, and surgery depending on the severity of the disease, patient factors, and clinical context.
Over 1 million preventable deaths occur each year because of insufficient access to emergency and essential surgical and anesthetic care. Austere environments, such as low-income and middle-income countries, isolated and confined environments, disaster situations, and combat zones, present specific challenges due to limitations of infrastructure, resources, and the environment. Strategies to improve safe anesthetic care in austere environments include mission trips and humanitarian aid, building local capacity of anesthetists and equipment, and improvisation. Telemedicine, mHealth applications, and other novel technologies are also being used to increase access to anesthesia.